Tongue Piercing : experience of piercees and practice of piercers in Klang Valley , Malaysia

Introduction Body piercing involves the penetration of an ornament into an opening made in the skin or mucosa (1). The common site for intraoral and peri-oral piercings are the tongue and lip, or a combination of both the tongue and lip (2). A conventional tongue piercing is usually on the midline, just anterior to the lingual frenum on the sagittal plane (3). Typically, the tongue is pierced with straight barbell-style jewelry (4). The basic parts include the stud and the barbell. A stud is button-like object, usually ornamental, and mounted on a shank, and a barbell is a straight bar with a bead (stud) on each end. One or both beads on barbells used in tongue piercing can be unscrewed to permit bead removal or change. Generally, one bead is fixed so that only one bead is used to install or remove jewelry. In the past, tongues were pierced to express cultural identity or community status, and as a connection to ancestors or gods. For example, in the Aztec and Maya cultures, tongue piercing is a ritual used to honor the gods. In the 1980s, society in general came to know about tongue piercing when the first professional body-piercing studio was established in Los Angeles, California. Since then, tongue piercing has become fashionable (4). Based on the findings of Antoszewski et al. (5), people acquire body piercings to enhance individuality (67%), prove their bravery (35%), increase sexual attractiveness (68%), and for other reasons such ABSTRACT


Introduction
Body piercing involves the penetration of an ornament into an opening made in the skin or mucosa (1).The common site for intraoral and peri-oral piercings are the tongue and lip, or a combination of both the tongue and lip (2).A conventional tongue piercing is usually on the midline, just anterior to the lingual frenum on the sagittal plane (3).
Typically, the tongue is pierced with straight barbell-style jewelry (4).The basic parts include the stud and the barbell.A stud is button-like object, usually ornamental, and mounted on a shank, and a barbell is a straight bar with a bead (stud) on each end.One or both beads on barbells used in tongue piercing can be unscrewed to permit bead removal or change.Generally, one bead is fixed so that only one bead is used to install or remove jewelry.
In the past, tongues were pierced to express cultural identity or community status, and as a connection to ancestors or gods.For example, in the Aztec and Maya cultures, tongue piercing is a ritual used to honor the gods.In the 1980s, society in general came to know about tongue piercing when the first professional body-piercing studio was established in Los Angeles, California.Since then, tongue piercing has become fashionable (4).Based on the findings of Antoszewski et al. (5), people acquire body piercings to enhance individuality (67%), prove their bravery (35%), increase sexual attractiveness (68%), and for other reasons such as aesthetics, peer pressure, and affiliation with subcultures.
It has been reported that diverse complications are associated with the tongue piercing procedure.Early complications (within 24 hours) include tongue swelling (98%), pain (71%), difficulty eating (66%), and speech problems (51%).Similar problems have also been reported up to 1 week after the piercing, but at a lower frequency.For late complications (after 1 week), the most common complications reported were ingestion of jewelry (29%), tooth fracture (28%), plaque and calculus deposit on the jewelry (26%), and piercing hole enlargement (12%), as reported by Stead et al. (3) in South West England.
Oberholzer and George (6) reported that some participants experienced soft and hard tissue damage, which includes atrophy of the tongue, scar tissue formation, loss of interdental papilla, and teeth chipping or fracture related to the tongue ornament.Based on their study, 59.4% of the participants had no knowledge of the potential complication risks.
There is inadequate information about individuals who carry out tongue piercings.Oral piercings are usually performed by unlicensed persons who may lack clinical and anatomical knowledge and who do not follow proper infection control procedures (6).However, Stead et al. (3) reported that the majority of piercing centers in South West England used an autoclave to sterilize their instruments.The participants also mentioned the use of disposable needles and latex gloves during the piercing, as well as the use of a sharps bin and surface disinfectant, which reflected the piercer's awareness of blood-borne diseases.Their study also revealed that the majority of piercers (86%) analyzed the client's health before carrying out the procedure, including querying clients about whether they had epilepsy, HIV, hepatitis, or other systematic diseases.Inchingolo et al. (2) reported that some piercers also carried out a clinical examination prior to piercing.
To date, there have been numerous case reports on tongue piercing from the Western countries, but little is known about it in Asia.In Malaysia, tongue piercing is not very common as compared to its prevalence in the Western countries.However, there are number of outlets providing the body-piercing services in Klang Valley.Therefore, this study is aimed to explore the experiences of those who had tongue pierced and the practice of piercers in tongue piecing in Klang Valley, Malaysia.

