Applied Research Teething: Misconceptions and Unhealthy Practices Among Residents of a Rural Community in Nigeria Olubunmi Olusola Bankole1 and Folake Barakat Lawal2 Abstract Misconceptions about the teething process has led to high infant morbidity and mortality, which was recently experienced in Nigeria due to consumption of an adulterated drug used in the prevention and treatment of teething-related illnesses in infants. It is however, unknown if these misconceptions still persist in a rural town in Nigeria despite oral health awareness campaigns targeted at this. The aim of this study is to assess the beliefs and practices of residents in Igbo Ora, a rural township in Nigeria, regarding the teething process. A descriptive cross-sectional study was conducted among 393 adults in Igbo Ora using a 33-item, semistructured question- naire. Symptoms such as diarrhea (80.7%), fever (69.2%), and boils (64.4%) were still considered as a must to accompany teething. Teething powder, teething syrup, and traditional concoctions were commonly recommended by (42.0%), (31.6%), and (48.1%) of the respondents, respectively, to treat and prevent teething symptoms. This study revealed that misconceptions about teething are still highly prevalent among the populace in Igbo Ora, and a structured oral health education intervention at the community level is urgently needed. Keywords beliefs, attitudes, practices, children, teething Introduction Eruption of teeth is a natural process that is experienced by all children. Studies have shown differences in primary teeth eruption age of children, and Nigerian children have been found to experience earlier teeth eruption1 than their Saudi2, Iraqi3, and American2 counterparts but later than Icelandic4 and Japanese5 children. Over centuries, despite the fact that eruption of teeth is considered an important milestone eagerly awaited by parents, symptoms such as fever, convulsions, meningitis among others, have been asso- ciated with the teething process.6 Furthermore, about 50% of infant deaths were attributed to teething in France from the 16th to the 19th century.7 Sarrell et al.,8 studying Israeli parents and medical person- nel’s beliefs about infant teething, found that 76% of them associated teeth eruption with morbidity in children. Studies within and outside Nigeria have reported that many believed that the teething process is associated with an array of symp- toms such as diarrhea, fever and conjunctivitis, vomiting, sleep disturbances, and loose stools.9–16 The integral hazard with such misconceptions is that mothers may not seek consultation from medical clinics for supposed teething symptoms in their children, thus indulging in self-medication, which has some- times led to tragic instances of infant mortality.17 Furthermore, the recent infant deaths attributed to an adulterated teething drug (My Pickin) in Nigeria was disas- trous17 and led to different oral health education programs and awareness campaigns in many parts of southwestern Nigeria to disabuse the minds of Nigerians against the symp- toms incorrectly associated with the teething process. However, of importance to the child oral health specialist and the community oral health professional is how far and how well disseminated this information regarding the teething process is aimed at bringing a halt to child mortality asso- ciated with these misconceptions. A need therefore arises to investigate if these erroneous beliefs and practices of Nigerians particularly in rural remotely located communities regarding the teething process still persist. This becomes important in regions such as Igbo Ora where a primary oral health care center (POHCC) exists, and efforts have been International Quarterly of Community Health Education 2017, Vol. 37(2) 99–106 ! The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0272684X17701262 journals.sagepub.com/home/qch 1Department of Child Oral Health, University of Ibadan, Nigeria 2Department of Periodontology and Community Dentistry, University of Ibadan, Nigeria Corresponding Author: Olubunmi Olusola Bankole, Department of Child Oral Health, University of Ibadan, Ibadan 20001, Nigeria. Email: bumbank2002@yahoo.com UNIV ERSITY O F I BADAN LI BRARY journals.sagepub.com/home/qch made by the workers of this center in creating awareness about the negative implication of the teething myths and its contribution to infant morbidity and mortality. This study thus assessed the beliefs and practices as it relates to teething process in infants among adult residents of Igbo Ora, a rural community in southwest Nigeria. Material and Methods Study Area Igbo Ora is a rural town in the tropical rain forests of southwestern Nigeria. It