WHAT ABOUT OROFACIAL PIERCINGS?

This information was taken from a presentation by Elizabeth Reynolds, RDH, MS at the 2003 IAOM Annual Convention, Denver, CO.

Body piercing has been practiced in ritualized form or decorative form in almost all human cultures and for as long as we have any historical or fossil evidence . Some piercing have had religious significance, while other practices have been to enhance beauty or cultural status.

Mainstream American views have tended to view facial piercings as occurring only with punk rockers, bikers, or prison inmates. Trends have been changing with more teenagers, college age students, and older adults getting piercings for a variety of reasons. A recent survey of “piercees” found that:

The popularity of piercing has been shifting to the middle class.
All health professionals need to become more knowledgeable about piercings because of the considerations for health and safety.

TEENS ARE VULNERABLE TO INFECTIONS AND COMPLICATIONS.

This vulnerability is primarily because they are more likely to try to perform the modifications on themselves. This is because:

Use of piercing products bought from displays or piercings done without regard to good sterilization and antiseptic standards can cause problems.

Even ear piercing should be approached very carefully. Just going down to a neighborhood store that sells pierced earrings is not sufficient.

Most often the piercing equipment is “sterilized” with only alcohol or a weak cleaning solution. That’s not good enough.

Getting the piercing done at a physician office also may not be sufficient. They may not be "piercing friendly" or knowledgeable.

The best place to get a piercing done is by a member of the Association of Professional Piercers. They have very strict criteria for membership. They must have current CPR training, First Aid, and Blood borne Pathogens training. Also, they have to have monthly spore test documentation. They also have better knowledge about caring for the piercing.

You can find one at: www.safepiercing.org

Understanding of the healing process is important. The piercing heals by forming epithelial cells along the inside of the piercing. This creates a “tunnel” inside of the piercing.

The process of creating the first cell layer (the epithelium) takes about 6-8 weeks.
After the epithelial layer has formed. the piercing constricts around the jewelry.
During this time, care must be taken to lubricate and cleanse properly. The single epithelial layer can be easily torn or dislodged. If the epithelium is pressed into the underlying connective tissue, it can become encapsulated and easily form a cyst.

Once the epithelial layer forms, the underlying cell layers that toughen and strengthen the piercing take 6 months to 2 years to form. As this tougher layer develops, the entrances to the piercing will round inwards. The piercing will become more relaxed and flexible around the jewelry.

Removing the piercing for any length of time while a piercing is forming the layers and healing will increase the risk of shrinkage or closure. This will tend to increase the damage to the epithelial layers when the jewelry is forced through the piercing again. On some piercings even a few minutes of jewelry removal will start the closure process.

Changing the jewelry during the healing time requires a “continuous approach.” The replacement jewelry is introduced to the piercing as the in-place jewelry is removed. Appropriately cleaned and lubricated jewelry is a must.

JEWELRY SELECTION

Correct jewelry selection can help to promote healing.
Jewelry that is too thin will tend to be rejected.
Wearing heavy jewelry may cause a piercing to migrate or to reject.
Biocompatible jewelry should be used. This means one of the following:

Tigon is:

--used more in non-viable piercings or those that are difficult to heal.
--is a clear, hollow, flexible medical grade tubing that comes in 14, 12, 10 gauge sizes and can be cut to varying lengths.
--couples with standard sizes of externally threaded beads, which self-
thread into each end of the tubing to create a barbell.
--is flexible enough to allow the jewelry to bend and move with body
motion, minimizing tension and stretching of the piercing.
--will stiffen and slowly break down over time, which will increase
porosity.
--jewelry should be changed and discarded every 2 months.

Jewelry to avoid:
• Plated gold--The plating rapidly wears and the base metal can leach nickel and other metals into the body at the piercing site.
• Sterling silver--These have a high nickel content with potential for leaching into the body.
• White gold--The alloys used for hardening and the white color tend to have high nickel content.
•Any jewelry with high nickel content.
(Nickel sensitivities are becoming more prevalent. The symptoms are swollen, granulated gum tissue. Even soft touch will cause bleeding. This is a hyperemic reaction. It does not hurt. This can happen with orthodontic treatment if the wires have too much leachable nickel.)

Jewelry to discard:
• Nicked or scratched.
• Burrs or irregular surfaces.
• External threads (The threads will tend to abraid the epithelial layer and press it into the underlie tissue. Internal threads are made in a way to prevent damage to the epithelial layer.)

ORAL AFTER CARE FOR A LIP, TONGUE, OR CHEEK PIERCING

•Over use of antimicrobials upset the oral pH balance and deplete the normal flora resulting in Candida Albicans infection (oral thrush).
•Rinsing with a mild saline solution after eating and drinking is preferable. For making a saline rinse at home use only kosher salt or sea salt (otherwise iodine is absorbed through the mucous membranes of the mouth).
•Mouth rinses with high alcohol content quickly dry out mucosal surfaces. These should be diluted with 50% distilled water.
•During 24-48 hours post-piercing, the tongue will swell to almost twice its normal size. Application of ice helps to relieve swelling and minimize post-piercing bleeding.
•The only NSAID to use is ibuprofen, which will help to reduce pain and swelling. Aspirin is to be avoided.
•Healing barbells are designed to accommodate for post-piercing swelling and are approximately 1.5”-1.75” in length.
•The first barbell should be changed out after swelling subsides to a shorter piece of jewelry to avoid complications with speech, swallowing, and oral care.
• Chewing on foreign objects must be avoided.
•Tobacco use should be discouraged, especially smokeless tobacco. This seriously interferes with the healing process.
•Contact with cosmetics, lotions, perfumes, or hairspray should be avoided for the same reasons.
•Healing times will vary tremendously between piercees.

