Tooth decorations and modifications – current trends and clinical implications

A potted history of tooth modification

‘Intentional tooth modification’ or ‘tooth decoration’ refers to the process of deliberately changing or altering natural tooth tissue for reasons other than treating dental disease. This global phenomenon dates back several thousand years. Ancient civilizations practised tooth modification for a number of reasons: ethnically for enhancement of physical attractiveness; in ritual ceremonies involving transition into adulthood; as a symbol of wealth, religion, tribal identification; and for survival purposes.

The ancient Mesoamerican-Maya civilization are well known for introducing tooth filing, whereby grooves and notches were created to achieve a variety of shapes in anterior teeth. They were also the pioneers of placing decorative dental inlays. Precious stones such as jade, jadeite, turquoise, obsidian, pyrite, gold and haematite were cemented to fit perfectly over cavities prepared on the labial surfaces of anterior teeth.¹

African tribes were observed to carry out tooth ablation whereby healthy anterior teeth were enucleated pre-eruption in infants. This process involves removal of developing tooth follicles from below the alveolar process in infants by traditional healers. Predominantly practised in East Africa, the rationale for enucleation is led by a powerful cultural belief whereby developing tooth germs are responsible for appetite loss, vomiting and diarrhoea in children.² In adults, the extraction of healthy anterior teeth was carried out prophylactically in case of the contraction of tetanus, to enhance language and permit the enunciation of particular sounds associated with tribal identity. In some cultures, these practices persist to the present day.³

Other practices included those carried out by the Vikings in Sweden who placed horizontal and diagonal furrows on the frontal surface of the maxillary incisors as a badge for certain occupational groups, such as tradesmen. Furrows in teeth could also signify a warrior's achievements which were denoted by multiple or deeper furrows.⁴ The Vietnamese, along with other Asian tribes, blackened their teeth to symbolize elegance⁵ and the Nigerian people filed their teeth to a pointed appearance to incise food with harder textures.³

In today's society, the aesthetics of the teeth not only contributes to beauty, self-image and self-esteem, but are also regarded by some as health, economic and social indicators.⁶ Historical tooth modifications have set a strong foundation for modern day tooth decorations to evolve. Unlike the past, where tooth blackening signified beauty, society now considers tooth whitening the ‘norm’, with the hope of creating a sparkling white ‘Hollywood smile’.

The equivalents of Mayan dental inlays are still appearing on the smiles of today's youth in the form of dazzling tooth jewels. Gold overlays that replaced an entire band of enamel were found in the skeletal remains of Pre-Columbian Ecuadorians⁷ and have now morphed into the dental grill, a renowned tooth fashion accessory in the Hip Hop world.

While the drivers of tooth modification in ancient and modern populations have diverse purposes, it is likely that the underlying needs have in common uniqueness, boosting self-esteem, keeping up with the fashion, peer pressure and status.⁸

Lip and tongue piercings are common-place and the associated risks and dangers to oral health have been well documented.⁹ However, intentional tooth modification is a practice that has seen a rapid increase in some groups in recent years and it is increasingly likely that a patient who has had such modifications, or who wishes such modifications, will present in general practice. There is therefore the need for dental professionals to be aware of the types of modification currently in vogue and the clinical implications of such modifications.

Purpose

The purpose of this commentary is therefore to:

Tooth jewels

In today's world where, for some people, physical appearance is of utmost significance, patients are not only demanding the perfectly aligned white smile, but also the inclusion of sparkles and jewels to enhance their appearance. The scientific literature on the use of tooth jewels is limited to anecdotal reports. Modern day tooth jewellery comes in the form of precious metals or stones available in different colours and shapes (Figures 1, 2 and 3).

The technique utilized to bond the jewel onto the tooth surface has been outlined as painless, non-invasive and temporary, whereby the standard acid-etch procedure (37% phosphoric acid for 30 seconds followed by a light-curing bonding agent) is used.^10,11 The jewel is then bonded to the desired position using flowable composite and the excess removed and polished to minimize plaque accumulation. The procedure is described as being similar to placing an orthodontic bracket whereby ‘it can be attached to your teeth without any consequences’¹⁰ and ‘enamel is not harmed’.¹¹

Clinical implications

The question therefore arises: ‘Should dental professionals encourage patients to bond jewels onto their teeth?’. At present, no studies are available that reveal the effect of such action on the dentition. Patil recognizes that dental caries can occur if the composite isn't polished sufficiently.¹¹ Moreover, if jewels are similar to placing orthodontic brackets, it could be argued that they pose a similar risk, such as enamel decalcifications and subsequent white spot lesions, particularly if oral hygiene is suboptimal.

