1http://dx.doi.org/10.20396/bjos.v20i00.8660967 Volume 20 2021 e210967 Original Article 1 Faculty of Medicine, Department of Pediatrics,College of Medicine, Gadarif University, Gadarif, Sudan. 2 Departments of Pediatrics and Medical Education, College of Medicine, University of Bisha, Saudi Arabia. 3 Unaizah College of Medicine and Medical Sciences, Department of Obstetrics and Gynecology, Qassim University, Unaizah, Kingdom of Saudi Arabia. *4 King Khalid University, College of Medicine, Department of Obstetrics and Gynecology, Abha, Saudi Arabia. * Corresponding author: Bahaeldin A. Hassan King Khalid University, College of Medicine, Department of Obstetrics and Gynecology, Abha, Saudi Arabia. Email: bahasuikt@hotmail.com Received for publication: August 21, 2020 Accepted: December 21, 2020 Misconceptions and traditional practices toward infant teething symptoms among mothers in eastern Sudan: a cross-sectional study Mohammed Ahmed A. Ahmed1*,Karimeldin M. Salih2 , Abdullah Al-Nafeesah 3, Ishag Adam3, Bahaeldin A. Hassan4,* There is no much published data on the mothers’ false beliefs about signs and symptoms associated with teething in Sudan. Aim: This cross-sectional hospital-based study was conducted to assess mothers` knowledge about infant teething process and to evaluate mothers’ practices used to alleviate teething disturbances in Gadarif city, eastern Sudan. Methods: Questionnaires were used to collect data. Multivariate logistics regression models were performed and adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. Results/Conclusion: Of a total of 384 participating mothers, 126 (32.8%) had good knowledge about infant teething. The  mothers’ knowledge was associated with a higher number of children in the family (adjusted odds ratio [AOR] = 1.14) and with having a job (AOR = 2.22). Mothers residing in rural areas (AOR = 0.40) and mothers with lower than secondary education (AOR = 0.43) were less likely to have good knowledge about teething. Diarrhea (88.5%), fever (86.5%), an urge to bite (76.6%), and poor appetite (71.9%) were the signs and symptoms most attributed to teething by mothers. Only  the mother’s knowledge about teething was associated with reporting fever as a sign. A considerable number (317; 82.6%) of mothers reported performing “Dokhan” (acacia wood smoke), 313 (81.5%) preferred to administer paracetamol or other systemic analgesics, 262 (68.2%) agreed that a child with tooth eruption should be taken to a hospital or health center, and 216 (56.3%) believed that antibiotics relieved symptoms related to teething. Keywords: Tooth eruption. Knowledge. Signs and symptoms. Mothers. Child. http://dx.doi.org/10.20396/bjos.v20i00.8660967 mailto:bahasuikt@hotmail.com https://pubmed.ncbi.nlm.nih.gov/?sort=date&size=100&term=Ahmed+MAA&cauthor_id=31794569 https://orcid.org/0000-0002-0681-0827 https://pubmed.ncbi.nlm.nih.gov/?sort=date&size=100&term=Al-Nafeesah+A&cauthor_id=31794569 https://pubmed.ncbi.nlm.nih.gov/?sort=date&size=100&term=Adam+I&cauthor_id=31794569 https://orcid.org/0000-0003-0528-9723 2 Ahmed et al. Introduction Tooth eruption (teething) is a normal physiological process whereby a tooth moves from within the jaw (intraosseous position) to the oral cavity1. Teething usually starts at around six months and continues up to around three years of age2. Symptoms such as fever, diarrhea, dermatitis, constipation, irritability, respiratory dis- eases, repeated finger sucking, rashes, facial flushing, and poor appetite were believed to be associated with teething3,4. Traditionally, “blistering, placing leeches on the gums, and cauterization of the back of the head were the treatment options reported by the parents for teething”5. Mothers usually