Dental Mutilation and Associated Abnormalities in Uganda J. J. PINDBORG Dental Department, U n i v e d t y Hospital a n d Department of Oral Pathology, Royal Dental College, Copenhagen, D e n m a r k ABSTRACT In 1966 during a dental survey of four districts in Uganda-Acholi in the north, Bugisu in the east, and Kigezi and Tor0 i n the southwest - 1169 Africans were examined. In the sample from Kigezi District 11.9% of the Bakiga tribe showed a form of dental mutilation consisting of the filing away of the mcsial angle of the upper central incisors. In the sample Irom Acholi District 16.1% of the Acholi tribe showed abnormal conditions related to the ritual extraction of the primary canines. Extraction of the lower permanent incisors was seen occasionally in the Acholis ( 8 ) , Batoros (1) and Bugisus ( 3 ) . Removal of the primary canines is attributed to a belief that infantile fever originates from these teeth. Because the primary canines were removed i n a crude fashion, malformation, non-eruption or premature eruption of the underlying permanent canines resulted. I n 1966 the author made a dental survey of four districts of Uganda by invitation of the Ministry of Health of that country.' Although the main purpose of the survey was to determine the prevalence of periodontal conditions, dental caries and dental fluorosis (Mgller, Pindborg, Gedalia and Roed-Petcrsen, '69. Skougaard, Pindborg and Roed-Petersen, '69) it offered an opportunity also to look for dental mutilations due to local customs or superstitions. The present paper deals not only with the observed mutilations, but with certain associated abnormalities which may not have been recorded before. Since the native way of Me is changing rapidly, it will not be possible much longer to observe dental alterations of this sort, and therefore a record of the present incidence and distribution is important. PROCEDURES The four districts selected for the survey -- in order of visit, Kigezi, Toro, Acholi and Bugisu -- are shown in figure 1. The population here consists of tribes which are either Bantu- or Nilotic-speakers. In each district the Government Hospital served as the headquarters for the survey. With the assistance of the local gombolola chiefs, invitations were issued for all who could to come to the headquarters for examination. They only exceptions were those in need of dental treatment. I n order to make the sample more representative, AM. J. P H Y s . ANTHROP.,31: 383-390. excursions were made to one or more rural dispensaries and to at least two schools (one rural and one urban). The resulting total sample amounted to 1169, of which 70% were in the age range from 5 to 19 years. The subjects were examined out of doors, using a probe and two mirrors, the sunlight being the only source of illumination. Unfortunately, facilities for taking radiographs were not available. RESULTS Only three types of dental mutilation, mostly independent of one another, were observed: ( 1 ) Filing of the upper incisors, usually the central ones alone; ( 2 ) extraction of the primary canines, usually the lower ones; ( 3 ) extraction of the lower permanent incisors. Filing was seen only in the Kigezi District, in a Bantu-speaking tribe. Canine extraction was seen only in the Acholi District, in a Nilotic-speaking tribe. Incisor extraction, the least common type of mutilation, was mostly associated with canine extraction in the Acholi District. 1. Filing of the upper incisors. As figure 2 shows, in a typical case, this type of mutilation was produced by filing the 1The author's visit to Uganda was sponsored by the Ministry of Health in Uganda and the Secretariat for Technical Co-operation with Developing Countries under the Danish Ministry of Foreign Affairs. The author is grateful to the Chief Medical Officer, Mmistry of Health, Uganda, for permission to publish this paper. 