is located in Oyo State and situated 80 km north of Lagos which is a cosmopolitan city. It is the headquarters of Ibarapa Central Local Government with a population of 60,000 people.18 Igbo Ora was selected as the study site because of its indigenous history of a typical rural setting as well as the location of a POHCC within the town, thus endowed with dental care resources in terms of man power. The major activity of the POHCC is conduct of oral health promotional programs to different sub population groups of which is the enlightenment oral health talks as it relates to teething conducted in the child welfare and ante- natal clinics. Sampling Method Igbo Ora has five clinics providing children’s welfare (four primary child welfare clinics and one secondary health-care center). Two of the five clinics providing children’s welfare were randomly selected by balloting. A descriptive cross- sectional study was conducted among parents aged 18 years and older attending these child welfare clinics. Using a preva- lence of 31.8% for rural Nigerian residents who did not asso- ciate symptoms with the teething process from a previous study by Oyejide and Aderinokun,10 a minimum sample size of 333 was calculated. Consecutive adult attenders who agreed to participate in the study were interviewed. The study instrument consisted of a 33-item semistructured ques- tionnaire newly constructed from compilation of questions from the literature with similar aims to this study. The ori- ginal English version of the questionnaire was translated into Yoruba language, the local language of the inhabitants of Igbo Ora community by an independent professional who is versed in both English and Yoruba language and back trans- lated by another linguistic not aware of the aims and object- ives of the study. Minor differences noted were adjusted after reaching an agreement by the two-professional linguistics. The level of agreement in Kappa coefficient is 0.922. The Yoruba language is the native language spoken in southwes- tern Nigeria. Information obtained included basic demo- graphic data and symptoms believed to be associated with the teething process. Remedies they would use for teething symptoms in children, advice they will give other mothers and pregnant women regarding the teething in their children and method to prevent the occurrence of teething symptoms in children were also asked. The questionnaire was content validated by pilot testing among 10 adult women who were not part of the study population. Ambiguous and unclear statements were noted and modifications effected in the final questionnaire. The questionnaires were interviewer adminis- tered by three research assistants who had undergone a 1-day training. Data were collated, cleaned, and analyzed using the Statistical package SPSS 21. The open-ended questions were first coded before entry into the statistical software (SPSS) with the other variables and analyzed. For the purpose of cross tabulations and to reduce the number of empty cells, age was constructed into a binary variable using the median, educational qualification was recoded as higher educational qualification (postsecondary) and lower educational qualifica- tion (made up of ‘‘no formal education, primary and second- ary levels of education’’). Association between variables was carried out using Chi-square statistics, and the level of signifi- cance was set at <5%. Ethical Approval The study was approved by the Oyo State Ethical Review Board in Ibadan, Nigeria. Permission to carry out the survey was obtained from the heads of the child welfare clinic in Igbo Ora and the participants in the study. Results Sociodemographic Characteristics of the Study Participants Three hundred and ninety-three adults participated in the study. Three hundred and thirty-five (85.2%) were females, and the mean age of respondents was 32.7 (SD¼ 12.2) years, median age was 30 years, and the modal age was 28 years. Regarding educational qualification, (15.8%) had no formal education while the rest had primary or higher qualifications (Table 1). Perceived Signs and Symptoms of Teething Diarrhea, fever, and boils were believed by (80.7%), (69.2%), and (64.4%) of respondents, respectively, to be synonymous with teething. Other symptoms associated with teething men- tioned include crying, sleeplessness, appetite, and weight loss (Table 2). Only (3.8%) were of the opinion that teething was a natural process that was not linked with any symptoms (Table 2). Remedies for Teething in Infants Remedies for teething in children as mentioned by respond- ents included traditional concoctions (48.1%). Others include 100 International Quarterly of Community Health Education 37(2) UNIV