use systemic and topical analgesics to relieve teething pain and antibiotics to treat associated symptoms6. Moreover, they have their children bite objects to alleviate symptoms7. Many medical and non-medical (tradi- tional or other) practices are used as teething treatments without consultation of a dentist or pediatrician8. Mothers’ misconceptions about teething might lead to misdiagnosis and mismanage- ment of potentially serious childhood diseases9. Therefore, ideas about teething must be assessed and changed if they are not based on evidence. Although several rele- vant studies have been conducted in African and other neighboring countries6,10,11, lit- tle research has been conducted in Sudan and none in eastern Sudan8. Therefore, the aim of this study was to assess mothers’ knowledge about teething and to evaluate their practices for alleviating teething symptoms in eastern Sudan. Materials and Methods A cross-sectional hospital-based study was conducted between May 1st and May 31st, 2019 in Gadarif Pediatric Teaching Hospital in eastern Sudan. Gadarif is situated at a mean altitude of 496 m above sea level, has a population of 1,727,401 residents, covers an area of 75,000 km2, and lies between latitudes 14 and 16 north and longi- tudes 33 and 36 east. It is 400 km from the capital Khartoum, on the Ethiopian border. Gadarif Pediatric Teaching Hospital is a 170-bed tertiary care facility that serves as a referral center in Gadarif State. It is a public hospital with dental unit which providing a free health services. Between 150 and 200 patients refer to the pediatric outpatient clinic every day. Between 40 and 80 patients are discharged within 24 hours. The pedi- atric hospital is staffed with 8 consultants, 10 specialists, and 25  medical doctors (registrars and residents). Inclusion and exclusion criteria Mothers with children between six months to three years of age referring to the hos- pital who agreed to participate were included in the study. Mothers with only one child younger than six months or older that three years of age and mothers with more than one child whose youngest child was over three years old were excluded. Mothers who did not agree to participate and mothers who were mentally unable to communicate were also excluded. Questionnaire A questionnaire composed of four parts was used to collect data. 3 Ahmed et al. The first part regarded sociodemographic information about the mothers and their families. The second part regarded mothers’ knowledge about teething. The third part concerned symptoms attributed by mothers to teething. The fourth part concerned treatments used by mothers for teething. Responses to the second to the fourth sections were structured using “agree,” “dis- agree,” and “don’t know” options Sample size A sample size of 384 mothers was calculated based on the expected knowledge rate of maximum 50%. The sampling was conducted at a 95% confidence level with a 5% margin of error and 80% power. Statistics IBM SPSS Statistics version 22.0 for Windows was used for the statistical analysis. Absolute numbers and frequencies were used to express mothers’ teething-related knowledge, experiences, and practices. Multivariate logistics regression models (using backward likelihood ratios) were performed with mothers’ knowledge as a dependent variable (other models were performed for symptoms) and the mothers’ age, residence, and education, the children’s age and sex, and the number of children in the family as independent variables. Adjusted odds ratios (AOR) and 95% confi- dence intervals (CI) were computed. A two-sided p value less than 0.05 was consid- ered statistically significant. Results General characteristics of the study population A