Are They Just Skin Deep?

July 1, 1996
Whatever their reasons are, your patients are frequenting tattoo parlors in growing numbers. More may be showing up in your chair with rings hanging from their noses and the hint of a tattoo peeking up from underneath a garment. And these are just the `normal` patients?

Whatever their reasons are, your patients are frequenting tattoo parlors in growing numbers. More may be showing up in your chair with rings hanging from their noses and the hint of a tattoo peeking up from underneath a garment. And these are just the `normal` patients?

Heidi Emmerling Jones, RDH, BS

Jake is 15 years old. A sophomore in a private Catholic high school, he is on his school`s swimming, diving, and gymnastics teams. His exceptional athletic performance makes him a celebrity in his home town. He is a college-bound 4.0 student. He wears a tongue stud and a naval ring.

Suzanne is 28 years old. She is a part-time graduate student pursuing a degree in nutrition. She is also a part-time dental receptionist. And she sports a ring through her septum.

Erik is 24 years old. He is a full-time graduate student majoring in history with a minor in art. His left nipple is pierced, and he is contemplating having the inside of his lower lip tattooed.

Riki is 21 years old. She recently earned her Certified Dental Assisting certificate and is planning to continue her education towards a career in dental hygiene. She eagerly awaits her first paycheck as a dental assistant. A new wardrobe? A stereo? Neither. Instead, her right shoulder blade will boast a large, brightly colored tattoo of a fairy.

A statement by the mainstream

What`s going on here? Only skinheads, Hell`s Angels, nymphos, punk rockers, and psychos would do such things to themselves, right? Not anymore. Body art is moving from the underground to the mainstream. "Normal" people are doing it. And the reasons people are fascinated with body play, body art, or body mutilation (the term you choose depends on your view) are as varied as people`s personalities.

Part of the popularity is due to supermodels (Julia Roberts and Drew Barrymore flaunt "pieces" on their shoulders, ankles, and lower backs), sports heroes (Chicago Bulls` Dennis Rodman has nothing left to pierce, dye, or tattoo that would cause us to give him a second look), and MTV (Janet Jackson wears a chain that extends from her nose to her ear; and Joan Osborne displays a ring through her nostril).

Tattooing and piercing continue to be seen as societal rebellion and prized for "shock value" - like the ultimate Mohawk that doesn`t grow out. This is a way for teenagers to annoy parents, and for young people to thumb their noses at societal values they perceive to be restrictive or alienating.

But besides rebellion, bonding also occurs. Body jewelry and tattoos identify the bearer as a member of a select group. When publicly displayed, tattoos and piercings may act as conversation pieces. Fellow tattooees and piercees recognize and acknowledge their shared experience and decorative tastes.

Another theory is the issue of control. A number of tattooists report that the display of tattoos and piercings are a proclamation to the world that the bearers own and indeed control their bodies. A recently divorced woman receiving a tattoo remarked how, in her marriage, her husband controlled her body. For her, getting a tattoo symbolizes how she has her body back, how she has the courage to do what she wants to do and has to do to survive. People want to be proud of something they had perhaps dreamed of changing.

Some believe the prevalence of body decorating is the emergence of a new primitive culture that uses ancient rituals and markings to mean new things. Piercing has always been considered decorative, although some tribal cultures use it to symbolize marital status or sexual maturity. Among the Tchikrin of central Brazil the male infant`s lower lip is pierced and after he is weaned, the hole is gradually enlarged and decorated with strings of beads. At puberty he participates in a ceremony in which his lip ornament is changed to that worn by grown men. As a mature adult, he may wear a lip disk four inches in diameter or larger.

Others feel that the trend is a growing acceptance of sadomasochism in mainstream culture. Reporter John Leo writes in the July 31, 1995 issue of U.S. News & World Report, that piercings of nipples and genitals arose in the homosexual, sadomasochistic culture of the West Coast. Leo writes, "The Gauntlet, founded in Los Angeles in 1975, mostly to do master and slave piercings, now has three shops around the country that are about as controversial as Elizabeth Arden salons."

