Murray Dickson
Author: Where There Is No Dentist-Hesperian Foundation (1983, 2012)
Date: 2012-06-27T21:31:30+00:00
Keywords: TODO

Where There Is

No Dentist
by Murray Dickson
updated and expanded
with information about HIV and AIDS
by Richard Bebermeyer,

Martin Hobdell and Gene Stevenson

Introduction by David Werner,
author of Where There Is No Doctor
health guides

Berkeley, California, USA
www.hesperian.org

Hesperian encourages others to copy, reproduce, or adapt to meet local needs any or all parts of this book, including the illustrations, provided that the parts reproduced are distributed free or at cost – not for profit.

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Copyright © 2012, 2006, 1983 by Hesperian. All rights reserved.

Library of Congress

Catalog card No. 82-84067

Dickson, Murray

Where there is no dentist.

Includes index.

Berkeley, CA: Hesperian Foundation

ISBN: 978-0-942364-05-7

First edition, November 1983

15th printing (updated), July 2012

Printed in the USA on paper from responsible sources by Quad/Graphics.

Hesperian Health Guides

1919 Addison St., #304

Berkeley, California 94704

USA
tel: 1-510-845-1447
fax: 1-510-845-9141
bookorders@hesperian.org
www.hesperian.org

Where There Is No Dentist 2012
iii

THANKS

Where There Is No Dentist, updated edition, 2012

Thanks from Hesperian

We continue to be inspired by Murray Dickson and his tireless efforts to encourage health and dental promoters and community members to respond self-reliantly to their health needs. A few years ago, Murray introduced us to Richard Bebermeyer, Martin Hobdell, and Gene Stevenson, whom we thank for volunteering their time to write and develop the manuscript for Chapter 12 in this book, “HIV and Care of the Teeth and Gums.” That material was originally published in 2002 and distributed as a supplement to the previous edition of Where There Is No Dentist. We also thank Jane Maxwell, who edited the supplement with assistance from Darlena David, Julie Gerk, and Todd Jailer.

Hesperian is lucky to be able to draw upon a large pool of people committed to grassroots health, and we owe a debt of gratitude for their insightful comments and suggestions to: Rodrigo de Amorim, Jean Arthur, Alma Carolina Blanco Reyes, Claire Borkert, Roman Carlos, Stephen Cox, Alan Dare, Callum Duward, Belinda Forbes, Jo Frencken, Monica Gandhi, Gene Gowdey, Gerardo Gutiérrez, Martin Hobdell, Christopher Holmgren, Marie Klaipo, Patcharin Lekswat, Brian Linde, Theresa Noe, Francina Lozada Nur, Stephen Moses, Foluso Owotade, Francis Serio, Michael Terry, Garth von Hagen, and P. Wanzala.

New illustrations in this edition of the book are by: Silvia Barandier, Sara Boore, Heidi Broner, José de Jesús Chan, Gil Corral, Regina Faul-Doyle, Anna Kallis, Susan Klein, Gabriela Nuñez, Kathleen Tandy, Sarah Wallis, Lihua Wang, and Mary Ann Zapalac.

Editing and updating of the 2006 edition was coordinated by Kathleen Vickery with assistance from Todd Jailer and Susan McCallister, production by Iñaki Fernández de Retana and Leana Rosetti, and additional writing by Fiona Thomson. For the 2012 edition, coordination by Dorothy Tegeler, with support from Jacob Goolkasian, Zena Herman, Todd Jailer, Melody Segura, and Kathleen Tandy.

Thanks from Murray Dickson, 1983

Where There Is No Dentist is here to fill a need. To many people, it has seemed that the existing books about dental care were either too incomplete or too complicated. If this book fills that need, it is only because a number of people worked hard to make it happen. To them I owe my sincere thanks.

Much has happened since that day in Papua New Guinea when David Werner’s letter arrived. His challenge was simple: “Since no one else has written a dental manual like this, why don’t you?” With David’s encouragement and constant support, I was able to take teaching notes and produce a suitable draft that was the basis for this book. To you, David, for

iv

Where There Is No Dentist 2012
your patience in helping me learn, my heartfelt thanks. Thanks also to Trude Bock and Bill Bower for the home, food, direction, and support, during a short visit to Hesperian in which the book took a definite turn for the better.

Michael Blake deserves special mention. As editor of Where There Is No Dentist, it was he who took the manuscript and nursed it along to completion. Michael’s commitment to finishing the book was vital, and I sincerely appreciate it.

My thanks go to Maggie Leung for typing the final draft, and to those dedicated persons who helped get the book into final form: Annaloy Nickum (page design); Hal Lockwood (typesetting and paste-up); Paul Chandler, Serena Clayton, and Elaine Rossi (proofreading); Pat Bernier (typing); and Howard Uno (photostats).

For their outstanding drawings, I am exceedingly grateful to: June Mehra, Janet Elliott de Jacques, Michael Marzolla, Joan Thompson, Mindy Mead, Arlene Ustin-Cartagena, and Lynn Gordon. My own drawings in the manual appear amateurish in comparison.

I want to thank the many persons who reviewed the manuscript and offered valuable suggestions: Ken Cripwell, Bill Bower, Jeff Vore, Aaron Yaschine, Rosalie Warpeha, Norma Francisco, Mike Muller, Marcia Anderson, Phil Haskett, Bert Bali, Tom Coles, Sunil Mehra, and John Rogers. In particular, thanks to Chris Lennox who, faced with stressful times in Papua New Guinea, found time to read through two drafts; and to David Morley for his ideas for improving the book and his assistance with its eventual publication.

For their financial help, I am grateful to the Ella Lyman Cabot Trust, Muttart Foundation, the Canadian Organization for Development through Education, and the James C. Penney Foundation.

I thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to adapt several drawings from the Handbook of Clinical Pedodontics, and the Medical Missionary Association (244 Camden Road, London NW1 9HE, U.K.) for permission to use parts of David Halestrap’s book Simple Dental Care.

This book is based upon several years of practical experience, made possible by the Canadian Organization CUSO. For this opportunity, and for CUSO’s active interest and involvement in this book, I most gratefully say thanks.

Finally, I want to acknowledge my family’s contribution. For weeks on end, my wife, Gerri, faithfully read and discussed with me each part of the book as it changed and was rewritten. She did this cheerfully, at a time when she was fully occupied in a graduate study program. For much longer than I had anticipated, Gerri and our two boys, Michael and Brennan, had to tolerate my preoccupations.