383 384 J. J. PINDBORG SUDAN / CONGO Fig. 1 Fig. 2 tribe. Map of Uganda showing the four districts where the survey was performed. Mutilation OP thc uppcr central incisors in a 15-year-old girl from the Bakiga 385 SURVEY O F TRIBAL DENTAL MUTILATIONS I N UGANDA mesial incisal angle of each of the upper central incisors, thus creating a n artificial diastema between these teeth. In only two cases, both females, the mutilation involved also the lateral incisors in the same way. In Kigezi District, the only place where this type of mutilation was observed, 285 members of the Bakiga tribe, almost equally divided as to sex, were examined and of these 34 (11.9% ) were found to have the condition present. Table 1 shows the distribution by sex and age. According to this summary, almost twice as many females as males bore the mutilation. Also, there were more females than males with the mutilation under the age of 20 and therefore the affected females as a group had a younger average age: 24.5 vs. 32.9 pears for the affected males. The fact that this type of mutilation is not seen in the juveniles and younger children probably means that it is connected with a puberty ceremony. Pulp necrosis was seen in one central incisor in only two cases. 2. Extraction of the primary canines. Since the primary canines appear in babyhood, extraction was done at a very early age. And because it was done by witch doctors or other non-dental personnel, damage to the underlying germ of the permanent canine was a n ever-present possibility. Depending on the amount of damage, the permanent canine would not erupt or it would erupt in a malformed state. Only rarely were the upper primary canines extracted. In the Acholi District, the only place where canine extraction was observed, 322 members of the Acholi tribe were examined. Table 2 shows the distribution by sex and age. Although males predominated in the ratio of 179 to 143, the sexes appeared to he about equally affected: 15.6 vs. 16.8. Canine extraction jn thus more common in this tribe than filing is in the B akiga tribe. The frequency of various types of canine abnormalities is seen in table 3 . In 33 individuals with lower primary canines, the condition was bilateral in 29. In only TABLE 1 Age and sex distribution of Bakigas w i t h tribal mzitilution of upper incisors. Figures in parentheses give the total n u m b e r examined Sex Age 0-4 5-9 10-14 15-19 20-29 30-33 Total Number percent. ::\: age Males (O) (5) (54) (22) 3 (16) 8 (32) (13) 12 (142) 8.5 Females (3) (I2) 1 (35) 4 (31) 11 (26) 5 (22) 1 (14) 22 (143) 15.4 (17) (89) 14 (42) 13 (54) 1 (27) 34 (3) (285) 11.9 Total 1 1 5 (53) TABLE 2 Age and sex dlstrihution of Acholis affected by ritual extractions of primary canines or romplications hereof. Figures in parentheses give t h e total n u m b e r examined Sex Males Age 0-4 7 (13) 5-9 a (30) 10-14 15-19 20-29 30-39 ","b:t 5 (44) (7) Total Number Percentage 15.6 386 J. J. PINDBORG one individual were the upper primary ca- in the lower permanent latcral incisors of' nines missing. In 9 individuals with non- three individuals. In another individual a erupted lower permanent canines, the transposition was observed involving the condition was bilateral in iwo. For lack of left lower permanent lateral incisor and caradiographs it could not be determined nine (fig. 6). One individual had an unwhether the absence of the permanent ca- erupted lower left permanent canine, the nines was due to severe damage to the malformation of which was visible a5 small tooth germ, to removal of the germ itself, irregular enamel pearls piercing the ginor to a damaged tooth germ exfoliated as giva (fig. 7 ) . The upper primary canines were found a sequestrum. to be malformed in only one individual. The number of malIormed permanent Early eruption of the permanent canines, canines was 14, of which 12 were in the due to an early removal of the correspondmandible ( 3 bilateral cases). The slightest ing primary canine, was seen in nine indidegree of malformation appeared as a peg- viduals. Eruption was considered premaor shovel-shaped form (fig. 3 ) In other tiire only ii' i t occurred before nine years individuals the malformation resembled a 01age. partially split tooth (fig. 4 ) . 3. Extraction of the lower permanent A malformation resenibling a severe i??cisors. This type of mutilation was so type of invagination (fig. 5) was observed uncurnmon that little will be said about it. TABLE 3 Various types of Lanine involvement cazised by riturrl extractions umong Acholis Missing canincs Lower primary upper primary Nmi-erupted lower permanent canines Lower permanent hlalformations of canines Lriwer permanent Upper permanent canines qpcr primary erupting before years of ape 33 1 Fig. 3 9 12 2 1 Pegshaped lower right permanent canine in a 16-year-old Acholi boy. 9 S U R V E Y O F TRIBAL DENTAL MUTILATIONS I N UGANDA Fig, 4 Partly split lower right pcrrnanent canine in a n 18-year-old Acholi boy. Note also the non-erupted lower left canine. Fig. 5 Malformed lower right lateral permanent incisor, resembling a n invagination, in a 16-year-old Acholi boy. Also note the non-erupted lower right canine. 