Successful Regenerative Therapy of Periodontal Defects Associated With Tongue Piercing: A Clinical Report
Sultan Albeshri, BDS, MS; Dennis P. Tarnow, DDS; and Philip Kang, DDS
Abstract: Oral piercing habits are associated with various degrees of complications. Tongue piercing increases the risk of gingival recession and infrabony defects, subsequently leading to localized periodontitis. In the case presented, the patient had persistent swelling and suppuration around her mandibular anterior teeth attributed to tongue piercing jewelry that was placed approximately 12 years prior. Intraoral examinations revealed a localized deep pocket, purulent discharge, swelling, plaque accumulation, bleeding on probing, gingival recession, and teeth mobility. The patient was diagnosed with localized stage III, grade C periodontitis. Following full-mouth debridement and the placement of an extracoronal lingual splint, minimally invasive, papillae-sparing incisions were made, and regenerative therapy with bone allograft and collagen membrane was used to manage the infrabony defects. During the 18-month postoperative follow-up, complete soft-tissue healing was observed along with a significant reduction in pocket depth and the absence of bleeding on probing or suppuration. Radiographic evaluation showed evidence of bone fill. The reported case demonstrates how careful diagnosis and treatment planning are crucial for managing different periodontal defects and emphasizes the importance of proficient periodontal management, which can save teeth that would otherwise be extracted and replaced with implant therapy or fixed bridgework.
Body piercing practices often begin during adolescence and have gained popularity in recent years. They involve inserting jewelry into soft-tissue sites, including the tongue, lip, cheek, frenum, and uvula, for any number of reasons, such as cultural, religious, or identity-related purposes.1 The most common oral and perioral piercings used are captive rings, magnetic studs, and barbells.2 Tongue and lip piercings are particularly common, with incidence rates ranging from 3% to 50%.3 Meanwhile, the rate of complications associated with oral piercings varies significantly, ranging from 14% to 86%.4 Early complications include edema, pain, bleeding, and acute reaction. Extreme complications, such as cerebral abscess, endocarditis, airway obstruction, and an increased risk of viral infection, have also been reported in the literature.5,6 Late local complications may involve cracked teeth, fracture, gingival recession, localized periodontitis, difficulty in chewing and speaking, swallowing impairment, allergy, and tissue overgrowth.7
A case-control study conducted by Pires et al found that patients with tongue piercings had a higher risk of gingival recession in the mandibular anterior lingual region compared with control (odds ratio 11.0, 95% confidence interval 5.02-24.09).8 The incidence of gingival recessions appeared to be 44% in patients with a tongue piercing.9 Other studies have demonstrated a positive correlation between the severity of the gingival recession and the length of both the physical tongue piercing and time in use.10,11 Long-term use of a tongue piercing further increases the risk of complications; for instance, mandibular lingual recession defect was found in 50% of patients who had worn a tongue piercing for more than 2 years.10 Tongue piercing is considered a local risk factor that can result in significant periodontal attachment loss and tooth loss.12
Case Presentation
A 27-year-old Hispanic female patient with no systemic disease or medications presented to the Postgraduate Periodontics Clinic at Columbia University College of Dental Medicine with a complaint of persistent swelling and suppuration in the mandibular anterior region. The patient was a nonsmoker, a social drinker, and had no known drug allergies. She had a tongue piercing placed about 12 years ago, and the jewelry had been permanently removed by her general dentist a week before the periodontal appointment, as the patient presented at an emergency room complaining of pain and suppuration. History of the present illness revealed dull aching pain upon function, which had started a few months prior. The patient's dental history indicated that extractions, scaling and root planing (SRP), and restorations had been performed. Extraoral examinations showed facial symmetry with no signs of swelling or other abnormalities.
After a comprehensive periodontal evaluation, it was observed that the patient had fair oral hygiene. In the lingual aspect of mandibular teeth Nos. 23 through 26, localized deep pockets ranging from 6 mm to 11 mm, purulent discharge, swelling, plaque accumulation, bleeding on probing (BOP), and gingival recession were present (Figure 1 and Figure 2). These teeth also exhibited grade I to grade II mobility (Table 1). An endodontic consult revealed that all teeth were vital and asymptomatic upon percussion, and there were no pulpal pathoses. Radiographic examinations showed well-defined radiolucency and severe bone loss associated with teeth Nos. 23 through 26 (Figure 3 and Figure 4). The radiographic lesion was also noted several years ago from the patient's electronic health record with her primary dentist. The periodontal diagnosis given was localized stage III, grade C periodontitis.13
In addition, the papilla between teeth Nos. 24 and 25 showed some recession, but there was no significant pocket depth on the facial aspect of these teeth. Alternative treatment plans of extraction of teeth Nos. 23 through 26 and replacement with a fixed partial denture (FPD) on Nos. 22 through 27 or an implant-supported FPD on Nos. 23 through 26 were discussed with the patient. It was decided, however, to attempt to save these teeth through advanced periodontal treatment using guided tissue regeneration.