My parents endured my wanderings and search for answers to human problems with love and a growing sense of understanding. It is my only disappointment that they did not live to see this book in its final form.

v

CONTENTS

Introduction by David Werner

Part One: Learning and Teaching about Teeth and Gums Chapter 1: Your Own Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Eat only good healthy foods . . . . . . . . . . . . . . . . . . . . 3 Sore bleeding gums . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Clean your teeth every day . . . . . . . . . . . . . . . . . . . . . 4 More serious gum disease . . . . . . . . . . . . . . . . . . . . . 8

Cavities, toothaches and abscesses . . . . . . . . . . . . . 6

Chapter 2: Teaching Family and Friends in Your Community . . . . . . . . . . . . . . 9

Chapter 3: Teaching Children at School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Chapter 4: School Activities for Learning about Teeth and Gums . . . . . . . . . . 35

Why do we need teeth and gums?. . . . . . . . . . . . . . 37 How do germs make holes in the teeth? . . . . . . . . . 50

Why do some teeth look different? . . . . . . . . . . . . . 39 What makes the gums feel sore? . . . . . . . . . . . . . . . 52

What holds the teeth? . . . . . . . . . . . . . . . . . . . . . . . . 41 What does it mean if a tooth is loose? . . . . . . . . . . 54

How often do teeth grow in? . . . . . . . . . . . . . . . . . . 43 How can we prevent cavities and What makes teeth hurt? . . . . . . . . . . . . . . . . . . . . . . 46 sore gums? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Chapter 5: Taking Care of Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Part Two: Treating Dental Problems

Chapter 6: Examination and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Where to examine . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 A good diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

The instruments you need . . . . . . . . . . . . . . . . . . . . . 75 Learn to tell similar problems apart . . . . . . . . . . . . . 80

Chapter 7: Treating Some Common Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

The first rule of treatment: stay clean! . . . . . . . . 86

Pain in the joint. . . . . . . . . . . . . . . . . . . . . .114

Problems you will see most often . . . . . . . . . . . 92

Swollen gums and epilepsy . . . . . . . . . . . . .115

Cavities . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Blood in the mouth . . . . . . . . . . . . . . . . . . .116

Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . 93

After you take out a tooth . . . . . . . . . . . . . . . .116

Infected sinus . . . . . . . . . . . . . . . . . . . . . . 95

Swelling of the face . . . . . . . . . . . . . . . . . .116

Tooth injuries. . . . . . . . . . . . . . . . . . . . . . . 96

Pain from the socket . . . . . . . . . . . . . . . . . .117

Loose tooth . . . . . . . . . . . . . . . . . . . . . . . . 99

Bleeding from the socket . . . . . . . . . . . . . . .118

New tooth growing in . . . . . . . . . . . . . . . . .100

Tetanus . . . . . . . . . . . . . . . . . . . . . . . . . . . .118

Gum disease . . . . . . . . . . . . . . . . . . . . . . .101

Infection in the spit (saliva) gland. . . . . . . . . . . .119

Fever blisters . . . . . . . . . . . . . . . . . . . . . . .104

Sores on the face . . . . . . . . . . . . . . . . . . . . . .120

Thrush . . . . . . . . . . . . . . . . . . . . . . . . . . .105

Noma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121

Canker sores . . . . . . . . . . . . . . . . . . . . . . .106

Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125

Some special problems . . . . . . . . . . . . . . . . . .108

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125

Broken bone. . . . . . . . . . . . . . . . . . . . . . . .108

“Meth Mouth” . . . . . . . . . . . . . . . . . . . . . . . .126

Dislocated jaw . . . . . . . . . . . . . . . . . . . . . .113

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Where There Is No Dentist 2012

Chapter 8: Scaling Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Chapter 9: Injecting Inside the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Chapter 10: How to Fill a Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Chapter 11: Taking Out a Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

The instruments you need . . . . . . . . . . . . . . . . . . . 160

False teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Where you work is important . . . . . . . . . . . . . . . . 162

Problems that can occur . . . . . . . . . . . . . . . . . . . . 171

How to take out the tooth . . . . . . . . . . . . . . . . . . . 163

Clean your instruments after you finish . . . . . . . . 173

How to place a suture . . . . . . . . . . . . . . . . . . . . . . 167

Chapter 12: HIV and Care of the Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . 175

What is HIV? . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

White or yellow patches in the mouth . . . . . . . 186

How is HIV spread? . . . . . . . . . . . . . . . . . . . . . . 178

Sores of the skin of the mouth . . . . . . . . . . . . . 188

Who gets HIV? . . . . . . . . . . . . . . . . . . . . . . . . . 179

Infection of the gums . . . . . . . . . . . . . . . . . . . . 189

How HIV affects the mouth. . . . . . . . . . . . . . . . 179

Cold sores or fever blisters . . . . . . . . . . . . . . . . 192

How to examine the mouth for

Red or purple patches in the mouth . . . . . . . . . 194
signs of HIV or AIDS . . . . . . . . . . . . . . . . . . . . . 180

Dry or painful mouth and throat . . . . . . . . . . . . 195

Dental care for a person with HIV . . . . . . . . . . 183

Helping people with HIV in

Common problems caused by HIV
your community. . . . . . . . . . . . . . . . . . . . . . . . . 196
and how to treat them . . . . . . . . . . . . . . . . . . . 184

Working for change in your community . . . . . . 197

Appendices

Get Rid of Wastes Safely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

The Dental Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Records, Reports, and Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Vocabulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Other Books from Hesperian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Where There Is No Dentist 2012
vii

INTRODUCTION
by David Werner

A healthy tooth is a living part of the body. It is connected by ‘life-lines’ of blood and nerve to a person’s heart and brain. To separate the tooth from the body, or even to interrupt those ‘life-lines’, means death to the tooth. It also means pain and injury to the body, to the person.

Let us look at it another way. The health of the teeth and gums is related to the health of the whole person, just as the well-being of a person relates to the health of the entire community.

Because of this, the usual separation between dentistry and general health care is neither reasonable nor healthy. Basic care of the teeth and gums—
both preventive and curative—should be part of the ‘know-how’ of all primary health care workers. Ideally, perhaps, Where There Is No Dentist should be a part of Where There Is No Doctor. Think of it as a companion volume, both to Where There Is No Doctor and Helping Health Workers Learn.