total of 384 mothers were enrolled in the study. The ranges and means ± standard deviations (SD) of the mothers’ age, number of children in the family, and age of the youngest child were 16–48 and 29.2 ± 6.4 years, 1–12 and 3.7 ± 2.4, and 6–36 and 14.7 ± 8.4 months, respectively. A total of 294 (76.6%) mothers resided in rural areas. The education level of 203 (52.9%) mothers was secondary or higher. Of the 384 chil- dren involved in the study, 197 (51.3%) were male. Mothers’ knowledge about tooth eruption Four-fifths (80.5%) of the mothers knew that the first primary teeth erupt at 6–7 months, and 89.6% knew that the lower central incisors are the first to erupt. However, less than half (167; 43.5%) were aware that delayed eruption could be associated with the presence of a systemic disease. A total of 126 (32.8%) moth- ers answered correctly all the questions related to knowledge about teething (Table 1). 4 Ahmed et al. Table 1. Mothers’ knowledge about teething Yes n (%) No n (%) I don’t know n (%) Teeth start to erupt at 6–7 months. 309 (80.5) 45 (11.7) 30 (7.8) The lower central incisors are the first teeth to erupt. 344 (89.6) 26 (6.8) 14 (3.6) Tooth eruption is complete at 2–3 years of age. 268 (69.8) 36 (9.4) 80 (20.8) Delayed tooth eruption may indicate the presence of a systemic disease. 167 (43.5) 111 (28.9) 106 (27.6) The associations between demographic variables and mothers’ knowledge about teething are shown in Table 2. Logistic regression showed that knowledge about teething was associated with a higher number of children in the family (AOR = 1.14, 95% CI = 1.4–1.27; p = 0.007) and with having a job (AOR = 2.22, 95% CI = 1.21–4.01; p = 0.009). Mothers residing in rural areas (AOR = 0.40, 95% CI = 0.21–0.77; p = 0.006) and mothers with lower than secondary education (AOR = 0.43, 95% CI = 0.25–0.73; p = 0.002) were less likely to have good knowledge about teething. The mother’s age and the age and sex of the youngest child were not significantly related to knowledge about teething (Table 3). Table 2. Comparing the variables between women with poor and good knowledge Variables Total (n = 384) Poor knowledge (n = 258) Good knowledge (n = 126) p Mean (SD) Mother’s age (years) 29.2 (6.4) 29.0 (6.5) 29.6 (6.1) 0.377 Number of children in the family 3.7 (2.4) 3.6 (2.3) 3.9 (2.6) 0.284 Age of the youngest child (months) 14.7 (8.8) 14.2 (7.9) 15.8 (10.0) 0.092 Number (%) Residence Urban 294 (76.6) 182 (70.5) 112 (88.9) <0.001 Rural 94 (23.4) 76 (29.5) 14 (11.1) Mother’s education level Secondary or higher 203 (52.9) 118 (45.7) 85 (67.5) <0.001 Below secondary 181 (47.1) 140 (54.3) 41 (32.5) Mother’s occupation Housewife 326 (84.9) 232 (89.9) 94 (74.6) <0.001 Employee 58 (15.1) 26 (10.1) 32 (25.4) Child’s sex Male 197 (51.3) 132 (51.2) 65 (51.6) 1.000 Female 187 (48.7) 126 (48.8) 61 (48.4) SD Standard deviation 5 Ahmed et al. Table 3. multivariate logistic regressions analysis for the factors associated with good knowledge Unadjusted Adjusted Variables OR CI p OR CI p Mother’s age 0.95 0.90–1.01 0.150 Residence Urban Reference Rural 0.39 0.20–0.76 0.005 0.40 0.21–0.77 0.006 Mother’s education level Secondary or higher Reference Below secondary 0.40 0.23–0.70 0.001 0.43 0.25–0.73 0.002 Mother’s occupation Housewife Reference Employee 2.39 1.30–4.40 0.035 2.22 1.21–4.01 0.009 Number of children in the family 1.283 1.109–1.48 0.001 1.14 1.4–1.27 0.007 Age of the youngest child 1.250 0.912–1.70 0.156 Child’s sex Male Reference Female 0.97 0.61–1.53 0.887 OR Odds ratio, CI Confidence interval Perception of symptoms associated with teething Diarrhea (88.5%), fever (86.5%), an urge to bite (76.6%), and poor appetite (71.9%) were the most common signs and symptoms attributed to