Fall 2008

Scientific Article 1

"Intraoral Piercings Associated with DMFT
Indices in Nevada Adolescents aged 13-18"
Nick Azar, Ashley Hoban, Todd Bringhurst, Adam Stout, Carson Hopkins

Abstract
Lifestyle behaviors have been linked with unhealthy conditions of the oral cavity. These include, but are not limited to, tobacco smoking, high fermentable sugar diets, and acidic drink consumption. Recent trends among young adults have included elective intraoral piercings. The purpose of this study was to examine cross-sectional correlations between intraoral piercings and associated caries status (DMFTDecayed, Missing, Filled Teeth) indices defined as the number of permanent teeth present with visible decay (D), entirely missing for any reason (M), and/or filled (F) at the time of an oral examination. Beginning in 2001, the University of Nevada, Las Vegas School of Dental Medicine (UNLVSDM), began a statewide oral cancer screening program whereby students in both rural and metropolitan areas are screened by trained dental professionals to identify dental conditions and self-reported lifestyle behaviors. Participants in this study were a convenience sample of middle and high school students (n= 9226) between the ages of 13-18 years who participated in the program in 2005-06 academic year. Using Chi-square statistical analysis there was no significant correlation between mean DMFT scores and the mean number of intraoral piercings in this cohort. Limitations suggest that future studies include longitudinal data to further address questions about associations between oral piercings and oral health status.

Introduction
The nation’s oral health awareness has dramatically increased, leading to the best overall status this country has ever seen; however, oral diseases remain very common in the United States (1). These include, but are not limited to, decayed and missing teeth, highly carious teeth, and various oral cancers. According the World Health Organization (WHO), tooth decay is one of the most common childhood diseases- 5 times as common as asthma and 7 times as common as hay fever in 5-to-17 year-olds. Moreover, by age 17 years, 78 percent of young people have had a cavity, 7 percent have lost at least one permanent tooth, and roughly one-third of persons across all age groups have untreated decay (1). Although the nation’s oral health status has improved, some struggle to maintain a healthy oral lifestyle.

Many studies have been performed in an effort to link various lifestyle habits with an unhealthy oral cavity. Of particular interest is oral piercings. Research has shown the most common complication of oral piercings is infection, although other complications may include swelling, pain, bleeding from lingual frenum, impaired mastication, impaired swallowing and impaired speech (2). Researchers have proven that oral piercings caused chipping and cracking of teeth, cusp fractures, dental abrasion, galvanic currents, dental infections, trauma to lingual gingiva, and increased salivary flow (3). Moreover, in a study performed by Jornet et al. in which 98 tongue, lip and cheek piercings were evaluated in 97 patients with piercings, it was determined that 33 people (34%) had dental complications of which 13 people had chipped or fractured teeth and 23 people had gingival recession (4).

Evidence exists of the association between oral piercings and many associated intraoral complications. However, very little research focuses on oral piercings and the coupled problems with DMFT scores. For the purposes of this study DMFT scores were defined as the mean number of permanent teeth decayed, missing, and/or filled present at the time the subjects were examined. The aim of this study was to identify a possible correlation between intraoral piercings and associated DMFT scores in Nevada adolescents who participated in an oral cancer screening program.

Methods
In 2001 the UNLV SDM began conducting the Crackdown on Cancer program that was developed in part to determine oral health needs, to document cancer screening results and ultimately, to pursue tobacco cessation programs for students enrolled in middle and high schools in the state of Nevada. Two fully-equipped mobile dental clinics were used to conduct the oral screening. Trained and calibrated dental professionals conducted oral screenings and documented the prevalence of tobacco use, identifiable tissue abnormalities, oral diseases, dental findings (including DMFT indices), brief health histories, and other possible self-reported risk factors. Oral piercings were recorded by the dentists.

Participant information was kept completely confidential by using numbers assigned by school officials rather than student names. This study was approved by the Institutional Review Board for the Protection of Human Subjects at UNLV. Furthermore, participants identified as needing additional necessary educational resources to seek follow up treatment as well as information on the cessation of tobacco use were given referrals through the health offices in the schools.

Subjects for this study represented a cohort screened in the 2005-2006 academic school year. This convenience sample included 9,226 high school students, between the ages of 13-18 years old who attended one of 90 public high schools and select venues, such as alternative schools, in the state of Nevada. There were no exclusion criteria used to eliminate student participation, thus all students were allowed to participate on a free will basis, following written assent. Due to the ages of the subjects involved, written parental consent was also obtained prior to student participation.