Murray Dickson has taken care to write this book in a way that will help the readers see dental care as part of community health and development. The approach is what we call ‘people centered.’

Where There Is No Dentist is a book about what people can do for themselves and each other to care for their gums and teeth. It is written for:

• village and neighborhood health workers who want to learn more about dental care as part of a complete community-based approach to health;

• school teachers, mothers, fathers, and anyone concerned with encouraging dental health in their children and their community; and

• those dentists and dental technicians who are looking for ways to share their skills, to help people become more self-reliant at lower cost.

Just as with the rest of health care, there is a strong need to

‘deprofessionalize’ dentistry—to provide ordinary people and community workers with more skills to prevent and cure problems in the mouth. After all, early care is what makes the dentist’s work unnecessary—and this is the care that each person gives to his or her own teeth, or what a mother does to protect her children’s teeth.

viii Where There Is No Dentist 2012

While dental disease is decreasing in richer countries, it is on the increase in most poor countries. One reason for this is that people are eating fewer traditional (unrefined) foods and more pre-packaged commercial foods, often sweetened with refined sugar.

Even as the need for dental care is growing, there are still far too few dentists in poor countries. Most of those few work only in the cities, where they serve mostly those who can afford their expensive services.

People in many countries cannot afford to pay for costly professional dental care. Even in rich countries, persons who do not have dental insurance often do not get the attention they need—or go into debt to get it.

Two things can greatly reduce the cost of adequate dental care: popular education about dental health, and the training of primary health workers as dental health promoters. In addition, numbers of community dental technicians can be trained—in 2 to 3 months plus a period of apprenticeship—to care for up to 90% of the people who have problems of pain and infection.

Dentists’ training usually includes complicated oral surgery, root canal work, orthodontics (straightening teeth), and other complex skills. Yet most dentists rarely do more than pull, drill, and fill teeth—skills that require a fraction of the training they have received. The simpler, more common dental problems should be the work of community dental technicians who are on the front lines (the villages), with secondary help from dentists for more difficult problems.

Would this reduce quality of service? Not necessarily. Studies have shown that dental technicians often can treat problems as well as or better than professional dentists. In Boston (U.S.A.), for example, a study showed many of the basic treatments commonly given by dentists to be done just as well, and often better, by dental technicians with much shorter training.

Fortunately, in some countries skilled dental technicians have managed to become the major providers of the most needed dental services. In India, there are still ‘street-corner’ dental technicians with footpedal drills, who drill and fill teeth at remarkably low cost.

In Honduras, dental technicians (who learn largely from each other, starting as helpers) have formed their own union. Their political strength was tested when, in the town of Trujillo, a dentist tried to put a technician out of business. The local technician had removed an infected root left mistakenly by the dentist. The technician had commented on the dentist’s carelessness, and the dentist heard about it. The dentist sent a policeman who shut down the technician’s office and took away his tools. However, the dental technicians’ union took this to court. They argued their rights to

Where There Is No Dentist 2012
ix
practice dentistry, because they are the only persons working in marginal communities where dentists’ prices are too high for the people. The court decided in favor of the technicians, and ordered the dentist to return the technician’s tools and pay him for work lost.

In other countries dentists and community dental workers work in closer harmony. In Guatemala, Ecuador, Papua New Guinea, and Mozambique, dental technicians are now recognized by the Ministries of Health. In Papua New Guinea and Ecuador, professional dentists train and supervise them to provide dental care to school children. In Ecuador, they work mostly as dentist assistants, bringing high quality services to more people while decreasing costs. The ‘dental therapists’ in Papua New Guinea are trained to extract, drill, and fill teeth, as well as to work on prevention of dental problems in school children.

In Guatemala and Mozambique, dentists from the dental school have trained village health promoters as dental workers who work with people of all ages.

Their training includes community dental health education, cleaning of teeth, extractions, and drilling and filling. These health workers are provided with the few basic instruments needed to provide these services.

In Project Piaxtla Mexico (with which I and the Hesperian Foundation have worked for many years), visiting dentists have also helped train village

‘dentics’. They, in turn, now teach basic dental skills to the part-time village health workers. These village dentics, some of whom have had only 3
to 6 years of primary school, now practice—and teach—a wider range of dental skills than the average dentist. Their activities include dental health campaigns with school children, community puppet shows about low-cost dental self-care, cleaning of teeth, extractions, drilling and filling, and the making of dentures (false teeth). Several of the dental workers can now do root canal work—a special treatment to remove the central nerve in order to save an infected tooth. One of the village dentics, remembering what he had seen a dentist do, taught himself how to do root canals when his girlfriend had an infected front tooth that he did not want to pull. (He had also learned to check the tooth from time to time afterward to make sure this treatment had been successful.)

We still have much to learn about dental health. Dentists need to learn from the knowledge of the local people, as well as the people from the dentists.

We have learned that villagers with little formal education often can learn skills with their hands—such as tooth extractions, puppetry, or surgery—
much faster than university students (who have never learned to use their hands for much more than pushing pencils). We also have observed that the best way to learn dentistry is not through school but through practice, helping someone with more experience who is willing to teach.

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Where There Is No Dentist 2012

Where There Is No Dentist has 2 parts. The first part (Chapters 1–5) discusses teaching and learning about preventive care. It begins by encouraging the health worker to examine herself and her family. To be a good example is the best way to teach.

The second part (Chapters 6–11) talks about diagnosing and treating common dental problems. It is especially for those who live where they cannot reach or afford a dentist. A poor neighborhood in the city can be as distant and neglected as a far-off village. This second part is intended mainly for health workers who have helped organize people to meet their own needs.

Murray Dickson— a Canadian with primary care experience in Northern Canada, Nigeria, Papua New Guinea, and Mozambique—has written this book in clear, simple language. He takes care to use popular names instead of unfamiliar scientific words. For example, instead of speaking of ‘dental plaque’ the author speaks of the ‘coating of germs on the teeth’. Such simple language does not weaken the message. The message is stronger because everyone understands.

The author has said:

I am sure some dentists will disagree with parts of this book.

Some points of disagreement may be small, like the failure to use accepted dental terminology. Other ideas, particularly the suggestion that non-dental people can be trained to provide many kinds of treatments, may make some dentists angry.

The book is meant to be a source for argument and
discussion. This way, it may stimulate others to write the kind of manual that is really needed in their countries.