ERSITY O F I BADAN LI BRARY analgesics (paracetamol), antibiotics capsule (red and yellow color—tetracycline) sedatives, teething powder, and teething syrup (Figure 1). Advice to Other Mothers About Teething When asked about advice, they would give if other mothers came to ask them for counsel concerning their child with tee- thing symptoms (7.0%) would advise that the child be taken to the hospital. Others will advise teething syrup, teething powder, antibiotics, and herbs in different combinations (91.9%), teething soap (0.5%), palm oil to drink (0.5%), or that the erupting tooth at that period should be removed (0.3%). Self-Reported Methods of Prevention Teething Symptoms Children The majority (71.5%) of the respondents mentioned that using traditionally compounded teething soap to bathe infant was effective as a preventive measure for teething symptoms. Drinking and bathing with herbs and traditional concoctions were believed by 14.5% and 5.9% of respond- ents, respectively, to forestall teething symptoms. Traditional objects such as wearing of traditional wrist bands, amulets, bangles, native beads around child’s waist kebekebe, and inci- sions made by herbalists and witch doctors on child’s skin were mentioned by (8.4%) of these community members as useful and effective measures to preventive symptoms and problems related to teething in children (Figure 2). A few of the respondents (3.1%) were of the opinion that if the mother herself drank traditional concoctions, it will pre- vent teething problems in the child. Perceived Measures for Pregnant Women to Prevent Teething Symptoms in the Unborn Child Regular consumption of herbs by women when they are preg- nant (35.1%), avoidance of breach of cultural taboos of the land by pregnant women (14.5%), and following laid down traditional doctrines for pregnant women (17.0%) is believed to forestall teething problems in the child when born. Some respondents (28.2%), however, believed that teething prob- lems could not be prevented by giving anything to the preg- nant women and it was just their fate while (5.1%) had no response to the question (Figure 3). Sociodemographic Characteristics and Association of Teething With Symptoms There was a significant difference between age and beliefs that teething is associated with symptoms with the older age- group, (1.4%) believing this more than those less than 30 years of age (p¼ .009). A higher proportion of respondents with postsecondary education (10.0%) mentioned that tee- thing is not associated with symptoms compared with those with secondary, primary, or no formal education (2.2%; p¼ .001). There was no significant difference between gender and belief that teething is not associated with symp- toms (p¼ .185; Table 3). Table 1. Sociodemographic Characteristics of Respondents. Characteristics of the respondents n % Gender Males 58 14.8 Female 335 85.2 Age (years) �20 61 15.5 21–30 148 37.7 31–40 99 25.2 41–50 45 11.5 51–60 29 7.4 60 11 2.8 Educational qualification No formal education 62 15.8 Primary 98 24.9 Secondary 153 38.9 Postsecondary 79 20.1 No response 1 0.3 Religion Christian 119 30.3 Muslim 255 64.9 Traditional worshiper 1 0.3 Other groups 18 4.6 Note. n, number of respondents. Table 2. Respondents Perceived Signs and Symptoms of Teething in Infants. Perceived signs or symptoms of teething n % General irritability 249 63.4 Crying 235 59.8 Sleeplessness 163 41.5 Increased salivation 232 59.0 Increased thirst 35 8.9 Loss of appetite 189 48.1 Weight loss 186 47.3 Fever 272 69.2 Diarrhea 317 80.7 Boils 253 64.4 Cough 239 60.8 Conjunctivitis 79 20.1 No symptoms 15 3.8 Note. n, number of respondents (multiple responses). Bankole and Lawal 101 UNIV ERSITY O F I BADAN LI BRARY Discussion Even though tooth eruption is a natural process of child development, its effect on the health of an infant has contin- ued to be controversial.19 The American Academy of Paediatric Dentistry however states that teething can lead to irritability, excessive salivation, and intermittent localized dis- comfort in the area of erupting primary teeth.20 This study aimed to provide information about the current perception of the teething process and more evidence for structured health promotion intervention aimed at addressing misconceptions about teething in this Igbo Ora township and Tradi�onal concoc�on 48.1% Analgesics 67.7 An�bio�cs 14.2% Seda�ve drugs 4.6% Teething powder 42.0% Teething Syrup 31.3% 0 10 20 30 40 50 60 70 80 Tradi�onal concoc�on Analgesics An�bio�cs Seda�ve drug Teething powder Teething Syrup Figure 1. Respondents remedies for teething in infants (multiple responses). 