Culture and Oral Health

by Dr. Meenakshi Chopra (Author) Dr. Charu Mohan Marya (Author) Dr. Ruchi Nagpal (Author)

Textbook 2015 110 Pages

Medicine - Dentistry











Health has been called ‘an abstract concept’ that people can find difficult to define. Different attempts have been made (1). One of the most frequently referenced definitions of health in the last few decades is the classic one offered by the World Health Organization. Health is defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity (2).

Health is multifactorial. The factors which influence health lie both within individual and externally in the society in which he or she lives. It is truism to say that what man is and to what diseases he may fall victim depends on the combination of two sets of factors- his genetic factors and environment factors to which he is exposed these factors interact and these interactions may be health promoting or deleterious. The factors which determine the health are biological, behavioural and social-cultural, environment, socio-economic conditions, health services, ageing of the population, gender etc (2).

Oral health is integral part and essential to general health. Oral health means more than good teeth; it is integral to general health and essential for well-being. It implies being free of chronic oro-facial pain, oral and pharyngeal (throat) cancer, oral tissue lesions, birth defects such as cleft lip and palate, and other diseases and disorders that affect the oral, dental and craniofacial tissues, collectively known as the craniofacial complex (3).

Oral health is a determinant factor for quality of life. The craniofacial complex allows us to speak, smile, kiss, touch, smell, taste, chew, swallow, and to cry out in pain. It provides protection against microbial infections and environmental threats. Oral diseases restrict activities in school, at work and at home causing millions of school and work hours to be lost each year the world over. Moreover, the psychosocial impact of these diseases often significantly diminishes quality of life (3).

The mouth is a window into the health of the body. The interrelationship between oral and general health is proven by evidence. The strong correlation between several oral diseases and noncommunicable chronic diseases is primarily a result of the common risk factors. Many general disease conditions also have oral manifestations that increase the risk of oral disease which, in turn, is a risk factor for a number of general health conditions (3, 4).

While oral health care is integral to our general well-being, it is not readily available or accessible to everyone who needs it. Barriers, be they financial, structural, or cultural, prevent people from accessing oral health care. Due to these barriers (and potentially others), the apparent demand for oral health care does not reflect the true need. Due to financial problem, people cannot afford dental care without dental insurance, and even for many who do have dental insurance. Financial considerations are the reason cited most often for lack of access to oral health care (5). Even when insurance is available to help defray the costs of oral health care, oral health care providers may not be available to provide necessary care. This is a particular challenge for patients with special health care needs because many dentists are uncomfortable or un equipped to work with these patients. This is called as structural barrier. One of the greatest barriers to accessing oral health care is a person’s culture or environment, which significantly influences behavior. Culture can affect diet, oral hygiene habits, and perceptions of the seriousness of tooth decay. The influence of culture on use of dental services and oral health outcomes means that even when income is not an issue and services are available, learned behaviors can determine health-seeking behavior (5).

Culture plays an important role in human societies. It lays down norms of behavior and provides mechanisms which secure for an individual, his personal and social survival (6). Culture includes everything which one generation can tell, convey or hand down to the next. Culture has three parts. It is an experience that is learned, shared and transmitted (7). Acculturation refers to culture contact. There are various ways by which the acculturation can occur, like in the way of trade and commerce, industrialization, propagation of religion, education and conquest to name some (2).

Every culture has its own customs which may have significant influence on health and oral health. The increased incidence of lung cancer because smoking, cirrhosis because of alcoholism in many developed countries, the surge in the incidence of oral cancer in India due to pan chewing habits are some classical examples to demonstrate the influence of culture on health and oral health. It is now fairly established that the cultural factors are deeply involved in the whole way of life, like in the matters of nutrition, immunization, personal hygiene, family planning, child rearing, seeking early medical care, disposal of solid wastes and human excreta etc (7).

All cultural practices are not harmful. Every human has the culturally ingrained habit of cleaning or brushing the teeth early in the morning. The use of soap for personal hygiene, oil massaging, exposure of the new born to sunlight etc are some cultural practices that needs to be encouraged. The inclination to get into the habits of smoking, alcoholism, drug addiction in the name of civilization among the younger generation needs to be countered at the earliest, otherwise, it may have a huge deleterious impact on the health status of the generation to come. Keeping in mind, the very significant role, the culture plays on health and oral health, this topic of library dissertation is taken up to review the available literature on effects of key cultural factors on health and oral health (7).


SOCIOLOGY: Sociology is the science concerned with the organization or structure of social groups.