teething by mothers (Table 4). Logistic regression showed that among all the examined factors (moth- er’s knowledge about teething, age, residence, education, and job status, age and sex of the youngest child, and number of children in the family) only the mother’s knowledge about teething was associated with reporting fever as a sign. None of the investigated factors were associated with reporting diarrhea as a sign (Table 5). Table 4. Symptoms attributed to teething by mothers Yes n (%) No n (%) I don’t know n (%) Fever 332 (86.5) 46 (12.0) 6 (1.6) Diarrhea 340 (88.5) 42 (10.9) 2 (0.5) Vomiting 260 (67.7) 112 (29.2) 12 (3.1) Irritability 284 (74.0) 82 (21.4) 18 (4.7) Poor appetite 276 (71.9) 94 (24.5) 14 (3.6) Excessive salivation 266 (69.3) 104 (27.1) 14 (3.6) Sleep disturbance 206 (53.6) 156 (40.6) 22 (5.7) Ear problems 110 (28.6) 233 (60.7) 41 (10.7) Inflammation of the oral mucosa 153 (39.8) 189 (49.2) 42 (10.9) Continue 6 Ahmed et al. Pain 198 (51.6) 165 (43.0) 21 (5.5) Facial flushing 91 (23.7) 232 (60.4) 61 (15.9) Gum irritation 233 (60.7) 118 (30.7) 33 (8.6) Finger sucking 236 (61.5) 127 (33.1) 21 (5.5) Constipation 85 (22.1) 264 (68.8) 35 (9.1) Urge to bite 294 (76.6) 72 (18.8) 18 (4.7) Rhinorrhea 215 (56.0) 139 (36.2) 30 (7.8) Respiratory problems 177 (46.1) 155 (40.4) 52 (13.5) Skin rash 59 (15.4) 260 (67.7) 65 (16.9) Convulsion 50 (13.0) 272 (70.8) 62 (16.1) Increased susceptibility to diseases 118 (30.7) 164 (42.7) 102 (26.6) Table 5. multivariate logistic regressions analysis for the factors associated with fever and diarrhea as signs of infant teething Fever Diarrhea Variables OR CI p OR CI p Mother’s age 1.02 0.96–1.09 0.539 1.06 0.98–1.14 0.144 Residence Urban Reference Rural 1.98 0.87–4.48 0.102 0.52 0.25–1.12 0.097 Mother’s education level Secondary or higher Reference Below secondary 0.93 0.47–1.84 0.845 1.71 0.78–3.70 0.179 Mother’s occupation Housewife Reference Employee 1.61 0.57–4.50 0.365 0.62 0.25–1.54 0.310 Number of children in the family 1.11 0.91–1.37 0.227 0.96 0.77–1.19 0.685 Age of the youngest child 1.02 0.98–1.07 0.235 0.99 0.96–1.03 0.716 Child’s sex Male Reference Female 1.29 0.70–2.38 0.407 0.95 0.50–1.82 0.881 Good knowledge Reference Poor knowledge 2.50 1.13–5.52 0.023 1.88 0.85–4.18 0.118 OR Odds ratio, CI Confidence interval Table 6 displays the mothers’ reported practices for alleviating pain and other teeth- ing symptoms. A considerable number of mothers (317; 82.6%) reported performing “Dokhan” (acacia wood smoke), 313 (81.5%) preferred to administer paracetamol or other systemic analgesics, 262 (68.2%) agreed that a child with tooth eruption should be taken to a hospital or health center, and 216 (56.3%) believed that antibiotics relieved symptoms related to teething. Continuation 7 Ahmed et al. Table 6. Treatments provided by mothers for teething Yes n (%) No n (%) I don’t know n (%) Taking the child to a hospital or health center 262 (68.2) 109 (28.4) 13 (3.4) Performing “Dokhan” (acacia wood smoke) 317 (82.6) 62 (16.1) 5 (1.3) Taking the child to grandmother 177 (46.1) 199 (51.8) 8 (2.1) Taking the child to a more experienced mother in the neighborhood 113 (29.4) 261 (68.0) 10 (2.6) Administering paracetamol or another systemic pain killer 313 (81.5) 66 (17.2) 5 (1.3) Administering extra fluids to prevent dehydration (ORS or other) 280 (72.9) 91 (23.7) 13 (3.4) Administering antibiotics 216 (56.3) 153 (39.8) 15 (3.9) Applying topical analgesia 99 (25.8) 252 (65.6) 33 (8.6) Rubbing the gums with carrots 169 (44.0) 201 (52.3) 14 (3.6) Using sesame oil 246 (64.1) 115 (29.9) 23 (6.0) Giving a pacifier 95 (24.7) 239 (62.2) 50 (13.0) Giving herbs 144 (37.5) 199 (51.8) 41 (10.7) Extracting the teeth 74 (19.3) 283 (73.7) 27 (7.0) Bottle