Susuk - Black Magic Exposed “White” by Dental Radiographs

Susuk or charm needles are a facial cum body art widely practiced among women of Malaysia, Brunei, Singapore, Thailand and Indonesia. These are small, needle-shaped metallic talismans inserted subcutaneously in different parts of the body. The concealed art of susuk was “exposed” by routine radiographic examination in the oral and maxillofacial region. This paper reports two such cases of unusual incidental radiographic finding in dental radiographs which were taken on a routine basis as part of the diagnostic work up. This article will also primarily enlighten the importance of radiographs in detecting such charm needles as the wearer keeps the body art a “hidden divret” thereby avoiding misdiagnosis.

A 32-year-old Malay Muslim woman presented to the dental outpatient department for pain in the right mandibular molar teeth suggestive of sclerosing osteitis. The Intra oral Periapical radiograph (IOPA) was advised for a diagnostic workup. The radiograph was reported as having two linear needle shaped radiopacities measuring approximately 10 mm in length and 2 mm in width superimposed over the cervical thirds of the right mandibular molar teeth [Table/Fig-1]. Past history of acupuncture was noncontributory or any needles or body piercings visible externally. There was no history of any eventful oral/dental treatment done till date. On repeated questioning the patient revealed the implanting of susuk in the region six years ago.

A 50-year-old Malay man presented as a dental outpatient with multiple carious and grossly decayed teeth. Orthopantomogram (OPG) was advised for a diagnostic workup. In addition to multiple carious teeth, partially edentulous arches, root stumps and poor periodontal bone support was evident. Overlying the zygomatic processes there were two symmetric bilateral linear radiopacities. The linear needle like radiopacity was sharply defined on the right zygomatic process, while on the left the linear radiopacity appeared unsharp, hazy and magnified conforming as to the ghost image [Table/Fig-2].The linear radiopacity on the right is the true image of the susuk needle while on the left it’s the ghost image of the susuk needle. Foreign objects which don’t lie within the confined area of focal trough in an OPG appear as ghost images on the contralateral side and hence not to be mistaken as two foreign objects.

The ancient art of susuk with roots in Malayan culture is a taboo practiced widely among women in Southeast Asian countries [1].These susuk needles are made of gold or other treasurable metals [2] which are implanted by witch craftsmen called “bomoh” [3] into the subcutaneous tissues of the face and body to act as talisman i.e., to enhance the charm and hence the synonym “charm needles” [4]. Sometimes it is also reflected as a “deceitful religious rite”. The practice of susuk is predominantly done with the intention of appearing attractive to others or invincible. The other benefits of a susuk wearer are to bring success in business or career, while others are of the opinion that the needles relieve headaches, or aches and pains in the joints, back and abdomen [5]. These invisible implanted materials become evident on routine diagnostic imaging leading to misdiagnosis. So the treating specialists or diagnosticians should be aware of such deceptive substances. In this article we have reported two such cases of susuk implants in faciomaxillary regions which we astounded during routine dental radiographic diagnostic workup.

Susuk, or charm needles, are the needles made of gold or other precious metals, which are implanted in the soft tissues of the body to act as talismans. Talisman is an Arabic word “Tilasm” an object which is believed to contain certain magical or ritual properties which would provide good luck for the possessor or possibly offer protection from evil or harm [6]. Among the stuffs which are believed to possess beneficial qualities are gold needles, diamond specks, mercury, silver and copper. Apart from these metallic products,organic constituents such as fruits, betel leaves, turmeric, pepper and shallots are also used as susuk.

It is common practice of implanting susuk primarily in Southeast Asian countries viz. Malaysia, Brunei, Singapore, Thailand and Indonesia [1] and is virtuously related to traditional Malay beliefs, though the wearers also include Chinese and Indians [7]. It is extensively seen among women fraternity of this region, but this charm needles do not spare male as in our case.

Susuk has various supposed purposes, ranging from the purely aesthetic to the treatment of joint pain and other minor ailments or to protect against injury and accident. A darker threat to susuk wearers is the belief that these charms may last for life, and are hard to get rid of.

The most common site for insertion of susuk is the facio-maxillary region nonetheless they have also been reported in the chest, abdomen, breasts, spine, mons pubis and limbs [1,8-10]. In the cranio-facial region, the most common sites for insertion are over the mandible followed by forehead, cheeks and lips. The susuk needles range between 0.5 to 1 mm in diameter and 5 to 10 mm long and are implanted subcutaneously by “bomoh” [3] or “dukun” a Malay shaman (magic healer). The needles are painless, invisible to the naked eye and not easily felt on palpation. The wearer might be unaware of its existence inside the body as the needles could have been inserted at a young age [11]. Moreover, these hidden talismans are kept secret as failure to do so eliminate the effectiveness of the charm. These invisible implanted needles are usually detected incidentally when an X-ray is taken for diagnostic drives. These are usually mistaken for foreign bodies introduced during an accident, acupuncture needles, broken endodontic files or even root fillings, restorative pins and furthermore sclerosis.

Susuk rarely cause any symptoms and are unlikely to lead to any complication. Moreover no complications have been reported in the English medical literatures till date. However, potential damage to vital organs or penetration of neurovascular structures cannot be ignored [4]. Though the objects which are used as a susuk are precious metals and biocompatible, a point of contention will always raise in the minds of the health professionals regarding its safety.

[Table/Fig-1]:

White arrows showing implanted susuk

[Table/Fig-2]:

White arrows showing implanted susuk

The practice of implanting the susuk in the subcutaneous tissues is a common practice in Southeast Asian countries but rare in other parts of the globe. But, the recent worldwide promotion of medical tourism in general and dental tourism in particular is talk of the time. Secondly, the government’s initiative of professional university exchange programs of swapping students from Southeast Asian countries is more prevalent. Furthermore, these talismans are kept as a hidden secret. Therefore, the above two cases illustrate the importance of awareness for the clinicians/diagnosticians practicing away from these Southeast Asian countries of such implants to minimize adverse and unexpected outcomes during diagnosis and treatment planning.

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