REFUGEE DENTAL EXTRACTIONS

Anterior Dental Extractions among Dinka and Nuer in the United States: A Case Series Mary S. Willis, PhD’*; Ryan N. Schacht, BSc’; Randy Toothaker, DDS, FACP, FACD, FICD2 ’Assistant Professor, Department of Anthropology and Geography, University of Nebraska, Lincoln, NE; ’Associate Professor and Director, Prosthodontics, University of Nebraska Medical Center, College of Dentistry; *Corresponding author: [email protected] Spec Care Dentist 25(41: 193-198, 2005

Introduction Ethnomedicine focuses on the idea that even “exotic-appearing health beliefs and behaviors” can be understood if they are examined within the cultural context where they have been developed.’ In a different cultural setting, many health-related practices become meaningless or even detrimental to health status. Traditional dental practices of refugees of ’s Nuer and Dinka tribes, resettling in the United States, provide an illustration of “. . .cultures in violent collision,”2demonstrating that practices which are healthful in one culture may not be so in another. In this case series, we discuss the experiences of five Sudanese refugees, aged 25 to 34, who had six mandibular anterior teeth removed during childhood. Although the modified dentition was not problematic while in Sudan, it represented a prominent toothless condition in the United States. As a result, after relocation, the refugees requested and received restorations with dental implants of the anterior teeth.

Adult Nuer and Dinka refugees from toralists whose lives center around cattle. the Sudan, many of whom were missing Historically, at least nine such cultures up to six mandibular anterior teeth, have from Southern Sudan removed anterior been resettled in the U.S. for nearly a teeth during some or all of their recent decade.’ In Sudan, as in much of Sub- history, and this practice has become Saharan Africa, extracting incisors (and inextricably linked to tribal sometimes canines) occurs just after In Western cultures, however, tooth loss eruption of permanent dentition. The has been associated with lower standards practice is associated with achieving of health, socioeconomic achievement, adulthood, beauty and tribal identity, and education, attractiveness and is necessary for emitting specific linguis- In Western culture, dental standards can tic sounds and consuming softer food alter one’s self image if they cannot be This ancient practice in Sub- achieved or maintained.2’.2329 Consequently, Saharan Africa is at least 1,500 years old8 refugees who arrive in the U.S. missing and may have originated when tetanus their anterior teeth, particularly young incidence rates were high and fluid adults aged 17 to 45 years, face a differ- ingestion through locked jaws was ent set of cultural standards and health Those populations that once factors that prompt a desire to restore extracted teeth and those that continue their dentition. to extract two to six mandibular or max- Although no references were found illary anterior teeth (such as the Dinka in the literature concerning the extrac- and Nuer people) live near Africa’s Nile tion of healthy teeth among refugees to River or in the Nile valley, or are pas- the U.S. from Bosnia, Vietnam, Russia or