The people must answer to the people’s needs. The health of teeth and gums, along with general health, will improve only when people take the lead in caring for themselves. The challenge for dentists and other health professionals is to allow and encourage this to happen.

— 1983

CHAPTER 1

Your Own Teeth
and Gums

Next time you look in a mirror, look at your teeth and the skin (gums) around them. Look in your children’s mouths, too. Look at both gums and teeth, because the health of one often depends on the health of the other. To be strong, teeth need healthy gums . Healthy gums need clean teeth .

What can good teeth
give you?

• GOOD HEALTH

• GOOD LOOKS

• GOOD SPEECH

• GOOD EATING

• GOOD BREATH

And when you think of your teeth, think of your gums . Gums are important for holding each tooth in place .

You need strong teeth to eat different kinds of foods. Different foods are important for health. Nuts, maize, fruits, and meat are some of the best foods—but they are difficult to bite and chew if your teeth are loose and hurting!

1

2

Where There Is No Dentist 2012

You can usually tell if your teeth and gums are healthy or not. Look at the pictures on pages 73 and 74 and compare them with your own mouth. If you find a problem in your mouth, look for its name in Chapter 6 and look for its treatment in Chapter 7.

Most important: when you are not sure of a problem or how to treat it, talk to an experienced dental worker .

If you notice a problem early, often you can stop it from getting worse. It is even better to prevent the problem from starting. You can do this if you know how to keep your teeth and gums healthy.

Learn to take care of your own teeth and gums before you try to teach others . A good example is one of your best teaching tools. People will see that you are healthy, and they will want to know why. When you tell people ways to care for their teeth, they will believe you if they know that you do these things yourself. First take care of your own teeth and gums. Then teach your family what you have learned. They, too, will be good examples for others to see.

Where There Is No Dentist 2012

3

EAT ONLY GOOD HEALTHY FOODS

The best food is food that you grow or raise yourself. Mix different kinds of food together and eat several times a day. This helps your body as well as your teeth and gums to stay strong and healthy. Traditional food is usually good food .

Sweet food, especially the kind you buy from the store, can mix with germs and make cavities—holes in the teeth. Soft food sticks to the teeth easily and it, too, can make a coating of germs and food on the teeth that starts an infection in the gums—gum disease.

Soft and sweet food
and drinks with a lot
of sugar are bad for
both teeth and gums .

Breast feed to help a child’s teeth

Do not give a baby anything to drink
grow and stay strong. An older child
from a bottle. Sweet tea, sugar water or
can drink from a cup.

fruit juice can easily make holes in the
child’s teeth.

REMEMBER:

BREAST

IS

BEST!

YES

NO

GOOD FOR TEETH

BAD FOR TEETH

Even milk has sugar that can wash over the baby’s teeth and cause cavities when it comes from a bottle.

4

Where There Is No Dentist 2012

CLEAN YOUR TEETH EVERY DAY

If you do not clean properly, the food that is left on your teeth can hurt the teeth as well as the gums near them.

HIDING PLACES

Bits of food stay longer in
grooves and ‘hiding places’.

This is where both tooth and
gum problems start.

To prevent problems you
grooves
must take special care to
on top
keep these protected places
clean.

between

It is better to clean your
the teeth
teeth carefully once every
near the gums
day than to clean poorly
many times a day .

Here are 3 places where problems start.

Use a soft brush to clean your teeth. Buy one from the store (be sure it says soft on the package), or make a brush yourself. To make a brush: 1. Use a small branch of young

2. Cut a piece that is
bamboo, strong grass, or the skin
still green and soft.

from sugar cane or betel nut.

3. Chew one end to make it

4. Sharpen the other end so
stringy like a brush.

it can clean between the
teeth (see pages 71-72).

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5

You can twist the fiber from inside a coconut husk into a kind of brush. First rub it and shake away the loose bits. Then use the end to clean your teeth.

Whatever kind of brush you use, be sure to clean your back teeth as well as your front teeth. Scrub the tops and sides where the grooves are. Then push the hairs between the teeth and scrub (page 69).

Toothpaste is not necessary .

Charcoal or even just water is
enough. When your teeth are
clean, rinse away the loose
pieces of food.

6

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CAVITIES, TOOTHACHES AND ABSCESSES

‘Cavities’ are holes in teeth. Cavities are made by the infection called tooth decay . If you have a black spot on your tooth, it might be a cavity. If that tooth hurts some of the time, such as when you eat, drink, or breathe cold air, it probably has a cavity in it.

You will get cavities in your teeth if you eat sweet food and then do not clean your teeth. If you see a cavity starting in your mouth or feel a tooth hurting you, get help right away . If you do not fill a cavity, it grows bigger and deeper. A dental worker knows how to fill the cavity so you can keep that tooth. Do this before the pain gets worse.

Each tooth has roots

When decay touches

When infection
that hold it in the jaw
the nerve, inside the
reaches the
bone. Inside each
tooth aches, even
inside of a root, it
root is a nerve. (p. 41,
when you try to
is called a tooth

42, and 46)

sleep.

abscess.

A tooth with an abscess needs treatment at once, before the infection can go into the bone (page 93). In most cases the tooth must be taken out. If it is not possible to do this right away, you can stop the problem from getting any worse if you follow these steps:

1 . Wash the inside of your mouth with warm water. This removes any bits of food
caught inside the cavity.

2 . Take aspirin or acetominophen for pain.

See page 95 for amount.

3 . Reduce the swelling:

• hold warm water inside your mouth
near the bad tooth.

• Wet a cloth with hot water and
hold it against your face. Do not
use water hot enough to burn

A tooth abscess can cause
yourself!

swelling like this.

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7

SORE BLEEDING GUMS

Healthy gums fit tightly around the teeth. Gums are infected if they are loose, sore, and red, and if they bleed when the teeth are cleaned. Infection in the gums is called gum disease .

Gum disease, like tooth decay, happens when acid touches the teeth and gums. This acid is made when sweet and soft foods mix with germs (see page 50).

HEALTHY TEETH AND GUMS

CAVITIES AND GUM DISEASE

Infection from gum disease can spread into the root fibers and bone (see page 42). But you can stop gum disease and prevent it from coming back . There are two things to do: clean your teeth better and strengthen your gums.

1 . Even if your gums are sore and they bleed, you must still clean the teeth beside them. If more food collects on the teeth, the gum infection will get even worse. Get a soft brush and use it gently. This way you will not hurt the gums when you clean.