A risk-benefit approach to determine whether it is really necessary to etch and subsequently demineralize a healthy anterior tooth for aesthetic purposes should be undertaken. A teenager with a high caries rate who has difficulty maintaining adequate levels of oral hygiene requires careful counselling on whether the addition of another plaque retentive factor is in his/her best interests. However, perhaps a carrot and stick philosophy, with the tooth jewel as a reward, may prove a motivation to enhanced toothbrushing and flossing.

In terms of managing patients with existing tooth jewels, it is crucial that dentists educate the patients on the importance of good oral hygiene. Whilst always being mindful and respecting patient's wishes, advising patients to remove the tooth jewellery can be justified if it is the cause of gingival inflammation and caries after preventive methods have proven unsuccessful. Patil suggests treatment with fluoride to remineralize the etched area.¹¹ This is supported by a systematic review that concluded applying fluoride varnish to orthodontic brackets every 6 weeks reduced the risks of developing demineralized white lesions by nearly 70%, although requires further studies to confirm this.¹²

The dental team also has a professional duty to caution patients against placing jewellery themselves or from those not qualified to practise dentistry at the local beauty salon. Clearly, the placement of tooth jewels by non-dental professionals raises important questions of adequate indemnity being in place, in the event of mishap or, indeed, when such procedures constitute the practice of dentistry and should be drawn to the attention of the General Dental Council.

Dental grills (grillz)

Dental grills are a fast-growing craze in the world of Hip Hop. A dental grill is ‘a removable cosmetic cover, often made of gold, silver or jewel encrusted precious metals that snap over one or more of an individual’s teeth'.¹³ Different designs are available. They may fully or partly cover single/multiple maxillary and/or mandibular teeth with a variety of decorative combinations (Figures 4, 5 and 6).

An impression of the dentition is required to construct a grill. They are usually not a fixed appliance, but can be removed by the wearer to facilitate eating and cleaning.¹⁴

Dental grills were first given prominence by American artists in the music industry as a symbol of wealth, success and social status. Celebrities such as Nelly, Chris Brown, Miley Cyrus and Madonna have captured many headlines in the media ‘flashing their Grillz’ along with gold medal-winning swimmer, Ryan Lochte, who is known to own a grill decorated with stones to create the American flag in his smile. The popularity of grills amongst the famous, who are role models to many, encourage their use in the general population. In the USA, they are now highly popular amongst all age groups, with prices ranging from $40 to in excess of $5,000.^13,15 At the bottom end of the market, the impression is taken by the patient themselves and returned to online companies for the manufacture of the grill. Alternatively, American celebrities have been reported to spend millions of dollars to ensure a good quality fitting grill supplied by high-end jewellers.¹⁵ The UK similarly has an extensive range of grills on offer from jewellery stores to online companies, readily available from popular internet sites such as Amazon and eBay.

Clinical implications

Evidence on the adverse effects of dental grills is presented in a number of case reports. These include the development of localized gingivitis with plaque deposits,^13,14 dental caries and decalcification.^13,15 One report described a hypersensitivity reaction in a 16-year-old girl where the oral tissues had become inflamed and bulbous, attributed to the nickel in the grill. There is therefore the risk of allergic and even anaphylactic reactions from grills that are made from non precious metals fitted by jewellery companies which do not consider the patient's medical history.¹³ However, there is to our knowledge no current information on the frequency with which grills are associated with adverse reation.