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Iraq, examining culture-specific practices from the Dinka tribe were missing the were exposed through a second surgical can serve as models for similar conditions mandibular incisors and canines (Figure procedure (Stage II), and healing abut- in other low-income American populations. 1); the Nuer refugees also were missing ments were placed on the implants. A the maxillary canines (Figure 2). series of appointments were then Anthropologists collected patient and required to fabricate the fixed restora- Case Series cultural data, and transported and moni- tions. All surgical and restorative proce- In 2001, the staff from the Office of tored refugees pre- and post- treatment. dures proceeded without incident. Minority Health within Nebraska’s Health Two of the five subjects reported that Because neither Medicaid nor private and Human Services system requested a they, like many in the Sudanese commu- insurance reimburses for implants, which health survey among a newly arriving, nity, had used removable partial dentures. are considered elective, and the cost of little-known Sudanese refugee population. Both subjects reported dissatisfaction the definitive restoration was more than The University of Nebraska’s Department with the removable partial prostheses $6,000 per person, we were unable to of Anthropology convened 10 focus (RPD) because they did not provide ade- assist more refugees. groups over 12 months to construct a quate confidence or oral function; the culture-specific health instrument. Sudanese were embarrassed to wear them Before the formal survey process because the dentures did not stay in Quality of Life Factors began, it was clear that many refugees place, and they could not eat desired To maximize the results of the dental from at least three Sudanese ethnic foods. The treatment teams and refugees restorations, which were costly in both groups-Nuer, Dinka and Maban-who preferred fixed restorations secured with resources and time, we examined other had undergone ritual anterior dental dental implants because the stability areas related to the effect of anterior extractions in childhood, wanted their could improve function, and successful dentition for these refugees, including dentition restored. Also, during all focus osseointegration would result in less cultural factors, incisal ability, current group discussions, Nuer and Dinka alveolar bone loss over time as compared dietary habits, language-related issues, refugees asked about dental care and to continued edentulism. Consequently, social concerns and dental hygiene. education regarding nutrition in the each refugee was provided, free of U.S.’O Thus, our work began with charge, a fixed prosthesis attached to Food Acquisition Ability unsolicited requests from the refugee three titanium implants. All dental Before and after restoration with community. materials and staff time were provided dental implants, we assessed how the through the support of Nobel Biocare lack of incisors and canines might affect USA, Inc. (Yorba Linda, Calif.) and the eating ability of these patients using Dental Restoration Dental Designs Laboratory, Inc. (Lincoln, a six-item bite index adapted from We approached the University of Neb.), and the faculty and staff of the Leake’’ (see Table 2 on the following Nebraska Medical Center’s (UNMC) UNMC COD. page). The foods used in the index were College of Dentistry (COD) to perform All subjects had the initial surgical selected because of their prevalence in the restorations, knowing that the placement of the mandibular anterior the U.S. diet and use in social settings replacement work would provide a implants (Stage I) in October 2002. Once like restaurants and community events. much-needed teaching and research placed, the implants were left submerged The items-apple, beef jerky, carrot, opportunity for dental students. In for four to six months to allow for celery, roast beef and spinach leaves- addition, the UNMC COD, as a teaching osseointegration. All of the implants covered a range of textures and posed a institution, could provide lower charges for a refugee population, among which more than 60 percent lived at or below the 2004 U.S. poverty level and just 38 percent had dental insurance.’ We offered assistance to two men of the Dinka tribe, and one man and two women of the Nuer tribe because each was missing at least six mandibular anterior teeth (see Figures 1-2) and were young (ages 24 to 35) (see Table 1 on the following page). All were born and lived part of their lives in Southern Figure 1. Anterior Dentition of a Dinka Male Figure 2. Anterior Dentition of a Nuer Female Sudan, and had teeth extracted as part of at Initial Examination. Childhood extraction at Initial Examination. Note extraction pattern a traditional practice near the time of included mandibular incisors and canines. included mandibular incisors and canines and Photo credit: R. Toothaker maxillary canines. permanent eruption. All participants Photo credit: R. Toothaker

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and jerky-had ever been consumed raw by any of the participants; specifically, two of the five participants had eaten Refugee ID Sex Approx Age Tribe Extractions* Total these items uncooked. By contrast, most

A Male 24 Dinka 112 c1 6 of the items in the food index were either cut or cooked prior to ingestion. The B Female 31 Nuer It 2 C’. ct 8 only food that participants did not cook ~ before eating was an apple, and this fruit C Female 30 Nuer I, 2 CI, c, 8 was not consumed regularly. Spinach and D Male 23 Dinka 112 c, 6 beef jerky were seldom cut but instead were torn into small pieces by hand E Male 35 Nuer I, 2 c,. c, 8 before eating.

