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Anterior Dental Extractions Among Dinka and Nuer Refugees in the United States: a Case Series Mary S

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Anterior Dental Extractions Among Dinka and Nuer Refugees in the United States: a Case Series Mary S REFUGEE DENTAL EXTRACTIONS Anterior Dental Extractions among Dinka and Nuer Refugees 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 Sudan’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 Spec Care Dentist 25(4) 2005 193 REFUGEE DENTAL EXTRACTIONS 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 194 Spec Care Dentist 25(4) 2005 REFUGEE DENTAL- EXTRACTIONS 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.
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