Materials and Methods
This study employed qualitative research design.This study was divided into two parts.The first part focused on people with a tongue piercing (piercee), and the second part focused on people who carried out tongue piercing (piercer).Ethical approval has been granted from the Medical Ethics Committee, Faculty of Dentistry, University of Malaya (DFCO1201/0048 (U)).The study has been conducted in full accordance with the Declaration of Helsinki.Verbal consent was obtained from the participants' parents/guardian before the interview was conducted among those below 18 years of age.It was approved by the Ethics Committee.

Part 1: Study of pierces
A semi-structured in-depth interview was conducted to obtain information regarding tongue piercing from the piercee's perspective.The interview queried piercees on the reason of piercing, other body piercings they had, problems experienced within and after 24 hours of obtaining a tongue piercing, expectations on potential problems and their source of information, and factors that influenced decisionmaking during piercing studio selection.
Piercees were included if they were Malaysian, have a tongue piercing or had their tongue pierced, and were aged 15-50 years old.The first few participants were identified from the internet.Subsequent participant recruitment were carried out using the snowballing or chain sampling method, whereby existing participants were asked to suggest other potential participants who met the inclusion criteria.
We contacted and invited those identified individuals to participate in this study.Those who agreed and met the inclusion criteria were informed of the aims and objectives of the study.Each participant was provided a written statement about the study (patient information sheet) and written consent was obtained.Both the patient information sheet and consent from were available in two languages: Malay and English.
A face to face interview was conducted following a mutually agreed-upon place and time.The semi-structured interview consists of openended questions and probing questions.Interviews were conducted in Malay or English based on the language preference of the participants.The interview was tape-recorded and transcribed into Microsoft Word for data analysis.We stressed to the pierces that all data would remain private and anonymous.Data were collected until data saturation between all participants was achieved.

Part 2: Study of piercers
The second part of the study was designed to obtain information regarding the practice of tongue piercing by piercers.The information obtained include the piercer's background and experience in providing the service, client history-taking, consent procedure, safety measures before and after providing the service, advise to clients following a tongue piercing, common complications reported by clients, and management of a client's complications.
Piercers working in piercing studios in Klang Valley were identified from the internet or from piercees' feedback from the first part of the study.We contacted the piercers and invited them to participate in the study.Those who agreed were informed of the aims and objectives of the study and their written consent was obtained.
A face-to-face interview was conducted at their workplaces using a semi-structured interview that consists of open-ended questions and probing questions.Interviews were conducted in Malay or English based on the language preference of the participant, and audio data were recorded to accurately reflect what the researchers discussed.We stressed to the piercers that all the data would remain private and anonymous.Data were collected until data saturation was achieved.

Data Analysis
After each interview, the collected audio data were transcribed using Microsoft Word.Data were analyzed using content analysis.The researcher carried out the content analysis for each interview to identify keyword/theme it was then verified by the expert researcher.This was done immediately after each interview.Keywords/theme obtained from each interview were highlighted and compared between participants.Interview was continued until no new keywords/themes emerged (saturation reached).

Participation
Eight piercees were interviewed to achieve data saturation.Their reported ages at tongue piercing were 16-25 years old.All but one piercee had multiple extraoral piercing sites other than tongue.The majority of the piercees had piercing(s) on the ears (conch, lobes, tragus, helix), lips, nose, septum, navel and nipples.Some mentioned that they had cheek, neck, eyebrow, and genital piercings.

Participation
We contacted 14 piercing studios in the Klang Valley area by telephone.Five studios did not provide tongue piercing and four did not wish to be interviewed.Five piercers representing five studios eventually agreed to be interviewed.