Like piercing, tattooing is a part of rituals. Undecorated skin among the Shan of the Society Islands is a sign of immaturity since those without tattoos did not yet have the courage to withstand pain. Additional benefits of tattooing are to assure a pleasant afterlife, insure good luck, charm the members of the opposite sex, protect one from accidents, preserve youth, and bring good health. A tattooist with Kelly Miller`s Shadowbrite Tattoo Studio in Reno, Nevada (which has as its slogan, "Hated Worldwide"), claims a number of his clients want tattoos and piercings in order to affiliate with tribal heritage.

Still others think of tattooing as therapy. A woman who wears a "Madison" hoop where a locket might hang, says that, while other people internalize their rituals, "we put them on our body, they`re little celebrations of life."

A number of tattooists reject all of this psychological and Freudian analysis. They equate tattooing and piercing with cosmetics, hair styles, and fashion. The ancient act of body modification involves everything from wearing high-heeled shoes to foot binding, from tanning to branding, from plastic surgery to scarification. The bottom line, according to some, is: piercings and tattoos look good. One tattooist puts it this way: "Tattooing is really just a form of personal adornment. Why does someone get a new car and get all the paint stripped off of it and paint it candy-apple red?"

In the arm, nose, and elsewhere, but not the cheek

The types of body decorating are as varied as the reasons one chooses. According to an article in The New Yorker, Dan Kopka, a professional body piercer, has pierced his own ears, nose, tongue, eyebrow, nipple, navel, penis, and scrotum. At last count, he had 17 holes that could hold a gold ring, a silver hoop, or a safety pin. He has done very intimate male and female piercings, and his business card reads "Master Piercer." But even he advises clients of places not to go. For example, he rarely pierces mid-cheek because, "It`s gaudy and the skin`s too thick." Also, he discourages piercing a "hand-web," which entails opening a hole in the flesh between the thumb and index finger, because it requires elaborate maintenance. Dan charges $35 for the first piercing and $15 for each additional piercing.

Most males who opt for a tattoo choose the arm. Females choose their breast. Females regard the tattoo as a permanent body decoration for the personal pleasure and enjoyment of those with whom they are most intimate. Therefore, they choose discreet locations. This contrasts with males who view tattoos more for identity (connection to a group such as military, sports teams, etc.) and symbols for public display. They generally choose larger, more violent images. Favorite designs include birds, mammals, mythical animals, insects, humans (male and female), hearts, crosses, military insignia, floral, and name/vow tattoos.

One tattooist says some young people now choose to have the insides of their lower lips tattooed - not an image, but rather a profanity. Apparently, the trend is to be able to tell someone off without uttering a word. All one has to do is stick out the lower lip, and the message is loud and clear.

Permanent makeup is similar to tattooing and is gaining popularity. The appeal of being able to wake up every morning with perfectly lined eyes, neatly defined brows, and lips colored just the right shade is very real.

The procedure is called dermapigmentation, and, like tattooing, involves dipping a needle into dyes that are then injected into the dermis. It is applied with a handheld device that looks and sounds like a dental handpiece and works like a sewing machine, piercing the skin hundreds of times per minute. Each injection leaves a tiny dot of color. If the dots are close enough together, they appear to be an unbroken line or cluster of color for larger areas.

In a January 1994 article in Redbook, writer Constance Cardozo explains that the most popular choices are eyeliner and eyebrow definition (about $500) and lip color (about $750). Less common are blush and eyeshadow that cost $800 and up. Permanent makeup is a $15 million dollar industry and growing. Not only is permanent makeup popular with women who, due to arthritis or Parkinson`s disease, have limited manual dexterity, but the vast majority who choose it just want to save time and still look good.

To some, this procedure can be intensely painful, especially in the eye and lip area. About Faces, a studio in Sausalito, Calif., that does permanent makeup exclusively, employs a team of dentists to give anesthesia for the procedures.

