This article was based on five interviews with Somalis conducted in the summer of 2001 by University of Washington students and faculty.
Oral Health: Infant Nutrition
Most Somali mothers living in Mogadishu prefer to give birth in a hospital. Somali women who choose to give birth at home use a midwife, who is usually a hospital worker with some western medical training who is paid privately for assisting at the home birth. Whether giving birth in the hospital or at home, a woman relies on the help of midwives and will rarely see a doctor unless birthing complications arise. Somali mothers receive information about how to feed and care for their babies from their mothers and other relatives, and from those who deliver their child.
It is culturally important for Somali mothers to breast feed their babies; not doing so is seen as a sign of poor mothering. Somali children are breast fed until they are two years old, or until the mother becomes pregnant again. Children raised in Mogadishu are fed breast milk supplemented with goat’s milk at six months; nomadic Somali mothers feed their child cow’s milk mixed with water at three months. Few Somali mothers use canned formula milk because it is expensive and is believed to cause stomach problems.
In addition to breast milk, children of urban Somalis are fed soft foods such as bananas and rice at eight months. Children of nomadic Somalis are not fed any solid food until they are one year old. Most Somali children are fed normal solid foods at eighteen months. Normal adult food mainly consists of carbohydrate and meat; such foods are cooked until they are soft enough for the child to chew.
In both urban and rural areas, when babies are one year old, if they are able, most drink from a glass or cup without their parent’s help. Bottles are difficult to keep clean and are not usually used. Children who are born outside of the city are given their milk in a traditional hand made wooden cup.
If their children have stomach sickness, mothers will stop feeding bottled milk and give them sugar water for three or four days. Children are also fed breast milk during this time. If the symptoms do not abate, the child is taken to a hospital or medication is sought.
Somalis associate teething with diarrhea, fever, nausea, and vomiting. Children usually begin teething when they are between nine months and one year, although it can occur as early as four months. Those who get their teeth earlier are thought to have more difficulties. An oil is sometimes placed on the gums to calm teething children, but pacifiers are not used.
To alleviate these symptoms, some Somalis may have their children’s four primary cuspids removed, or have the gums burned before the teeth come in. When their mothers determine that they are sick, children are taken to the “mo- alem,” and the “mo-alem” determines if the teeth are coming in. If they are, it is assumed that this causes the diarrhea and fever, and the “mo-alem” either recommend that the gum be burned or the teeth removed. While anesthesia is not usually available, there is a leaf that is chewed to provide local pain relief. This practice was once quite common, but is becoming less so because most urban Somalis understand that it causes permanent damage to the child’s mouth, and can prevent their adult teeth from developing normally. These procedures are not practiced by Somalis living in the US.
It is of note that, when asked about these practices, more than six Somali immigrants reported never knowing about these procedures happening in Somalia and believed that they in fact did not happen, now or in the past. Authors of an article published in the Western Journal of Medicine note that there are numerous reports of “traditional healing practices of many African countries in which the cuspids and incisors were removed or mutilated”, including some East African countries. The authors say they found no documented reports of the practice among Somalis, however they describe cases of Somali patients seen by clinicians at Harborview Medical Center in Seattle who appeared to have previously undergone mutilation and burning procedures. According to the article, the parent of one of these patients said that a traditional Somali healer “made cuts in the area of the child’s lower cuspids and removed gum tissue to prevent diarrhea”. (Western Journal of Medicine, Vol 173, August 2000 p 135-137)
Oral Health: Dental Care
Although most Somalis do not go to a dentist for cleaning or preventive care, those who live in the city may go to a doctor if they have tooth pain. Their doctor will refer them to a dentist who will either fill the cavity or pull the tooth.
Somalis who cannot afford dental care may seek treatment from community members known as “Mo-Alem” (teacher). The Mo-Alem have no western training and use crude tools such as pliers to pull teeth. Mo-Alem are usually the only dental care option available to Somalis who live outside the city.
