The removal of incipient canine teeth in infants/babies is a practice which has been identified in many parts of Rwanda. Benzian Habib in his Rwanda Project Visit Report stated that extraction of primary canine tooth buds is commom.

Children commonly subjected to harmful oral mutilation are those aged 12 months and below. This kind of violence against infants is not justifible or acceptable at all. International human rights law is based on respect for every person’s human dignity. Infants, as people, should receive no less protection than adults. Thus, the state is obligated to protect infants from the malpractice as it does in other forms of violence. Infant Oral Mutilation (IOM) is a process of gouging out an infant’s healthy baby canine tooth buds imbedded underneath the gums, using unsterile tools such as a hot or sharpened nail, a bicycle spoke or knitting needle, with no anaesthesia. It is a dangerous and sometimes fatal traditional practice. According to the 2010 Dentaid document, extraction of unerupted milk canine tooth buds from infants is common as they are believed to cause diarrhoea, vomiting and fever. For many years, village healers have adopted the practice of extracting canine tooth buds claiming to cure or prevent these conditions.  Harmful traditional practices that exist today in Rwanda are of various types, but those that are of dental interest include "Infant Oral Mutilation” (gukura ibyinyo), "uvulectomy” (guca ikirimi)  and "tonsilectomy” (gukata ibirato). Skin cuts are also performed on chest wall of some children – a practice referred to as extracting millet "gukura uburo” claimed to be the remedy for chest infections in infants. Rwanda’s vision 2020 and its modernization programmes have caused tremendous changes in the lifestyles and health expectations of the citizenry. However, this very success has not rendered impractical and irrelevant harmful traditonal practices such as infant oral mutilation. Due to lack of oral health literacy among the populace, some parents in the countryside as well as in urban areas still believe that retaining the primary canine buds subject children to possible death by infection. Oral cavity (mouth) is a major portal of entry to the body and is equipped with formidable mechanisms for sensing the environment and defending it against toxins or invading pathogens.  In the event that the integrity of the oral tissues is compromised, the mouth can become a source of disease affecting other parts of the body.  The traditional practice of gouging out deciduous tooth buds (perceived to be "tooth worms”causing diarrhoea and fevers and thought to be potentially fatal) and failure to realise that unhygienic methods used can cause blood infections (septicaemia), tetanus and transmission of blood borne diseases such as HIV/AIDS, is an indication that general awareness of IOM and its detrimental consequences within the population is negligible.The aim of this article therefore is to bring the practice of IOM to the forefront of public awareness and especially to make village healers, traditional births attendants and others who are completely unaware of it understand that the underlying belief associated with the IOM practice is harmful to children. History of Infant Oral Mutilation According to August 2010 document on Infant Oral Mutilation of Jonathan Gollings (BDS) and Rosemary Longhurst (BDS), a group of Danish dentists, in 1969, carried out a dental survey in the Acholi region of Uganda and found that the Acholi tribe (Lugbara) removed the lower canine tooth buds in infants as a cure for fevers. It appears the practice may have indeed originated from Uganda, started by the Lugbara tribe who initiated and spread it amongst other tribes. The practice seemingly moved fast within regions of the country and across the borders into neighbouring countries. The prevalence of IOM in Rwanda today demonstrates the point and shows how the practice can be transported far away from its original source to another country. Although nobody currently knows who brought in or invented the tradition, it seems that after the 1994 war, refugees returned to their homeland from neighbouring countries, bringing with them traditional beliefs acquired from such places. Traditions, however, don’t have to be ancient, they can be invented at anytime and become part of the cycle of traditions. Why believing in "Ibyinyo” has been ingrained in people’s consciousness?A village healer is a person who has no formal medical training but is recognised by the community in which he/she lives as competent to provide health care. When a parent takes a sick child to a traditional healer, he looks in the child’s mouth and attributes the illness to "tooth worms” and consequently extracts the tooth buds which he shows to the parent, telling him/her that the extracted tooth buds are worms supposedly causing the child’s illness.  When parents are given such information by people taken to be "competent to provide care”, they  confide in them and ignorantly believe that the soft white, developing tooth buds of the new erupting teeth are actually worms in the mouth of the infants and are parasitic, diarrhoea/fever-causing and can be fatal. Misleading information of this nature is dangerous as it makes  parents apprehensive about consequences of diseases. The tragedy is that parents believe that their infants are being helped get rid of alleged disease "false teeth”.Myths about teething also play a big role as some parents believe that a child contracts the disease whilst in the womb. Others believe that when a pregnant mother steps where somebody threw the remains of false teeth removed from another child, her own child will become infected. Others say that some extractors cause the disease by bewitching pregnant mothers. Facts about TeethingAccording to the 1968 article on general and local effects of eruption of deciduous teeth of Tasanen and the 2000 cohort study on teething and tooth eruption in infants conducted by Wake et al showed that teething does not cause fever, infections or diarrhoea. Instead, wrongly ascribing these to teething can delay the diagnosis and treatment of serious infections, sometimes with tragic consequences.  Despite the fact that teething is a common occurences, it has been associated with many myths and erroneous beliefs. Some infants go through the process of teething without any problems and yet other infants develop some symptoms. On this point, an expert from Baby Center Medical Advisory Board in USA, William Sears, pediatrician and author of The Baby Book associates teething with loose stools, but not diarrhoea per se. He says that excessive saliva ends up in an infants’ gut and consequently loosens the stools.  