Pre-operative procedure
The three main themes that emerged from these piercers' pre-operative procedure were (a) medical history, (b) consent and age restriction, and (c) infection control procedure.
(a) Medical history Medical history was the most common issue discussed.The majority of the piercers enquired about clients' diabetes, hemophilia, and allergy status.Only one piercer did not enquire about client's health status prior to providing the service.Interestingly, only one piercer routinely queried clients about blood-borne disease such as hepatitis and HIV.Other health problems reported include asthma, heart problems, hypertension, and keloid scars.
" "We look at the size of the tongue, short or long then make a mark using this marker then pierce.Oh before… We use this spray… Antibacterial."Piercer D In addition, one piercer also asks whether clients have eaten before the procedure.
"We will ask the customer whether already taken the lunch.Before the procedure, try to eat something sweet or something with sugar… Because some customer will feel dizzy after the pierce."Piercer B

Post-operative procedure
The themes that emerged from this aspect were (a) infection control procedure and (b) post-operative advice.
(a) Infection control procedure "Infection control procedure" refers to the management of used instruments and waste disposal.All piercers reported that they used an autoclave.Additional infection control methods include using an ultrasonic cleaner, antibacterial liquid, boiling, or alcohol wipes.
"First, we using the ultrasonic.Some sort of like… vibration to make blood or anything, the crusty on jewelry… it will automatically clean.

Post-operative advices
Post-operative advices given by the piercers include (i) maintaining good oral hygiene, (ii) using ice cubes or cold drinks, (iii) avoiding seafood and egg yolks, (iv) avoiding trauma and irritation to the piercing site, and (v) getting enough sleep and food.
(i) Maintaining good oral hygiene All piercers recommended that their clients regularly gargle with salt water, mouthwash, or saline.They also advised clients to gargle with plain water after every meal, and to brush their tongue and wash their hands before touching their jewelry.
"When in shower or wash the face, try to brush the tongue.Like morning… brush the teeth or cleaning face… brush the tongue to make sure area around the piercing is clean.

Discussion
Although many health complications are known to occur following tongue piercing, it remains popular.Thus, the present study aimed to explore this phenomenon in modern society in Klang Valley.
People pierce their tongue for several reasons.The present study identified three reasons that motivated people to have their tongue pierced; appearance enhancement, expression of individuality, and curiosity.According to Caroll and Anderson (7), the most common reason for tongue piercing was for improvement from an aesthetic aspect.In modern society, some people consider body piercing nothing more than fashionable accessorizing.
Previous studies have reported that complications can follow tongue piercing.In our study, the immediate complications reported during the first 24 hours after piercing were pain, bleeding, tongue swelling, and difficulty speaking and eating.Similar complications have also been reported to occur up to one week following piercing.However, these complications are expected to follow a piercing procedure, as piercing leads to tissue damage and localized inflammatory responses (8).For late complications, only one piercee reported food deposition on jewelry.Surprisingly, one piercee experienced prolonged sensitivity to spicy food.As far as we know, there was no other study in the medical literature that has reported this.
In this era of technological advancement, all information can be obtained easily.Therefore, it is not surprising that piercees in the present study were aware of the complications that could follow tongue piercing.Furthermore, to prevent legal issues, piercers were expected to provide an explanation of the piercing procedure and possible complications before carrying out the procedure.Some believed that the risk is minimal if sufficient care is taken, and one piercee believed that it was possible to obtain a piercing safely.
Similar to decision making in piercing studio selection, most piercees believed that choosing a piercer and studio with care before obtaining a piercing was crucial to reduce the risk of complications (9).Factors that were considered in the selection of a studio were the piercer's professionalism, studio hygiene, friends' recommendations, and finally, cost and convenience.
The present study also found that all piercers appeared to have basic knowledge of safety measures when providing their services.Although majority of the piercers interviewed took note of their clients' health, only one piercer specifically enquired about blood-borne diseases such as hepatitis and HIV, which may endanger an individual.However, the piercers' knowledge regarding serious medical conditions such as valvular heart disease was inadequate, as evinced by four case reports that documented infectious endocarditis following tongue piercing (3).
Currently, neither specific regulations nor guidelines for body piercing are available in Malaysia.This may be due to a lack of data reported on the complications following tongue piercing.In contrast, health regulations are updated periodically in many Western countries because there is more body piercing complications in these countries, which have been reported in the international medical literature (9).Moreover, increased public acceptance of piercing as a mainstream phenomenon in Western society has led to greater awareness of public health and the need for regulations related to body piercing.There are no guidelines for body piercing in Malaysia, and the majority of piercers require client consent only to legitimize their business.
Nevertheless, the cross-infection measures reported by the piercers in our study were commendable.Most of the piercers cited the use of an autoclave to sterilize their instruments, and wore latex gloves while piercing.This concurs with the findings of Stead et al. (3) in South West England.In addition, the sterilization of multi-use instruments, similar to the approach taken by healthcare providers, was reassuring, as it reflects professionalism.
This study also demonstrated that all piercers provided good service to their clients.Providing verbal post-care advice to clients, such as emphasizing the importance of good oral hygiene, may reduce the potential complications of tongue piercing.The piercers also stressed the avoidance of certain foods and activities that can impair the healing process.One piercer also routinely reviews clients' conditions following a tongue piercing.Written advice in pamphlet form is useful guidance to the piercees.The piercer who provided such advice reported that clients rarely, if ever, returned with complaints.One piercer also stated that if a serious medical problem arose following tongue piercing, clients were advised to seek medical attention immediately.Problems such as an acute infection may require removal of jewelry.However, it has been reported that the majority of emergency medical staff do not know how to remove the common types of tongue jewelry.Subsequently, this can lead to further tissue trauma (10).
There were several limitations of the present study.The piercee data were subject to recall bias, as the time since piercing in our sample varied widely and some piercees had already removed their tongue piercing.Even though they were assured of information confidentially and anonymity, some piercers might have been suspicious of our purpose and were thus unwilling to participate in this study.Therefore, it was difficult to establish whether any bias was introduced into this part of the present study.