SOCIETY: Society is defined as “an organization of member agents” or in other words society is made up of group and group of individuals.

COMMUNITY: A community is a social group determined by geographical boundaries and/or common values and interests. Its members know and interact with each other. It functions within a particular social structure and exhibits and creates certain norms, values and social institutions. The individual belongs to the broader society through his family and community.

CUSTOMS: Custom is abroad term embracing all the norms classified as folkways and mores.

MORES: Mores are socially acceptable ways of behaviour that involve moral standard.

FOLKWAYS: They refer to customary ways of behaviour people conform to these ways not out of fear penalized but because it is obligatory in the proper situation.

CULTURE: Culture is defined as “learned behavior which has been socially acquired”

SOCIAL NORMS: Every society specifies certain rules of conduct to be followed by its members in certain situations these specified rules of conduct are technically known as social norms (2).


All people, whether rural or urban, have their own beliefs and practices concerning health and disease. It is now widely recognized that cultural factors are deeply involved in all the affairs of man, including health and sickness. Not all customs and beliefs are bad. Some are based on centuries of trial and errors and have positive values, while others may be useless or positively harmful. Some of these cultural factors, hallowed by centuries of practice, have stood in the way of implementing programmes. In places where a change of behaviour was involved, the resistance of the people was maximum in acceptance of new programmes. Information about these factors, i.e., customs, cultural mores, habits, beliefs and superstitions is still woefully lacking. A brief account of the cultural factors relating to health and sickness, as observed in India, is given below (2):

1. Concept of aetiology and cure:

Broadly, the causes of disease, as understood by the majority of rural people, fall into two groups: (a) supernatural and (b) physical.

Supernatural causes:

1. Wrath of gods and goddesses: There are good many people (even among the educated) who believe that certain diseases are due to the wrath of some god or goddess. Chickenpox is an outstanding example, it is known as Chhoti Mata. Where the disease is considered to be due to the wrath of gods and goddesses, administration of drugs is considered harmful. Cases are not notified and pujas are made to appease the gods.
2. Breach of taboo: Breach of taboos is believed by some people to be responsible for certain diseases. Venereal diseases are believed by some to be due to illicit sexual intercourse with a woman of low caste, or a woman during menstruation.
3. Past sins: Diseases such as leprosy and tuberculosis are believed by some to be due to their past sins.
4. Evil eye: A widely held belief throughout the country is the effect of "evil eyes". Children are considered to be most susceptible to the effect of evil eyes. In order to ward off the effects of the evil eye, charms and amulets are prescribed and incantations recited by the exorcist.
5. Spirit or ghost intrusion: Some diseases such as hysteria and epilepsy are regarded as due to a spirit or ghost intrusion into the body. The services of an exorcist are sought to drive away the evil spirit or ghost (2).

Physical causes: Physical causes are also considered to be responsible for certain diseases. Among these are:

1. The effects of weather: Exposure to heat during summer is responsible for an attack of loo (heat stroke). The folk remedies consist of application of oil and ghee on the soles of feet and administration of mango-phool (prepared by keeping unripe mangoes under hot ashes for a few minutes, and extracting the pulp in cold water) with a pinch of salt.
2. Water: Impure water is associated with disease.
3. Impure blood: Skin diseases, viz. boils and scabies are considered to be due to impure blood. Eating neem leaves and flowers is considered to purify blood.

2. Environmental sanitation:

a) Disposal of human excreta: Approximately 78 per cent of the people in rural areas use open fields for defecation. This practice is time-honoured and is considered harmless. The average Indian villager is averse to the idea of latrines. He considers that latrines are meant for city dwellers, where there are no fields for defecation. He is ignorant that faeces is infectious and pollutes water and soil and promotes fly breeding. Thus the problem of excreta disposal is bound up with numerous beliefs and habits based on ignorance.
b) Disposal of wastes: The average villager is not aware that mosquitoes breed in collections of waste water; it is permitted to flow into the streets. The solid waste (refuse) is invariably thrown in front of the houses where it is permitted to accumulate and decompose. Periodically it is removed to the fields and used as manure. The animal dung (cow dung) is allowed to accumulate. It is used sometimes as manure and often times pressed into cakes, sun-dried and used as fuel (2).
c) Water supply: The well occupies a pivotal place in the cultural environment of villages. It is also a common meeting place of men and women of the village, when they go to draw their supply of water. It is the place where animals are washed and given a drink. These cultural practices lead to the pollution of well water. Tanks and Pools are used for washing, bathing, and ablution and sometimes even a source of drinking water. Some rivers are considered "holy". People go on pilgrimage to these rivers to have a dip. They not only have a dip but drink the raw water which they consider sacred. Samples of 'holy water' are bottled and carried over long distances for distribution among friends and relatives. Epidemics of cholera and gastroenteritis have been due to these cultural practices. Step-wells are associated with guinea worm disease (2).
d) Housing: Rural houses are practically the same all over the country. They are usually katcha and damp, ill-lighted and ill-ventilated. For reasons of security, no windows are provided, and if at all one is provided, it is merely a small hole. Absence of a separate kitchen, latrine, bathroom and drainage are characteristic features of an average rural house. Animal keeping is very common in villages. Infrequently, human beings and animals live under one roof. Houses are generally kept clean inside, regularly white-washed or plastered with mud and cowdung (2).

