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Tropical Medicine and International Health

doi:10.1111/tmi.12740

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Review

Infant oral mutilation in East Africa – therapeutic and ritual grounds Roland Garve1, Miriam Garve2, Katharina Link1, Jens C. T€ urp1,3 and Christian G. Meyer4,5 1 Center for Natural and Cultural History of Man, Danube Private University, Krems, Austria 2 Department of Quality Management and Accreditation, Leuphana University, L€ uneburg, Germany 3 Clinic for Reconstructive Dentistry and Temporomandibular Disorders, University Center of Dental Medicine Basel, School of Dental Medicine, Basel, Switzerland 4 Institute of Tropical Medicine, Eberhard Karls University T€ ubingen, T€ ubingen, Germany 5 Vietnamese-German Center for Medical Research, Hanoi, Vietnam

Summary

This paper reviews the practice and ritual traditions of infant oral mutilation, drawing on a literature search in PubMed and Google Scholar, historical reports, relevant textbooks, NGO materials and personal observations of the authors. keywords infant oral mutilation, canine teeth, deciduous teeth, ritual extraction, pseudotherapy

While genital mutilation has become an issue of substantial concern in the last decades, far less is known about the phenomenon of infant oral mutilation (IOM). A systematic analysis of current IOM practice and ritual traditions is difficult to achieve, as reports on IOM differ greatly in study design – if structured studies with reasonable numbers of study subjects were performed –, in geographical location, in ethnic groups surveyed and in dental/medical, ethnological and anthropological priorities. Therefore, we address the issue based on our own observations – made as a dentist in Europe, Africa and South America (RG) and as a physician in Europe and Africa (CGM) –, and based on results retrieved through PubMed and Google Scholar searches, on observational, historical and chronicled reports, on anthropological textbooks and on deep Internet searches. Lastly, materials and sources provided by the NGO ‘Dentaid’ proved to be extremely valuable. Even today many parents from both rural and urban areas of Africa seek remedy for their sick, febrile child from traditional healers rather than from healthcare professionals and educated dentists. Reasons for this include unaffordable doctors and hospital fees, irrational anxiety and a strong feeling of dislike of or deep-seated aversion towards academic medicine. More important, however, are firm beliefs and an engrained trust and confidence in ritualistic practices of traditional healing [1]. Moreover, trained health professionals and hospitals or other medical institutions often are unavailable or inaccessible. Traditional healers and their clientele are usually members of

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the same ethnic group and guided by similar mythological values and credence. Among pseudomedical practices applied by many traditional healers in East Africa are uvulectomies, scarifications as treatment for minor infections and diarrhoea and various orofacial modifications such as gingival tattooing or sharpening and acuminating of permanent anterior teeth. Widespread practices – performed by traditional healers, herbalists, priests and midwives – are germectomies of deciduous tooth buds, mostly but not exclusively of the lower canines, for curative purposes, typically against vomiting, diarrhoea and fever [2], and the extraction of permanent anterior teeth for ritual reasons. Although these procedures may endanger the lives of infants, they are widely accepted, carried out and claimed to be a ‘causative cure’ of various diseases. Indeed, improvement in the primary disease is reported by up to two-thirds of parents whose children underwent germectomy [3]. The rationale for germectomy of deciduous canines is the firm belief that dentition and teething are associated with the occurrence of severe diseases. Only sick infants, mostly between 4 and 18 months of age [4], female and male children in equal proportions [3], are subjected to this procedure. Swelling of the gums during dentition is often considered indicative of ‘parent’ helminths or maggots [5] residing in the gingiva and responsible for pathogenic agents in the intestine or elsewhere. Buds of the deciduous teeth may be falsely interpreted as parasitic

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Ebino; ‘therapeutic’ IOM Ritual extraction of incisors

Figure 1 ‘Therapeutic’ and ritual IOM in Africa according to the NGO Dentaid (www.dentaid.org) and [13]. First observations of ‘therapeutic’ IOM were made in the 1960s [22]. A wider distribution of IOM appears to result from inner African migration, possibly in the context of forced displacement during acts of war under the Idi Amin regime in Uganda.

and fever-causing ‘mouth worms’ or weevils [6, 7]. Notably, gingival swelling accompanied by fever was known to Hippocrates, who wrote in his aphorisms that ‘teething children suffer from itching of the gums, fever, convulsions, diarrhea, especially when they cut their eye teeth, and when they are very corpulent and costive’ (Hippocrates 400 B.C.E) [8]. In Europe and other industrialised countries too, dentition was taken to be the cause of several paediatric infections, such as convulsions, common colds, diarrhoea and other communicable conditions. Even in the 19th century dentition was frequently an official cause of childhood death [9–11]. The reasons of ritual extraction of teeth are manifold and may vary between ethnic groups. They include aspects of cultural and ethnic identification, in particular initiation rites. Among the Nilotic Shilluk in Sudan, reverence for tribal chieftains and leaders who, in contrast to their populace, usually abstained from teeth extraction, has been reported [12]. Most important, however, appears to be the impulse of everlasting identification with ruminant animals, which in most rural societies are the foundation of human existence and survival [12–14]. [15] explicitly report that Kenyan Maasai explain and justify ritual extraction of teeth with the desire to 2