Conclusion
Improvement from an aesthetic aspect is the common reason people have their tongues pierced.Most piercees encountered problems such as tongue pain and swelling in the first 24 hours after piercing.Only a few piercees reported long-term consequences following piercing.However, most of the piercees were aware of what to expect after the tongue piercing procedure.Although cross-infection controls in their piercing studios were adequate, the piercers' knowledge of serious medical illnesses such as the risk of bacterial endocarditis to vulnerable individuals was inadequate.
There were three reasons for tongue piercing: (a) appearance enhancement, (b) expression of individuality, and (c) curiosity.Verbatim extracted from the interviews are as follows: (b) Expression of individuality "I pierced because it give me, because I find piercing interesting."Piercee G, female "I did it because not many living humans would do that kind of stuff when they're normal… Plus, I've been wanting to do it since after school but my partner won't let me" Piercee F, female "Sebab I memang minat bertindik dan bertatoo."["Because I am interested in piercings and tattoos."]Piercee D, female (c) Curiosity "Why I do my tongue?Because… I don't know.I saw maybe some people look…they look cool.Like you know, sometimes showing.And I also wanna try it.I wanna try it… how is the feeling of the thing."Piercee A, male "Simply of curiosity and I pretty like it.Just want to try." Piercee C, male "For fun.Then, stress study and boring.Wanna find new stupid stuff to do.Time to out of sudden terfikir nak piercing so I just go alone to Sg. Wang." ["For fun.Then, study stress and boredom.Wanted to find new stupid stuff to do.At the time, I suddenly decided to get a piercing, so I went alone to Sg. Wang."]Piercee E, female "For the first 2 days lidah I ok, Cuma nak cakap tu susah sikit."["For the first 2 days my tongue was alright, just that it was a bit difficult to talk."]Piercee G, female "Masalah cuma mulut penuh dengan air liur dan pelat selama seminggu.And tak boleh makan pedas."["The problem was that my mouth was full of saliva and I lisped for a week.And I could "Nak sampai seminggu dia macam bengkak and bernanah sikit sebab I degil tak ikut pantang larang dia.Time tu pun macam demam juga."