Health Considerations for Oral Piercing and the Policies That

CLINICAL REPORT
Health Considerations for Oral
Piercing and the Policies That
Influence Them
Tina Stein, RDH, BS
JoAnn D. Jordan, RDH, MS
Introduction
Only 26% of states have regulatory authority over tattooing
establishments and only 6 of these states exercise authority
over body piercing establishments (1). Some state legislatures
have introduced bills calling for regulation of body piercers
and their establishments, but they do not get much attention
from local government. State laws regulating body piercing vary;
some states prohibit body piercing for persons 18 years of age
while other states allow piercing of this age group. Texas is one
of 39 states that prohibits those under the age of 18 to acquire
body piercing without the consent of a parent or legal guardian
(2). The state of Texas does not have regulatory guidelines for
the piercing artists but does regulate piercing studios. The Texas
Department of State Health Services Drugs and Medical Devices
Group enforces the Health and Safety Codes, Chapter 146, Tattoo and Certain Body Piercing Studio Act (3). This act, however,
is primarily concerned with infection control rather than the care
of the client or patient during or after the procedure. The Texas
Department of Health requires that a person who operates a
piercing studio take precautions to limit the spread of infection.
Abstract
With the increase in popularity of piercings, the health
care professional needs to be
aware of the complications
that can occur due to lack of
regulations of the piercing
establishments. Due to lack of
training of piercing professionals and lack of enforcement
of sterilization procedures,
infection and life threatening
complications can arise. Complications include, but are not
limited to, hemorrhage, nerve
damage, gingival recession,
HIV, tongue swelling, tooth
fracture, Bactermia, Ludwigs
angina, increase salivary flow,
jewelry aspiration, and localized infection. Texas requires
an individual to be 18 years
of age to receive a piercing.
However, Texas does not
regulate the piercing establishment or the artist providing the
services. Oral health care providers should be aware of the
lacking regulations of piercing
studios so they can be more
vigilant of oral complications
that may occur.
oral piercing,
oral piercing complications,
piercing regulations, dental
complications due to oral
piercing
Key words:
Stein
Jordan
Ms Stein is a senior clinic coordinator and director of continuing education, Department
of Dental Hygiene, University of Texas Health Science Center at San Antonio Dental
School, San Antonio, Texas.
Ms Jordan is a research coordinator, Department of Periodontics, University of Texas
Health Science Center at San Antonio Dental School, San Antonio, Texas.
The authors have no declared potential conflicts of financial interest, relationships and/
or affiliations relevant to the subject matter or materials discussed in the manuscript.
Tex Dent J 2012;129(7):687-693.
This article has been peer reviewed.
Texas Dental Journal l www.tda.org l July 2012
687
CLINICAL
REPORT
Guidelines addressing infection
control include:
1. Using germicidal soap to
clean the hands of the tattooist or person who performs body piercing and the
skin area of the client to be
tattooed or pierced.
2. Wearing clean apparel and
rubber gloves.
3. Using sterile tools and
equipment as provided by
the Texas Health and Safety
Code Chapter 146.
4. Keeping the tattoo or body
piercing studio or temporary
location in a sanitary condition (4).
Piercing studios are inspected every 2 years in Texas and are subject
to more frequent inspections depending on the number of complaints
against the establishment. No formal license or CPR certification is
required of the piercing artist (4). The Texas Department of Health also
requires the following:
a. A tattooist or person who performs body piercing properly use and maintain sterilized tools and equipment for
tattooing or body piercing.
b. A tattooist or person who performs body piercing shall
sterilize tools and equipment used on one client before
using them on another client.
c. Tools and equipment shall be sterilized by either the use of
a dry heat sterilizer or steam pressure treatment in an
autoclave.
d. All needles and instruments shall be kept in a clean, dust
free and air tight container when not in use (4).
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CLINICAL
To register in the state of Texas, a body piercer is required
to submit all of the following in
order to open an establishment:
•
Have at least 1 year of
piercing experience.