Food, Fluid and Snack Intake Another item of interest concerned current dietary patterns, including con- sumption of all liquids and snacks. Participants were asked how often they Food Item Apple Beef Jerky Carrot Celery Roast Beef Spinach Leaves ate, when they ate, and what each “meal” included. They also were asked about the Refugee ID Processing Method amount and type of fluid consumed and what food was included in their daily A 11.3 15.7 14 I 4. 7 14.5 14 I diet that was not part of a meal, such as B 10 4, 7 4 4. 8 4, 6 4 a snack food. Four of the five subjects noted that rice was the most common C 1.2 9. 4 6 4, 6 4, 6 6, 8 item in their U.S. diet, while three con- sumed stewed beef during a typical meal. Bread was regularly consumed by two E 11.2 1 4, 7 l6 I4,7 14.6 14.9 l subjects as well. Overall, the subjects appeared to eat I =pierced w/ upper incisors; 2=pulled head back; 3=rolled apple toward left premolar & took bite; 4=placed in side of mouth; 5=pierced with premolar & top canine; 6=bit only with premolar, canine twice rather than three times daily as is missing; 7=twisted head away from hand; 8=separated food by pulling with hand; 9=tore into small common in the U.S. All five participants pieces; I0=unable to bite or process with teeth indicated that they now drank milk daily, and both juice and soda weekly. Alcohol variety of difficulties for people without molars and/or molars but moved the was never consumed. None of the anterior teeth. Each participant was pre- head to the side or back, or tore the food respondents ate common US. snack sented with each food item and asked to by hand, to obtain bite-sized portions. foods daily, such as candy, chocolate or demonstrate how they would eat it, if it Meat, such as roast beef, could be crackers, with the exception of fruit (pri- was served raw. Before restoration of the entirely separated by the molars and pre- marily bananas and oranges). However, extracted mandibular teeth, participants molars if the texture was tender. Still, the candy, chocolate and crackers were eaten generally were unable to use the remain- meat had to be placed at the side of the by three of the five participants weekly. ing maxillary incisors to nip or pierce a mouth in order to acquire a chewing piece. piece of carrot, celery or roast beef in Social and Emotional preparation for mastication (Table 2). All Food Recognition, Concerns participants but one used the outermost Consumption and Preparation A series of in-depth interviews was edges of the maxillary lateral incisors to All participants then were asked to conducted to explore social concerns perforate an apple; however, the upper indicate whether they had ever eaten the related to the absence of the lower ante- incisors were not used by any of the par- particular food and, if so, to describe rior teeth. Participants were asked if they ticipants to incise any other food type or how the item would be ingested (ie, felt that the missing teeth affected sound texture. To chew most of the food items, cut, cooked or eaten in raw form). production of American English and participants began by placing the food at Whether or not they knew the English whether they avoided any behaviors, the side of the mouth for incising (Table word for each food item, all participants such as talking or smiling, because the 2). When eating fibrous foods such as recognized each of the six foods used in teeth were absent. apples, beef jerky and celery, the partici- the index and had eaten them at least Participants reported that some pants held the food in place with the pre- once. Only three items-carrots, spinach English sounds were difficult to make