5.9 71.5 14.5 8.4 0 10 20 30 40 50 60 70 80 Tradi�onal Concoc�on Teething Soap Herbs Tradi�onal things Pe rc en ta ge Figure 2. Respondents perceived remedy for prevention of teething symptoms in children (multiple responses). 102 International Quarterly of Community Health Education 37(2) UNIV ERSITY O F I BADAN LI BRARY similar settings. The outcome of this study reveals that mis- conceptions about teething process still exist among the inhabitants of this rural town. Such misconceptions have been found to exist in other cultures.12,15,21,22 The most frequent symptom linked to teething was diar- rhea as (80.7%) believed that it was a normal part of the teething process. This proportion is higher than in other urban Nigerian towns like Lagos (64.0%),13 Ibadan (44.8%),16 and Enugu (53.3%).11 This difference is likely due to the remote and rural location of Igbo Ora as well as the fact that strong cultural beliefs play important roles in the various practices of such communities. In addition, it could be a reflection that people in rural areas may be less likely informed about keeping good oral health habits in their chil- dren due to their remote location. Diarrhea in infants is due to the fact that some of them are crawling and placing dirty, contaminated objects in their mouth. Unfortunately, some parents mistakenly believe that diarrhea is a natural cleansing procedure causing systemic cleansing of the child’s body system.12,16 Asakitikpi23 studying the diarrheal concept among Yoruba women in Ibadan, Nigeria discovered that it is viewed as a milestone that must accompany the teething process. Furthermore, it is believed that erupting teeth increase body temperature ultimately causing stomach upset and loose stools. The erupting teeth have also been associated with increased salivation, which when swallowed raises the 35.1 17.0 14.5 28.2 0 5 10 15 20 25 30 35 40 Take herbs Follow tradi�onal cultural prac�ces Aviod breaching cultural taboos None Pe rc en ta ge Figure 3. Respondents perceived remedy for pregnant women to prevent teething symptoms in the unborn child. Table 3. Sociodemographic Characteristics and Association of Teething With Symptoms. Sociodemographic characteristics Teething not associated with symptoms, n (%) Teething associated with symptoms, n (%) Total, n (%) �2 p Age (years) �30 3 (1.4) 172 (98.6) 175 (100.0) 6.896 .009* >30 12 (6.5) 206 (93.5) 148 (100.0) Total 15 (3.8) 378 (96.2) 393 (100.0) Gender Male 4 (6.9) 54 (93.1) 58 (100.0) 1.758 .185 Female 11 (3.3) 324 (96.7) 335 (100.0) Total 15 (3.8) 378 (96.2) 393 (100.0) Educational qualification Higher 8 (10.0) 72 (90.0) 80 (100.0) 10.461 .001* Lower 7 (2.2) 306 (97.8) 313 (100.0) Total 15 (3.8) 378 (96.2) 393 (100.0) Note. n, number of respondents (multiple responses). *Statistically significant. Bankole and Lawal 103 UNIV ERSITY O F I BADAN LI BRARY child’s propensity to diarrhea.23 Hence, many parents see no need for treatment since the symptoms are borne out of nat- ural causes. However, of particular concern is the fact that children with diarrhea have increased likelihood to develop dehydration which can be life threatening if not promptly treated. Primary care providers should thus be educated to recognize early signs of dehydration and discourage miscon- ceptions that teething causes diarrhea.24 Fever was the second most commonly reported symptom accompanying teething as (69.2%) of the respondents men- tioned this. This finding is in consonance with earlier reported findings in Enugu, Nigeria (71.0%),11 and India (70%)9 but higher than reported in Brazil (44.1%).25 This misconception poses hazards as children will not be taken for medical con- sultation when there is fever and hence more serious under- lying conditions may be overlooked. It is of grave concern to find out that only 7% of respondents would advise mothers to take their children to the hospital for perceived teething symptoms. An explanation for the misconception that tee- thing causes a whole avalanche of symptoms is that about the period of life when teeth start erupting, the infant experi- ences a decline in maternal immunity and is prone to infec- tions. This period also corresponds to the timing when the first clinical appearance of malaria infection, which is endemic in tropical countries like Nigeria, can occur in children.26,27 Loss of infant’s appetite and loss of weight were believed by 48.1% and 47.3% of the respondents, respectively, to accom- pany the febrile process and diarrhea as normal signs of tee- thing and believed that the child will return to normalcy after erupting the teeth. Schwann’s28 study confirms the fact that many symptoms have been incorrectly attributed to teething as out of 50 children on hospital admission for teething, 48 were diagnosed with a medical