Research on natal and neonatal teeth in Africa: A systematic scoping review of empirical evidence

Abstract Background and Aims In Africa, natal and neonatal teeth is a culture‐bound phenomenon which is associated with several sociocultural connotations which might affect child survival. Different empirical studies have been conducted in Africa on natal and neonatal teeth; however, no known scoping review has been conducted to map the empirical evidence. This systematic scoping review (SSR) aims to document the available empirical evidence, research gaps, and hotspots on neonatal and natal teeth in Africa. Methods The methodology of this SSR was informed by the Joanna Brigg's Institute guidelines for SSRs, and it was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews. Eleven research databases were systematically searched to scooped out all literatures relevant to the scoping review question, after which they were screened for eligibility based on the review's selection criteria. Only the eligible literatures were included in the review. Data were extracted from the included literatures, after which the extracted data were collated, summarized, and presented as results. Results This review included only three journal articles. All the reviewed articles revealed knowledge gaps about natal/neonatal teeth. These articles also found misconceptions around natal/neonatal teeth; for example, nurses' and traditional birth attendants' beliefs about these teeth are contrary to scientifically known facts. Multiple myths associated with natal/neonatal teeth, as indicated in the reviewed studies, point to a poor understanding of the condition. Conclusion Neonates and infants are highly vulnerable persons; they require care and safeguarding from dental myths that could threaten their survival. Educative information concerning natal/neonatal teeth should be included in public health education programs to address the observed knowledge gaps among African populations and correct wrong beliefs on neonatal and natal teeth.


| INTRODUCTION
Natal and neonatal teeth (NNT) have been called various names, including congenital teeth, fetal teeth, pre-deciduous teeth, premature teeth, precociously erupted teeth, and dentitia praecox. 1,2 A "natal tooth" presents at birth, while a "neonatal tooth" grows or erupts within the first 30 days of life. 2 The condition is rare as it only occurs about 1 in about 3000−3500 live births. [3][4][5] The exact cause is unknown, but some studies suggested it could be hereditary or genetic makeup. 6,7 Natal teeth are three times more common than neonatal teeth. 4 Irrespective of their incidence, what is common is that they are often attributed to some myths and superstitions, which raise curiosity and concerns, especially among primary caregivers. NNT is often portrayed as dental abnormities requiring treatment.
Leung and Robson 5 observed that natal teeth often occur in pairs and affect mostly the lower primary central incisors representing early eruption of normal primary (deciduous) dentition. Such teeth resemble normal primary dentition in size and shape but are often smaller and poorly developed with weak or no root formation. The most common concerns for mothers include discomfort during suckling and possible laceration of the mother's breasts, among others. 5 The interference with breastfeeding, degree of mobility, and cultural beliefs often prompt possible treatment in the form of tooth extraction. 8,9 Cultural beliefs regarding rare medical cases constitute fundamental concerns among community members. Cultural concern mounts due to the rarity of the condition and lack of knowledge among community members giving room for all sorts of interpretations. A rare medical case, such as NNT, may become a culture-bound phenomenon with a possibility of a negative connotation which might affect child survival. Hence, children with such rare conditions might face challenges. 10 In Africa, there is always a strong cultural milieu, practices, and superstitions concerning child health. 11 This is a systematic scoping review (SSR) of empirical evidence on NNT in Africa. The review aims to document the available empirical evidence, research gaps, and hotspots on NNT in Africa.

| Review design
This research was a SSR of empirical evidence. Unlike systematic reviews and meta-analyses, this review seeks to map all the existing empirical studies on neonatal and natal teeth across various African populations to identify the existing knowledge and gaps in the literature and inform future research on this area of interest. 12

| Deduplication
All retrieved literature was imported into the Rayyan software for deduplication. 17

| Selection of studies
The de-duplicated literature was screened to identify those meeting the review's inclusion criteria. A two-staged process was adopted for the screening. The screening was performed blindly by two independent researchers using the Rayyan software. 17 In the first stage, titles and abstracts were screened to exclude irrelevant literature. The remaining literature was then subjected to full-text screening-the second stage. Based on the selection criteria set for the review, only those eligible articles were included.

| Risk of bias assessment
Unlike systematic reviews, the risk of bias assessment of included articles is not a part of scoping review protocols. 12,18 2.8 | Data extraction, collation, and charting Data were extracted from the included articles with a customized data extraction sheet. The obtained data included citation data (authors' names and publication year), study design, study objectives, study's geographical location, studied population, sample size, results, and conclusions. The extracted data were thereafter collated and summarized into themes. Meta-analysis was not accomplished in this review due to the lack of statistical and methodological homogeneity in the included articles.