Pearson r correlations were calculated to investigate whether there was an association between mean oral piercings and mean DMFT scores. Mean number of oral piercings of the lip, tongue, cheek, and nose combined was the independent variable while mean DMFT score was the dependent variable. First order partial correlations were used to control for potential confounding variables including: sex, ethnicity, race, locale, tobacco use, and subject’s exposure to secondhand smoke.

Results
Of the students screened, only 462 (5%) had oral piercings of the lip, tongue, cheek, and/or nose. As shown in Figure 1, the mean DMFT score for the non-pierced group was 2.95 whereas the mean DMFT score for those with piercings was 3.08. No significant difference was found between mean DMFT scores for students that had piercings and those that did not., even when controlling for modulating variables including tobacco use (p=0.177), second hand smoke (p=0.162), race (p=0.247), ethnicity (0.367) and sex (p=0.139). Table 1 describes demographic and behavioral variables of interest.

Discussion
This investigation examined correlations between the mean number of intraoral and perioral piercing with mean DMFT scores of 9226 Nevada junior and high school students aged 13-18 who participated in a cross sectional oral cancer screening surveillance program in 2005-06. Correlations associating fracturing of teeth with oral piercings are documented in the literature (2), but there is little information on correlates of mean DMFT scores with oral piercing. Impact of oral piercing on oral health status has been examined from the perspective of damage to the tooth structure (7-10), but there are few studies that have identified associations with oral piercing status and carries risk.

The investigators hypothesized that an increase in mean DMFT scores in subjects participating in this study would be associated with mean number of oral piercings. However, results did not confirm a significant increase in DMFT scores among subjects with oral piercings. This finding is consistent with a similar study in first year university students by Venta et al. (11) who found that though there was an increase in average DMFT scores in individuals with oral piercings, it was not significant. Unlike Venta et al. (11), this examination of the relationship of DMFT scores and oral piercings utilized a much larger sample size (9226 versus 234). Those participating in the Crack Down on Cancer study accounted for a wider range of ages (13-18 years) than did the Venta et al (11) study which utilized a first year university aged sample. This study also focused on people living in rural and urban areas whereas the Venta et al. (11) study focused on people born in urban Helsinki, Finland. Unlike Venta et al. (11), the Crackdown on Cancer program did not include any radiographic measures or analysis. Radiographs, which are used to diagnose oral decay, would have allowed the DMFT scores in this study to be verified by diagnostic procedures; however because this study was a public health surveillance screening and not a clinical study radiographs were not used.

A lack of correlation between DMFT scores and oral piercings may have clouded the interpretation of tooth damage associated with oral piercing. Fractured and broken teeth were not recorded in the Crackdown on Cancer data base. Investigators recorded oral status using the DMFT index, which has no provision for recording chipped or fractured teeth. A fractured tooth may have contributed to an individual’s DMFT score if it had previously been filled. Likewise, a tooth damaged by oral jewelry may have lead to secondary decay and contributed to the decay measure of the DMFT score. If this were true for all fractured teeth associated with oral piercings, the mean DMFT score would have been significantly higher. One may speculate that broken or chipped teeth were not always filled immediately and that caries is a disease dependent upon time among other modulating variables.

In both this study and the study performed by Venta et al (11), the subjects were relatively young, middle through high school students respectively. These students may not have had their piercings for an extended period of time. The adverse effects that may come from oral piercing may not have had time to damage the dentition. Lack of randomization was a limitation in this study. However, the number of subjects who participated made the findings robust.

A future study examining correlations between DMFT scores and piercings in older patients or patients having oral piercing for a longer period of time should be considered. This may take the form of longitudinal studies allowing for extended durations of time with piercings and might examine the initiation or termination of a related behavior relative to the oral condition. This study design could demonstrate effects of oral piercings on dentition over time yielding a better understanding of possible correlations of the DMFT score and oral piercings and clinical and preventive interventions to address this issue.

A lack of correlation between DMFT scores and oral piercings may have clouded the interpretation of tooth damage associated with oral piercing. Fractured and broken teeth were not recorded in the Crackdown on Cancer data base. Investigators recorded oral status using the DMFT index, which has no provision for recording chipped or fractured teeth. A fractured tooth may have contributed to an individual’s DMFT score if it had previously been filled. Likewise, a tooth damaged by oral jewelry may have lead to secondary decay and contributed to the decay measure of the DMFT score. If this were true for all fractured teeth associated with oral piercings, the mean DMFT score would have been significantly higher. One may speculate that broken or chipped teeth were not always filled immediately and that caries is a disease dependent upon time among other modulating variables.

In both this study and the study performed by Venta et al (11), the subjects were relatively young, middle through high school students respectively. These students may not have had their piercings for an extended period of time. The adverse effects that may come from oral piercing may not have had time to damage the dentition. Lack of randomization was a limitation in this study. However, the number of subjects who participated made the findings robust.