2 . To make your gums stronger and more able to fight the infection:

• Eat more fresh fruits and green leafy vegetables, and fewer soft sticky foods from the store.

• Rinse your mouth with warm salt water. Do this every day, even after your gums feel better.

(1) Mix some salt with a cup of warm water. (2) Take a mouthful and rinse. (3) Spit it out. Repeat until all of the salt water is finished.

8

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MORE SERIOUS GUM DISEASE

Painful gums that bleed at the slightest touch need special treatment. If you have this problem, ask for help. A dental worker can explain what is happening and what needs to be done. A dental worker can also scrape the teeth and remove the tartar that is poking the gums, making them sore.

At home, you can do some things to help.

• Clean your teeth near the gums with a soft brush. Gently push the brush between the tooth and the gum. It may bleed at first, but as the gums toughen, the bleeding will stop.

• Make your food soft, so it is easier to chew. Pounded yam and soup are good examples.

• Eat plenty of fresh fruits and vegetables. If it is difficult for you to bite into fruit, squeeze it and drink the juice.

• Start rinsing your mouth with a mixture of hydrogen peroxide and water. You can get hydrogen peroxide from your clinic or your pharmacy (chemist).

The strength of hydrogen peroxide is important . Ask for a 3%
solution, and mix it evenly with water—that is, ½ cup of hydrogen peroxide with ½ cup of water.

WARNING: Read the label to be sure the solution is 3% . A mixture with more than 3%
hydrogen peroxide can burn the mouth .

Take some into your mouth and hold it there for about 2 minutes. Then spit it out and repeat. Do this every hour you are awake.

Use hydrogen peroxide for only 3 days. Then
change and start rinsing with salt water (page 7).

If you take care, you can keep your teeth for a lifetime .

9

CHAPTER 2

Teaching Family and

Friends in Your Community

Old people can remember when there were fewer problems with teeth and gums. Children’s teeth were stronger and adults kept their teeth longer.

Times are changing. Today there are more tooth and gum problems than ever before. In many countries, tooth decay and gum disease are two of the fastest growing health problems.

This unhealthy situation is getting worse, for two reasons: changes in the kind of food people now are eating, and not enough cleaning after they eat.

BEFORE, the food people ate

NOW, more people are buying
was their own, grown and
softer and sweeter food from
prepared by themselves.

the store. This kind of food
sticks to the teeth more easily
so it has more time to attack
the teeth and gums.

Even sugar cane was not as bad

Everyone must be more careful
as the sticky candy children eat
to clean away soft, sweet
today. The sugar was bad for the
food. But many people do not
teeth, but the fiber in the cane
know how. Some, especially
helped rub them clean.

children, do not even try.

9

10 Where There Is No Dentist 2012

Many people do not understand that tooth and gum problems are caused by certain kinds of food, and poor cleaning of the teeth. In fact, some have a completely different belief.

Do not attack a belief because it is traditional. Many traditions are more healthy than ‘modern’ things. Often, instead of telling people that their belief is wrong, you can remind them of a different tradition that is healthy.

Help your family and friends to recognize their healthy traditions . Then help them find new ways to use these same traditions for better health .

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11

BE A GOOD EXAMPLE

Other people like to watch what you do before they try something different.

First show members of your family and then they will be an example to others in your community. For example:

1 . Instead of buying all your foods from the store, buy fresh fruits and vegetables from the market. It is even better to grow food in your own garden.

Learn to use several different kinds of
foods in each meal. Mixing foods is a
healthy idea. Invite friends to share your
meals and see the number of different
foods you have at each meal.

2 . Do not buy fizzy drinks like Coca-Cola or Fanta.

They have a lot of added sugar which quickly
makes children’s teeth rotten.

Also, do not sweeten your child’s milk or tea.

When she is young she can learn to enjoy
drinks that are not sweet.

Clean, cool water, tea with little sugar, milk, or water from a young coconut are best to drink.

Fresh fruits are delicious when you are thirsty.

Most important: do not give your child a feeding bottle, especially one with a sweet drink inside . (See page 3.) 3 . Keep your children’s teeth clean.

Your friends will notice clean
teeth or teeth that are dirty or
have cavities. Remember, clean
teeth are healthy teeth .

An older child can clean his own
teeth if you show him how.

A younger child cannot. He needs
help. Each day someone older
should clean his teeth for him

(page 18).

12 Where There Is No Dentist 2012

When you teach, remember that as others learn, they too become teachers . Each person can teach another .

Encourage people to pass along what you have taught. Mothers can teach family and friends. Students can talk at home with brothers, sisters, and older family members.

FROM THE HEALTH CLINIC…

… TO THE HOME

FROM THE SCHOOL…

… TO THE HOME

If all learners become teachers, a simple message can begin in the health clinic or school and reach many more people at home.

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13

FINDING THE BEST WAY TO TEACH

Deciding what to teach is important, but just as important is how to teach.

Learning cannot take place
when you use words that
people do not understand.

They will learn something
only when they see how it
is related to their lives.

Remember this when you teach about eating good food and keeping teeth clean. Design your own health messages, but be ready to change them if people are not understanding or accepting what you say.

Here are five suggestions for teaching well.

1 . Learn First From the People

Get involved in your community’s activities. Learn about people’s problems, and then offer to help solve them. People will listen to you when they know that you care about them and want to help.

Sit and talk with people. Learn
about their customs, traditions
and beliefs. Respect them .

Learn about their health habits.

Improving health may require
changing some habits and
strengthening others.

Learn also about tooth
decay and gum disease in
your community.

Make people smile—then look into their mouths.

Find out how many children and adults are having
problems with their teeth and gums. Do a survey
such as the one on page 220.

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2 . Build New Ideas Onto Old Ones

People find their own ways to stay healthy. Many traditions are good, helpful, and worth keeping. But some are not.

When you teach, start with what people already understand and are doing themselves. Then add new ideas.

This method of teaching is called ‘association of ideas’. It helps people to understand new ideas because they can compare them with what they already are doing.

In this way people can more easily accept, remember, and do what you suggest.

A HEALTHY TRADITION
builds

NEW IDEAS AND WAYS

Sweeping the compound
in the

Brushing the teeth and gums keeps
makes it a clean and
same
them clean and healthy.

healthy place to live.

way

A small child cannot find
in the

A small child cannot see the
his own lice. Mother
same
food on his teeth. He needs
knows she must help him.

way
help with that also.