resemble oxen, based on the fact that bovine calves do not possess canines and are not prone to suffer from diarrhoea and febrile diseases. Another reason among Maasai may be that when removing teeth, space for feeding and an additional airway is provided in case the jaw is locked by disease (e.g. tetanus; R. Garve and K. Link, personal communication) [16]. Such practical mechanistic explanations may be proffered to researchers to avoid disclosing the true and authentic mythological background. After Hurlock’s first report on gingival incision over a tooth bud as pain relief in 1742 [17], therapeutic interventions by incisions of the gingiva as a measure to facilitate teething and to treat febrile diseases have been described in various reports since the beginning of the 20th century. At first mention of IOM in 1905, the yet unanswered question arose whether this practice was introduced from the United States to other countries [18, 19]. A comprehensive volume of observations of artificial deformations of the denture among various ethnic groups in Africa was compiled by Schr€ oder in 1906 [20]. In the following years, such practices were mentioned only sporadically. After IOM had been described as a prophylactic measure in 1932 in Nilotic Sudan among the Shilluk ethnicity [21], it was only in the 1960s that IOM was observed among Nilotic ethnicities

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Figure 2 (a) Removal of upper and lower deciduous teeth in a Nuer boy (Ethiopia). (b) Rusty non-sterile nail applied for IOM (Photos: R. Garve).

originating from North Uganda and South Sudan, and the term ‘mutilation’ was used to describe various practices of dental interventions [22]. The practice of germectomy appears to have increased considerably over time in underdeveloped countries [23], for example in Tanzania, with a rise from 0.5% of affected children in the 1980s to 60% in the late 1990s [24]. In addition to the pseudotherapeutic aspects, monetary incentives have been reported: for local healers, for example in Tanzania [25], and for the child’s parents, who sold extracted dental materials as medicine for other children [26]. Valuable compilations of IOM practices, consequences and sequels can be found in [27] and [4], while educational materials, including details of the role and significance of both deciduous and permanent teeth, the causes and therapeutic options of diarrhoeal and febrile diseases, complications and legal notes of IOM have been provided by [28, 29, 30]. Other reports focus on the absence of any association of IOM with diarrhoea [31], on geographical particularities in Tanzania [32], on the first appearance of introduced IOM practices among

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the Lugbara in South Sudan and Uganda [33], on IOM in Ethiopia [34] and on attempts to interrupt the practice of IOM [15]. Several publications have addressed the mythological backgrounds and beliefs of IOM [35–38] and IOM among migrants [6, 7, 39–41]. Among Ethiopian Jews who were airlifted into Israel in ‘Operation Solomon’ in 1991, extraction of canine buds was observed in 59% of children aged 3–12 years [42]. This observation was corroborated and confirmed by a more recent study of native Israeli and children of Ethiopian parentage living under similar socio-economic conditions, which compared 317 and 477 children, respectively, with regard to the presence of primary canines in two age groups (1.5–4 years and 4–7 years; [43]. In both age groups, canines were seen among Israeli rather than among children of Ethiopian descent (87.5% vs. 42.3% in the younger group, 92.6% vs. 40.4% in the older group). More recently, results from a cross-sectional study [44] and a review article on IOM [45] have been published. Notably, reports do not always discriminate ‘therapeutic’ IOM from ritual dental mutilation. According to the oral health charity Dentaid, a UKbased NGO widely engaged in dental care and prevention of IOM (http://dentaid.org/our-story/), IOM is still practised in East Africa (Kenya, Uganda, Tanzania, South Sudan, Ethiopia, Somalia, Burundi, Rwanda), Central Africa (Democratic Republic of Congo, Chad) and West Africa (Burkina Faso). IOM has also been observed in other African countries [13] (Figure 1). Among the different ethnic groups, a plethora of local synonymous terms for the germectomy or extraction of the deciduous canine teeth exists. While the procedure is addressed as ebinyo/ ebino/bino (‘false teeth’, ‘nylon teeth’) among the Acholi (‘Acholi disease’ [46]), Lango, Luganda, Runyankole and other ethnic groups in Uganda [47], it is known as lawalawa in the Tanzanian Singida region, as lagbir, azara, lechbor and achara in Sudan and South Sudan, as abua, ebisara, refugee teeth in Kenya, as iko dacowo and fox teeth in Somalia and as killer canines in Sudan, Ethiopia and Uganda [3, 30]. A comprehensive report on IOM and its consequences in Uganda, indicating that 30% of individuals are affected, is given in [47]. Proportions in other countries are available from the Dentaid website (dentaid.org/wp-content/uploads/IOM-September2013.pdf), indicating a prevalence ranging between 5.2% in Moshi, Tanzania [32], and 70% in the Sabbah Children’s Hospital in Juba, South Sudan [28]. Prevalences differ also among ethno-linguistic groups, for example in Uganda, where in 1121 children >36 months of age canine bud extraction was more frequent among Nilotics (45%) than among Bantus (22%) [48]. 3

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Figure 3 (a) Zo’e woman (Brazil) with wooden lip plug and (b) jaw model with late dental and osseous consequences (Photographs and jaw model: R. Garve).

