Dental Grillz

Grillz are a fashionable form of dental jewellery, often in the form of metallic tooth overlays, which may be patterned or etched on the buccal surface and can be inlaid with gems or precious stones – ‘blinged out’. These ‘tooth encasements’, which may replace one or more missing anterior teeth, may be referred to as ‘fronts’, ‘plates’, ‘golds’, ‘shines’, mouth bling and ‘caps’. Grillz, which are typically removable, may be self-retaining or retained using a variety of materials, ranging from traditional luting agents to chewing gum. The framework of the grillz is typically constructed from a precious or non-precious metal alloy, the specific composition of which has near limitless variation. Grillz may be provided by dental practitioners, online retailers or purchased prefabricated. Cost can range from tens of pounds to tens of thousands of pounds for a bespoke ‘blinged out’ set. An example of ‘full fronts’ gold alloy grillz is illustrated in Figure 1.

Origins

Grillz in their contemporary form, may have stemmed from gold restorations, favoured by certain residents of the diverse, multicultural Bronx and Brooklyn neighbourhoods of New York, becoming a fashionable symbol of wealth. A set of grillz implied the rise in affluence of an individual once from ‘the hood’ (an impoverished neighbourhood) who was now able to afford costly tooth ‘décor’. Disco queen and style icon, Grace Jones, has been credited with the first use of dental grillz as a fashion statement in 1975.¹

Popularity

Grillz gained popularity in the 1990s and 2000s through a rap (hip-hop) group based in Atlanta, Georgia, USA known as the Dirty South Rappers. Hip-hop culture, pioneered by African Americans, embodies their ‘street culture’ and has long been associated with ostentatious clothing and ‘chunky’ jewellery that is often ‘iced-out’ (bejewelled). The grandeur and opulence of the jewellery serves as a physical reflection of wealth and tells a story of success despite years of systemic oppression by prejudicial legislature. New York jeweller, Eddie Plein, owner of ‘Famous Eddie's Gold Teeth’, is considered to have been the grillz trend setter in New York in the mid-1980s.² Eddie, ‘King of the Grillz’, subsequent to undertaking some training in dental technology, acquired many celebrity customers. He initially adapted single crowns into multiple over-teeth appliances, originally referred to as ‘fronts’. Gangster-rapper, Just-Ice, one of Eddie Plein's first customers, helped popularize ‘fronts’ (grillz) by wearing them in the cover photograph of his 1987 album, ‘Kool and Deadly’ (Figure 2). Eddie Plein's many, different designs of grillz are the subject of a book entitled ‘Mouths Full of Golds’ (Figure 3).

Global phenomenon

Grillz have now become a global phenomenon, with people, typically adolescents and young adults of all genders and ethnicities, sporting them. The millennials and generation Z of the UK being no exception. The soaring popularity of grillz in the 2000s, in part driven by celebrities wearing grillz (e.g. Chris Brown and Madonna) and rapper Nelly's hit song ‘Grillz’, resulted in the American Dental Association (ADA) preparing a statement on grillz in cooperation with the journal of the association (Journal of the American Dental Association) and the ADA Council on Scientific Affairs.³ More recently Colgate issued a Colgate Global Scientific Communication on the subject of dental grills (grillz).⁴ These communications, targeted at members of the public, acknowledge that no studies have shown grillz to be harmful but emphasize that no studies have shown them to be safe either. Currently in the UK, the term ‘grillz’ is searched online more than 800 times per week,⁵ and there are a growing number of links to online providers, home and abroad, offering to provide grillz – there is no evidence of grillz wearing going out of fashion. On the contrary, all available evidence indicates a continuing upward trend in the use of this form of dental adornment.

Suppliers

A web search of ‘dental grillz UK’ gives the impression that online retailers, most of whom do not appear to be oral healthcare professionals, are the major suppliers of dental grillz. However, it should be noted that some dentists do provide such appliances. No information is available on the size, let alone the dynamics of the grillz market in the UK, but as indicated above it is presently considered to be buoyant and growing.

Online purchasing

The process of online purchasing involves:

• Selecting an online supplier (there were nine UK-based suppliers of grillz with an online presence at the time of preparing this article);
• Browsing the supplier's grillz catalogue, deciding on a design and selecting the metal to form the grillz. Most suppliers offer carte blanche in the design of grillz;
• Payment is made via the website and a ‘mould kit’ is dispatched to the customer;
• An impression, typically of the upper arch, is taken in accordance with instructions provided by the supplier. Once the impression has been taken, the customer signs an affixed laboratory instruction sheet, including a drawing of the design of grillz requested, a disclaimer and a declaration that they are at least 18 years of age and have no allergies to any metals;
• The customer sends the impressions along with the instruction sheet, disclaimer and declaration to the address provided by the supplier;
• Once made, the grillz of the selected design and metal is sent to the customer, together with some instructions. The finished product is usually sent to the customer 2 weeks from the impressions being received.