3. Food habits:

Food habits have deep psychological roots and are associated with love, affection, warmth, self-image and social prestige. The diet of the people is influenced by local conditions (e.g., soil, climate) religious customs and beliefs. Vegetarianism is given a place of honour in Hindu society. Even among vegetarians, the pattern of eating is not the same; some do not take onions and garlic on religious grounds. Muslims abhor pork, and Hindus beef - these food habits have a religious sanction from early days. The concept of hot and cold food is widely prevalent in the country. Foods such as meat, fish, eggs, and jaggery are considered to generate heat in the body; foods such as curd, milk, vegetables and lemon are considered to cool the body. These concepts are encountered by the modern physician when treating disease. Adulteration of milk is a common practice (2). Although the motive is economic gain, deep-rooted beliefs also responsible for this practice, i.e., if pure milk is boiled, the milk secretion of the donor animal may dry up. Muslims observe fasts during Ramzan and Hindus on several occasions. These fasts are considered important adjuncts to religion. Drinks and drugs are among the food habits of the people. Alcoholic drinks are tabooed by Muslims and high caste Hindus. Ganja, bhang and charas are frequently consumed by sadhus; these habits are now spreading into the general population, especially the younger generation. Eating and drinking from common utensils is considered as a sign of brotherhood among Muslims. Hindu women often take food left over by their husband. In some societies, men eat first and women last and poorly. Some people do not eat unless they have taken a bath. Thus food is a subject of widespread customs, habits and beliefs, which vary from country to country, and from one region to another (2).

4. Mother and child health:

Mother and child health is surrounded by a wide range of customs and beliefs all over the world. Marriage is universal in Indian society, and the family is incomplete without the birth of a male child. This has obvious implications in the context of the country's population problem and male: female ratio. The various customs in the field of MCH have been classified as good, bad, unimportant and uncertain (2).

a) Good: Customs such as prolonged breast-feeding, oil bath, massage and exposure to sun are good customs.
b) Bad: These vary from society to society. For example, some foods (e.g. fish, milk, leafy vegetables) are forbidden during pregnancy in some parts of the country. In rural areas, most deliveries are conducted by the traditional untrained Dai or birth attendant whose methods of conducting delivery are far from safe. The villagers have great faith in her. In some parts of the country, the child is not put to the breast during the first 3 days of birth because of the belief that colostrum might be harmful; instead the child is put on water, and sugar solution. Branding of the skin, administration of opium and drastic purgatives are all bad customs. The net result of these customs is high infant mortality and morbidity.
c) Unimportant: There are customs which are unimportant, viz, punching the nose, application of oil or a paste of turmeric on the fontanelle.
d) Uncertain: Sometimes, it may be difficult to say whether certain customs are good or bad. The practice of applying kajal or black soot mixed with oil to the partly for beautification and partly for warding off effects of "evil eye". Often-times, this custom has been blamed for transmitting trachoma and other eye infections. Knowledge of the local customs and beliefs is therefore very important for improving the health status of mothers and children. This is part of social paediatrics (2).

5. Personal hygiene:

Indians have an immense sense of personal cleanliness much of which is closely interwoven with ideas of ritual purification. Rituals are a set or series of acts usually, involving religion or magic, with the sequence established by tradition.