387 388 J. J. PINDBORG Fig. 6 Transposition of the lower left permanent canine between the two incisors i n a 16-year-old Acholi boy. Fig. 7 Severe malFormation of lower left permanent canine and persistence of the primary canine in a n 11-year-old Acholi boy. SURVEY O F T R I B A L D E N T A L M U T I L A T I O N S I N UGANDA None of the Bakigas showed lower incisor extraction either alone or in combination with upper incisor filing. However, among the Acholis three individuals showed extraction of the lower permanent incisors m d the lower permanent canines. Five other Acholis showed extraction of only the lower permanent incisors. The only other cases of lower permanent incisor extraction were observed in the Batoros (1) and Bugisus ( 3 ). DISCUSSION Filing of the upper incisors, i n one form or another, occurs, or has occurred, in many parts of Africa (von Jhering, 1882; Lignitz. ’19-’20; Moortgat, ’59). Yet in so far as the author can discover, the reports do not include references to the tribes of Uganda. Nor do thcy include for tribes anywhere details about the prevalence of the custom. For this reason it is not possible to compare the figures obtained in the present survey. However, to judge from what the author was told locally, the custom is decreasing rapidly in the Kigezi District. None of the Acholis who had been subjected to extraction of the primary canines could give a reason for the custom. The explanation that follows comes from one of the auxiliaries on the survey team: When an infant of the Acholi tribe has a fever, the primary canines, especially the lower ones, are believed to be the source. To get rid of the fever the canines are removed, or a n attempt is made to remove them. Since this procedure is carried out by non-dental personnel, the underlying germ of the permanent canine and sometimes also that of the adjacent lateral incisor may be subjected to a great force and this may lead to damage of one or both germs. It is impressive that, still in 1966, 16.1% of 322 Acholis examined were affected by this customary removal of the primary canines. The author has been able to locate only two accounts of similar procedures. Von 389 Jhering (1882) mentions a report by Fischer, dating from 1878, of deliberate attempts by the Wapokomos of the Tana River region in Kenya to prevent the eruption of permanent teeth. These people extracted the deciduous lower central incisors and, in order to prevent the eruption of the permanent central incisors, destroyed the germs of these teeth by inserting the tip of a glowing-hot knife. The second report is by Seligman and Seligman ( ’ 3 2 ) . In their monograph on the pagan tribes of the Nilotic Sudan they say in connection with the Nuer tribe: “ W h m a n infant is from a few days to a month old the canines are dug out of the jaw with a piece of iron. The lower incisors. however, are removed with a fish hook when the boys are about eight years old.” The procedures described in these two accounts, like the findings here reported, are unusual because tribal removal of teeth most often involves permanent teeth only. In most instances in African countries the lower incisors are extracted. Thjs type of tribal mutilation is markedly on the decline and this is reflected in the present study in which extractions of the lower permanent incisors were observed in only 0.9% of the total sample of 1169. LITERATURE CITED Lignitz, H. 1919-1920 Die kiinstlichen Zahnverstiimelungen in Afrika im Lichte dcr kulturkreisforschung. Anthropos. 14-15: 891-943; 16-17: 247-264, 866-889. Moortgat, P. 1959 Les mutilations dcntaires. ActualitCs Odonto-Stomat., No. 4 5 : 87-110. Mgller, I., Pindborg, J. J., Gedalia, I. and B.RoedPetersen 1969 The prevalence of dental fluorosis in Uganda. Arch. Oral Biol., in press. Seligman, D. G. and B. Z. Seligman 1932 Pagan Tribes of the Nilotic Sudan. Skougaard, M., Pindborg, J. J. and B. Roed-Petersen 1969 Periodontal conditions in 1394 Ugandans. Arch. Oral Biol., 14: 707-719. yon Jhering, H. 1882 Die kiinstliche Deformierung der Zahne. Z. Ethnol., 14: 213-262.