Eating different kinds of food

Different vegetables
in the
helps people to grow. Eating them
when planted together—
same
several times a day makes your
like maize and yams—
way
teeth and gums, as well as your
help each other to grow.

whole body, grow stronger.

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15

STORY TELLING—AN EXAMPLE

People everywhere have a tradition of teaching with stories. Many of the things we believe, we learned through stories we heard from parents, friends, and teachers. This is good, except when a story teaches something that isn’t true! When a woman gets pregnant, for example, she hears many stories, and she wants to learn whatever she can from these stories.

Unfortunately, some traditional beliefs about pregnancy are partly wrong . An example is the belief that one must always have dental problems during pregnancy.

Here is a story you can tell to help people see that they are partly right about pregnancy and dental problems, but that there is more to understand.

A Story: Bertine’s teeth

Bertine was the dental worker in her village. She was a young woman, but the villagers respected her because she was such a careful worker, and because she knew how to fill cavities and pull teeth without hurting people. She also spent a lot of time teaching people how to avoid dental problems. “Clean your teeth every day!”

she often said, at her clinic, at the schools, at village meetings. “Eat a mixture of foods, especially a lot of fruits and vegetables! Avoid candy and sweet, sticky foods!”

When Bertine was 23 years old, she got
married and became pregnant. She also
began to have some tooth problems of her
own. She saw that her gums were bleeding
when she cleaned her teeth, and she had
small cavities in two of her teeth. As the
dental worker, she was embarrassed to
have tooth problems, but an older woman
told her, “It’s natural to lose teeth when you
have babies, Bertine. As we say, ‘For each
child, a tooth’.”

One day Lucie, a dental worker from a nearby village, came to see her friend Bertine. Lucie had a young baby, and Bertine asked her a lot of questions about babies and about pregnancy. Then Bertine said, “Of course, l’m having lots of problems with my teeth.” “Why do you say ‘of course’?” asked Lucie. “Well,” Bertine replied, “For each child, a tooth.”

“But that’s not true!” Lucie cried. “You think you are having tooth and gum problems because you are pregnant, but I bet you are having these problems for all the usual reasons.”

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“The usual reasons?” asked Bertine.

“Yes,” said Lucie. “How often do you eat now that you are pregnant?” “Well, a lot more than I used to—I have two persons to feed!” “And do you still eat sweet foods sometimes?” Lucie asked.

“I guess I do,” said Bertine, “and more sweets than before, because I eat more often.”

“How about teeth cleaning?” asked Lucie. “Do you clean as often as you did before you were pregnant?” “No,” Bertine admitted, “I heard I was going to have tooth problems anyway, and I have been so tired lately…. Oh! Do you suppose that these are the only reasons I am having these problems? How do you know so much about this, Lucie?”

“Because I had the same problems, Bertine. I learned the truth the hard way. I had an infected tooth, and the infection passed to my kidneys. At the health clinic, they told me it is not necessary to have tooth problems during pregnancy—and it is even dangerous. I am lucky I did not lose my baby! That can happen, you know, when a tooth problem is not treated. We must fill your cavities right now.”

“You mean I can be treated now, before I have my baby?”

“Yes, and you should!” said Lucie. “And you
can take better care of your teeth. It is true that because of the pregnancy, your gums are weaker,
and they can get infected. But this means you
should take even more care than usual to: (1) clean regularly and (2) eat the right foods. You need to have strength when you are pregnant. An infection
in your mouth does not help that. Because your
gums are weak, it is also good to (3) rinse your mouth every day with warm salt water (see page 7), and if you cannot get fresh fruits and vegetables, then (4) take a tablet of Vitamin C every day.”

Lucie then offered to clean Bertine’s teeth and to fill her cavities. When she touched Bertine’s gums, they bled, and Lucie said, “They will bleed at first, but after you clean them regularly for a while, they will be stronger. Bleeding gums are dangerous to a pregnant woman. The bleeding can increase anemia, which is a serious problem.”

“If a pregnant woman’s tooth has an abscess, is it safe to pull it before she has the baby?” asked Bertine. “Yes,” said Lucie, “you just must be gentle. A woman gets tired sitting in a dental chair for a long time, and sometimes you must give some extra anesthetic so she does not feel any pain.”

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17

3 . Keep Your Messages Short and Simple

Instead of partially teaching too many things, it is better to discuss a few things well. After learning what health problems the people feel are greatest, decide what information will help them solve these problems.

Then think of how to share the information. Try to:

• Use simple words (see page 13). If you must use a big word, take the time to explain it.

• Teach people when they are ready to learn . A sick person, for example, usually wants to know how to prevent his sickness from returning. He will remember what you tell him.

• Repeat the most important message many times . Whenever you teach about staying healthy, remember to emphasize eating good food and keeping teeth clean. Repetition helps people remember.

• Let people see what you mean . See pages 26 to 34 for ways to use pictures, puppets, and plays.

4 . Teach Wherever People Get Together

Knowing where to teach is sometimes as important as how you teach.

Instead of asking people to come to a class you have organized, go to them. Look for ways to fit into their way of living. You both will gain from the experience. They will ask more questions, and you will learn how to work with people to solve problems.

Talk with people where they gather near their homes.

Talk to men

Talk to women
and women at
at health
church meetings,
clinics and in
in parents’

the market.

groups at their

Talk to men
children’s
at business
school, and
and farming
at community
meetings.

meetings.

Teach men and women at reading groups.

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5 . Teach Something People Can Do Right Away

It is good to tell a mother to keep her child’s teeth clean, but it is better to show her how to do it. She will remember how if she actually watches you clean her child’s teeth.

An even better way for a mother to learn is to let her clean her child’s teeth while you watch. A person discovers something for herself when she does it herself .

Pick out a child and clean his teeth yourself.

Let his mother watch.

Use a soft brush (or for a baby, a clean cloth).

Gently but quickly brush or wipe his teeth.

Do the best you can even if he cries.

If mothers make this into a habit, the child will
expect to have his teeth cleaned and will soon
cooperate—just the way he does to bathe or
to have lice removed from his hair.

Now let each mother clean her

Ask her to do the same at home
own child’s teeth. Teach her to
each day. At the next clinic, look
clean on top and on both sides
at the children’s teeth and see
of every tooth.

how well the mothers are doing.