a) Oral hygiene: Indians are very particular about oral hygiene. Many people in the countryside use twinges of neem tree as a toothbrush; some use ashes; and charcoal. The educated and those who have come in contact with urban life use toothbrushes. Eating pan leaves smeared with lime with or without tobacco is a common social custom.
b) Bathing: Bathing naked is a taboo. Apart from regular baths of which Indians are very fond, there are baths fixed on special occasions. The women after menstruation must have a purifying bath; after childbirth, there may be two or three ceremonial baths, the time for which is fixed upon the advice of the priest. The practice of an oil bath is a good Indian custom. Womenfolk in the countryside use a paste consisting of gram, mustard oil and turmeric powder and rub it on the body before a bath. Thus, bathing is a ritual in India.
c) Shaving: This is done by the traditional barber (nail) countryside. He does not sterilize the instruments used, as he does not have any idea of micro-organisms (2).
d) Smoking: Smoking hubble-bubble is a social custom in some parts of the country. It can spread tuberculosis. Smoking with burning end of the cigar in the mouth, which is a common custom among villagers in Andhra Pradesh, is association with oral cancer. The 1971 Report of the Royal College of Physicians of London (9) on the effects of smoking and health provides useful summary of information diseases now known to be associated with smoking – cancer of the lung, chronic bronchitis and emphysema, coronary artery occlusion, angina pectoris, cancers of the pharynx, larynx, and esophagus, cancer of the bladder and pulmonary tuberculosis. Among patients with peptic ulcer those who smoke have a higher death rate than those not. A mother's smoking during pregnancy may retard growth of the fetus (2).
e) Purdah: Muslims and some caste Hindu women observe purdah. The incidence of tuberculosis is reported to be high amongst those who observe purdah, which also deprives them of the beneficial effect of the sunrays.
f) Sleep: Many people in the villages sleep on the ground for reasons of poverty, and they are exposed to insect bites.
g) Wearing shoes: The transmission of hookworm disease is associated with bare feet. Many villagers in South India do not wear shoes.
h) Circumcision: This is a prevalent custom among Muslims, which has a religious sanction.

6. Sex and marriage:

Sexual customs vary among different social, religious and ethnic groups. For certain religious groups menstruation is a time of uncleanness when women are forbidden to pray or have intercourse; orthodox Jews are forbidden to have intercourse for seven days after the menstruation ceases (10). These customs have an important bearing in family planning.

Marriage is a sacred institution. It is the usual social custom in India to perform marriages early. It is considered a sound and desirable practice, because late marriages may create problems in adjustment, especially in joint family systems. Because of the universality of marriage in India problems of unmarried mothers and of illegitimate births are less than in the western countries. The mean age at marriage in India is 24 years in the case of boys and 21 years in the case of girls. There are differences in marriage-age by caste; females of the depressed classes have lower mean age at marriage. Child marriages are fortunately disappearing. Monogamy is the most universal form of marriage. Polygamy (marriage of one man with several women) prevails in certain communities. Polyandry (marriage of several men with one woman) is found among the Todas of Nilgiri hills, the inhabitants of Jaunsar Bawar in Uttar Pradesh and the Nayars in Malabar Coast. The high rate of venereal diseases in Himachal Pradesh is attributed to the local marriage customs (2).


Indeed, cultural influences overlap with dental health literacy, socioeconomic status, and personal experience in complicated ways, but it is possible to identify some common beliefs and care-seeking practices around oral health that are culturally-based and significantly different from the western dental medicine model (11).

Four domains that shape people’s cultural beliefs and practices related to oral health:

1) Help-seeking and preventive care
2) Oral hygiene practices
3) Beliefs about teeth and the oral cavity
4) The use of folk remedies

1) Help-seeking and preventive care:

Many cultural groups don’t have a strong preventive orientation when it comes to their health care, and this is definitely true when it comes to oral health. People often seek care only when there is a problem. An individual might go to the dentist for a painful tooth after suffering with it for a while, and then simply expect to have the bad tooth extracted. Advanced interventions to save a bad tooth, such as root canals and crowns, may be common in the U.S. and other western countries, but is often the privilege of only wealthy people in other cultures (12).

2) Oral hygiene practices:

In many cultures there is little understanding of gum disease. Brushing the teeth may be done to remove left over food from the mouth, but the concept of removing plaque and tartar is less well-understood. It follows that the use of dental floss, mouth rinse, and tongue cleaners may be virtually unheard of and might be viewed with skepticism. Americans are known around the world for being obsessive about perfectly straight bleached white teeth (12).

3) Beliefs about teeth and oral cavity:

In many cultures the esthetic appearance of teeth may be important, but having “healthy” teeth and gums is not connected to appearance in a direct way. Red or swollen gums, bleeding gums, painful chewing, loose teeth, receding gums, all these symptoms of gum disease may be ignored as long as the visible teeth “look good”. An interesting example comes from China where the appearance of teeth is psychosocially important. Having nice looking teeth can influence social interaction. However, a person with carious or discolored front teeth is considered to have low intellectual competence (12).

