The mortality of ill infants with false tooth extraction in a rural Ugandan emergency department

Abstract

False tooth extraction (FTE), a cultural practice in East Africa used to treat fever and diarrhea in infants, has been thought to increase infant mortality. The mortality of clinically similar infants with and without false tooth extraction has not previously been examined. The objective of our retrospective cohort study was to examine the mortality, clinical presentation, and treatment of infants with and without false tooth extraction. We conducted a retrospective chart review of records of infants with diarrhea, sepsis, dehydration, and fever in a rural Ugandan emergency department. Univariate analysis was used to test statistical significance. We found the mortality of infants with false tooth extraction (FTE+) was 18% and without false tooth extraction (FTE-) was 14% (P=0.22). The FTE+ study group, and FTE- comparison group, had similar proportions of infants with abnormal heart rate and with hypoxia. There was a significant difference in the portion of infants that received antibiotics (P=0.001), and fluid bolus (P=0.002). Although FTE+ infants had clinically similar ED presentations to FTE- infants, the FTE+ infants were significantly more likely to receive emergency department interventions, and had a higher mortality than FTE- infants. the emergence of a false tooth is the cause of illness, particularly, diarrhea and fevers in infancy. Extracting this tooth is believed to be the eventual cure for the symptoms. The extraction is often performed by a village medicine man or at the local village health center. FTE involves an incision and manipulation of the infant’s gums for removal of a suspected false tooth. Sometimes this procedure is performed with crude objects such as sharpened bicycle spokes, knives, and fingernails.5 In the district of Rukungiri parents of the infant will often describe the use of a sharp metal hook that is typically used for basket weaving to manipulate the infant’s gums. Manipulation of the gums, a highly vascular area, with such non-sterile objects provides opportunity for bacteremia and sepsis. There have been some descriptive reports of the practice of FTE in Northern and Eastern Uganda. The morbidity and mortality of this cultural practice has not been examined in Western Uganda or in the setting of an emergency department in a rural district such as Rukungiri. Karoli Lwanga Hospital in Rukungiri is a regional medical center that serves a population of 321,000 people in Western Uganda.6 It is one of the only rural hospitals in Uganda to have an emergency department (ED). Almost 40% of the patients seen in the Karoli Lwanga Hospital ED are younger than 18 years of age. Among those children are infants that present in septic shock after having the cultural procedure of false tooth extraction. The primary purpose of our retrospective cohort study is to describe infants with the diagnosis of diarrhea, or dehydration, or fever, or sepsis, or FTE that present to Karoll Lwanga ED with recent FTE, their clinical presentation, and management, and compare them to similar infants without evidence of recent FTE. The secondary purpose is to describe the prevalence of mortality of infants who have undergone FTE.