| RESULTS
A total of 37 publications were retrieved from the 11 databases (Table 1) Table 3). Two of the publications utilized cross-sectional survey design, 14,15 1 adopted a randomized control study design. 16 All three studies reviewed were conducted in Nigeria. However, the cross-sectional studies were conducted in an urban setting in Ibadan, 14,15 while the randomized study was domiciled in rural settings, Igboora and Idere. 16 Each paper focused on a different population group-mothers, 16 nurses, 14 and traditional birth attendants (TBAs). 15 One of the three papers was an intervention study. 16 The SSR produced results which are organized thematically, including knowledge and beliefs about natal/neonatal teeth; concerns around natal/neonatal teeth; behavioral dispositions toward natal/neonatal teeth; determinants of beliefs and attitude toward natal/prenatal teeth; and the effects of intervention on knowledge and beliefs about natal/neonatal teeth.

| Knowledge and beliefs about natal/neonatal teeth
Understanding of natal/neonatal teeth: All reviewed studies revealed knowledge gaps about natal/neonatal teeth. The studies also found misconceptions about premature teeth as nurses' and TBAs' beliefs about premature teeth are contrary to scientifically known facts. 14,15 This was assessed through different queries. Only one study conducted among TBAs assessed knowledge of the time of eruption of first milk teeth. The understanding of the time of milk teeth eruption was somewhat low for nearly half of the respondents who would be shocked and afraid to see a baby they assisted in delivering with natal teeth, and some (18.4%) would tag the child as weird. 15 The majority of both TBAs (46%) and nurses (49.2%) would reassure the mother of a child with neonatal teeth. 14,15 Practices toward prematurely erupted teeth further support evidence of the profound negative attitudes to the phenomenon.
Although, signs of positive practices are equally conspicuous such as advising that the child be left alone, as reported by the majority (59.6%) of TBAs and several nurses (33.9%). Nearly half of the nurses would reassure a mother whose child has neonatal teeth. 14 In addition, approximately 15.3% of nurses would advise the mother to take the child to a pediatrician. 14,15 Other practices include counseling mothers to extract the prematurely erupted teeth immediately as mentioned by many prematurely erupted teeth will bear misfortune compared to the more educated TBAs who did not share this idea.
Long years of practice (>20 years) are significantly associated with beliefs that families with a child with natal/neonatal teeth are cursed and the child would develop evil spiritual powers. This group is also likely to advise mothers to ingest concoctions during pregnancy as precautions. 15

| Effects of intervention on knowledge and beliefs about natal/neonatal teeth
Only one study (intervention) explored knowledge improvement and behavioral change in the study group. Following educational interventions by Bankole and Lawal, 16 19 The health conception also reflects in the knowledge, practices, including health and illness relating to oral health 20 (Simangwa et al., 2018 21-23 ). Beyond the cultural conception, oral is also mediated by several social factors, including gender, age, education, and socioeconomic status. 20,24,25 In Africa, scientific research on NNT is very low, as two reviewed studies were conducted more than a decade ago. The most recent study by Bankole and Lawal 16 is an intervention study which did not report details about the community knowledge, attitudes, and practices around premature teeth. The findings are, therefore, not comparable to other publications as the authors primarily focused on observed changes among mothers after the introduced intervention.
This low research output on the subject may be due to its infrequency.
However, community awareness might modify the response to the condition when it happens. The low research output on the subject is not peculiar to Africa. 26  conditions is always very high, including oral conditions or health disparities. 28 NNT constitute one of the "stigmatized biologies." 28 Moeller 29 reported discrimination concerning dental appearance, disproportionately affecting the socially marginalized. The primary conception is to describe NNT as "abnormal" teeth and hence a source of social concern.
This review shows that, currently, adequate documentation of the prevalence and incidence of NNT in Africa is lacking. This may be associated with the stigma and negative community reaction that the occurrence of NNT tends to attract. It could also point to the fact that mothers of affected children do not present them for treatment at medical facilities. As the TBAs and nurses revealed, extracting strange teeth is believed to require spiritual intervention to avert the negative spiritual consequences on the child and the family. This kind of spiritual interpretation of medical condition is common in Africa, [30][31][32] which also relates to oral health. 33,34 Spiritual affiliations might manifest in various forms, which require spiritual cleansing or intervention.
Negative attitudes toward affected child and the family by nurses and TBAs is linked to Yoruba cultural perception of natal teeth phenomenon and the age-long belief in myths. The TBAs' attitude is also strongly associated with their age, educational status, and long years of practice. 35 By implication, negative attitudes toward and myths associated with the eruption of premature teeth could expose the child and the family to untold social difficulties. Literature has indicated that in Nigeria, community's attitude to premature teeth is negative due to predominant cultural myths and beliefs. 34 Comparably, torture, abuse, stigmatization, abandonment, and death remain some of the common experiences of children tagged "witches" in Nigeria, Congo, 36

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.

TRANSPARENCY STATEMENT
The lead author Kehinde K. Kanmodi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.