4) Use of folk remedies

In some traditional cultures there is a preference for using traditional remedies and cures either in place of western medicine or in conjunction with it. Use of herbs or healing methods like acupuncture and moxibustion are common. Pain in any area of the body, including oral pain, is treated using culturally-accepted remedies passed down through generations. For example, in some African American families the use of cotton balls soaked in aspirin solution, alcohol or salt water is a well-known home remedy for pain and swelling (12).

Since dental decay can start as soon as teeth erupt, to be effective, preventive oral health strategies need to target children early when transmission of oral bacteria from mother to infant commences and eating habits are established. Since infants and children are seen by their primary care providers (medical) frequently during the first two years of life, there is an opportunity for these practitioners to promote oral health and refer children for dental care. However, primary care providers receive limited training in prevention of oral diseases, while general dentists care for young children, but their small numbers nationwide made such services unavailable to most children. High-risk children usually have dental insurance through Medicaid, but the percentage of dentists participating in Medicaid is low. Only one in five children covered by Medicaid actually receives preventive dental care (11).

Socio-cultural influences affect not only individual’s health status but also the entire health system. Keeping in mind, the very significant role and the culture plays on health and oral health, this is an attempt to review the effects of key cultural factors on health and oral health (11).


Humans have modified their bodies for centuries via different means and for numerous reasons. Body modification can be seen today in some fashion in virtually all countries. Modification can include piercings, tattoos, paint or ground minerals smeared on the body in particular patterns and even hair can be cut or styled in such a way that it can be considered body modification (13). The most dreadful form of permanent modification is scarification. It is intentional wounding subsequent healing with scarring of skin the term describes any technique that produces scarring, whether it by cutting, tearing or burning of skin with hot implement usually a heated needle. Among the Nuba of the Sudan, a girl’s body is decorated with its first scars when puberty begins, usually when she is nine or ten. The skin of the abdomen is repeatedly hooked with a sharp thorn, pulled away from the body, and sliced with a small metal knife.

Modification of the body can be done for as many reasons as there are methods of modification. Perhaps a culture believes that in order for a god or goddess to respond to their sacrifices, rituals, and requests, they must have their bodies painted in a particular way. Modifying one's body may also be a means of achieving self-identity. Additionally, modifying the body may be something that an entire society performs, thus allowing a person to identify with his or her kinsmen and women. If one comes in contact with someone who has a different form of body modification, then it is obvious that one of the two people is an outsider and does not belong in that particular area. Body modification can also be seen as a means of attracting a person of the opposite sex, or it can be viewed as an intimidation device when confrontation arises. Oftentimes, body modification is a means of signifying the crossing-over from one stage of life to the next, such as the change from adolescence to adulthood once puberty is reached (14).

Tooth related and oral soft tissue mutilations are well recognized forms of mutilations. The modification of human dentition, oral soft tissues is prevalent in many societies, both historically and in current contexts. Many societies view these modifications that they perform as a prideful ritual that even enhances beauty. These modifications help them identify with their kin or village groups. Tooth and oral-facial mutilation among various cultural groups, may signify a rite of passage, the mourning of a loved one, group identity, or be a means of conforming to a concept of beauty. A dentist must look at topics, from the perspective of a person living in a society that partakes in the ritual of tooth modification. The knowledge of dental and oro-facial mutilation is all important from forensic odontology view as they have relatively different ethnic and tribal affiliations (14).

Tooth modification

Dental modification, also called dental art and dental mutilation.Fastlicht (15) suggests that the term is probably a misnomer. Current dental anthropological literature prefers the term dental transfigurement instead of dental mutilation. Turner (16) feels that the latter imparts a racial tone and therefore its use should be abandoned.

As we have learned the basics in dentistry the essential function of teeth are mastication, speech and esthetics. Anthropology extends this classification with an additional term, the paramasticatory functions of teeth. This new dimensions offers learning and insight into cultural behaviour. It is these teeth are sometimes altered by intent or an unconscious by product of their daily lives (14).

Various forms of tooth mutilation are:

I) Unintentional modification of teeth
i. Habits
ii. Teeth as tools
iii. Tooth wear and function

II) Intentional modification of teeth

i. Tooth avulsion
ii. Tooth bud enucleation
iii. Altering the shape of teeth
iv. Dyeing and lacquering
v. Inlays and onlays decoration


A. Habits

Teeth reveal a wide variety of activities unrelated to eating that result in unusual and often distinctive patterns that are task-specific. Some anthropology literature will refer to this as accidental or artificial dental modifications(14).