Additionally, child development expert Penelope Leach asserts that teething cannot cause fever, diarrhoea, or vomiting, instead these signs of illness should be checked out. Similarly, American Dental Association (ADA) a leading advocate for oral health argues also that teething is not related to diarrhoea. Pediatrician T. Berry Brazelton states that such symptoms are probably due to an infection unrelated to teething, but that the stress associated with teething could make the child more vulnerable to infection. Teething is a normal physiological event in all infants. But as indicated in the 2010 Medical Observations compiled by Sood, teething causes little more than discomfort, restlessness, drooling and finger sucking, but no symptoms at all.  The association between teething and diarrhoea in an infant is basically a hygiene issue. The incidence is not as high in the high  socioeconomic group with clean environment. Around  the age of 6 months when a child starts bringing the first set of teeth, they are crawling and the tendency for them is to pick objects such as dropped food from the floor and straight into the mouth. Introduction of bacteria into the intestinal system gives rise to such diarrhoea. Similarly, the emerging tooth makes an opening in the gum through which bacteria introduced into the mouth as such can have access into the circulatory system to cause diarrhoea and fevers.  Most children of this age are susceptible to a myriad of relatively minor infections because during teething gums itch and as such kids tend to bite on anything they come across, including unhygienic objects.Tooth DevelopmentThe development of deciduous teeth begins while the baby is in utero (womb) and at about sixth week’s gestation, the first buds of primary teeth appear in the baby’s jaw.  The lower anterior teeth are formed first followed by the upper anterior teeth. At birth, the baby has a full set of 20 primary teeth (10 in upper jaw, 10 in lower jaw) hidden within the gums (this happens when the embryo is eight weeks). Crown formation of the milk canine tooth in the maxilla (upper jaw) is complete 9 months after birth whereas the crown formation of a deciduous canine tooth in the lower jaw (mandible) is complete between 8 and 9 months after birth.  Beginning of eruption of deciduous canine tooth in the upper jaw takes place between 16 and 22 months after birth. For the deciduous canine in the lower jaw, beginning of eruption is between 17 and 23 months after birth.  These are the teeth village healers and others brutally extract hence the reason to give their chronological development. Completion of root formation of deciduous canine teeth in both maxilla and mandible is realised within 43 months after birth. Effects of  IOMWhat is being read about here is definitely not a dental procedure, but an inappropriately practised iatrogenic belief with consequences that can ultimately lead to further ill health, and even the death of the baby/child. IOM inflicts pain and suffering on child who may be sick or who may be teething, and in some cases it is carried out on a healthy child in a bid to prevent illness. The procedure may lead to shock, and loss of blood may lead to anaemia. The unhygienic methods applied during exodontia of decidous canine tooth buds can cause blood infections, tetanus, pass on HIV/AIDS, facial disfigurement and can be fatal. The underlying permanent tooth buds can be damaged or eradicated, causing malformations and long term crowding in the anterior region of the maxilla and mandible (Fig. A & B below). Because of the belief, an illness, if  exists, may not receive the medical attention necessary. As shown in the pictures above, IOM causes displacement and impaction of permanent canine.When uvulectomy is performed, there is likelihood of  an infant developing the conditions of hypernasal speech known as velopharyngeal insufficiency (VPI) and/or Nasal Regurgitation (entering of food into the nasal cavity).Functions of the uvula include blocking the passage into the nasal cavity when swallowing so that foods or fluids do not enter the nasal passages. It also involves in articulation of voice to form sounds of speech.Why is it important to care for baby teeth?While it’s true that baby teeth are only in the mouth a short period of time, they play a vital role. The primary teeth enable infants to eat solid foods (vital for proper nutrition), give the face its normal appearance, aid in speech development, and serve as placeholders for the permanent dentition and help guide them into position. Teeth allow the jaw bones and muscles to develop normally. Keeping primary teeth is important because they help in preserving the dimensions of the dental arches and lessening the risk of developing dento-facial malformations. Thus, it is not appropriate to overlook the importance of baby teeth as they serve functions other than biting and chewing.      Protecting children against the practice of IOM is everyone’s responsibilty.Infant oral mutilation is a practice performed by a variety of village healers and it is a custom that passes between communities and tribes.  IOM causes severe pain, serious oral health complications and, often times, death.  The beliefs and attitudes of parents/relatives about teething have serious implications for management of childhood fevers which may deserve urgent medical treatment. Long-term effects of IOM can include malformation of primary and permanent teeth, facial disfigurement and transmission of blood borne diseases such as HIV/AIDS.  Failure of parents to disregard these attitudes and beliefs is indeed worrisome as serious childhood illness, which are unrelated to teething, are likely to be left untreated or may not be given the seriousness they deserve. False teeth is said to cause death. Ideally therefore, the removal of false teeth should not prevent actual teeth from appearing.  The fact that it does happen, has caused dissatisfaction and concern among many mothers. But because the belief is ingrained in many parents’ consciousness, they prefer practitioners who merely make a small cut or know how to avert the danger simply by rubbing the gums with a certain herb to ensure the child never suffers from the disease again. This process is termed silencing. What should be understood is that there is no disease called "ibyinyo”. However, there are many situations that can result in diarrhoea in infants which are more important than teething. In reality the cause of the illness is something quite different, often malaria, dehydration, or a stomach worm caused by contaminated water. Therefore proper and immediate attention should be paid to diarrhoea in infants and help should be sought as soon as they arise as diarrhoea in infants can be rapidly fatal.  In order to protect children against this type of violence (IOM), parents and guardians should take infants with diarrhoea/fevers to pediatricians (medical doctors for children) who are familiar with infintile diseases and not to village healers. Similarly, kids with suspected swelling of the gums which are mistakenly thought to indicate the presence of "tooh worms” should immediately be taken to a dentist for management. Together we can eradicate the malpractice prejudicial to the health of the child.Lt Col Frank Rwema, MDPH (Lond)Oral Health Specialist working in Department of Preventive Dentistryat Rwanda Military Hospital.