General dental practitioners who encounter patients wearing a grill should adopt a conservative and preventive management strategy. This should involve educating the patient on good oral hygiene practices where they should brush both dentition and the appliance twice a day to minimize the collection of food debris, use interdental brushes and remove the grill during meals and at night. Furthermore, 3-monthly recalls and regular fluoride treatments have been suggested due to the high caries risk.^13,15 Correction of defective grill margins, if present, may reduce plaque accumulation. Patients should be cautioned against buying cheap grills that are not made to custom fit. It is also important to check the occlusion, since grills may introduce occlusal interferences which may predispose to TMJ or other occlusal-related problems. Clearly, dentists have an ethical duty to draw to patients' attention any adverse consequences of these decorative tooth devices, irrespective of who has supplied or fitted them.

Tooth tattoos

If body tattoos are in danger of becoming passé, the latest fad on the other side of the Atlantic ocean is tooth tattoos. In the USA, dental labs are offering custom designed tattoos on ceramic crowns to add an original, individual and personalized touch. It is reported to be part of the ceramic manufacture process, whereby porcelain shades and designs are engraved onto the ceramic crown by artists (Figures 7 and 8) before being fired in the furnace. The reported ease with which the tattoo can be ground off the crown further attracts patients to have this art¹¹ and is presumably less of an issue if you change your nearest and dearest – the bane of those who over-personalize traditional body tattoos!

Clinical implications

There is no evidence in the literature on possible adverse effects of tooth tattoos. Presumably, as these are incorporated into ceramic crowns, tooth tattoos have the greatest potential to impact on the dentition. If a healthy tooth were to be prepared for the sole purpose of incorporating a tooth tattoo, then all of the usual issues with the placement of a ceramic crown, such as the impact on tooth vitality, the potential for secondary caries, and so forth, apply. The ethics of such an approach could surely be questioned. On the other hand, if the tooth has to be crowned for legitimate clinical reasons, then there is probably little to be concerned about other than the potential additional cost, and the consequences of the patients changing their minds about the images they have chosen.

Effect on policy and current regulation

Many countries face issues surrounding dental decorations, the most obvious ones involving impression-taking and the provision of these tooth adornments by unqualified dental professionals. With regards to tooth jewellery, the use of ‘Do it Yourself’ kits or bonding jewels by lay persons raises questions of adequate moisture control and the standard of bonding agents used. Neglect in any of these could increase the risk of aspiration should the jewel debond. Moreover, inappropriate polishing of the site could result and hence a higher risk of plaque accumulation.¹⁶

The taking of impressions for the construction of dental grills by inappropriately trained and qualified professionals raises patient safety issues related to aspiration and cross-infection. Such were concerns over this issue in the United States of America that the US state of Tennessee deemed it necessary to pass legislation in March 2007 that ‘taking dental impressions for the purpose of creating dental jewellery does constitute practice of dentistry’ and can only be undertaken by board licensed dentists, hygienists or assistants.¹⁴

It is currently unclear whether unqualified dental professionals are engaging in the above practices in the UK, but this would clearly conflict with the General Dental Council's (GDC) Scope of Practice that clearly states dental professionals and other competent dental auxiliaries are the only individuals that can undertake dental impressions. The GDC is also clear that ‘applying materials and carrying out procedures designed to improve the aesthetic appearance of teeth amounts to the practice of dentistry’,¹⁷ which was the basis used to prohibit any individual not registered with the GDC performing tooth whitening.

After what some would regard as a somewhat laissez-faire attitude to tooth whitening in beauty parlours by the regulatory authorities, the GDC is now clear that a dental professional should undertake a clinical examination, including a full medical history, to ensure that no relevant risk factors are present, ensure that the individual is aware of the benefits and risks of the procedure and that tooth whitening treatment is in the patient's best interest.¹⁷ If current trends in the USA transfer to the UK, as they inevitably will, then non-dental professionals offering tooth adornments is likely to be a greater issue than at present.

Conclusion

The role of dentists is no longer confined to the traditional approach of maintaining the health of the oral cavity and fighting disease. Tooth decorations are carried out for many reasons, but the prime factor is to enhance beauty and uniqueness. It can be argued that instructing patients to desist from tooth decoration is not an appropriate management strategy, since it does not promote freedom of diversity, cultural sensitivity, nor does it respect patient autonomy. Patients should have the freedom to express themselves without feeling judged. It is the role of the profession to encourage and facilitiate a conservative and preventive management strategy, aimed at minimizing negative effects on the dentition.