A future study examining correlations between DMFT scores and piercings in older patients or patients having oral piercing for a longer period of time should be considered. This may take the form of longitudinal studies allowing for extended durations of time with piercings and might examine the initiation or termination of a related behavior relative to the oral condition. This study design could demonstrate effects of oral piercings on dentition over time yielding a better understanding of possible correlations of the DMFT score and oral piercings and clinical and preventive interventions to address this issue.

Conclusions
As societal trends change and oral awareness increases, more research should be conducted to correlate DMFT scores and evidence of oral piercings. Oral piercings were previously implicated as causing many adverse oral consequences that are indicative of disease. Increased DMFT scores among those individuals with piercings suggest that these higher risk individuals need more frequent dental care and education. However, this study did not show a significant increase in DMFT scores among adolescents with oral piercings. Although not the focus of this study, there was a significant correlation between those with oral piercings and those that use tobacco as well as tobacco users and increased DMFT scores. Investigation into the interactions between DMFT indices, presence of oral piercings and tobacco use warrants further consideration. The likelihood of someone with oral piercings using tobacco is increased compared to those without piercings and was suggested in this study.

Some subjects may have recently obtained the oral piercings, suggesting that longitudinal studies should be investigated in order to more accurately determine the long-term consequences of oral piercings. A future study examining correlations in older patients or patients who have had oral piercings for a longer period of time could be considered.

Youth education in middle and high schools may reduce the occurrence of oral piercing and the use of tobacco. As more adolescents learn about the potential consequences of oral piercings and tobacco use, interventions could result in a significant decrease in the occurrence of dental disease and decreased DMFT scores within this population. Parental education would play a key role in making youth education successful. Preliminary findings in this study suggest further exploration of the strength of the variables in the possible interaction between elective oral piercings and oral health status.

Table 1- Self reported demographic and Behavioral Information *

*Note: N=9226, Due to missing data not all numbers
describe variables representing the total (N).

References

1. Office of the Surgeon General. Oral Health 2000: Facts and Figures. [monograph on the Internet] U.S. Department of Health and Human Services’ Resource Library; 2005, May [cited 2006 July 12]. Available from: http:// www.cdc.gov/OralHealth/factsheets/sgr2000-fsl.htm
2. Levin, L., Zadik, Y. & Becker, T. (2005). Oral and dental complications of intra-oral piercing. Dental Traumatology, 21, 341-343.
3. Campbell, A., Moore, A., Williams, E., Stephens, J., & Tatakis, D. (2002). Tongue piercing: Impact of barbell stem length on lingual gingival recession and tooth chipping. Periodontal, 289-297.
4. López-Jornet, P., Camacho-Alonso, F. (2006). Oral and dental complications of intra-oral piercing. Journal of Adolescent Health, 39, 767-769
5. Navarro-Guardiola, C., Lopez-Jornet, P., Camacho- Alonso, F., Vicente-Ortega, V., & Yanez-Gascon, J. (2006). Oral and facial piercings: A case series and review of the literature. International Journal of Dermatology, 45, 805-809.
6. Renicker, R. (2003). Piercing- It’s more than just skin deep. Missouri American Academy of Pediatrics and the Midwest Chapter of Society for Adolescent Medicine, 5, Jan/Feb. Available from: http://www.childrensmercy. org/mso/docs/janfeb03.pdf
7. Lopez-Jornet, P, Navarro-Guardiola, C., Camacho- Alonso, F., Vicente-Ortega, V., & Yanez Gason, J. (2006). Oral and facial piercings: A case series and review of the literature. International Journal of Dermatology, 45, 805- 809.
8. Leichter JW, Monteith BD. Prevalence and risk of traumatic gingival recession following elective lip piercing. Dent Traumatol 2006; 22: 7–13.
9. Kieser, J, Thomson, W, Koopu, P, Quick AN. Oral Piercing and Oral Trauma in a New Zealand Sample. Dental Traumatology 2005, 21: 254-257
10. Chinkitt-Wells, M., Perinpanayagam, M., Pearose, M. Trend in Oral Piercing in Buffalo, New York, High Schools. NYSDJ. 2006, August/September 30-32.
11. Venta, I.; Lakoma, A.; Haahtela, S.; Peltola, J.; Ylipaavalniemi, P.; Turtola, L. Oral piercings Among First-Year University Students. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005, May;99(5):546-9

Acknowledgements: This study was made possible by the Crackdown on Cancer Oral Health Surveillance Program which received funding through the Trust Fund for Public and The Fund for Healthy Nevada, both beneficiaries of the Master Tobacco Settlement.

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