With much concern about access to dentistry, there is growing concern that people are turning to DIY dentistry with all sorts of reports on TV, newspapers, radio and of course, social media about people undertaking their own extractions. There is no real data about the number of people around the world who undertake their own dentistry, but surveys have suggested 10% of the population have attempted DIY dentistry and a third of these have reported attempts to extract at least one tooth. At the same time, four out of every five dentists have also reported to have treated a patient who has attempted DIY dentistry of one form or another.
It is a great subject for headline writers who can deploy some of their best lexicography: anger, fear, pliers, pulled, shocking, scared, Victorian and so on. There are even websites providing information on DIY extractions and whilst some provide balanced information for patients, others provide a step-by-step guide. Who knew that this part of our undergraduate and postgraduate education could be reduced to postcard sized information? But what about the complications, the unexpected anatomy, the fractured root and all the other challenges that such websites failed to disclose? There is no evidence on these websites of any patient information on these aspects or indeed fractured alveolar bone or a dry socket.
I felt it was time for an article that does not simply complain about access to dental care but explores the social, medical, economic and cultural aspects of extract-it-yourself dentistry. Untreated dental pain is the most frequently stated reason for self-extraction being required and this often hits the media but there are actually many other reasons.
Mobile deciduous teeth are inconvenient and frequently interfere with eating and inevitably lead to the “snaggletooth” appearance during the mixed dentition stage. Whilst most dentists will reach for local anaesthetic in this situation, cryotherapy is another option and used in some parts of the world. As an orthodontist, I occasionally ask for a gauze swab to deal with a very mobile tooth. Inevitably there is a range of unconventional methods for extracting deciduous teeth including the string and doorknob technique, and the ‘tooth fairy’ method where the mobile tooth is extracted as part of the game. Magnets have been attempted, and inevitably You-Tubers showcase a range of innovative approaches including one small boy who has taught his pet parrot to extract loose deciduous teeth, and all sorts of kinetic energy methods involving a bow and arrow or crossbow, toy aeroplanes, remote-control cars, toy helicopters, small rockets, golf balls, high-performance cars, or employing the family dog to run in the opposite direction. If only Fido knew!
Once a deciduous tooth has been shed or extracted, attention turns to the Tooth Fairy, who only started rewarding children in relatively recent times. In the Middle Ages, there were many superstitions about children’s teeth. Burying teeth or burning them either avoided the need to spend eternity hunting for them in the afterlife or prevented a witch having total control over the owner were they to fall into possession. The Tooth Fairy does not have a complete monopoly across the world. The Little Mouse, El Ratoconcito Pérez in Spain and Hispanic America, La Petite Souris in France and French-speaking Belgium, white fairy rat in Lowland Scotland and Topolino in Italy (or Formichina, little ant, in Veneto) is responsible. In other parts of Europe, the situation differs: little angels (Els Angelets) and Les Animates (little souls) in Catalonia, and Mari Teilatukoa (Mary from the roof) in the Basque country catches teeth thrown by children while the tooth squirrel (L’Esquilu de los dientis) in Cantabria rewards children with a gift or coins.
Patients suffering from psychiatric disorders and severe substance misuse are also known to consider extracting their own teeth. There is crossover for such patients with some religious and spiritual interpretations of the need for dental extractions where there is a perception of “imbalance” either due to a curse, impurity or spiritual imbalance. Clearly people troubled by such feelings require professional help, with the dentist being part of the wider care-team to ensure self-harm is avoided.
Cultural beliefs and societal factors influence the practice of self-extractions in some communities, and it is important to understand these in the broader context of self-performed dental extractions around the world. Within the anthropological literature, it is reported that in some cultures, oral health problems are managed traditionally at home with focal remedies rather than accessing professional dental care. Extractions are therefore frequently performed by family members or sometimes traditional healer as the ''bad tooth' can be believed to be the root of systemic illness (which may be true), or at least that dental pain always represents infection which can also be treated by physical removal of the tooth. In other cultures, dental extractions are part of home remedies that are passed through the generations for the treatment of a range of conditions and diseases.
In some Eastern African countries (Uganda, Tanzania, Kenya, Ethiopia and South Sudan), infant canine removal, also known as "false teeth'' extraction is undertaken as the gingival swelling that accompanies erupting canine teeth is believed to be due to “false teeth” with the perception that the swellings are due to worms that cause illness including fever, diarrhoea, vomiting and malnutrition. The traditional healer may remove the developing canine tooth bud using a range of methods including sharp instruments, heated needles and herbal remedies.
In other cultures, dental extractions and modification of teeth is a rite of passage in relation to social and tribal identity. Whilst the majority of such practices performed by community elders involve dental modification, adolescent rites sometimes involve dental extractions, and it is sometimes symbolic to arrange for dental extractions in preparation for marriage. Such practices are reducing but are still documented in Africa, Southeast Asia with the practice being recorded historically within some indigenous Australian communities.
As the world continues to advance economically, educationally, technologically and in other ways, healthcare rightly follows, and everyone should have access to evidence-based dental care. However, global care is not universal by the majority of health metrics. Interestingly, whilst the majority of the scientific literature on DIY dentistry is at the level of the case report, narrative review and survey, self-performed extractions are by no means unusual in high income countries, which highlights societal inequalities. As a regular traveller, I am fully aware that the social gradient is a key factor in DIY dentistry and whilst systematic reviews and other evidence synthesis methods are limited in this area of healthcare, the distinction between a lack of access and the willingness to undertake self-treatment (including family-member induced “injury”) needs to be made clear.
Self-extraction in vulnerable populations including homeless, prisoners, remote and rural communities require specific and targeted interventions, but the economically or geographically disadvantaged people of the world should not be forgotten either. So-called auto-extraction is significantly under-reported around the globe and whilst governments should do more to address dental access issues, the overall story is nonetheless complex. DIY dental extractions are however part of the natural process of shedding the deciduous dentition whilst the Tooth Fairy and the European equivalents should be congratulated for magically turning teeth into financial or gift rewards.
If you would like to get in touch about this topic or any other issue, get in touch at dental@rcsed.ac.uk.