Since ancient times, the teeth, mouth and face have had an intrinsic interest and fascination to mankind expressed through many oral and written beliefs, superstitions and traditions as well as through a wide range of decorative and/or mutilatory practices.
A deliberate modification of the shape of the human teeth - called tooth mutilation - has been reported in various regions of the world, including the Pacific, Asiatic, African, South and Central American area. The intentional alteration of traumatic origin, including tooth extraction and modification of the tooth surface or shape (e.g. by filling, notching, drilling, grooving, grinding, staining and chipping) has been documented in human remains since prehistorical times.
Throughout the long history of mankind, healthy teeth have always represented a symbol of youth, beauty, strength and health, but they can send other kinds of messages because of the relative intrinsecal strength of the tooth structure .
Ritual mutilations include breaking, extracting, filling, inlaying or cutting away the crown of the teeth (or just part of it), sharpening to a point, laquering or staining, incrustating the crown with gems or precious metals (nota). Teeth mutilation practices have been noticed in inhabitants of the developed and under-developed world regions and similar rituals have been preserved until nowadays (1).
It was discovered that the unifying cultural and anthropological theme standing behind many forms of ritual mutilations, including tooth extraction, is blood flowing (2-4). The intentional dental ritual of re-shaping or mutilation is symbolically performed on many cultural, ritual and social occasions: initiation ceremonies (5), puberty, marriage, entry into the warriors’ society, feeding in case of tetanus, to allow more efficient spitting, to improve personal appearance, to mimic the appearance of an animal or just to avoid it, to provide a form of tribal and intra-tribal social class identification, to allow the emission of special linguistic sounds, to improve the masticatory function or apparently to facilitate oral sex (6) or even as a sign of mourning.
Modifying the shape of the teeth can also be a means to achieve self identity, or, on the contrary, of identification with kinsmen, if it is considered a widely performed practice. Some dental modifications are made as a means of sexual attraction, or as an intimidatory sign when a dispute arises. Dental modification is often a means to show the passing of status from one phase of life to the next, as it happens in the change from adolescence to adulthood. Even though performing dental mutilations is often a painful procedure, we can consider that there should be in some way a perceived benefit in the participation in them, which helps the individual endure the pain.
In many ethnic groups the dental mutilation performed during initiation ceremonies in puberty is perceived as a prideful ritual which enhances beauty and as a trial of resistance to physical pain (5). Many groups participate today in rituals which involve both tooth ablation and filing, whilst in some ethnic groups the tooth modification is limited to laquering or color application. Such dental ritual mutilations are performed today in rural communities or indigenous tribes in several areas of the world, most notably in Africa, Asia and Oceania (Table 1).
Continuously practiced in traditional but not primitive societies, the dental ritual mutilations are not the testimony of a missing culture, but are simply signs of a different one.
These mutilations are in fact closely related to the region and to the population of origin, and in our western countries they have been reported in immigrant patients, especially born in Africa or children with African parents, and have possibly been performed during visits to their home countries (7, 8).
The aim of this research is the systematic review of the literature and the systematic description of those ritual modifications of tooth morphology which nowadays persist in some areas of the world. Knowledge of such different types of ritual mutilations may help the forensic odontologists or forensic experts to understand the ethnic origin or the geographical provenance of the subject.
Moreover, the knowledge of typical aspects of ritual mutilation allows the forensic odontologist to discriminate the oral mutilation performed in ritual communities, from those related to very small groups, or practices carried out for curative purpose, mostly in children.
Mutilations of a “strictly ritual nature” differ from infant oral mutilation, since the latter, even if “ritual” in the practice, have however a primarily curative intent.
Infant oral mutilations (IOMs) are in fact practices carried out on young children mostly affected by diarrhea and fevers who undergo the extraction of deciduous tooth buds, often canines, as an accepted remedy for their illness. Since they are performed for a medical “benefit” and on infants who are incapable of consenting to this practice (8, 9), IOMs clearly and deeply differ from the more commonly recognized practices of culturally based dental modifications.