Clinical Management and Outcomes
Initial therapy included full-mouth debridement and placement of an extracoronal splint before the surgical phase. The splint was placed after the initial SRP. Profound local anesthesia was achieved using 2% lidocaine with 1:100,000 epinephrine (34 mg/1.7 mL) (Cook-Waite, Septodont, septodontusa.com). Intrasulcular incisions were made, and a full-thickness lingual flap was reflected from teeth Nos. 22 through 27 using a papillae-sparing incision with no facial incision to minimize esthetic changes after surgery (Figure 5).
Granulomatous tissue was removed, and SRP was completed. Root surfaces were treated with 24% ethylenediaminetetraacetic acid (EDTA) (PrefGel®, Straumann, straumann.com) for 2 minutes, followed by thorough irrigation with sterile saline. One-wall and two-wall defects were noted on teeth Nos. 23 and 26 and teeth Nos. 24 and 25, respectively. The defects were grafted with mineralized corticocancellous particulate allograft (Puros® Allograft, ZimVie, zimvie.com) and covered with a resorbable collagen membrane (Bio-Gide®, Geistlich, geistlich-pharma.com) (Figure 6). The flap was re-approximated and sutured with 5-0 resorbable sutures (Vicryl Rapide™, Ethicon, jnjmedtech.com) via a simple interrupted technique (Figure 7 and Figure 8). No postoperative dressing was used.
The patient was prescribed amoxicillin 875 mg twice per day for 7 days, ibuprofen 600 mg three times per day for 3 days, and 0.12% chlorhexidine gluconate mouthrinse twice per day for 10 days. Healing was uneventful in the immediate postoperative follow-up. Sutures were removed after 2 weeks (Figure 9). The patient was seen at 1, 2, 4, 6, and 10 weeks and at approximately 3, 6, 8, 10, 12, and 18 months (Figure 10 and Figure 11). Clinical examinations revealed a significant reduction in probing pocket depths and the absence of BOP and suppuration (Table 2). Periapical radiographs confirmed a gradual resolution of the defects with radiographic evidence of bone fill (Figure 12 through Figure 14).
Discussion
This article demonstrates a case of successful regenerative therapy of periodontal defects associated with tongue piercing. The clinical outcomes remained stable for 18 months, indicating the effectiveness of the treatment.
Various surgical treatments have been proposed to treat osseous defects.14,15 In this particular instance, the first crucial step in the management of the case was the elimination of etiological local factors, including the tongue piercing and plaque. The constant mechanical trauma caused by the piercing, coupled with the increased concentration of periodontal pathogenic bacteria at the pierced site, contributed to the progression of the periodontal defects.16 As evident in this case, prolonged use of tongue piercing intensifies the bone loss and further damage. Several studies have shown that the severity of gingival recession positively correlates with the length of the tongue piercing in terms of both the physical length of the piercing and the length of time of use.10,11 Long-term use of a tongue piercing increases the rate of complications.
In addition, the choice of piercing material has an impact on bacterial accumulation. For example, a study showed that stainless steel and titanium studs exhibited a higher bacterial count compared to other materials such as plastic. It appeared that bacteria had a tendency to adhere to and proliferate on metal surfaces, particularly more so than on plastic ones.17
This case was managed by a regenerative approach, as studies consistently reported better and stable outcomes. For instance, a systematic review by Murphy and Gunsolley concluded that in infrabony defects, guided tissue regeneration results in a significant gain in clinical attachment level and reduction in pocket depth compared to an open flap debridement.18 With respect to splinting of mobile teeth, firm teeth responded more favorably to various periodontal therapies than mobile teeth.19
The present case report used lingual flap surgery alone to access the infrabony defects because the facial aspect of the affected teeth had intact periodontal parameters (Table 1). Postoperative radiographs showed a very dense and optimum bone fill. The exact type of periodontal healing cannot be determined without histology. Patients should be educated regarding the complications that may follow the piercing of the oral cavity and the importance of frequent screening. Dental professionals need to be aware of the procedures and risks involved with oral piercings and that advanced periodontal surgical management featuring regenerative therapy may allow for the saving of questionable teeth.
Conclusions
Tongue piercing has negative consequences for periodontal health. Correct diagnosis and treatment planning are needed for the management of various periodontal diseases. The presented case was treated successfully via regenerative therapy with a combination of allograft and membrane. The end-result was that questionable teeth were saved and restored to periodontal health.
Disclosure
The authors declare no conflicts of interest.
About the Authors
Sultan Albeshri, BDS, MS
Assistant Professor, Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
Dennis P. Tarnow, DDS
Clinical Professor, Division of Periodontics, Section of Oral, Diagnostic and Rehabilitation Sciences, Columbia University College of Dental Medicine, New York, New York; Private Practice, New York, New York
Philip Kang, DDS
Associate Professor, Division of Periodontics, Section of Oral, Diagnostic and Rehabilitation Sciences, Columbia University College of Dental Medicine, New York, New York
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