•
Have knowledge of
appropriate sterilization
and cross-contamination
prevention through bloodborne pathogens training,
required annually for
membership.
1. A signed registration application to the department
on a form issued by the
department.
2. An application fee of $412.
3. Proof of completion of a
training course approved by
the department for tattooists and body piercers that
includes not less than 6
hours related to bloodborne
pathogens, infection control,
and aseptic technique (4).
These guidelines differ from
the recommendation by The
Association of Professional
Piercers (APP). The APP
is a non-profit group that
educates piercers and provides
information to the public about
piercing to maintain a good
image. The group does not
provide licensure nor does it
police their members, but it
maintains a website for the
purpose of educating people
who are curious about body
piercing. Their guidelines
include more stringent
regulations than most state
rules (5).
•
Must work in a studio that
meets rigorous standards
of environmental criteria
for health, safety, and
sanitation.
•
Undergo training and
certification in CPR, and
blood-borne pathogens
and first aid certification;
which must be renewed
according to membership
requirements.
•
Must conduct monthly
spore tests results for their
studio’s autoclave (sterilizer)
REPORT
and be able to show
documentation of the tests.
•
Must answer an extensive
questionnaire and sign
a health and safety
agreement (5).
Oral piercing has increased
in popularity over the last
10 years. The reasons for
piercing have remained the
same: fashion, peer pressure,
and sexual purposes. Oral
piercings continue to occur
in establishments that are
managed by non-licensed
individuals who have no
formal training in piercing.
While some states regulate
piercing establishments there
is not an agency that regulates
the person performing the
procedures (6).
Complications include systemic
and dental problems. Texas
Their regulations include:
•
Uphold a set of safety and
hygiene standards that are
equal to, or more stringent
than, those established by
state or local governments.
Figure 1. Gingival recession caused by labret placement (14).
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CLINICAL
REPORT
requires body piercing studios
to report any infection resulting
from piercing as soon as it is
known. General complications
include aspiration or ingestion
of the jewelry, bacteremia,
contraction of communicable
diseases, hemorrhage, localized
infections, Ludwig’s angina,
and nerve damage. In addition,
dental complications such as
cracked or fractured teeth,
damage of the peridontium,
increased salivary flow, and
gingival recession can often
arise (Figure 1).
Life-threatening complications
include disease transmission,
airway obstruction, prolonged
bleeding, and aspiration (7).
Oral piercing can introduce
bacteria into the bloodstream
which may cause complications
if certain patients have not
received prophylactic antibiotics prior to the piercing procedure (8). In addition, allergic
reactions to metals can cause
detrimental complications that
can block the airway.
Figure 2. Tongue piercing. (Photo taken by Emelda Hernandez BS, RDH).
Literature Review
While oral piercing has been
part of many different cultures
and religions for centuries, in
today’s western culture, oral
piercing is done more as a
fashion trend with social acceptance (9). Oral piercings
are placed on the tongue, lips,
and cheeks (Figure 2). While
trends in oral piercing have
increased in popularity, education of complications has not
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Texas Dental Journal l www.tda.org l July 2012
Figure 3. Ventral area of tongue with large barbell. (Photo taken by Emelda Hernandez
BS, RDH).
CLINICAL
REPORT
increased. Signs and symptoms
of infection have remained
consistent while regulations of
piercers and establishments
have not improved (6).
Due to the fact that many
complications can result from
oral piercing, oral health care
providers should be familiar
with the signs and symptoms
that are outlined below (10).
•
Hemorrhage: The tongue
is vascular; therefore, the
lingual artery and vein will
bleed during the piercing
procedure. If hemorrhaging
occurs, immediate action
should be taken to avoid
profuse blood loss (10).
•
Nerve Damage: The dorsolateral and the dorsoventral
nerve can be damaged during tongue piercing. If this
occurs, irreversible damage
to the sense of taste or motor effects can be affected
(10). (Figure 3).
•
•
HIV, Hepatitis, Tetanus,
Communicable Diseases:
Any of these infections can
occur through the transmission of contaminated
blood and body fluids present during the procedure
unless standard precautions are strictly followed
(10).