MATERIALS AND METHODS
The research was made through the following search engines: PubMed, Scopus, Google Scholar. The key words utilized were “self mutilation”, “body modification and teeth”, “ritual mutilation of teeth” and “tooth extraction”. The articles were selected from a time span ranging between 1960 and 2013. The research was deliberately limited only to the ritual mutilations, which can be defined as “any irreversible impairment of the integrity of the human organism (in this context, mouth and teeth), made with a ritual purpose and without any curative aim”. Therefore, all the articles dealing with single or multiple dental self extractions of psychotic origins were excluded, as well as the infant oral mutilations, since the practice is deemed to have therapeutical effects among ethnic groups dedicated to this practice. Mutilations have then been grouped into five categories: avulsions/extractions, filing and shape modifications, coloring, decorations, and others.
In South Africa, in the now modern city of Cape Town, the practice of ritual avulsion still abounds, often as a rite of passage for teenagers (blacks and also whites) almost exclusively belonging to low socio-economic status families. The people living on the Cape Flats (Western Cape) have been performing dental modification by having their incisors removed for at least 60 years (10, 11). One of the most enduring images of the so called South African “Coloureds” people is the absence of their anterior teeth, and the reason is still a mistery to many, but which is popularly believed to be a facilitation for oral sex. It is popularly called the “Passion Gap” or the “Cape Flats Smile”. Other reasons for removing teeth are fashion, peer pressure, gangsterism. The practice has increased, in the last few years, even though dentists are obviously bound to their ethical code and not allowed to remove healthy teeth. The South African dentists have therefore applied thousands of partial dentures in patients who need an acceptable look at their workplace or on special occasions.
The practice of tooth extraction is common among indigenous African tribes, but it is mainly a Nilotic custom in Kenya, Tanzania and Sudan (12).
In Sudan (Dinka, Nuer and Maban tribes) and especially in the rural villages of South-Saharan regions, people extract the lower incisors (and sometimes also the canines), shortly after their eruption, as a rite of passage, to enhance beauty, to show their tribal identity, to allow the emission of specific linguistic sounds and to facilitate oral sex (6, 13-15).
Sometimes, the tooth extraction is a form of initiation into adulthood, as in the Luo group, among which the extraction of six lower teeth is performed, or in the Maasai tribes of Kenya (Figure 1), among which the ritual extraction of lower deciduous incisors at six months and the extraction of the lower permanent incisors at six years are performed; this practice is performed only in males to facilitate the feeding in case of tetanus and to exorcize the kidnapping of little babies (16).
A similar reason explains the ritual extraction of the two upper central incisors in the New Hebrides, where this mutilation, made in puberty and only in females, is a sign of entrance into adulthood and a sacrifice representing the value of death in suffering, the price of the social reinassance for a girl becoming a woman (3).
The Turkana ethnic groups from northern Kenya, as well as the black population of Jebel Moya usually remove their two lower incisors and nearly all of them wear lip plugs. The plugs are usually nail or disk-shaped and sometimes the tooth extraction is performed to fit the larger types of plugs (17).
Among other populations, the ritual of removing the four upper incisors, as in Cameroon, Mali and Mozambique (12), still exists, or in Borneo, where the practice is performed because of magical-religious beliefs, to allow feeding in case of tetanus, or to allow the performance of a stronger blast at the sumpitan or blow-pipe, increasing the thrusting power of poisoned arrows (18).
In some Australian aboriginal tribes, tooth ablations as a rite of passage or as a sign of mourning is a very common practice; in puberty, many Australian boys have a tooth knocked out (2, 19), Table 1.
2) FILING AND MORPHOLOGICAL MODIFICATIONS
Among some tribes and cultures, the desire to be alike or to be clearly different from animals seems to be the core reason of many dental mutilations. Some South American Indians of the Amazon Valley, for example, continue the practice of filing their maxillary central incisors to a sharp shape as a means of imitating the piranha fish which they greatly fear; consequently, sharpened teeth are also considered a mark of beauty among them (20). In Cameroon, Congo, Guinea, Zaire and Uganda the teeth are sharpened to resemble those of a crocodile: this practice is named akuha.
In Tanzania (among Makonde tribes) the ritual of chipping off part of the upper and lower incisors enamel, so that the teeth appear peg-shaped, still exists. This practice is performed for decorative purposes, esthetic reasons, signs of strength, the passage from teenage to adulthood (21), as among Malay races, where the filing of teeth takes place with a ceremony at puberty.