The new look can be sickening

While the procedures are relatively straightforward, they are not risk-free. In fact, dentistry has been busy reporting the dangers to consumer magazines. In the February 1996 issue of Cosmopolitan, experts from the Academy of General Dentistry claim that, as a result of perforating lips or cheeks, clients could end up with permanent damage to teeth and gums. Cracked cuspids, scar tissue, inflamed and large lips, damaged salivary glands resulting in drooling all could result from this trendy fad. Additionally, they claim that implanting jewelry in the tongue might lead to numbness, loss of taste and mobility, and even a life-threatening blood clot.

But Dr. Kris Sperry, deputy chief medical examiner of Fulton County, Georgia, puts the risk of a beesting well above those from body-modification procedures. Dr. Sperry cautions that people who form keloids should avoid tattoos. Sperry also says there is little to no risk of contracting HIV from body-modification. "The volume of blood (extant during a tattoo) is not enough to cause AIDS. And you need an intermuscular stick, not just a dermal scratch."

However, the Centers for Disease Control and Prevention have a different view. Although "there have been no cases reported of HIV transmission that have been ascribed to tattooing, we do think the potential exists."

The biggest established risk is hepatitis. According to Ari Maravel, public relations director for the American Liver Foundation, tattooing and piercing may be causative factors in the approximately 40 percent of all hepatitis B and C cases with no known source of infection. "Get Hip to Hep" is a public awareness campaign recently launched by the American Liver Foundation and the Blues Heaven Foundation. Willis Maddrey, MD, an advisor to the campaign, says the risk of hepatitis could be greatly reduced if more young people received vaccinations against hepatitis B.

Delia O`Hara reports in the December 18, 1995, issue of American Medical News that there is no federal regulation of tattooing or piercing, and local regulations are uncertain. According to O`Hara, New York City outlawed the practice in 1961 after 13 tattoo-related cases of hepatitis B were reported despite a two-year experiment with regulation. But the fact that it`s illegal doesn`t mean nobody gets tattooed.

In addition to concerns about HIV and hepatitis, R. Roy Anderson, MD, of Massachusetts General Hospital is concerned about the tattoo inks. He writes in the January 16, 1992 issue of the New England Journal of Medicine that tattoo inks are the least regulated substances injected in an established business setting. He maintains that none are approved by the Food and Drug Administration. Hypersensitivity occurs with red inks, which contain mercury. "The FDA should regulate tattoo inks and devices. State health boards should license and inspect tattoo parlors. Tattooists should take mandatory courses before licensure. Why should someone who injects unknown compounds for profits be liable to less public health scrutiny than a cook or barber?"

In an effort to improve safety, Kris Sperry, MD, and tattooist Mick Michieli-Beasley co-founded the Alliance of Professional Tattooists (APT), a non-profit organization that educates tattooists in proper infection control practices. APT organizes seminars for tattooists throughout the country to instruct them in cleanliness and sterilization techniques.

"Our APT guidelines are often more rigorous than those imposed by local health departments," Beasley notes. "Thus, the fact that a tattoo parlor is operating and has not been closed down by the health department does not necessarily mean that the tattooists are following stringent health practices."

According to the APT guidelines, these practices should be followed:

- The tattooist should have an autoclave on the premises.

- Consent forms should be handled before tattooing.

- Immediately before tattooing, the tattooist should wash and dry her or his hands thoroughly and don medical latex gloves, which should be worn at all times during the application of the tattoo.

- Needle bars and tubes should be autoclaved after each customer. Nonautoclavable surfaces such as pigment bottles, drawer pulls, chairs, tables, sinks, and immediate floor areas should be cleaned with a disinfectant like a bleach solution.

- Used absorbent tissues should be placed in a trash can lined with a plastic bag.

- Used needles and razor blades should be placed in a sharps container for disposal.