Give further help when needed.

Always praise and encourage
those who are doing well.

19

Teaching Children

CHAPTER 3
at School

Children want to learn. They want to know more about things that are real to them. Family, friends, and teachers are all important sources of new knowledge for children.

It is important to keep alive their desire to learn, so that children can continue to ask questions, discover, and learn more for themselves.

When children are interested in something, they
will work hard to learn all they can about it.

If you relate your teaching to children’s interests and needs, they will learn more easily. New information added to what they already know helps children to understand your lesson better. As a result, they will want to learn more because the information is both interesting and worthwhile.

Teaching about teeth and gums is important. You must do it well if you want children to pay attention, learn, and finally act to take care of their own teeth and gums.

As school children continue to learn, they can share their new ideas and information at home with brothers, sisters, mothers, fathers, and grandparents. In this way, the circle of teaching and learning described on page 12 comes back into the family and is complete.

This chapter has two parts. Part 1 gives seven guidelines for assuring that learning takes place. Part 2 suggests ways to have fun while learning—with stories, games, and pictures. In Chapter 4 there are nine questions on teeth and gums with specific activities for learning how to answer them.

19

20 Where There Is No Dentist 2012

PART 1:

TEACHING SO THAT LEARNING CAN TAKE PLACE

More children than ever before are having
problems with their teeth and their gums .

A tooth that hurts or gums that are
sore can affect a student’s ability to pay
attention in school and learn.

Treating the problem makes the child feel
better, and that is important. It is equally
important to prevent the same problem
from returning later.

Working together, teachers and school children can do much to prevent both tooth decay and gum disease .

Keeping the mouth healthy involves learning about eating good food and keeping teeth clean. Just giving information is not enough, though. To truly learn, children need a chance to find out things for themselves.

Forcing a person simply to accept what
you say does not work very well.

A student learns not to question. What
you teach may have no relation to his
own experiences and needs.

As a result, he may end up not doing
what you teach—not eating good foods,
and not cleaning his teeth.

Learning happens when a student with a
question or an idea is able to discover more
about it himself.

It also happens when he has a chance to do
whatever is necessary to take better care of
himself and his family.

He can learn by doing. Give him a chance to
eat good food and clean his teeth at school .

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Learning about teeth and gums can be fun. When the teaching is real and practical, students love to learn. Here are some ideas: Teaching so that learning can take place

1 . Teach and learn together with school children.

2 . Start with what the students already know.

3 . Let students see and then do.

4 . Let children help each other.

5 . Teach about teeth and gums together with other subjects.

6 . Be a good example.

7 . Make the community part of your classroom.

1 . Teach and Learn Together with School Children Share ideas
instead of always
giving information.

Children learn
more when they
are involved.

A lecture transfers
your own notes
to the children’s
notebooks without
ever passing
through their minds.

A discussion draws out
information and opinions.

It helps you
to learn more
about the
school children,
what they
already know
and believe to
be true.

But it also allows
you to introduce
important
information that
is related to the
discussion.

22 Where There Is No Dentist 2012

2 . Start with What the Students Already Know

To have meaning, learning should be a part of daily living. Talk with your students. Find out what they know about teeth and gums, and what questions they might have.

Add information by building upon
what a person already knows .

Do not use big words. Scientific names and textbook explanations are confusing, and you usually do not need them. Talk about teeth and gums using words that a school child can understand and use later at home.

This way makes
students feel
stupid.

This way lets the
students feel good,
because it makes
sense and they know
something about it.

When you can understand new information, you gain confidence and you look forward to learning more.

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3 . Let Students See and Then Do

Students learn best when they can take part and find out for themselves about something new.

A lecture about brushing teeth is usually not interesting at all.

Learning is more interesting when students can see how to make a brush and how to clean teeth properly.

If students can actually make their own brushes and clean their own teeth, it is not only interesting but fun.

A student who takes part will not forget. What he learns by doing becomes part of himself.

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4 . Let Children Help Each Other*

In most families, older children have important work to do—taking care of their younger brothers and sisters. These older children can do much to teach the younger ones about care of teeth and gums. For example:

• When they feed their younger
brothers and sisters they can
encourage them to eat good food,
like fruit instead of candy.

• They can do a play or puppet show
about care of teeth and gums.

• They can check the teeth and
gums of the younger children and

‘score’ them on how healthy they
are (see p. 60).

Here a group of school children
in Ajoya, Mexico is putting a

• Best of all, they can actually clean
high-fluoride paste (see p. 211)

the teeth of the younger ones,
on the teeth of the younger
and show them how to clean their
children.

own teeth when they are able.

5 . Teach About Teeth and Gums

Together with Other Subjects

Teeth and gums are part of a bigger health picture. Teach about them in class at the came time.

Eating good food can be part of a discussion on nutrition, teeth, farming methods, and the politics of who owns the lands.

Cleaning the teeth can be part of a
discussion on hygiene, clean water, and
traditions and customs.

A good way for school children to learn
about using numbers is to do a survey in
the community.

The results will tell the children
something about health problems in
their community. For an example of a
survey of health problems, see page

3-14 of Helping Health Workers Learn.

* For more ideas on how school children can help each other, write to Child-to-Child Trust, Institute of Education, 20 Bedford Way, London, WC1H 0AL, UK. Tel: 44-207-612-6649.

Fax: 44-207-612-6645. E-mail: ccenquiries@ioe.ac.uk. Website: www.child-to-child.org

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6 . Be a Good Example

Children watch people around them. They pay attention to what you do, as well as to what you say.

Be a good example.

Take care to do
yourself what you
are teaching to your
students .

Your family can be
a good example for
others.

• Clean your teeth carefully every day. Also, help your children keep their teeth clean.

• Make a garden near your house and plant a variety of vegetables and fruits in it.

• Buy only good, healthy food from the store. Do not buy sweet foods and drinks for yourself or your children.

7 . Make the Community Part of Your Classroom

A child’s home and his community are really more important to him than his school. Learning will be more interesting for a student if the day-to-day needs of his home and his community are part of school discussion.

Let students find out more about problems
at home and in their community.

For example:

• How many small children have
cavities or red, bleeding gums?

• How many stores have mostly
sweet snack foods on their
shelves?

• Why do the people not grow
and eat more local food?