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without their anterior teeth, such as “h,” pant indicated that he still used cleaning With the lack of anterior teeth, “th,” “v” and “s.” Two said they avoided sticks from the ‘toothbrush tree (i.e., refugees from the Nuer and Dinka tribes speaking because they could not enunci- twigs from Salvadora persica and related were unable to incise most U.S. food ate English words in the same way that species) as he would have in Sudan types or textures. Once the implants had most native English speakers did. Post- and/or in the . restored the dentition, all participants restoration, however, the refugees were able to incise food as if they had a reported a change in their confidence natural dentition. This was significant for and ability to produce sounds in English. Discussion the refugees to be able to eat common Also, before the implant placement, All of the Sudanese refugees were food in the U.S., in public settings and all participants noted that they limited or missing at least six lower anterior teeth with American colleagues and friends, altered their smile, rarely smiled or and had been without these teeth for at without needing to use noticeable head placed their hand over the mouth as they least 15 years before they were restored movements or extensive food prepara- smiled, due to the embarrassment associ- with implants. Thus, they had not used tion. The inability to use the anterior ated with missing anterior teeth. 12 anterior teeth for all of their adult lives. teeth for incising may result in prema- After all implant restorations were in ture wear of the premolars and molars. place, all participants reported greater The inability to use the This wear may not have been a problem comfort in public settings. As one in Sudan, where traditional diets include refugee noted, “I look like the people anterior teeth for incising liquids such as milk and well-cooked or here, and they look like me.” Another stewed foods,6,32but in the U.S., there is expressed a new ease for eating in public may result in premature no doubt that a compromised posterior places such as restaurants. All partici- wear of the premolars dentition can have a detrimental effect pants indicated that they smiled more on one’s health.?’,’+ often and noted a change in self-image, and molars. This wear Healthy posterior teeth generally from a positive general attitude to feeling may not have been a allow for a broader food election.^^.^^ A “very good” about their appearance. compromised anterior dentition also problem in Sudan, where impacts food selection. Pre-treatment, Current Dental Hygiene traditional diets include refugees who chose to eat a food repre- Practices sented in the index, or other foods of a Participants were asked to discuss liquids such as milk and tough or fibrous texture, were forced to their oral hygiene habits as practiced well-cooked or stewed make noticeable head movements and/or before restorative treatment. All partici- increase preparation time before chewing. pants indicated that they performed foods, but in the U.S., For some participants, noticeable head dental hygiene on a daily basis and used movement and the associated embarrass- U.S. dental products. For example, all there is no doubt that a ment limited or prevented altogether the but one participant used a toothpick to compromised posterior consumption of the foods in the index. clean hisher teeth after a meal. Also, all Refugees reported that their diets reported using toothpaste and tooth- dentition can have a and/or food preparation techniques had brushes after arriving in the United detrimental effect on not changed after implant restoration; States, despite the fact that Western they ate the same foods and used the hygiene products were not used in Sudan one’s health. same preparation techniques. One partic- or in refugee camps as they were neither ipant continued the same food selection available nor affordable. Although all The extraction patterns of mandibular and preparation because a spouse was participants reported that they once used teeth for both tribes is an old one;’ still without anterior teeth and could not cow dung ash to create a paste for clean- however, the extraction of the upper easily eat raw or tough foods. The rest of ing their teeth in Africa, none continued canines by the Nuer has not been previ- the refugees stated that they were this practice in the U.S. Before dental ously documented in the literature. From unfamiliar with typical American foods, implant placement, none of the partici- this small sample, it is unclear if the hence rice and stewed beef remained pants had been educated about dental extraction of the maxillary canines among staples in their diets. However, a change floss and had never used it before they the Nuer people is a traditional and in eating behaviors after the restorations received oral hygiene training at the widespread practice throughout Sudan. of the anterior teeth may not have been UNMC COD. Yet, once the dental Nevertheless, the traditional removal of anticipated. People do not necessarily implants were in place, and they had six to eight permanent and healthy teeth, alter dietary patterns once oral health completed dental visits, all participants just after eruption, is the largest number status has Education is reported the use of dental floss from one of anterior extractions performed by any required to alter established food selec- to three times per day. Only one partici- culture now documented in the literature. tion habits among U.S. dental patients;