feeding 98 (25.5) 273 (71.1) 13 (3.4) Nothing 7 (1.8) 352 (91.7) 25 (6.5) Discussion This study found that 32.8% of the participating mothers had good knowledge about teething. Knowledge was associated with the number of children in the family, job status, residence, and education level. A study conducted in neighboring Ethiopia reported that 65.4% of mothers knew that teeth start to erupt at 6–7 months of age, and 74.8% knew that the lower central incisors are the first to erupt. Their knowledge was associated with their age and place of residence11. In a study conducted in Saudi Arabia, over three-quarters (87.5%) of participants had poor knowledge about teething, and none of the investigated factors were associated with knowledge6. Another study similarly found that 60.5% of parents in Saudi Arabia had poor knowledge about teeth- ing and reported that knowledge was significantly associated with a higher number of children in the family9. A study conducted in Jordan reported that 65.4% of mothers knew that tooth eruption normally starts at 6–7  months of age and found that the mothers’ knowledge was associated with their age9. A considerably higher knowledge rate (71.4%) about teething was reported in India12. We observed that diarrhea (88.5%), fever (86.5%), and an urge to bite (76.6%) were the signs and symptoms most commonly attributed to teething by mothers and that citing fever as a symptom was associated with the mother’s knowledge. This is in line with a study conducted in Khartoum, Sudan, which reported that fever (86.6%) and diarrhea (80.3%) were the symptoms most commonly attributed to teething8. However, in that study, the mothers’ age and educational status were not associ- ated perceived8. In our study, there was no association between the child’s sex and systemic signs and symptoms reported by the mother. This is consistent with the findings of Oziegbe et al.10, who also found no significant relationship between the child’s sex and signs and symptoms noticed by the mother9. Also, a study in Ethio- 8 Ahmed et al. pia reported that 91.6% of the mothers believed that teething was associated with various symptoms, such as diarrhea (90.7%)11. Owais  et  al. reported that 75% of the parents incorrectly associated fever and diarrhea with teething9. An urge to bite (93.1%), fever (87.0%), and diarrhea (83%) were the most common signs and symp- toms reported by Saudi parents6. Contrary to our findings, fever (51.8%), diarrhea (12.5%), and vomiting (2.9%) were the most commonly reported signs and symp- toms by Nigerian mothers10. This and other studies’ findings show that although teething does not cause fever, diarrhea, or any respiratory illness, these are common misconceptions related to teething. Unfortunately, such misconceptions may be obstacles to proper diagnosis and effective treatment of many illnesses. A high fever (>39°C) should not be con- sidered a teething symptom and needs to be investigated. Attention should be paid to detecting or excluding coincidental infections, such as upper respiratory and gas- trointestinal infections. A plausible explanation for the presence of coincidental but unrelated systematic diseases during the teething period is a decrease in passive immunity/antibodies13. In our study, 81.5% of the mothers preferred to administer paracetamol or other sys- temic analgesics. In contrast, in a study in Ethiopia, only one mother stated that the child should be given paracetamol to relieve symptoms, while 12.1% reported rub- bing children’s gums with garlic, and 6.5% reported rubbing them with herbs to relieve teething pain11. In Saudi Arabia, 76.1% of parents used systemic analgesics, and 65.6% applied topical analgesics to children’s