To test this process, one of the two authors (SS) selected what appeared to be a popular online supplier and followed the above process, ordering a ‘white gold’ grillz that covered his upper right canine and extended onto the incisal edge of his upper right lateral incisor. The cost of the grillz was £140 along with a £6 shipping fee. Following the instructions provided with the impression pack (Figure 4), two upper arch impressions were recorded in medium-sized, perforated stock trays, using what was believed to be a heavy-bodied silicone material, supplied as equal quantities of base and catalyst putties in plastic tubs. The impressions were considered to lack critical detail below the maximum curvature of the teeth, specifically detail of the gingival margin (Figure 5). No adhesive was provided to help retain the impression in the tray. The impression pack provided by the supplier (Figure 4) did not include a tray or impression material to record a lower arch impression.

The grillz was delivered 2 weeks after returning the impression. It was supplied on a model (Figure 6), together with instructions for wearing, cleaning and storage when not in use.

As Illustrated in Figure 7, the grillz, which lacked any retention, had very poor marginal adaptation. When fully seated there was a 1-mm gap between the buccal-cervical margin of the grillz and the surface of the canine tooth

Inspection of the model indicated that the gingival margin, which had not been recorded in the impression (Figure 5), had been added to the upper right canine by modifying the model (Figure 8), presumably using the contralateral tooth as a guide.

The grillz opened the occlusion by 0.5 mm, with the palatal surface of the canine component of the grillz being the only occlusal contact (Figure 9).

The instructions for cleaning and care of the grillz when not in use, which appeared to have been copied from an online article⁶ were as follows.

Cleaning

‘If you use a detachable grill, it is recommended to clean it daily by removing it. Cleanse the grill by brushing it with toothpaste to eliminate any debris and rinse it with warm water. Additionally, after each use, sanitize the grill by immersing it in antiseptic mouthwash.’

Care of teeth

‘Grills are removable gold-plated covers you snap over your teeth. Make sure that you don't wear your grill all the time. Food and bacteria can get trapped beneath the grillz, and if you wear it for extended periods of time, it can lead to tooth and gum decay.

To keep your teeth clean and healthy, remove your grill before eating. Eating while wearing a grill can cause food to get trapped beneath the grill, leading to the growth of bacteria and tooth decay. Food caught under the grill can also injure your sensitive gum tissue.’

This advice indicates that the grillz, which were non-retentive, were intended to ‘snap over’ the teeth and that the grillz were ‘gold-plated covers’ when a ‘white gold’ grillz had been ordered. As the grillz were intended to have a ‘snap fit’, this may explain the absence of any advice on the use of adhesives. Anecdotal evidence suggests that a range of substances have been used to retain grillz, such as denture adhesive, commercially available dental cements and in some cases, chewing gum.

In presenting SS's experience of online purchasing a dental grillz, it is acknowledged that the experience gained is based on the provision of one grillz provided by a single provider and that other providers may work to different standards. That said, a patient-recorded impression, using a heavy-bodied impression material in only a generic stock tray, is unlikely to provide an accurate cast. In the absence of an impression of the opposing arch, let alone an occlusal registration, it is inevitable that the grillz provided will interfere with the client's occlusion.

Risks

As alluded to in the ADA statement,³ Colgate communication⁴ and instructions provided with the grillz, wearing grillz carries several risks. These risks are assumed to increase, the poorer the fit of the grillz, duration for which they are worn, and the poorer the oral health and oral hygiene of the wearer. The risks include:

• Gingival trauma and periodontal inflammation
• Demineralization and subsequent caries in the tooth surfaces covered by, and adjacent to the margins of the grillz
• Damage to existing restorations
• Abrasive damage to tooth and restoration surfaces, specifically surfaces in contact with the fit surface of the grillz. This risk may be much greater in situations where the grillz engage undercut areas and need to be pushed into place to be fully seated and dragged or eased out to be removed.
• Damage to tooth surfaces caused by the use of inappropriate adhesives or cements to retain non-retentive grillz.
• Loosening of teeth covered by/included in the grillz, most probably as a result of occlusal overload or increased torquing forces.
• Temporomandibular joint (TMJ) dysfunction
• Alterations to the occlusion if the grillz is worn for prolonged periods of time.

In addition, there is the risk that the use of the grillz may affect speech and make eating difficult, if not impossible when being worn.

