How should we be addressing this in pedo hygiene patients?
I never considered how difficult it would be to answer this question until a patient I provided care for about six months ago. As a parent, I believe oral piercings are dangerous and unnecessary. I personally would not consent to them for any of my minor children. As a hygienist, I know the dangers of oral piercings and have seen the damage they cause - specifically, gingival recession. But here is where the difficulty was: I had a patient with a lingual frenum ("tongue web") piercing. It quickly became apparent the patient's mother did not know about the piercing. This was perplexing to me because the patient already had an exam by Dr. (X) before I came to start her prophy.
I could not figure out why on earth someone would pierce their lingual frenum!?!? After all, how would anyone even see it? That was when I had my 'lightbulb moment'....no one would see it, including mom! I thought about this more as I polished. I took off my gloves, reviewed the chart notes, and saw no record of the piercing in the chart notes from the doctor's exam. I also noticed the doc had ordered a panorex. The only explanation I could rationalize was the doctor who did the exam did not see the piercing. But was that possible? We all miss or overlook things occasionally, right? Isn't that is why we need a dental 'team', and it's called the 'practice', not the 'perfect' of dental hygiene? RIGHT?
What to do??? First, I know infections and complications from oral piercings can be life threatening. I also know the patient is a minor, and I have the ethical responsibility of maleficence-doing no harm and/or avoiding harm-to my patient. In my mind, the potential harm here is infection (potentially life threatening) and excess radiation exposure if the piercing obscures vital anatomy or pathology and the pan needs to be retaken. The second risk is minor, but I personally am not a fan of radiation to the very radiosensitive juvenille thyroid. Secondly, what do I expect from my own children's healthcare providers? No brainer there!
I had made my decision: I would inform mom, and then discuss with the examining dentist. I thought through several possible approaches as I flossed the patient and applied fluoride. I sat the patient up, went over oral hygiene instruction with patient and mom, and then said something along the lines of "her tongue web piercing seems ok today, but it really needs to be checked daily for signs of infection. I'm going to check with the dentist before we take her x-ray to be sure it won't be in the way of the roots of her teeth." SILENCE.
And then...."my daughter DOES NOT have a tongue piercing! I want to see this!" (of course, I show mom) followed by "that is coming out TODAY!" You can imagine the back-and-forth between teen girl and mom as I casually wheeled backward and quietly made my chart notes. The next question from mom really stung: "why didn't the dentist say anything to me about this, especially if it can get infected and get in the way of the x-ray?
OH BOY. The dreaded res gestae. Latin for 'things done', English for 'speak carefully, lest you find yourself and your doctor in hot water'. I spoke the truth of I what I knew and not another word more..."I'm not sure, I'll have Dr. (X) stop back over and answer any questions you may have." "OH, YOU DO THAT!"
This story is already long enough so here are the cliff notes for the ending: Dr. (X) did see it, assumed mom did not know, wanted to protect her patient's choice not to tell mom, would not return to chairside to speak with mom, and no longer practices at our office (for other reasons).
Why oral piercings are a problem for our patients
Most likely this is not new information for you, or maybe it will be a refresher.
Oral piercings are dangerous to our pedo patients because they can:
- cause infections, which may become life threatening
- damage teeth
- cause gingival recession and root damage
- result in bloodborne infections such as hepatitis and herpes simplex (especially if done improperly)
- cause excess salivation
- affect speech and swallowing
- be accidentally aspirated or ingested
Both the ADA and AAPD strongly advise against oral piercings and jewelry. The AHDA concurs, and adds it is our role as dental hygienists to educate patients and caregivers about the dangers and potential long-term consequences.
So what about Dr. (X)'s position that she should respect her patient's choice to keep her piercing from her parent? Both the ADA and AAPD advise providers to involve the adolescent in their own care and treatment planning whenever possible, and to consider the patient's age, maturity, and emotional ability while helping them exercise autonomy. The AAPD does, however, make a recommendation that I personally use as a guide for my interaction with teen patients and caregivers. The AAPD recommends informing caregivers or responsible parties when 'risky behaviors' are disclosed and goes on to list oral piercings as one such behavior.
Life-threatening complications
Any oral infection has the potential to become life-threatening, and oral piercings are no exception. The extensive blood supply to the oral cavity comes from the internal carotid arteries and returns to the heart via the internal jugular veins. In the interim, blood from the different structures in the head, including the mouth, collect and mix in the cavernous sinus (Fig. 1). This pooling of blood to and from vital cranial structures is one way oral infections can escalate so quickly. Bacteria from dental infections, including infected oral piercings, can infiltrate this sinus and rapidly spread to the brain, eyes, ears and heart.
Similarly, the tongue, tissues under the tongue, and the submandibular glands can become infected and swell rapidly (Fig. 2). This rapid tissue swelling, known as Ludwig's angina, is a medical emergency because the airway becomes obstructed (Fig. 3).
Patients and parents should be made aware of the possibility of oral piercing infections, and how quickly these infections can spread to the heart and brain, or cause airway obstruction.
Damage to teeth and oral tissues
The most common damage to teeth is broken teeth (Fig. 4) and recession (Fig. 5). Of course, broken teeth are a direct result of damage from oral jewelry and can occur when the patient is awake, or from mouth movements during sleep.
Recession is caused by trauma or friction from oral jewelry. Informing patients and parents of these risks, and showing them areas to monitor at home, is an important educational point and may serve as a deterrent to wearing oral jewelry.
Tearing and scarring of oral tissues can be another complication or oral piercings. If oral jewelry gets caught or snagged it can be ripped out and the tear can scar, as seen in figure 6.
Infection can also result from traumatic loss of oral jewelry. Fig. 7 shows an ongoing infection of the tongue after the patient's tongue stud was torn out.
Any oral piercing can become infected. Oral jewelry provides surfaces for plaque to accumulate. The figures below depict infected tongue (fig. 8), uvula (fig. 9), and lingual frenum (fig. 10) piercings.
Documentation
Documenting oral piercings and their oral manifestations can be confusing. The patient's chart should document the location of the piercing, type of jewelry present, and appearance of piercing site and surrounding tissues. Figure 11 identifies different descriptors for lip piercing locations, and fig. 12 names common intraoral piercings. Some common oral jewelry types are identified in fig. 13.
Fig. 13
It is also necessary to document any recommendations or patient education given at each visit. The main concerns and patient talking points have been reviewed here, but it can also be helpful to provide written information to patients and caregivers. Below are two information/fact sheets for use in your practice. The first is published by the ADA and is available here or at ada.org. The second is one I made myself, the 'Twenty Tiny Teeth' edition!
WOW that was a long one! Thanks for hanging in there and staying awake until the end! I hope you found something you can use in your practice. I would love to hear how you address the oral piercing issue with your pedo patients, and if there's anything you would add to improve this post. Have a beautiful week....I'll get to work on the next topic!!! ~Janel
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