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therefore, assistance-including nutri- some of the sounds or phonemes that and remove plaque.4’ Refugees rarely tion-related training-will be required if these refugees reported were difficult to received a dental health screening upon the refugees are being exposed to U.S. produce while missing teeth-namely arriving in the U.S., and annual dental foods for the first time.36Sudanese “th” and “s”-are indeed easier to enun- visits were not generally reported by the women prepare food and men never ciate after restoration of the dentition. Sudanese refugee p~pulation.~Given that cook. In the United States, many male It has been suggested that “. ..poor the refugees are currently among the refugees lived alone and had to procure dental esthetics may produce greater low-income families that generally expe- or cook food without assistance from negative reactions than an unattractive rience more caries, have more untreated women, but they typically had not appearance of other parts of the body”lb oral disease and experience greater tooth received any education about foods eaten and that facial attractiveness is usually ~oss,~~,~~we can expect that the Sudanese in the U.S. or or how to prepare them.’ It determined by the eyes and teeth;2’how- refugees will not have a healthy dental was unclear if numbers of meals and ever, we could not locate any study of a status without intervention. The ability food consumed by these five patients U.S. population that measured the per- to replace extracted or missing teeth were representative of the Sudanese ceptions of appearance related to social appears to be an important solution refugee population as a whole. To factors, health status and education for for improving the overall health status generalize our observation would require those missing visible front teeth. For of refugees. expanded data collection methods, these Sudanese refugees, the removal of including food diaries, observations of all six lower front teeth appeared to food intake and long-term data collection. impact their self-esteem in the U.S., Conclusion The most notable dietary change for further altered by verbal and social Many adult refugees from Nuer and these Sudanese refugees was the inclu- responses from Americans. A study of Dinka tribes in Sudan face a difficult sion of refined sugar in both fluids and young adults in Holland3’ suggested that transition in the United States because snacks. In Sudan, refugees rarely eat missing anterior teeth meant that one they do not have functional anterior foods or products that have sugar added. was less likely to initiate or encourage teeth, a visible trait that appears to be By contrast, in the U.S., it is hard to social contact, more likely to cover the necessary for incising a typical American avoid sugar in many available foods as mouth while smiling and less likely to diet with ease and creating a positive the average American consumes 64-plus laugh or smile for photographs. The self-image. The inability to eat, speak pounds of sugar per year.37The negative change in self-image after the restoration and look like other Americans, coupled impact on dental health of sugary foods, of the dentition was clear, and the partic- with lack of dental hygiene training and drinks and snacks would be similar to ipants indicated that they were now more the inclusion of refined sugar in the diet, that seen in the dental health of U.S. comfortable in public settings. may have a deleterious effect on overall children.38 One participant expressed increased health status. Studies have demonstrated To determine whether tooth replace- ease eating in public places. A reluctance the importance of having front teeth for ment improved sound production of to eat with others when one is edentu- health status and self-image. This study English words would also require a larger lous has also been reported among contributes to an understanding about sample size to determine which sounds Americans with missing teeth.40All study the impact of traditional dental extrac- could not be made by native speakers of participants indicated that they smiled tions on individuals who move to Nuer or Dinka and which might be more often and reported a change in another culture where the anterior teeth related to post-dental restoration. self-image, ranging from a more positive are important socially and functionally. Specifically, was a particular phoneme or general attitude to feeling “very good.” sound present in the indigenous lan- The adults in this case series were young guage, such that there was actual experi- (25 to 34 years old), and this age range Acknowledgments ence forming the sound, or did the appeared to be a common demographic The authors wish to thank all of the missing anterior teeth alone actually description for Sudanese refugees in Sudanese refugee participants for their account for the sounds produced and the Nebra~ka.~Refugees from war-torn Sudan assistance and patience during data col- noted changes? Historically, the Dinka have a strong desire to succeed because lection, a process that was no doubt extracted teeth to produce a “hissing” they cannot return home in the near future. intrusive at times. We also thank the fac- but such a sound is not valued in Annual dental check-ups will be ulty and students at the University of the U.S. and often signals missing teeth. essential to maintain their dental health, Nebraska Medical Center’s College of We were unable to locate any study of especially given that all subjects reported Dentistry for their contributions to the native English speakers who were miss- higher rates of sugar consumption in the refugee patients and this project. We are ing the lower teeth and had produced U.S. for themselves and their children. grateful to Nobel Biocare USA, Inc. recorded sounds to establish what impact Also, they no longer had access to tradi- (Yorba Linda, Calif.) and Dental Designs the anterior teeth might have on speech. tional hygiene materials, such as chewing Laboratory, Inc. (Lincoln, Neb.) for pro- Nevertheless, it does appear that at least sticks that are known to reduce bacteria viding implant restoration components

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