Consumers should ask to see the certificate earned by completing an APT course. Also, Beasley advises that consumers visit several parlors to see whether the tattooists follow these recommendations and ask lots of questions about cleanliness and sterilization.

Even if the tattooist or piercer follows the most stringent infection control methods, there is still the likelihood of post-op discomfort and possible infection. Temporary inflammation around the tattoo is common for the first day or two. The skin crusts slightly and peels within the first week after application. Some people occasionally have an adverse reaction to the tattoo ink resulting in swelling and itching. This can usually be relieved with topical corticosteroid cream and by remaining out of sunlight.

Piercers say body piercings usually heal pretty quickly. Tongue piercings generally take the longest, averaging about three months. When the tongue is first pierced, a larger barbell is placed first to accommodate swelling. When the swelling subsides, the smaller barbell is placed. Piercers also warn not to twist hoop rings through their holes; this draws outside bacteria internally. Rather, they recommend cleaning exposed metal with alcohol and not twisting the ring. For tongue studs, they recommend rinsing with mouthrinse.

Wayne Hearn, senior reporter for American Medical News, offers these tips to help measure and minimize the health risks of tattooing and piercing by being proactive:

- When taking medical histories, ask patients if they`ve undergone these procedures. Be sure to ask those who test positive for hepatitis but have no other known risk factors.

- Don`t assume any patient is "not the type" for a tattoo or piercing - this growing fad cuts through many demographic boundaries.

- If a patient expresses interest in getting tattooed or pierced, counsel about the risks, but don`t be judgmental or preachy.

- Urge patients to patronize businesses that practice proper sterilization techniques and use single-use, disposable needles. Tell them to ask for evidence that such procedures are followed.

- Learn what, if any, laws or health standards regulate these practices in your area.

Dr. Sperry has no trouble believing an estimate he has heard that one-quarter of all 15- to 25-year-olds in the United States have tattoos. As hygienists, we will probably see more and more of our younger middle-class clients contemplating body decoration. By being familiar with body decoration, we can feel confident not only in our ability to offer nonjudgmental, objective advice but also to better understand and relate to our patients.

Author Max Beerbohm undoubtedly had the right idea when he wrote, "For those who like this sort of thing, this is the sort of thing they like."

Heidi Emmerling Jones, RDH, BS, is a consulting editor for RDH and practices dental hygiene in Sparks, Nevada.

When Dear John letters follow the everlasting gifts...

Left alone, tattoos are meant to be permanent, to last a lifetime. Merely conforming to the latest rage will inevitably result in "tattoo regret." Unlike haircuts or clothing, they cannot easily be grown out or discarded with next season`s trend.

The good news is that the majority who receives tattoos have no regrets. But what about the rest? For example, what about those who had the name of a significant someone embedded into their flesh for eternity only to have the relationship fail? Or consider the 20 year-old who thinks Tweety Bird looks cute on her ankle today. What is she going to think in, say, 10 years? There are several options.

The first is fairly straightforward. People who have regrets can resign themselves to an unsatisfactory tattoo. This is sort of like accepting other aspects of our appearance like large noses, thin hair, stretch marks, or cellulite. Another option is concealing the tattoo with makeup or clothing. This can be problematic on the beach or in intimate situations. People can get a cover-up tattoo placed over the original. Tattooists say obliterating names of old flames and fixing inferior tattoos account for a huge portion of their business.

Medical procedures such as dermabrasion, salabrasion, surgical excision, and vaporization work, but most result in scarring and cannot return the skin to its pretattooed appearance and texture.

Finally, there`s laser surgery. Roy Geronemus, MD, director of the Laser and Skin Surgery Center of New York, states, "The lasers that have been developed since 1991 offer a nonscarring option for removal." He explains that lasers destroy the deeply embedded ink without sacrificing the surrounding skin. The treated area may look a bit smudged until the ink is reabsorbed by the body. It might take multiple visits at about $200 to $300 each. And it`s painful. But, for some, regaining tattoo-free flesh is worth it.