(a) Clay-stemmed pipes -Clay-stemmed pipe is a device specifically made to smoke tobacco. It leaves a distinctive imprint on the teeth. Clay tobacco pipes were made in England shortly after the introduction of tobacco from North America, in about 1558. The earliest written description of smoking was in 1573 and probably described a pipe derived from native North American types (17). Scott and Turner (18) report such pipe wear in prehistoric up to an including modern populations from Melanesia and Siberia to the North Atlantic region.

(b) Labrets - Laberts are the 'cheek plugs' worn using incisions cut into the cheek or lips. The continuous movement of the labret against the teeth leaves distinctive polished facets of varying size on the facial surfaces of the teeth. Labret usage is known from many New World populations ranging from Eskimo in the north to Mesoamerican peoples in the south (14).

Sixteenth century teeth from Europe occasionally show a notable loss of enamel accompanied by scratch marks as a result of metal toothpick usage-which was popular at that time. Grooves on the approximal surfaces of molars in Paleolithic persons are attributed to the sustained use of bone needle tooth picks used to remove food from between teeth. The bone needles have been found in the same cave strata as the skeletal specimens (14).

B. Teeth as Tools (Paramasticatory Behaviour)

The most spectacular contemporary report of teeth-as-a-tool usage is the opening of a 55-gallon drum by an Eskimo with his teeth (19). They used their teeth when their fingers couldn't do the job. Tools now available such as pliers, vises, and scissors have replaced many ancient tool uses of teeth.

When distinctive occupational wear of the teeth is reported, it is often described as task-related wear. Teeth have been used for working leather, softening boots, making grass baskets, the use of bow drills, and making cordage. The classic example of 'extramasticatory wear' is the pattern of occlusal surface grooves seen on the surfaces of permanent mandibular incisors and canines of Great Basin Indians of Nevada (14).

The high polish and orientation of the grooves reveal the use of teeth in the processing of plant fibers for basketry (20). Virtually all occlusal surface grooves in anterior teeth are found in New World foragers.

Occupational modifications are found in the teeth to dressmakers (thread), shoemakers & carpenters (nails), butchers (string), glass-blowers and musicians (mouthpieces), office workers (pens), jugglers, and trapeze artists (21).

Neandertals had unusually robust anterior teeth that were worn down in a distinctive manner, suggestive of their use in the preparation of hides (2).The chipping of posterior teeth has been documented in Aleuts, Eskimos and Indians. It seems associated with the biting of very hard objects. Eskimo and Australian Aborigines have been studied for many craft functions. The most unusual for me was in pressure flaking a stone projectile point (22).

C. Tooth Wear and Function

The process of tooth wear is well understood. Wear of teeth reflects their use in life, and the degree of wear is used by anthropology to estimate the age of an individual at death. The severity of wear is highly influenced by the consistency and texture of food and by how it is processed. The introduction of grinding tones for making flour from cereal grains is a consistent finding around the world (20, 23).

In some settings, the degree of wear reflects social status. In the Medieval Edo period of Japan, members of the elite Shogun class had virtually no occlusal wear suggestive of a soft diet, unlike lower class persons. The related dental and skeletal findings are intriguing: Those elite individuals who consumed a soft, processed diet in childhood had narrow faces, reduced size of the maxillae and mandibles, and more gracile muscle attachment sites. These findings corroborate the disuse theory which we'll encounter later in this course (20). In contemporary society, excessive tooth wear is often found among individuals exposed to mineral, metal, or vegetable dust.

Dental chipping of the enamel and tooth fractures are frequently found in prehistoric populations, suggesting encounters with hard objects in chewing (14). Scratch marks have been seen on the labial surfaces of anterior teeth of some adult Neandertal specimens. They seem to have been caused by incidental contact with stone blades used to cut meat held between the anterior upper and lower teeth. The direction of the cratchmarks is evidence of right or left handedness (24).


Intentional modification of teeth is a global phenomenon, however modifications are indicative of varied cultural practices and are usually specific to a continent or region. This type of modification is also described in literature as scarification or mutilation of teeth (14).

Our clinical ideas of dental beauty as straight, white, vertically positioned teeth in perfect bilateral symmetry. Indirectly, we associate attractive teeth with health and vigor. From the dentist point of view, no culture idealizes broken-down, dirty teeth. These ideas are not universal (1).People in other places and times modify their teeth. Intentional dental modification is more prevalent throughout history than one might think. Though some modification may have been performed to relieve the pain of carious lesions and decay (13). It has been recognized that the practice of deliberate mutilation of the dentition like non-therapeutic extraction, filing of teeth (25, 26), dyeing of teeth is distributed throughout the world among certain societies (26). Such alterations in the dentition have been observed in the Neolithic and Mesolithic archeological record, being particularly common in Africa (27). Although a number of investigators have noted reductions in the incidence of these activities (25,26,28,29), their frequency in the certain forms remains at significant levels even today (29, 31, 32).