Inflammation of the
Tongue: Inflammation of
the tongue occurs immediately after the piercing procedure and can last for 3
to 5 weeks. The submental
Figure 4. Localized Infection of the tongue (15).
and submandibular lymph
nodes may also become enlarged. Sucking on ice chips
helps to reduce the inflammation (10).
•
•
Localized Infections: Localized infection can occur
if proper aftercare is not
practiced. If an infection
does not respond to treatment within 1 or 2 days,
the patient should seek
medical attention. Spread
of these infections to the
mediastinum or cavernous
sinus can be life threatening (Figure 4) (10).
Trauma to the Gingiva:
This can occur when tongue
jewelry rubs against the
gingiva causing trauma to
the tissue (10). (Figure 5).
•
Bacteremia: An infection
can occur both during and
after the piercing procedure. It is spread when
bacteria is introduced into
the bloodstream. Also, it
can spread from a localized infection. The symptoms consist of fever, chills,
shaking, or a red streaked
appearance from the
pierced site (10).
•
Ludwig’s Angina: This is
a serious infection due to
compromise of the airway
and can be life threatening.
Symptoms consist of painful swelling of the tongue,
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CLINICAL
REPORT
best opportunity to educate
patients on the complications
of piercing. Today oral health
care professionals focus on the
overall health of the individual,
not just the oral cavity (11-13).
Figure 5. Facial trauma due to lip piercing. (Photo taken by Emelda Hernandez BS,
RDH).
difficulty swallowing,
breathing, or speaking (10).
•
Cracked or Fractured
Teeth: This occurs when
the patient speaks or
eats and the barbell that
is inserted in the tongue
strikes the teeth. Both
anterior and posterior teeth
can be affected depending
on the size of barbell (10).
•
Aspiration or Ingestion:
If jewelry becomes loose,
the patient can aspirate
or swallow the jewelry
which can result in either
respiratory or gastric
distress (10).
•
Increased Salivary Flow
and Impediment of
Speech: Increased salivary
flow occurs because a
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Texas Dental Journal l www.tda.org l July 2012
foreign object has been
introduced into the oral
tissues (10). Also, speech
may be altered due to
the presence of a heavy
barbell that restricts tongue
movement (9).
Conclusions
Literature indicates that
piercing has increased in
popularity although rules,
regulations, and outcomes
have remained the same over
the last 10 years. Reporting
of complications has not
affected state regulation of
piercing establishments or
piercers themselves. Because
people seek oral health
care more frequently than
medical care, the oral health
care professional has the
According to the literature,
there continues to be a need
to educate our society on the
complications involving the
health risks of piercing. Future
studies regarding the social
and psychological basis which
cause people to engage in this
art form would be beneficial
for health care providers.
The information would assist
oral health care providers in
counseling patients considering
oral piercing and aid the
oral health professional to
understanding this behavior. As
oral health care professionals,
it is our responsibility to be
proactive in educating all our
patients about healthy lifestyles
and providing information
about choices such as piercing
which may have adverse
consequences.
References
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A. (2002). Haemophilus
aphrophilus Endocarditis after
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2. Tattoos and Body Piercings
for Minors. (October 2011).
Retrieved from http://
www.ncsl.org/default.
aspx?tabid=14393
3. Tattoo and Body Piercing
Studios - Drugs and Medical
Devices Group. (March 2011).
Retrieved from http://www.
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dshs.state.tx.us/dmd/tattoo.
shtm
Health and Safety Code. (2003).
Retrieved from http://www.
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HS/htm/HS.146.htm
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uploads/2010/01/APP_
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Dubose, J., & Pratt, J. (2004).
Victim of fashion: Endocarditis
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MD: Agency for Healthcare
DDR Dental Trust
Serving Texas Dentists for more than 40 Years
• Practice Appraisals • Practice Sales • Associate Agreements
800-930-8017
James L. Dunn,
Trustee
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