As with other forms of body adornment, the wearer must weigh the risks against the perceived benefits, status and pleasure derived from using the grillz. Problems are most likely to occur if the wearer is unaware or fails to understand the risks and takes no action to mitigate them. Despite the relatively large and growing number of grillz wearers in the UK, it is possibly surprising that there have been no reports of grillz related dental problems in the UK dental literature. Globally, there have been a small number of case reports including a teenage wearer of grillz who had developed ‘rampant anterior decay’ in the teeth covered by his grillz⁷ and some cases of localised gingival inflammation, plaque deposits and decalcifications, and in one case a hypersensitivity reaction to nickel in the alloy used to construct a grill.^8,9

Discussion

The aim of this article was to review the history of grillz, alert oral healthcare professionals to the growing trend in grillz wearing, and highlight the risks associated with the use of this type of tooth adornment, specifically prefabricated grillz, and grillz made by individuals, such as jewellers, with little, if any dental knowledge and understanding.

As with oral piercings,¹⁰ wearing grillz carries a risk of significant sequalae. This risk is particularly high if the wearer has poor oral health, dental hygiene and the grillz are plaque retentive and interfere with the occlusion. If grillz users wear their grillz for extended periods of time or have their grillz permanently cemented,⁶ the result may be a complex and seriously detrimental combination of the various negative effects of grillz wearing.

Dental modifications (mutilations), adornments and decorations have been practised in many cultures and societies throughout history.¹¹ Today, dental jewellery and decorations come in various forms, such as tooth gems, tooth tattoos, metal veneers, crowns, tooth piercings, and grillz.¹¹ Dental grillz have evolved from a fringe form of dental adornment to a mainstream, global phenomenon, embraced by popular culture icons and emulated by their fans and admirers. Furthermore, dental grillz may evolve into new forms of tooth jewellery that may have even wider appeal (Figure 10).

Important questions may, however, be asked about the provision of grillz, including the following.

• Is it appropriate for a dentist to provide grillz, given the risks associated with the use of these tooth adornments?

It could be posited that there is nothing unethical or unprofessional about a dentist providing grillz for a patient able to give informed consent. For a patient determined to have grillz, it is better that a dentist designs and provides the grillz rather than the patient resorting to online purchasing, considering all the limitations of ‘remote’ provision of grillz, as illustrated in this article. As concluded by Sanghavi and Chestnutt,¹¹ in such matters, dentists should not judge an individual's cultural or personal preferences or deny them freedom of expression and uniqueness. The authors can envision a mid-ground where a conservative and preventive approach to meeting the patient's wishes is adopted, care is taken to minimize any negative effects, and the patient is fully apprised of the risks associated with the use of grillz. Furthermore, a dentist would have the knowledge and skills to modify the design of grillz to mitigate some of the associated negative effects. These modifications may include, posterior occlusal coverage to avoid creating anterior occlusal interference, or if ‘full fronts’, a Dahl type appliance.

• Is it an illegal practice of dentistry for grillz to be provided through a self-directed process requiring the purchaser to record the impression(s) of their teeth?

While this approach to the provision of grillz, in common with the remote provision of splints, nightguards and ‘clip-on’ veneers, suffers limitations as illustrated in this article, to the best knowledge of the authors it has not been identified by the General Dental Council (GDC) to be the illegal practice of dentistry, as is the case for tooth whitening.¹²

Remote providers of grillz, who may not be registered with the GDC, or an equivalent body overseas, may not imply that they are registered to practice dentistry, but tend to give the impression that they have dental skills and knowledge. The vast majority do not provide any face-to-face contact with clients, as provided by an oral healthcare professional, and believe grillz to be simply tooth adornments requiring no operative interventions. They may, however, provide unattributed, dentally related advice in the form of ‘aftercare instructions’. It is suggested that the provision of some elements of this advice, albeit in the best interests of the client, could give rise to cause for concern over the protection of the public – the primary role of the regulator. It is anticipated that if impressions were recorded, or any other intra-oral procedures (e.g. adjustments) were undertaken by either a lay person, such a jeweller or an inappropriately trained oral healthcare professional, such actions would rightly and properly be cause for concern.

Given the above, if an individual is determined to have grillz, it is suggested that it would be in their best interests if a dentist provided them rather than resorting to some form of remote purchasing, even if there were a significant cost difference. In providing grillz that minimize the risks associated with their use, dentists could possibly influence both trends in the design of grillz and the responsible use of this form of tooth jewellery. Better this, than more remote providers, including those with no dental knowledge and understanding, taking advantage of the continuing growth in the grillz market thereby exposing grillz users to unnecessary risks.

Given that grillz are anticipated to remain fashionable for the foreseeable future, oral healthcare professionals could do more to alert existing and potential future users of grillz to the risks posed by these potentially damaging items of tooth jewellery. In addition, parents of teenage children who may be tempted to obtain grillz surreptitiously, typically remotely using the low-cost (poor-quality) end of the market, should be encouraged to contribute to limiting grillz use in minors. Immediate actions could include dental teams providing cautionary notes on grillz in patient information sections of their practice websites and including comments on grillz in existing educational programmes they may provide locally, possibly in schools and colleges.