Figure 4 Ritual extraction of the two middle lower deciduous incisors in a 2-year-old Tanzanian Massai girl (Photograph: K. Link).

To control bleeding and facilitate healing, unidentified herbal components are administered into the wound or smeared on the gums. Invasive techniques applied comprise crude manipulations such as incision of the gingiva with a hot knife, bicycle spoke or iron nail, loosening the deciduous canine teeth or tooth buds with other unsterile tools or even only fingernails, metal clasps or strong wire filaments, and subsequently levering the tooth or germ (Figure 2). No anaesthesia is given. Remaining bone and gingival lesions are often treated with herbal substances. If so performed, IOM may result in unbearable pain, severe loss of blood and transmission of infections through unsterile tools, including HIV, hepatitis, tetanus, 4

Figure 5 Displacements of permanent canine and lateral incisor, mesial drift and missing middle incisor, possibly exfoliation (40-year-old Arba Minich man, Ethiopia) (Photograph: R. Garve).

osteomyelitis, ostitis and septicaemia, which are considerable causes of morbidity and mortality [3, 6, 15, 33, 35, 49, 50]. Other outcomes involve critical dehydration, malnutrition and growth retardation due to inability to drink, suck and swallow. In contrast to ‘therapeutic’ germectomies, acute consequences of ritual dental mutilations are less severe. The history of ritual dental mutilation in Africa is long [13, 51]. While ritual extractions of the upper incisors are still practised among the Damara in Namibia and other groups, today mostly the two permanent lower middle incisors, and rarely the two adjacent teeth, are removed. These removals are performed at the age of 7– 8 years using unsterile knives, scissors, needles, strikes of

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stones, broken glass, bicycle spokes or other inappropriate tools. People involved in East Africa are Nilotic ethnic groups, among them Hamar, Banna, Bume, Karo, Surma, Mursi (Ethiopia), Toposa, Dinka, Nuer (South Sudan) and the Massai (Kenya, Tanzania). In South-West Africa, extraction of lower incisors occurs among the Himba and the Herero groups in Namibia. Besides mythological reasons, there are others for IOM. In some ethnic groups, removal of the lower incisors was a prerequisite to form a solid abutment for wooden lip plugs or plates. While carriage of plugs and plates has been widely abandoned today in Africa, removal of the lower incisors appears to be a persisting relict. Notably, among the obligatorily plug-wearing Zo’e, an indigenous tribe in the Amazon region of Brazil, the development of a corresponding dental and mandibular abutment is observed; however, the incisors are not extracted, but lost naturally due to enormous pressure exerted by the wooden plugs (Figure 3) [52]. Our own observations in 2016 indicate that not only permanent lower incisors, but also the two deciduous lower middle incisors may be extracted for ritual reasons. As the 2 year-old Massai child in Figure 4 was otherwise completely healthy, a ritual background can safely be assumed and was indicated as such by the child0 s parents. Although this is a single observation only, personal communications indicate that this practice is increasing in frequency in Tanzania. Although acute infections are rare in ritual mutilations of children who are in a good physical condition, later manifestations of both ‘therapeutic’ and ritual mutilations are frequent. In ‘therapeutic’ IOM, mechanical malocclusion may occur in permanent dentition [53, 54]. Further complications may be impaction and dislocation of permanent canines [3]. Less frequent are odontomata [55; case report of a maxillary odontoma] and loss of or hypo-/dysplastic deciduous and/or permanent lateral incisors. Again, late complications in ritual extractions are rare and mainly relate to chronic infections and mesial drift of virtually all teeth in order to compensate and close the gap that results from extraction (Figure 5). Cases of speech disorders, mostly lisping, are common. In 2004, the World Medical Association put IOM on its agenda and urgently called for an end of this practice (http://www.wma.net/en/40news/20archives/2004/ 2004_07/, [56]. Although access to academic dental care is rare in many parts of Africa, improved dental care, especially in rural areas of affected countries, received high priority and appropriate commitment was imperatively demanded. Considering the small number of dental surgeons in many parts of Africa, the

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problem cannot be solved by NGOs such as Dentaid or Dentists Without Limits alone. Concerted efforts involving political commitment, a legal basis, appropriate stimuli and adequate incentives for medical students and dentists, plus better formal dentistry education are required. Most importantly, awareness-raising campaigns among both the general population [5] and healthcare professionals, separation of facts from fiction and sound oral public health education will encourage indigenous populations [18] to refrain from the injurious custom of IOM.

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Corresponding Author Christian Meyer, Institute of Tropical Medicine, University Hospital and Faculty of Medicine, Eberhard Karls University T€ ubingen, Wilhelmstr. 27, 72074 T€ ubingen, Germany. Tel.: +49-7071-29-85981; Fax +49-7071-29-4684; E-mail: [email protected] or [email protected]

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