Historical Perspective- According to the study conducted by Pindborg (33) on dental mutilation among villagers in central Java and Bali, From SUKADANA (34) they came to know that mutilations have been found on skulls from Neolithic times. When they (authors) visited the temple of Borobudur 27 km from Jogjakarta they found that one of the reliefs had a dental motif (Fig 1)

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Fig 1- Relief from Temple of Borobudur (34)

They did not come to know exactly what the man was doing to the girl's mouth as shown in the relief but as the temple is in an area where dental mutilation is widespread it appears logical to assume that he is performing a mutilation. The girl to the extreme right had something in her hand; it may be a grinding stone she was handing to the man for use in the mutilations. As the temple of Borobudur was built at about 800 A.D (35) they might have assumed that dental mutilations were practiced in that area more than 1100 years ago.Many reasons have been offered by residents of that area for practicing the mutilation of teeth (33).


It is also called as intentional removal of teeth.


Tooth extraction is an ancient practice that is carried out worldwide. The practice of tooth avulsion is one which dates from early Mesolithic period to late Paleolithic times. The practice has a wide geographic distribution and has been described in Africa, central and South America, parts of South East Asia, the Philippines, Indonesia, Melanesia, Polynesia and Australia. It has been a common practice of traditional healers in sub-Saharan Africa for centuries. In the West, evidence of these practices was first noticed among slaves transported from sub-Saharan Africa to the new world in the early 18th century (36).

Most common reasons for tooth extraction in Africa are:

1) Initiation ceremonies concerning puberty (25, 26, 27), marriage (25, 26), or entry into a warrior society (25).
2) For feeding of the individual as well as more efficient spitting under more ordinary circumstances (25).
3) To improve personal appearance (25, 26).
4) To mimic the appearance of certain animals (25, 26).
5) To provide a form of tribal and intra-tribal class identification (25).
6) To improve masticatory function (25).
7) A rite of passage (27).
8) A sign of mourning of loved one (27).
9) Group identity (27).
10) In order to properly speak their language (27).

Van Rippen quoted a situation involving the Baganda tribe, who occupied an area formerly referred to as the Upper Congo, in which a uniform attempt was made to ensure that all deciduous teeth of the children were exfoliated or, if necessary, extracted in proper anatomic and temporal sequence. It was felt that this was necessary in order to prevent the development of malaligned succedaneous teeth (25).

Instruments and methods used for carr ying out tooth avulsion

The instruments used for dental extraction include:

A wooden stick struck by a stone, an axe head hit with a wooden mallet, an iron wedge driven by a wood block, strings or sinews tied about teeth. In addition, Pindborg describes the use of a piece of iron, as well as fish hooks, to remove developing tooth germs (29).

Age and Sex distribution:

The age at which tooth avulsion is carried out also varies. The ritual is carried out at any age from childhood onwards. In general, permanent tooth avulsion is done on individuals in their late childhood teenage years. In some cultures the practice of tooth avulsion is associated with events such as puberty and initiation rites in males or the time of first menstruation or marriage in females (13, 29).

Complications following Tooth Avulsion:

A number of adverse effects have been noticed, arising from such kind of dental mutilation. Apart from the pain and loss of masticatory function associated with tooth extraction (2), the improper extraction of deciduous teeth has been implicated in the production of severe localized enamel hypoplasia in the succedaneous teeth (29). Abnsinna (32), described serious infection leading at times to death, following excision of deciduous tooth follicles.

A rare case of an erupted compound odontoma associated with a malformed and dilacerated maxillary left lateral incisor has been reported by Amailuk and Gaubor of a 15-year-old immigrant Sudanese boy who had a malformed right maxillary lateral incisor and missing central incisors. His guardian reported he had undergone traditional extraction of his primary teeth as a child whilst in Africa. Treatment and possible mechanisms for development of the condition are discussed. The number of refugees and migrants from Africa to developed countries has increased in the past 20 years. Dentists serving in the developed countries may likely see more patients with dental abnormalities in the respective populations (37).