Beauty is extremely important for the natives of the Mentawai Islands (Indonesia), because they believe that if a soul is not satisfied by the appearance of its owner’s body, the person dies. In order to get more beautiful, young Mentawaian females who have reached puberty sharpen their teeth with a rock and a chisel and reduce them to a point.
Among Java, Sumatra and Borneo ethnic groups, the incisors are thinned and shortened. Deep transverse grooves are also made with a file, a stone, bamboo or sand, and the teeth filed to a point. Pointed teeth would act as a talisman against spirits of the ancestors or to facilitate the green bamboo chewing in the purgatory life, Table 2.
The intentional dying of teeth, which is typically performed around puberty, is a habit with strong roots in the past, documented in societies from all around the world. Such dying of the whole or just the visible surfaces of the teeth is known as “teeth blackening”.
Together with the extraction, filing and metal decoration of teeth, the process of teeth blackening has been ranked among dental mutilations (22). This is a practice with an important role in many cultures, especially across Southeast Asia islands and mainland (23).
The majority of these practices are performed by traditional healers, especially in African rural communities.
Black staining exists in Borneo where the teeth are colored in black with a mixture of burnt coconut shells and oil. Sometimes the tooth surface is abraded or etched with ginger or mango fruits. The mixture is applied on the tooth surface giving the impression of a black varnish. The practice lies in the conviction that white teeth are characteristic of animals and European people (27). More specifically some individuals in Malay blacken their teeth in order to differentiate themselves from dogs.
The blackening of the teeth is performed also among the Jivaro Indian people of Northern Peru and Ecuadorians, with the belief that the practice could prevent dental caries (18). Tooth lacquering and dying is performed also in several other regions of the world like Vietnam, Laos, Thailand, Indonesia and Philippines (28, 29), where teeth blackening is related to sexual maturation and full membership in society. In Indo-China the blackening of the teeth is also done because the mouth is considered the evil’s door.
Red staining is common in Morocco, it is the consequence of the habit of chewing “mkua fruit” (Hexabolus Senegalensis) or guru nuts (Cola Acuminata), Table 3.
The habit of applying decorations to the teeth has ancient origins, since the ancient Mexicans put precious stones as inlays in the teeth (18).
This habit is typically widespread in the region of Borneo, where the natives apply a thin brass plate called lios, worn over the incisors and hooked onto the molars. Total tooth coverage is made in the form of anterior gold crowns in the four maxillary incisors, shaped as a basket with a front window with a heart, diamond, club and spade in it (18). The Dyaks, a tribe from the same region, make a small hole in the transverse groove and insert a pin of brass, which is hammered to a nail-head shape in the hollow, or they inlay the teeth with gold and other metals. Also the Iban people of Borneo both blacken and file their front teeth which are further beautified by a brass stud in a hole drilled in the middle. The patient usually bites a piece of wood during the painful procedure.
Furthermore, in a north-eastern tribe of Uganda (Albert Nyanza Lake) they usually extirpate with a metal thread the four lower incisors of children of both sexes (30).
Teeth decoration is a practice still commonly performed in many places; Friedling said that the dentures themselves have become a fashion item, being decorated with gold or pieces of precious stones in various shapes and design (10).
There are, howewer, more unusual trends of dental modification nowadays in the United States, mainly involving African-Americans. Ornamental gold crowns placed on the anterior teeth, as a sign of pride and wealth are nowadays a fad among African-Americans in the US. The gold crowns, that are placed on the teeth, purely for esthetic reasons, are named as tooth jewelry; some of these crowns even have cutout designs or windows that are popular in various cultures throughout America (23). Only the wealthy people can afford the luxury of having gold teeth and this is useful to show to the opposite sex that the individual is someone who should be considered in the sexual partner selection.
Even more recently, another developing trend among the African-American community in the US is the application of a dental grill as a demonstration of high social status. A grill is a dental device, made of gold, platinum, or other metals, that is often encrusted with jewels and which can be inserted on the top of the maxillary anterior teeth (31). This device can be easily removed so that, during the day, the person can normally perform its duties with no grill on. The grill can be later inserted over the anterior teeth when in the desired social context. The grills are more expensive than gold caps, and therefore these people are most likely viewed as higher ranked in the social scale than those who have just gold caps. As far as different types of oral jewelry have become status symbols within the hip-hop industry and milieu, a lot of such items are usually crafted by jewelers and then applied by dentists. People of lower socio-economic status, however, wear grills of lower quality (32). Additionally, we must say that grill-wearing is a cost-inducing practice since the grill allows food and debris trapping and is a ground for bacterial growth and the cause of carious lesions (33). An example of American celebrities who love grills culture are Ke$ha, Kanye West, Nelly and Li’l Wayne, Usher, Snoop Dogg, Lil Jon, Thug Mike Jones, Bun B. and Sean Diddy Combs, Table 4.