Cavities and Tooth Decay
Some Somalis report that both adult and children’s teeth are more healthy among Somalis living in Africa than among Somali immigrants to the US. This is primarily due to the Somali diet, which is rich in calcium and meats, and which is considered by some people to be relatively low in sugar. Somalis notice that their teeth develop cavities soon after they immigrate to America and begin eating an American diet of softer foods and more sugar. In fact, many Somalis had never seen a cavity until they came to the US.
Somalis are not concerned if their children’s baby teeth have cavities, since these will fall out anyway. It is thought that the new, adult teeth will remain healthy because they are growing.
Although cavities are rare in Somalia, many children have overcrowded mouths, and straight teeth are not as desired in Somalia as in other parts of the world. If a child’s teeth are not growing in straight, their mother will push the tooth into place every evening.
Some adult Somalis chew a substance known as “chat” or “quat”—a stimulant derived from a plant—that stains their teeth green and may contribute to cavities and oral health problems. Although this substance is controlled in the United States, it is still used, primarily by Somali men.
If they cannot afford dental care, or if they live outside the city, they may use a natural medicine derived from a tree called “Havakeddy” on their teeth to ease tooth pain. They may also use cloves, which are kept in most Somali homes and are also used by Somalis in the US.
Somalis who live in the bush may heat a nail and put it on a painful tooth until it cracks. This is only done to the back teeth, and the nail is held on top of the tooth, not pushed into the gum.
Somalis do not use toothbrushes, they use a stick collected from the branches of a tree called “Roomay” found in Somalia, or a stick called “Muswaki” made from the root of another type of tree. Both types of sticks can be found in the U.S. in Somali grocery stores and shops. A stick is soaked in water for twenty-four hours to soften the wood, and the end is chewed to create fiber bristles. This is used at least twice a day to clean the teeth and tongue and is replaced as often as every week, when affordable. The stick starts out with a length of approximately 6-8 inches and can be used until it has run down to just a couple inches and then it is replaced. Ashes and wood charcoal, derived from tree burning, are also rubbed on the teeth to whiten them. Most Somalis do not use dental floss. Toothpicks are used to pick meat out of teeth.
Nomadic Somalis are fastidious about oral hygiene and have few cavities. They clean their teeth twice a day and scrape their tongues with thecleaning stick. Bad breath is unacceptable. The practice of good oral hygiene among Somalis may be related to their practice of Islamic faith. It is said that the Prophet Mohammed urged people to clean their mouths every time before they pray, and to pray 5 times each day. People are often close in proximity to each other during daily prayer, which is spoken out loud. It is undesirable, if not disrespectful, to have bad breath disturb others who are in prayer.
Children are taught to clean their teeth when they are eighteen months old. Since Somali families are large, often with six or seven children, it is difficult for mothers to monitor their children’s dental care, and children are usually expected to clean their teeth on their own by the time they are three years old.
Somalis living in the US say they are more aware of preventive dental care because of advertisements. As a result, most mothers in the US begin cleaning their children’s teeth as soon as they appear, take their children for regular dental check ups, and look after their own oral health as well. It is possible, however, that since cavities are rare in Somalia and since there is no public health information, that new immigrants to the US are not aware of cavities or the need to floss or have their teeth cleaned. Some Somalis say that they are reluctant to seek dental care in the US because of the fear that they will contract AIDS from needles used to administer anesthetics.
Somalis don’t traditionally practice cosmetic dental care, unlike their Ethiopian neighbors who may pinch their gums to make them darker in color. In the 1960s in Somalia, it was popular to have a gold tooth made to fit over an adult tooth as a show of status and money.
Practical Implications for Providers
- Somalis may go first to a doctor if they have tooth pain and expect their doctor to refer them to a dentist.
- Dental work may not have been done to American standards, and may result in necrotic roots and residual fragments of roots remaining a nidus of chronic infection. Providers should consider substandard dental care as reasons for symptoms such as facial pain, headaches and fever without origin.
Dental injuries due to African traditional therapies for diarrhea.
Graham EA, Domoto PK, Lynch H, Egbert MA., West J Med. 2000 Aug;173(2):137.