SPECIAL CONSIDERATIONS FOR OROFACIAL PIERCINGS

Lip and Labret Piercings:
•The vermilion border is to be avoided; there are too many complications with healing and care if the border is pierced.
•Labret jewelry can lead to gingival recession, abrasion of enamel, and bone loss around teeth.
•Swallowing can be difficult, depending on the number, type, and size of labrets.
Fishtail labrets are designed to reduce gingival recession. The must be placed at the medial gingival juncture.
•Tend to create flattened incisive papilla and chip the incisors.
Marilyn or Chrome Crawford Piercings:
•Set to emulate a mole or “beauty mark.”
•Made above the upper lip.
•Must be placed carefully to avoid the facial artery
•Has potential for infection.
Cheek Piercings:
•Considered very dangerous because of the proximity to the facial vein, artery, and nerve and the parotid duct.

Scrumper/Lip Frenulum Piercing:
•Can be upper or lower frenulum piercing.
•These are prone to rejection.
•Gingival recession and enamel abrasion are common.
Uvula Piercing:
•Very dangerous piercing due to aspiration possibilities.
•Difficult to perform because of gagging reflex.
Tongue Splitting:
•Begins with a piercing.
•Laser splitting or scalpel severing of the fascia.
•Some prefer the gradual monofilament (weed whacker thread) pulling.
•Sides move separately following healing.
•The splitting will tend to readhere.
Tongue Piercing:
•Should be placed in the center of the tongue to minimize neural and blood vessel damage.
•The piercing should be anterior to the frenulum. If the frenulum is shortened or
restrictive, a frenuloplasty should be done first.
•The piercing should be at an angle when the tongue is protruded. When the
tongue is retracted into the mouth, the piercing will sit erect.
•After the healing and reduction in swelling, replace with a shorter piece of jewelry to minimize damage to dentition, problems with swallowing and speech.
•Barbells with one fixed ball should be avoided.
•Barbells should be checked daily for tightness.
•If indentation on the tongue forms, the barbell may be too short.
•Piercing through the sides or margins of the tongue will damage not only taste buds, but also muscle cells, motor and sensory nerves, and blood vessels.
•Use of plastic or acrylic balls on the barbells may reduce chipping of the teeth, but will tend to break easier.

•Always use internally threaded jewelry to avoid damaging the epithelium.
•Chipped and cracked teeth are a chronic problem.
•Scar tissue from friction of the jewelry will need to be surgically excised.

SCAR FORMATION AND CYSTS

Only 7% of patients with scars are given “unprompted” medical advice on how to deal with scarring; the medical profession tends to view scarring as “Mother Nature’s bandage” signaling the end of healing.
Any penetration of the skin can result in a scar.

Wound infection increases the risk of unsightly scar formation, as do genetics (family history) and hormone changes during puberty and pregnancy. This is why piercings in younger children are discouraged. Their bodies tend to have more undifferentiated cells. This is why naval piercings often reject; the cells there are more of the undifferentiated type.

Problem scars occur 50 times more in African-Americans and 10 times more in Asian-Americans than in Caucasians.

All piercings of the head and neck heal as scars.
Purposeful scarring by branding or incisions has become another form of body modification.

Types of scars

Keloid Scars
•These are hard, raised, bulky formations of collagenous scar tissue.
•They often spread with continued irritation.
•Cartilage piercings often heal with keloid-like formation.
•Ear and nose piercings are prone to keloid scars; the higher on the ear the
greater likelihood of keloid scarring.

Hypertrophic Scars
•These occur in fleshy sites.
•They stay within the bounds of the injury.
•There will be a tissue protuberance at the piercing entry.
•These generally reabsorb when the piercing heals or the irritation is removed.

Methods of treating scars

•Steroid injections
•Surgery
•Laser resurfacing
•Silicone gel sheets/cushions
•Home remedies
•Prescription products
•OTC scar therapy pads (eg. Curad® Scar Therapy)
•Designed to be used on old or new scars
•Self-adhesive polyurethane pads
•Help to flatten raised scars and decrease redness, usually best on hypertrophic scars
•Creams/ointments (Mederma® Cream)
•Non-prescription topical gel
•Key ingredient is Cepalin (botanical extract derived from onions)
•Can be used on the face, but must avoid eye contact
•Economical (about $15 for 3 months supply)

The cause of the irritation must be eliminated to begin treating the scar.

If the epithelium cells (basal cell type) are displaced into the connective tissue, a cyst may form at that site.

Use of externally threaded jewelry, especially during the 2 month healing phase, tends to increase the risk of epithelium tearing and displacement and the likelihood of scar formation.

WHEN JEWELRY MUST BE REMOVED

The growing popularity of body piercings increases the likelihood that a therapist will come into contact with a person who has a piercing.

If they remove a tongue piercing before you see them, you will likely not know that they have one.

If they have an oral piercing, they should demonstrate to you how to remove it in the unlikely event of an emergency.

Check carefully for chips and cracking of the teeth, especially the incisal and lingual surfaces of the teeth.

You do not want to have them remove a piercing, even for a few minutes if it is still within the 2 year healing phase. The wound can begin to close within a few minutes, making reinsertion of the jewelry problematic.

In ER situations it is rarely necessary to excise tissue to remove jewelry from a piercing. They do not have to remove them for an MRI. The problem with gold jewelry is that it is very thermal conductive.

Those who have novel oral piercing need to have good advice on hygiene and care and oral movements for swallowing and speech with the piercings in place.

We all have body modifications: Hair cuts, earrings, nail clipping, wearing clothes, etc. We do not need to know the reasons someone has chosen body piercings as their modification style. Just how to keep them as healthy and functional as possible.

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