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Exploring Body Art Trends

Pierced Tongues Raise Concern

Body art is becoming more mainstream among active people, which raises new sports medicine issues, particularly those surrounding oral piercing.

Tracking Trends

If body art is just a fad, its popularity is still increasing, if Texas trends apply to the rest of the nation. Myrna L. Armstrong, EdD, RN, a professor in the School of Nursing at Texas Tech University Health Sciences Center in Lubbock, has been tracking body art trends and their medical implications since 1991. She notes that Texas began registering piercing studios in 2000. By January 2002, she says the number of studios rose from 405 to 467.

Assessing the number of pierced or tattooed individuals is difficult, Armstrong says. One recent study1 recorded a piercing rate of 17% in a sample of college students; another such study2 reported a rate of 51%. Recent data3 from Armstrong and her colleagues indicate a 33% rate in the same population (Armstrong ML, Roberts AE, Caliendo C, et al, December 2002, unpublished data).

Young people are getting more creative and daring with their body art choices, she says. Four years ago, the primary sites were ears, navels, and nasal areas, with fewer numbers of tongue and genital piercings. Now, tongue piercings have become more mainstream. Other forms of body art that have a more limited appeal are branding, which is "a design made out of second- and third-degree burns," Armstrong says, and implanting objects such as plastic, ivory, or wood beneath the skin.

Tattoos are still popular; male athletes are more likely to be tattooed than their nonathletic peers.2 There is an infection risk during the healing period. The best known long-term concern is the potential risk of hepatitis B and C from contaminated needles. Armstrong says another tattoo consideration that healthcare providers should be aware of is that the metallic oxide dyes used in some tattoo procedures can heat up and cause burns during magnetic resonance imaging.

Armstrong and her colleagues have collected preliminary data to specifically gauge piercing-related behaviors in athletes and other active people. In their survey of college athletes, they found that women are more likely to keep their jewelry in during activity, even during contact sports. Some athletes took precautions such as covering the jewelry with a small piece of adhesive tape; some with tongue piercings removed their jewelry and put in a retainer or spacer to maintain the hole while the jewelry was out.

In a study of adults who have nipple or genital piercings, women were also more likely to leave the jewelry in during activity (Armstrong ML, Caliendo C, December 2002, unpublished data). Those who left the jewelry in reported they either did nothing to secure the jewelry or used tape, tight sports apparel, or a sports bra to reduce friction and prevent trauma to the sites.

Concerns About Tongue Piercing

Trauma from contact sports and the risk of infection from dirty activity settings is a concern with any piercing; however, the bulk of the worries are shifting to risks involving oral piercings. One report3 estimates that about 20% of intraoral piercings become infected, and that athletes are at greater risk because of increased blood flow and breathing rate and chance of contact trauma.

Dennis N. Ranalli, DDS, MDS, professor and senior associate dean in the School of Dental Medicine at the University of Pittsburgh, has treated several active patients who have tongue piercings. "While various forms of body art are appealing to some individual athletes, they need to be aware of the the local and systemic risk factors," he says.

Health complications can arise during the initial healing period, which include hemorrhage, airway restriction from tongue swelling, and chemical burns from piercing aftercare products. After healing, athletic trauma can damage teeth and gums and cause patients to aspirate or swallow dislodged jewelry parts. Serious systemic complications, though rare, do occur. Recent reports describe cases of endocarditis4,5 and brain abscess6 after tongue piercing.

Ranalli says a major problem is that many athletes don't want to remove their tongue studs during competition, despite high school and college rules against wearing the jewelry during play. (The hole in the tongue can close in a relatively short time, he says.) As such, many athletes who keep their tongue studs in forego required mouth guards. Ranalli says modifying the mouth guard to accommodate the stud is probably unwise. Some athletes use a piece of fishing line to keep the hole open during stud removal. "But that's not really very comfortable," he says.

Physicians' Role

Armstrong and Ranalli recommend asking athletes about their body art during the preparticipation exam. Physicians can counsel athletes about proper site care, and knowing where the piercings or tattoos are may be useful in acute situations. "Promoting zero tolerance for infections may get farther than thinking you can outlaw the piercing," Armstrong says. One exception would be to discourage athletes from getting tongue piercings during the sports season. The swelling can cause airway problems, and the wound is most vulnerable to infection during the first 3 to 5 weeks.

Ranalli says most sports medicine providers can easily diagnose most piercing-related infections; however, recognizing a tongue infection may be a little more challenging. Like other infected skin, the tongue will be red, swollen, and hot to the touch. Pus can often be expressed from the hole. The patient may also have swollen lymph nodes and a sore throat.

Lisa Schnirring


  1. Forbes GB: College students with tattoos and piercings: motives, family experiences, personality factors, and perception by others. Psychol Rep 2001;89(3):774-786
  2. Mayers LB, Judelson DA, Moriarty BW, et al: Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77(1):29-34
  3. McGeary SP, Studen-Pavlovich D, Ranalli DN: Oral piercing in athletes: implications for general dentists. Gen Dent 2002;50(2):168-172
  4. Akhondi H, Rahimi AR: Haemophilus aphrophilus endocarditis after tongue piercing. Emerg Infect Dis 2002;8(8):850-851
  5. Harding PR, Yerkey MW, Deye G, et al: Methicillin resistant staphylococcus aureus (MRSA) endocarditis secondary to tongue piercing. J Miss State Med Assoc 2002;43(4):109
  6. Martinello RA, Cooney EL: Cerebellar brain abscess associated with tongue piercing. Clin Infect Dis 2003;36(2):e32-e34

Field Notes

Outdoors Revolution?

From sport-utility vehicles to rugged cargo pants, products that reflect outdoor activity are hot sellers. Such purchases, however, don't seem to translate to more active lifestyles, according to a recent study released by American Sports Data, Inc (ASD), based in Hartsdale, New York.

The "outdoors revolution" appears to be a mix of attitudes, values, and psychological needs rather than a focused behavioral lifestyle, according to an ASD press release. Traditionally active outdoor recreational activities such as hiking, camping, backpacking, and mountain biking have declined or plateaued. (Gains were seen in only two activities: indoor wall climbing and kayaking.) Meanwhile, more passive outdoor recreational activities, such as observing wildlife and visiting national parks, are on the rise.

In its analysis, ASD notes that the disconnect between the new "ecoconsciousness" and outdoors participation is analogous to American attitudes toward physical fitness; attitudes and value changes can be swift, but behavior changes are far less dramatic. ASD also notes that consumers may have tired of the white-shoe athletic look.