gums9. In our study, 56.3% of the mothers believed that antibiotics relieved teething-related symptoms. In Saudi Arabia, 45% of parents believed that antibiotics were indicated for teething6. Antibiotic overuse or misuse is a harmful practice for both the individual and the community, as it can lead to bacterial resistance. Unfortunately, in Sudan, antibiotics are sold without restrictions. This study had certain limitations. As it was a single-center study, its results cannot be generalized to the rest of the population. Moreover, as the data were obtained from mothers’ responses regarding teething, they may be subject to recall bias. In conclusion, this study documents a poor level of knowledge about teething, espe- cially among mothers residing in rural areas and those with a low education level. Ethics approval Ethics approval was obtained from the Ethics Committee of the Faculty of Medicine of Gadarif University (reference number: 2019/012), Sudan. Written informed consent was obtained from each participant. Competing interests The authors declare that they have no competing interests. Funding None received. 9 Ahmed et al. Acknowledgment The authors would like to thank all the mothers who participated in the study. References 1. Cunha RF, Pugliesi DM, Garcia LD, Murata SS. Systemic and local teething disturbances: prevalence in a clinic for infants. J Dent Child (Chic). 2004 Jan-Apr;71(1):24-6. 2. Sahin F, Camurdan AD, Camurdan MO, Olmez A, Oznurhan F, Beyazova U. Factors affecting the timing of teething in healthy Turkish infants: a prospective cohort study. Int J Paediatr Dent. 2008 Jul;18(4):262-6. doi: 10.1111/j.1365-263X.2007.00893.x. 3. Massignan C, Cardoso M, Porporatti AL, Aydinoz S, Canto Gde L, Mezzomo LA, Bolan M. Signs and symptoms of primary tooth eruption: a meta-analysis. Pediatrics. 2016 Mar;137(3):e20153501. doi: 10.1542/peds.2015-3501. 4. Tighe M, Roe MF. Does a teething child need serious illness excluding? Arch Dis Child. 2007 Mar;92(3):266-8. doi: 10.1136/adc.2006.110114. 5. Hatibovic-Kofman S, Ari T. Managing discomfort caused by teething. J Can Dent Assoc. 2013;79:d141. 6. Elbur AI, Yousif MA, Albarraq AA, Abdallah MA. Parental knowledge and practices on infant teething, Taif, Saudi Arabia. BMC Res Notes. 2015 Nov;8:699. doi: 10.1186/s13104-015-1690-y. 7. Kumar S, Tadakamadla J, Idris A, Busaily IA, AlIbrahim AY. Knowledge of Teething and Prevalence of Teething Myths in Mothers of Saudi Arabia. J Clin Pediatr Dent. 2016;40(1):44-8. doi: 10.17796/1053- 4628-40.1.44. 8. AwadKamil M. Mothers’ misconception and traditional practises towards infant teething’ symptoms in Khartoum. IOSR J Pharm. 2012 Jan;2(3):448-51. doi: 10.9790/3013-0230448451. 9. Owais AI, Zawaideh F, Al-Batayneh OB. Challenging parents’ myths regarding their children’s teething. Int J Dent Hyg. 2010 Feb;8(1):28-34. doi: 10.1111/j.1601-5037.2009.00412.x. Erratum in: Int J Dent Hyg. 2010 Nov;8(4):324. Erratum in: Int J Dent Hyg. 2017 Aug;15(3):258. 10. Oziegbe EO, Folayan MO, Adekoya-Sofowora CA, Esan TA, Owotade FJ. Teething problems and parental beliefs in Nigeria. J Contemp Dent Pract. 2009 Jul;10(4):75-82. doi: 10.5005/jcdp-10-4-75. 11. Getaneh A, Derseh F, Abreha M, Yirtaw T. Misconceptions and traditional practices towards infant teething symptoms among mothers in Southwest Ethiopia. BMC Oral Health. 2018 Sep;18(1):159. doi: 10.1186/s12903-018-0619-y. 12. Kakatkar G, Nagarajappa R, Bhat N, Prasad V, Sharda A, Asawa K. Parental beliefs about children’s teething in Udaipur, India: a preliminary study. Braz Oral Res. 2012 Mar-Apr;26(2):151-7. doi: 10.1590/ s1806-83242012000200011. 13. Jones M. Teething in children and the alleviation of symptoms. J Fam Health Care. 2002;12(1):12–3.