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General

Authors: Dr. Sh. Priyadarshini, Dr. T. Premlata, Dr. Babina Chirom


Abstract

Modifications of body, including tattooing and body piercing have been performed by various population groups over centuries, in different geographic regions, producing distinct cultural and social meaning. Decorating teeth has been practiced since ancient time. Therefore it is not surprising to state that the modern cosmetic/aesthetic dentistry has swept to a new trendy fashion of smile enhancing procedure like tooth jewellery and dental tattoos. Oral and perioral piercing, which were once thought of as part of religious, cultural, or sexual symbolism, has showed increased popularity among teens and young adults. It is popular especially among the youth, who view this practice as a sign of individuality, marginality, decoration or a group identity. Most popular among oral piercing is tongue piercing. This literature is mainly focused on oral and perioral decorations and their benefits and drawbacks as smile enhancing procedures.

Introduction

The focus in restorative dentistry has shifted from the mere restoration of carious teeth to advance treatment which enhance the aesthetic appearance of already healthy teeth. Esthetic dentistry primarily focuses on the modification or alteration of a patient’s oral structures in a visually pleasing manner while at the same time restoring optimal function1. Until recently, restorative dentists were mainly attending to the patient’s basic dental problems but now the shift is towards “Want based dentistry” due to patients’ preoccupation with their appearance. Thus, there has been a paradigm shift from “Need based dentistry” to “Want based dentistry”1. The concept of decorating or enhancing teeth is since time immemorial. Historically, in China and Japan, women stained their teeth black as part of their beauty regimens, and in many cultures, teeth may be bordered in gold or replaced as a status symbol2 (fig 1.1, 1.2). Earlier Pre- Hispanic Maya widely practiced dental decoration by tooth filling and inlaying various semiprecious stones on the facial aspect of anterior teeth and first premolar 3,4,5,.

They utilized round inlay preparations placed in the enamel with corresponding round inlay of jadeite, turquoise, hematite, or other local available minerals4,5 (fig 1.3) The culture of body piercing was once thought to help in spiritual contacts which was commonly practice among the African and Southern African tribes6. In European culture body piercing symbolizes taking part in some social groups and is associated with risky behaviour6. It has its historical meaning, but lately so called body art has becomes a fashion, especially among the young people as a sign of individuality, marginality, decoration or a group identity7. Ever changing dynamic fashion also applies to dentistry. The body art of oral soft tissue piercings especially tongue and lip piercing are of significance to dentists. Recently, oral decorations have become a new craze to create a dazzling smile. Some of them include tooth jewel, tooth tattoo, tooth grills and oral piercing. Most widely practiced types is tooth jewel which are applied to the teeth with an adhesive8. Tooth cap grills and gold teeth are popular among the Hip-Hop trend8. Dental tattoos are not new; they started in the West decades ago when hip hop singers and rappers started sporting them.

Tooth tattoos

Tattoo is a pigment mark made by piercing the skin whereas tooth tattoo are custom designs which are added to dental crowns before the crowns are sealed and set in the mouth. Dental tattoos can be applied to any tooth, and is available in wide gamut of styles, colours, and designs. As tooth tattoo has become a new rage in the fashion dentistry, it is available in various designs like cartoons, custom designs or hand- painted artwork like celebrities, flowers, religion, devotion to person or issue, and animals etc 9. These are commonly practiced among the 14-35 years age group. The most preferred areas for dental tattoos are the upper canine, upper lateral incisors, premolars and molars on labial or buccal side3,10,11,12. According to the use dental tattoos are of two types.

1) Permanent tattoos

In this type, tattoo is inked on ceramic and then placed at the crown of the teeth. It can be single tattoos on single crown or a set of tattoos placed on a set of teeth (fig1.4)

2) Temporary stick-on tattoo

These are direct stick on tattoos similar to nail art. The designs are in the form of templates that are stuck on the teeth which takes just 15-20 minutes. Temporary tattoos are also called temporary tooth decals

Clinical considerations

Even though the procedure is painless and the tattoos can easily be removed with little grinding of the surface for short duration there is plaque accumulations around the tattoo 12. The tattooing or stone-studding if not done professionally can cause dental caries/stains around the margin of the teeth and sometimes get abraded with time. Therefore, precaution like maintenance of proper oral hygiene methods and periodic recall evaluation is required. With the advancement in technology, tooth tattoo has its implication in Forensic Dental Identification as “Tooth ID System”.2

Dental jewels

Dental jewel, recently demanding aspect in cosmetic dentistry, is a special decoration, where stone or crystal glass are mounted on a thin foil of aluminium to create the attractive spark12, which can be attached to teeth. These are available in different colours, green, red, blue and silver and various shapes such as a cross, Christmas tree, shamrock, letters, etc (fig 1.6). Different types of jewels available are skyce (Vivadent), rainbow crystal (DecoDent), twinkle, yellow and white gold tooth jewel (DecoDent) etc.

Clinical considerations

Drilling or tooth preparation is not required rendering no loss of tooth structure and is painless. Proper etching protocol should be followed to avoid over etching of enamel. Carefully polish any sharp edges of the composite or any remaining bonding material to avoid accumulation of plaque12. If the stone gets deboned it may be aspirated into the respiratory tract which may result in emergency.

Removable teeth jewellery

Here, neither etching nor preparation of the teeth is required. The stones are permanently mounted on an invisible glass clear micro-skin which fits accurately on to the teeth. This glass clear micro skin is fabricated in laboratory after making impression on which the stones are attached13. Since it is a non invasive procedure, tooth preparation is not required and easily can be removed.

