Tropical Medicine and International Health doi:10.1111/tmi.

12740

volume 21 no 9 pp 1099–1105 september 2016

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 num-
bers 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 pro-
fessionals 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 medi-
cal institutions often are unavailable or inaccessible. Tra-
ditional healers and their clientele are usually members of
the same ethnic group and guided by similar mythologi-
cal values and credence.
Among pseudomedical practices applied by many tradi-
tional healers in East Africa are uvulectomies, scarifica-
tions 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 germec-
tomies of deciduous tooth buds, mostly but not exclusively
of the lower canines, for curative purposes, typically
against vomiting, diarrhoea and fever [2], and the extrac-
tion 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 germec-
tomy [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 mag-
gots [5] residing in the gingiva and responsible for patho-
genic agents in the intestine or elsewhere. Buds of the
deciduous teeth may be falsely interpreted as parasitic

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R. Garve et al. Infant oral mutilation in East Africa
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]. Nota-
bly, gingival swelling accompanied by fever was known
to Hippocrates, who wrote in his aphorisms that ‘tee-
thing children suffer from itching of the gums, fever, con-
vulsions, 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, denti-
tion was taken to be the cause of several paediatric infec-
tions, 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, rev-
erence for tribal chieftains and leaders who, in contrast
to their populace, usually abstained from teeth extrac-
tion, 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
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volume 21 no 9 pp 1099–1105 september 2016
resemble oxen, based on the fact that bovine calves do
not possess canines and are not prone to suffer from diar-
rhoea 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 explana-
tions 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 inter-
ventions by incisions of the gingiva as a measure to facili-
tate 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 eth-
nic groups in Africa was compiled by Schr€ oder in 1906
[20]. In the following years, such practices were men-
tioned 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
© 2016 John Wiley & Sons Ltd
Tropical Medicine and International Health
R. Garve et al. Infant oral mutilation in East Africa
(a)
(b)
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 prac-
tices 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, mone-
tary 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 feb-
rile 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
© 2016 John Wiley & Sons Ltd
volume 21 no 9 pp 1099–1105 september 2016
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 UK-
based NGO widely engaged in dental care and prevention
of IOM (http://dentaid.org/our-story/), IOM is still prac-
tised 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 differ-
ent 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 lawa-
lawa 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-September-
2013.pdf), indicating a prevalence ranging between 5.2%
in Moshi, Tanzania [32], and 70% in the Sabbah Chil-
dren’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].
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R. Garve et al. Infant oral mutilation in East Africa
(a) (b)
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 com-
prise 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, sev-
ere loss of blood and transmission of infections through
unsterile tools, including HIV, hepatitis, tetanus,
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volume 21 no 9 pp 1099–1105 september 2016
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 consider-
able causes of morbidity and mortality
[3, 6, 15, 33, 35, 49, 50]. Other outcomes involve criti-
cal dehydration, malnutrition and growth retardation due
to inability to drink, suck and swallow.
In contrast to ‘therapeutic’ germectomies, acute conse-
quences 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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Tropical Medicine and International Health
R. Garve et al. Infant oral mutilation in East Africa
stones, broken glass, bicycle spokes or other inappropri-
ate tools. People involved in East Africa are Nilotic eth-
nic 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 pre-
requisite 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 corre-
sponding 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 com-
munications indicate that this practice is increasing in fre-
quency 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 mutila-
tions 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 perma-
nent lateral incisors. Again, late complications in ritual
extractions are rare and mainly relate to chronic infec-
tions and mesial drift of virtually all teeth in order to
compensate and close the gap that results from extrac-
tion (Figure 5). Cases of speech disorders, mostly lisp-
ing, are common.
In 2004, the World Medical Association put IOM on
its agenda and urgently called for an end of this prac-
tice (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
© 2016 John Wiley & Sons Ltd
volume 21 no 9 pp 1099–1105 september 2016
problem cannot be solved by NGOs such as Dentaid or
Dentists Without Limits alone. Concerted efforts involv-
ing 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 cam-
paigns 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 injuri-
ous 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:
christian.g.meyer@gmail.com or c.g.meyer@bnitm.de

© 2016 John Wiley & Sons Ltd 1105