5) OTHER KINDS OF MUTILATIONS
The aspiration to differentiate from other people or animals is the reason why the habit of breaking teeth is still so common among some populations. Some Papuans for example, practice this rite in order to be different from individuals of other disliked Papuan tribes. In the Maldives Islands there is a habit to break all four upper incisors in order to have the teeth aligned at the same level, so differentiating humans from animals (34). The Eskimos of the Mackenzie River, in Canada, instead, cut down the crowns of the upper incisors to be seen different from dogs (18).
The Mois (Stiengs) of Cochin-China break the two upper central incisors with a flint as a means of protection from sickness; this is always performed during a sumptuous ceremony at puberty.
Among hindu tribes of Bali the “spiritual tooth drilling” (Mapandes ceremony) is performed as a rite of passage: in this case, the entrance into adulthood is celebrated with the symbolic act of destroying the six enemies of the soul such as anger, pride, greed, lust, envy and confusion (35).
The women in certain Senegal tribes, finally, force the eruption of the upper incisors outward to obtain an overjet beyond the lower lip, Table 5.
Conclusions and forensic considerations
|In the course of human history, from prehistoric times until nowadays, there has always been the wish to change the appearance of the body, also of the teeth, with filings, engravings, precious stones, bezels, for esthetic purposes, as a sign of social status and as a tribal identification.|
Similar mutilations have been found with different anthropological meaning in ethnic groups very far from each other. Mutilation and extractions were carried out in the past, but are still practiced today among some ethnic groups, for initiation rites and tribal identification.
The geographical distribution of these procedures may result important for identification purposes; given the tribe/region specificity of dental mutilations, they may be useful for forensic identification, to determine the geographical area and ethnic and cultural backgrounds of the individuals. The irreversible morphological changes of the teeth, moreover, are preserved, after death, in the skeletal remains. But the detection of these morphological modifications of the teeth could be valuable also in the identification procedures of living subjects. Personal identification is in fact a growing problem due to the increase of illegal immigration, human trafficking and organized crime. Forensic odontology plays a relevant role in identification, but sometimes findings may be nonspecific, and identification therefore very difficult. For this reason, oral mutilations, even if infrequent, may provide a valuable contribution, because of their ethnic and geographic specificity.
Nevertheless, dental mutilations arouse medical-legal interest which goes beyond personal identification. These practices, in fact, raise ethical as well as legal issues. Dental mutilations are often performed by healers in unsafe environments and poor hygienic conditions, with possible relevant health consequences. The most common immediate risks include excessive bleeding, infections, osteomyelitis of the jaws, anemia, noma, tetanus, meningitis, aspiration bronchopneumonia, transmission of infectious diseases (including HIV and hepatitis) and death, often from sepsis (36-39).
Dental mutilations are also associated with irreversible alterations of the oral system, and can result in reduction of its functionality. Extractions, for example, can lead to malocclusions or orthodontic complications that are associated with defects of mastication, also related to shape modification. Sometimes it may result in malnutrition, but nowadays even psychological consequences cannot be ignored; especially in the case of immigrants, individuals express their embarrassment about dental status, which limits smiling, speaking and social interaction (40).
The identification procedures allow the forensic odontologist to carry out a campaign of awareness and information, especially among immigrants and healers, warning about the risks. Moreover, since such practices are dangerous and harmful to physical and mental health, they are ethically unacceptable and unlawful. It is therefore necessary to report all cases of dental mutilation in order to identify any individuals engaged in such practices within our countries.
Even if they are generally accepted practices in European countries or in America, dental grilling, can actually lead to complications or detrimental effects especially for hygienic reasons. It can be associated with irritation or metal-allergic reactions, and in the absence of careful hygienic practices it could lead to the development of dental carious lesions (31).
The possible health hazards, pose questions about the legitimacy of the act also connected with ethical and legal issues of information and consent to treatment.