condition. This study demonstrated that younger respondents believed more that the teething process was associated with symptoms. This is in consonance with reports among some nursing mothers by Ige and Olubukola.16 This may be due to less experience with child bearing. Furthermore, the less edu- cated community members were of a greater opinion that teething in their children is associated with symptoms. This is contrary to the finding of Uti et al.13 in which no relation- ship to educational status was found. Self-medication with analgesic, mainly paracetamol, was a popular remedy for teething symptoms as 67.7% of the respondents engaged in this. This finding was higher than in the study by Opeodu and Denloye29 where 31% of parents utilize paracetamol for children’s teething. It was however in consonance with the findings of Kakatkar et al.9 While it may be essential to lower body temperatures in febrile states, this may conceal more serious underlying illnesses by giving a distorted clinical picture. Of particular worry is the hazardous outcome of drug interactions when additional agents such as herbal remedies or local traditional preparations containing high concentrations of ethanol are given to these infants with paracetamol,30 a scenario commonly observed in Nigeria. This is worrisome as a lot of herbal preparations in Nigeria are often soaked in alcohol to allow fermentation of the leaves and plant roots to produce the required potent extract. It is important to note that 14.2% of the respondents will engage in self-medication with antibiotics for teething prob- lems in children. Tetracycline is the favorite antibiotic par- ticularly among community members from the lower social class. This is popularly given to infants for treating teething diarrhea. A major problem with tetracycline is the grayish discoloration caused in actively calcifying tissues like the teeth. Aderinokun et al.31 revealed that over a third of 12 year-old children in Ibadan, Nigeria had tetracycline stains on their teeth as a consequence of tetracycline consumption in childhood. Antibiotics in Nigeria are readily purchased from local drug peddlers and over the counter from patent medicine stores without prescriptions. A lot of them lack imprinted expiry dates. Some drug peddlers have made some of the local populace erroneously believe that the red color on the red and yellow tetracycline capsule is a form of blood tonic conferring additional immunity to the child, thus heightening parents’ interest in the drug use. Inadequate doses for insufficient number of days are usually given to these infants. Arbitrarily antibiotics abuse thus poses the risk of development of hypersensitivity reactions and building of resistant bacterial strains in individuals.32 Teething powder and teething syrup appeared as a favorite treatment for teething symptoms as 42.0%will give their infants teething powder while 31.3% will give teething syrup. Teething powder in the earlier years contained mercury33 but now con- tains essential oils usually Matricaria chamomilla (chamomile) and lactose.34 Teething syrup in Nigeria usually contains para- cetamol base and sometimes antihistamines. Hazards of infant consumption of teething syrup are that mothers may give unregulated doses, unaware of the maximum doses of the active ingredient. Excessive doses might be consumed when mothers also administer prescription drugs to their children and at the same time give teething syrup. Adulterated forms may exist, as seen in Nigeria in 2008 when paracetamol-based mixture in My Pickin teething syrup was laced with an agent more commonly used as engine coolant—diethylene glycol. This led to the death of 84 babies17 and consequently to the publicity on the media about the dangers associated with misconceptions about the teething process and use of teething drugs among the populace. Many public health professionals were also involved in the counselling and education of themasses to discourage this act, but obviously, this effort is grossly inadequate as observed in this study as many still engage in this habit. This may prob- ably be due to low coverage or inadequate educational tools which must be looked into. Exploring other means of educating and enlightening people in this community may have to be con- sidered and large coverage at the community level may be promising. Babies will be given traditional concoctions to treat tee- thing symptoms by 48.1% of the study participants. This can be easily purchased from local concoction hawkers 104 International Quarterly of Community Health Education 37(2) UNIV ERSITY O F I BADAN LI BRARY alagbo and also from elewe omo who are traditional specialists who compound