The term ‘germectomy’ was coined by Morgenson for the more radical form of practice involving removal of the primary canines and / or permanent tooth germs.The removal of the incipient canine teeth (`germectomy') in small babies is a practice carried out in many parts of eastern Africa (38). In the dental literature, it has been reported that some rural populations of sub Saharan and eastern Africa and other isolated areas around the world, practice gouging and enuleation of primary cause of vomiting, diarrhea and fevers. It is also been reported that the practice of tooth gouging is no longer confined to rural areas and may well be performed by communities that have emigrated to the UK (39).

Early Perceptions of Teeth

Caries in human dentition was rare prior to the days of agriculture and mass food production, a particular type of food can be harvested in a region, though, it can feed a larger population of people, allowing for further development of civilization. The downfall to this pattern began to harm the health of a person, along with his or her teeth. When the people started experiencing toothaches and cavities due to bacterial infections, they tried to find the reason for toothache (13).

In early societies, magic was quite prevalent, and the idea of the toothworm was created. When severe pain was felt in the tooth, it was believed that the worm was angry and thrashing about and when the pain had stopped, it was believed that the worm was in a state of rest. The earliest record of the story of the toothworm was found in the royal library in Babylonia. The document found was written on a Sumerian clay tablet in cuneiform and dates back to 3000 BC (13).

Later, in addition to the presence of a worm in the tooth, it was also believed that the demons located within the body were displeased, causing toothache. Today, it is believed that the idea of the toothworm may have emerged when ancient people saw the pulp of the tooth. The pulp is comprised of the tooth’s nerves and these nerves may have had a worm like appearance (13).

The concept of the toothworm was dispelled after the scientific thought came into picture. Interestingly, a belief of toothworm is still present in some African societies, where deciduous mandibular canines are still removed in children prior to the complete eruption of teeth. This procedure is considered a success if the toothworm has been completely removed. Oftentimes teeth, notably the mandibular canines or incisors, are removed in infants in African societies to fulfill a ritual. It is also believed that the removal of these teeth prior to eruption will prevent illness, especially diarrhea (40).

Geographical distribution

Maasai reports show that in Kenya the practice of ‘plastic tooth’ removal came from Tanzania and Uganda in the 1960’s (41). In Sudan this belief was virtually unknown before 1965. However, after the civil war in 1972, refugees began returning to their homelands from neighbouring African countries, bringing with them traditional beliefs acquired from such places. It has also been suggested that the custom of extracting the unerupted canine tooth is named after the Ugandan Lugbara tribe which practised the habit (42). Generally it is more common in the rural areas where traditional healers are more, as hospitals are mostly in the cities. Most of the research done on this practice show alarming results:

Uganda: First reports showed a prevalence of 16.1% of a population of 322 examined with signs of canine enucleation (29). In Northern Uganda an average of over 100 admissions a year with complications following ebiino extractions were documented in one paediatric unit (43) (21% resulting in fatality).

Kenya: A report on the dentition of Maasai children studied in 1988, showed 35% of 5-7 year olds had undergone removal of deciduous canine tooth buds (44). In 1995 a further study reported the percentage of children aged between 3-7 years who had removal of the canine tooth buds to be 72%.This shows that the belief of deciduous canines causing febrile illness in children is spreading (41).

Sudan : In a report on 80 infants in a children’s hospital, 70% of infants admitted with diarrhoea had their deciduous canine teeth extracted as the remedy for their illness (10). A later study at a different paediatric department revealed that out of 90 children admitted, all were found to have had at least one or more deciduous canines extracted before presentation (7). A further study conducted on 398 children aged 4-8 years showed 22.4% had been subjected to ‘haifat’ (lancing of the alveolus over the deciduous tooth) (46).

Ethiopia: A study on the prevalence of ‘killer canine removal’ was conducted in Addis Ababa amongst children from 300 poor families and 15% of primary canines were affected (47). In 1991 there was an emigration of Ethiopian Jews to Israel, and an investigation into the practice of the removal of tooth buds was carried out. A prevalence of 59% of 59 children screened had extraction of primary tooth buds (48).

Tanzania: One report in 1991 looked into the regional variation of the practice of “nylon tooth”extraction, examining 1890 children from 8 different areas. The results showed the highest prevalence being in Morogoro (16.9%) and Singida (13.3%), and the lowest in Moshi (5.2%) and Mwanza (7.8%) (49). Shortly after, a further study in the Dodoma region revealed that out of 262 children examined for missing primary teeth, 37.4% had clinical evidence (50). The authors repeated a similar study in 1997 (51) and discovered the prevalence in Dodoma had increased to 60.3%. This confirms the fact that this traditional practice is not necessarily on the decline; in fact, it could even be increasing in certain regions (52).



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Title: Culture and Oral Health