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Referral and warning signs
When to refer
Refer children with complications (severe sepsis, anaemia, dehydration, severe malnutrition) to higher level care (HC4/H). Refer for dental assessment later if malocclusion or significant dental damage is evident.
Red flags
- Signs of severe sepsis.
- Severe dehydration.
- Severe anaemia.
- Severe Acute Malnutrition (SAM).
Signs and symptoms
- Presenting illness (misattributed to 'ebinyo'): Fever, Diarrhoea, Vomiting, Failure to thrive, General infant illness.
- Signs of the harmful practice: Missing primary or permanent canine teeth, Damage to adjacent teeth, Oral sepsis/infection, Gum lacerations/scarring, Malocclusion, Anaemia (from bleeding/infection), Dehydration (if underlying illness untreated).
Risk factors
- Traditional cultural beliefs attributing common infant illnesses to teething/tooth buds.
- Lack of access to appropriate healthcare and health information.
- Peak age for practice: 4-18 months (coincides with common infant illnesses and canine eruption).
Diagnosis
Clinical assessment
History from caregiver about child's illness and seeking traditional treatment involving gum rubbing or tooth removal ('ebinyo'). Clinical examination revealing missing tooth buds (especially canines), gum trauma, or signs of complications (sepsis, anaemia, dehydration, malnutrition). Diagnosis of the actual underlying illness (e.g., malaria, pneumonia, gastroenteritis) is crucial.
Investigations
- Investigations directed at diagnosing the true cause of the child's symptoms (fever, diarrhoea, vomiting) - e.g., Malaria test, CBC, Stool analysis, Chest X-ray as appropriate.
Diagnostic criteria
History of the practice + Clinical signs of missing tooth buds/gum trauma. Exclusion of teeth as the cause of systemic symptoms.
Management
Non-pharmacological management
- Counseling (Crucial): Educate parent/caregiver about the true cause of the child's illness and the dangers/ineffectiveness of the 'ebinyo' practice. Emphasize that teeth do not cause systemic illness like fever/diarrhoea. (LOC: HC2+)
- Address nutritional status.
- Provide oral hygiene instructions.
Pharmacological treatment
- Treat the Underlying Condition: Provide appropriate medical treatment for the actual cause of the fever, diarrhoea, vomiting (e.g., antibiotics for pneumonia, ORS/Zinc for diarrhoea, antimalarials). (LOC: HC2+)
- Manage complications: Treat oral sepsis/infection, manage anaemia, manage dehydration.
Monitoring
Monitor resolution of the underlying illness and any complications from the harmful practice.
Complications
- Oral sepsis, Bacteraemia, Systemic infection.
- Anaemia.
- Dehydration (if underlying cause untreated).
- Malnutrition.
- Damage/loss of permanent tooth buds.
- Malocclusion.
- Death (from untreated illness or complications).
Prevention
- Community sensitization and health education about the dangers of the 'ebinyo' practice.
- Dispel myths linking systemic illness to teething.
- Promote access to timely and appropriate healthcare for common childhood illnesses (IMCI).
- Improve child nutrition.
- Engage with traditional healers to discourage the practice.
Patient education
- Clear explanation that 'ebinyo' practice is harmful and does not treat the illness.
- Education on common childhood illnesses and their appropriate treatment.
- Importance of seeking care from trained health workers.
- Nutritional advice.
- Oral hygiene advice.
Uganda-specific notes
'Ebinyo' is a specific harmful traditional practice prevalent in many Ugandan communities. Health workers must be aware of it, counsel caregivers firmly but respectfully, and treat the underlying childhood illness causing the symptoms.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 23, Section 23.1.5