concoctions for children. Despite the recent drive for traditional and alternative medicine in Nigeria, the formulations and doses of the constituents of some these con- coctions are unknown and some may be hazardous for infants. Research has also revealed unhygienic practices in their preparation with the level of microbial contamination in some local concoction or herbal preparations clearly exceeding tolerable limits.35 The presence of a large number of pathogenic organisms, including Staphylococcus aureus, Bacillus cereus, and Escherichia coli, in some Nigerian herbal concoctions have been reported in literature.36 It is disturbing that some of the participants would counsel other mothers to use teething soap, give infant palm oil to drink, and recommend that teeth erupting at that period should be removed to eliminate supposed teething symptoms. Premature removal of sound primary teeth is usually per- formed by quack doctors and traditional doctors who use unsterilized and crude instruments traumatically forcing out these teeth and thus exposing infant to undue pain, bacterial infection, hepatitis, HIV, and Ebola virus. Palm oil in Nigeria is culturally believed to neutralize toxic substances and poi- sons in the Yoruba culture to which the respondents belong. This may be the reason for erroneously recommending it to ignorant mothers to supposedly neutralize the effects of tee- thing process producing symptoms in their children. The majority of respondents believe that teething symp- toms can be prevented usually by bathing a child with trad- itionally compounded teething soap (71.5%). This consists of the traditional black soap mixed with local herbs particularly eru which is considered medicinal. Furthermore, 14.5% and 5.9% of the participants would give babies herbs and trad- itional concoctions, respectively, to drink at an early age before the teeth erupt to forestall teething symptoms. Traditional spiritual preventive methods included wearing of traditional wrist bands, amulets, bangles, native beads around child’s waist kebekebe, and incisions made by herbal- ists and witch doctors on child’s skin were practiced by 8.4% of the respondents. The use of teething necklaces viewed as a protective amulet has also been practiced by some mothers.37 This has however been associated with the risk of strangula- tion or aspiration of small beads in infants.38 A few of the respondents were of the opinion that drinking traditional con- coctions regularly by mothers will prevent the whole array of teething symptoms in their children. They also believed that if pregnant women, consumed herbs and concoctions regularly, adhered to laid down traditional doctrines for pregnant women and avoided breaching of cultural taboos of the land, it would prevent teething symptoms in their babies. Conclusions The outcome of this study showed that misconceptions about teething are still highly prevalent among the populace in Igbo Ora despite previous attempts at creating awareness about the negative implication of the teething myths. This gives a ser- ious cause for concern as mothers are not likely to seek med- ical consultation for childhood ailments incorrectly attributed to teething, which may be a strong contributing factor to the high infant mortality rate in Nigeria. Obstacles to effective- ness of previous health education programs may include the issue of transportation for some those living in the environs and poverty as some would prefer to set off early in the day to go and sell their wares in the local market than wait and listen to health talks. There is therefore a dire need to strategize and plan an educational intervention in this community and other rural settings targeted at mothers and pregnant women, in particular the younger and less educated ones, to help dispel this cultural myth. Limitation The limitation of this study is that only community members attending the child welfare clinics were recruited for this study. Other members of the community who were not found at this study sites were excluded from the study as the study site was in the child welfare clinics. The fact of not putting into consideration, the child rearing experience of the women is a limitation of this study as this may be an important contributory factor to teething myths. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 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Folake Barakat Lawal, is a Community oral health dentist and a senior lecturer at the University of Ibadan, Nigeria 106 International Quarterly of Community Health Education 37(2) UNIV ERSITY O F I BADAN LI BRARY http://www.medicines.org.uk/emc/medicine/25623 http://www.medicines.org.uk/emc/medicine/25623