Through a grant from the ICD USA Section Foundation, Fellow Jean L. Creasey recently traveled to Southwestern Uganda to learn more about Ebino, a rural African practice in which primary, mandibular, canine tooth buds are removed from febrile infants. Otherwise known as “infant oral mutilation” or IOM, it is performed by “traditional healers” or Abafumu as they are known locally. While results of this practice are usually limited to loss of primary canines and collateral damage to permanent teeth, occasionally there are consequences far more serious, including sepsis, tetanus, HIV transmission or death. The procedure itself is performed utilizing a variety of instruments, including wire, bicycle spokes, or razor blades. Because this remedy has no relationship to the underlying illness, critically needed medical care is often postponed and complicated when Ebino is performed.
Dr. Creasey first became aware of Ebino in 2009 while performing a dental health survey in the Kanungu district of Uganda, focusing on the Batwa pygmy communities. Along with a generally lower incidence of caries in this population, she noted the mysterious phenomena of missing lower canines in several young children and started asking her translator, Richard Mahgezi questions about it. Then, eight years later, she found herself asking more.
Her ultimate goal is to design an effective community education outreach that will reduce the incidence of the Ebino practice. She is privileged to be associated with a rural private hospital, the Bwindi Community Hospital located on the edge of the Bwindi Impenetrable Forest in Southwestern Uganda. The local population is comprised of the majority Bakiga (90%) and minority Batwa Pygmy (10%) tribal groups. Fifty percent of the population is under age 15 with approximately 1800 young children in the immediate primary school catchment. Other community inhabitants include the endangered Mountain Gorillas which live in the nearby forest and occasionally show up for surprise visits around the hospital guesthouse.
During her visit, Dr. Creasey had the support of the hospital dental officer, Onesmus, a dental therapist with three years of post-secondary school training. She found they had much in common, including a love of dentistry. Onesmus’ skill set includes fillings, extractions, and uncomplicated root canal. The equipment in the hospital’s one room dental clinic was extremely modest and limited his ability to deliver quality care. A large, inoperable, motorized dental chair occupied the center of the room, surrounded by countertop space overflowing with various items: unpouched instruments stored in plastic tubs, anesthetic vials, disposables, wadded up cleaning rags and empty boxes galore. Peering into the drawers she saw a scanty selection of restorative materials and oral surgery instruments, some a little rusty from incomplete drying during sterilization. The only working hand piece was attached to an old workhorse, a basic aseptico unit. Onesmus was excited to help with her Ebino project and was thrilled to receive a new handheld x-ray unit and ultrasonic unit. He had been without any operable x-ray unit or ultrasonic scaler for some time and was delighted to be better able to serve his patients.
They visited two local schools and screened 3-6 year olds for the presence of Ebino and caries. Her survey of 244 children revealed an Ebino rate of 12% and a visible caries incidence of 15%. Attitudes among the hospital staff and school teachers towards Ebino ranged from vague familiarity, ridicule of the practice, to denial of its existence; all depending on where they grew up.
One evening she interviewed a local Abafumu of great renown named Warren, who doubles as a traditional musician at one of the nearby upscale lodges. To reach him she tentatively ascended the long, lantern-lit steps to the lodge and was rewarded to find an oasis of hospitality: an open-air restaurant and bar serving cold beer and exotic drinks to guests who pay upward of $600 per night. Surrounding the veranda was a lush lawn complete with a perfectly arranged central campfire and camp chairs draped with neatly folded blankets around the circumference. She gazed across the valley to a mountain side covered in a lattice of mahogany and ficus trees, one seemingly stacked upon the other, forming a mesmerizing weave of branch, trunk and leaf, just perfect for gorilla habitat.
Warren sat in front of the fire, flame and spark dancing in the soft light of early evening. He was dressed in simple costuming of a loose-fitting tunic covering his pants and shirt, a large-brimmed straw hat and sandals. In one hand he held a traditional African instrument and in his other, a pipe of sorts. He quickly recognized translator and friend, Dr. Scott Kellermann and greeted him warmly. His eyes crinkled and sparkled in a lovely way that revealed age, kindheartedness and wisdom, all at the same time.
Abafumu are reluctant to talk with outsiders about their practices as many are considered illegal under the law. Therefore, Dr. Creasey’s opportunity to meet him was unusual and while she was anxious to get her questions answered, the interview needed to be handled with care. Relationships are paramount in African culture.
Scott and Warren spent time catching up. Warren recounted how Scott, who founded the Hospital when there was no health clinic in the Bwindi area, once saved Warren’s wife from bleeding to death following the difficult home birth of a stillborn child. Scott in turn recalled how Warren’s mother in law, a powerful Abafumu named Batusa, had come to Scott’s aid when he sought to engage traditional healers in assuring the success of TB medication compliance and bed net distribution. Indeed, mutual trust and relationships were important to both men and had proven indispensable to the success of the hospital.
Dr. Creasey waited patiently while Scott eventually got around to the topic of Ebino. She was not there to change Warren’s attitudes toward the practice; simply to learn more. He proudly shared that he had learned the art of his medicine from his father who had in turn learned from his father. She recalled a saying that, around the world anyone who engages in health care no matter what the approach, surely must have a love of his fellow man; this was evident in Warren.
Warren became animated as he demonstrated the practice of removing the immature tooth buds from a fever-laden baby. According to the tradition of the Abafumu, when a feverish child is bothered by a worm in the gum, it must be removed. When the child dehydrates coincident to diarrhea or malaria, the primary canine tooth buds become prominent in appearance, making them easy targets for misplaced blame and removal. Many Africans are familiar with the infection and pain frequently associated with third molar eruption. Hence, the theory seems plausible that these primary teeth are the source of the problem.
Warren described the process of using a thin wire to cut under the tooth bud while he demonstrated the action of how the tooth bud would pop out once it was separated from the alveolus. He spoke about the fact that many of the poorest of the poor in the outlying villages could not even afford to visit a health clinic, and he felt that he was providing a needed service. Dr. Creasey surmised that convincing the Abafumu that Ebino was not effective treatment would be ineffective in reducing the practice.
Instead, given the prevalence she noted in her initial survey of 3-6 year olds, she was encouraged that the Buhoma community would likely be a good community to initiate a prevention strategy to reduce the incidence of Ebino.
Dr. Creasey’s plan is to develop visual aids that communicate best practices for good oral health in children. These visual aids can be used by the hospital's existing Village Health Teams, (VHTs) a group of 500 trained community liaisons that deliver basic health messages and monitor up to 25 families each for signs of malnutrition, difficult pregnancies, malaria and medication compliance. She also plans to deliver these oral health messages as a part of the education program given to pregnant women at the waiting mother’s hostel operated on site at the Bwindi Community Hospital. Additionally, related public service announcements can be developed for local broadcast on existing community radio programs that the hospital operates. Her theory is that by increasing parent awareness of the possible dangers, utilization of the practice will be reduced.
Coming as an outsider with an agenda into a community to make changes in their cultural practices can be risky business. Her expectations are tempered by her experiences back home as a dentist who daily tries to inspire patients toward more positive oral health behaviors; always with mixed results. One outcome is certain though, stronger relationships will be established, information will be exchanged and friendships will be forged through the global outreach of the International College of Dentists USA Section Foundation.
Through increasing parental education and awareness of the detrimental aspects of Ebino (IOM), Dr. Creasley is hopeful its utilization will be reduced.
Submitted by: Jean Creasey DDS, International College of Dentists Fellow