Tooth rings

Tooth rings are invasive procedure as tooth preparation is required. Here a small hole is prepared on disto- incisal area most often on maxillary incisors to hang the ring through it. Care should be taken while drilling the tooth to avoid any pulpal involment. Proper occlusion should be maintained after the placement of ring to avoid any interference13.

Tooth grills

A grill is a form of detachable jewellery accessory and comes bathed in metal and on-demand it is available in gold, silver or platinum, encrusted diamonds or precious stones, imprinted alphabets etc thereby making it more attractive12 (fig 1.7). They are generally removable13, though some may be permanently attached to the teeth. Grills are considered status symbols within the hip-hop fashion scene13 and are mostly worn by 18- to 35-year-old. However, tooth ornaments favour the accumulation of plaque and can diminish the ability to articulate teeth and speech12.

Oral piercing Oral and perioral piercing has become more and more popular, especially among the teens and young adult14. These practice often symbolized as a sign of individuality, marginality, aesthetic, spiritual, sexual connotation and decoration or group identity15,16. Most of the teenagers undergo oral piercing usually to decorate their tongues, mentolabial sulcuses and lips with metallic or other jewellery6. Rarely some piercing in uvula, frenum or cheeks is observed. Tongue piercing is a form of oral body art that presents a unique concern for the dental profession16 (fig 1.8,). The jewellery decorating body is made of metal (surgical steel, titan, nickel, gold, platinum), rarely made of ceramics, nylon, teflon wooden or ivory. Jewellery made of nickel or surgical steel are withdrawn due to the possibility of allergies 6,16,17. Oral jewellery is decorated with different shapes mostly in the form of barbells with studs, labrettes with one stud, or hoops16 Clinical considerations

Oral piercings and especially tongue piercings are harmful fashion trend since they can be associated with local and systemic risks and complications18. The most common oral complications are bleeding (fig1.9), swelling, edema, increases salivary flow, metal hypersensitivity19, and difficulties in speech, parasthesia, local infection, gingival recessions and damage to the dental structure such as chipping teeth, dental cracks, halitosis and fractures20. Late complications appear some time after the procedure of piercing and are not a result of procedure itself but rather a result of contact of the jewellery with surrounding tissues21. Late complications refer not only to teeth but also to periodontal site like gingival recession which are common in mandibular incisors, ulceration of soft tissue, scars, kiloids and allergies to metal can appear20. Tongue piercings have been directly related to dental and gingival injuries in the anterior lingual mandibular region, whereas buccal gingival recession has been observed in cases where the lip stud is located in such a manner as to traumatize the gingiva. Barbells in the mouth can block the radiographic pathway thus preventing the accurate evaluation of abnormalities like cysts, abscess and tumour. Owing to the brittleness and low resistance to impact force, porcelain are not compatible with barbell tongue ornaments22.

Discussion

The conceptual understandings of dental adornments are valuable things for the clinician to implicate these types of practice in world of dentistry as it may be associated with many complications. Minimally invasive procedure, such as tooth tattoo and dental jewels do have the drawback of plaque accumulation if not attended properly, apart from that improper attachment and even swallowing of jewels is of high risk. Invasive procedure of tooth rings required tooth preparation thus careful understanding of internal anatomy of teeth is important factor before drilling the tooth to avoid any pulpal involment.

Several literatures, a limited number of studies, and reviews describe a wide variety of complications, especially in patients who have undergone oral and perioral piercing8,13,22. Peries et at reported that the individuals with tongue piercings presented an 11 times greater chance for the occurrence of gingival recession in the anterior lingual mandibular region as compared with controls group. In the study by Oberholzr et at reported that 34% of the tounge piercing patient shows chipping and fracture teeth and which was evident on both anterior and posterior teeth23. The constant contact of oral jewellery with teeth may cause tooth damage like chipping teeth, dental cracks and abrasion24 which is termed “Wrecking ball syndrome. Study has reported soft tissues changes are encountered like depapillation of the dorsum of tongue in the area surrounding the ornaments due to the chronic irritation23. Occurrence of electro-galvanic current is caused by presence of two different metals in the oral cavity and is also possible complication after oral piercing at people with amalgam fillings or prosthetic appliances18. Tongue piercings may also cause the obstruction of the upper airways and the disruption of innervations and risks of infection and bacterial endocarditis25. Systematically, oral piercing has possibility of the transmission of blood –borne virus such as human immune deficiency virus, hepatitis ( B,C,D and G), herpes simplex and Epstein Barr virus23.

Conclusion

Apart from treating dental problems or diseases now modern dentistry is gaining popularity towards smile enhancing, aesthetic and cosmetic restorative procedure that are minimally invasive. Enthusiastic and trendy fashions of tooth tattoos, dental jewels and even oral piercing have become a new style statement. Even though tooth tattoos and dental jewels are minimally invasive procedure without any pain or loss of tooth structure they may cause accumulation of plaque if not attended properly. Patients wearing dental jewellery have to be aware of risks of tooth damage, and must be periodically monitored to avoid complications. Oral piercing are associated with several complications some of which may also be life threatening. The dentist should motivate patient to maintain a good oral health care, provide instructions and conduct periodic inspections and also should play an active role in educating, and informing those patients for the possible short and long term complication associated with these form of body art.

REFERENCES
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