Back in the classroom, students can record what they find. Ask the children to think of ways to solve the problems they found. If they can think of a program to help solve a health problem, let them go back into their community and try it.

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PART 2

MAKING LEARNING EXCITING, VISUAL, AND FUN

Here are some ideas to help students see what you are teaching, and to have fun while they learn. Students can also show these things to others.

Teaching others is an excellent way to learn.

Tell a story about food or teeth. For example, tell a story about why a wild cat’s teeth are different in shape from a goat’s teeth (page 40). Stories are an excellent way to learn, both for the storyteller and for those listening.

Leave time at the end to discuss the story and to introduce new information.

See the example of storytelling on pages 15 to 16.

Make up a play or drama about good food or clean teeth. Show it later to the community.

The play should be about looking for an answer to a real problem. If the children invent the play, they will have to think, plan, and solve problems. A play also helps children learn how to talk with and teach others.

These school children in Nicaragua are doing a play about cavities. On the left, germs and sweet food are combining and trying to make a hole in the ‘tooth’. But a giant toothbrush (right) beats them away!

Do a demonstration using local resources.

Try, for example, the

‘tooth in the Coca-Cola’

test on page 48.

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Puzzles can help school children discover answers for themselves. You can make your own. The best puzzles are with words that the students know and can use easily.

EXAMPLE (for younger children just
learning to read) Try to find these words:

As you find each word, put a beside it.

An older child can try to find important words that are more difficult.

Spell some of the words diagonally (slanted). It will make the puzzle harder.

28 Where There Is No Dentist 2012

You can use pictures on posters, flip charts, and on flannel-boards.

Pictures that school children draw themselves are best. They learn simply by drawing them. Also, school children will draw local people and local experiences, and the people will understand their pictures better than the ones sent from a central office far away.

Photographs of local people and events are also good. If there is a photography club in a local secondary school, have them take some pictures for you. They may even print the photographs larger so that you can use them as posters.

Ask the children to make pictures big enough so that a person can stand far away and see them easily.

Let each child carry her
poster home to show her
family and friends.

Hang up other posters in
the store, church, or other
places where people will
see them.

Pictures can be made to
stick to cloth and then used
to tell a story. Cover a board
with a piece of flannel cloth
or a soft blanket, to make a
flannel-board . *

Mix some flour and water to
make glue. Then glue a strip
of sandpaper to the back of
each picture. The sandpaper
sticks to the cloth and lets you
place the picture where you
want on the cloth.

Let the child use her pictures
and cloth outside of the
school, to show her story to
family and friends.

*For more ideas on flannel-boards, see pages 11-15 to 11-19 of Helping Health Workers Learn.

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Flip charts are excellent for telling a story with pictures. Often, people can guess what the story is about just from the pictures. When showing the pictures on a flip chart, ask as many questions as you can, to get the people to tell you the story.

Here a health worker from

Mozambique is holding a flip chart
with pictures about care of teeth
and gums. There are no words
with the pictures.

But he can read a short message
written on the back of the page
before. There are
also examples of
questions to ask.

This way,
anyone who can
read can tell the

‘flip chart story’

to others.

This is part of a flip chart presentation on

There is also a
mothers’ and children’s health. Notice
small copy of the
the rings at the top that hold the flip chart
big picture on the
together. They are made from old electrical
back of the page
cords.

before.

Find a way to attach the sheets of heavy paper. Here are two ways: with 2 thin pieces of wood
with metal or wire rings

30 Where There Is No Dentist 2012

FLIP CHARTS—AN EXAMPLE

Dental workers in Mozambique created this flip
chart presentation for teaching in schools.

1) Here is a healthy, happy schoolboy. In the circle you see the inside of his mouth. His teeth are
white and clean. Look at his gums . What color are they? Are they tight or loose? Between the
teeth, are the gums pointed or flat?

2) This is an unhappy, sick boy. What color are his teeth? Not only are they yellow, there are
black spots. These are cavities .

What color are his gums? Are they pointed?

Loose, red, swollen gums are signs of gum
disease .

Both cavities and gum disease can be treated.

3) What happens if tooth and gum
problems are not treated?

a) The black hole grows bigger on
the tooth and a sore forms on the
gums near the root. The tooth hurts
whenever you touch it.

b) The red, loose gums pull away from
the tooth. Infection gets to the bone
and eats it. The tooth loses the bone
and the gum around it.

The first problem is a tooth abscess . The second is advanced gum disease . If either of these things happens, the tooth must be taken out.

4) Why does the boy have cavities and gum disease?

There are 2 reasons.

a) He eats too many sweet foods .

What foods do you see here?

What other foods hurt the teeth?

b) He does not clean his teeth regularly .

The germs in his mouth eat sugar from
his food and make acid. Acid causes
both cavities and gum disease.

Where There Is No Dentist 2012 31

5) What foods can the boy eat to keep his teeth and gums healthy? What do you see in this picture?

Natural foods, with no sugar added, are the best.

The foods you grow yourself and local foods
from the market are better than sweet foods
from the store.

6) How can we clean our teeth?

Carefully is the
important word to
remember. Clean your
teeth at least once a day, carefully brushing every part of every tooth—outside, inside, and top. Be
very careful to push your brush between your
teeth . That is where the germs and food collect to make acid.

If you do not have a toothbrush, you can make
one from a stick. Toothpaste is not necessary.

Clean water is enough.

Chapter 12 in Helping Heath Workers Learn is full of ideas on how to make and use pictures effectively. Once you have a good original, you do not need to be an artist to make a good copy. Here is an easy method that can involve every student.

Place thin see-through paper over the original drawing. Carefully trace a copy.

Now place the copy on a new sheet of heavy paper. Pressing firmly with a pencil, retrace all of the lines on the thin copy paper.

Remove the tracing
paper. Pressure from
the pencil has made
fine lines on the
poster paper. Redraw
them with a pencil so
they stand out clearly.

Your copy is now
ready for coloring.

And you can use your
copy paper again to
make another copy.

32 Where There Is No Dentist 2012

Use puppet shows to act out the
messages of eating good food and
keeping teeth clean.

Students can make their own
puppets to look like people or
animals.

Using puppets, it is often
easier to say things that people
themselves cannot. For example,
they can talk openly about the bad
food sold at the village store.

Children can make puppets easily from paper bags. They are good for showing teeth because you can make a wide-open mouth.

Open and close your
hand to make it eat
or speak.

To make a
bigger puppet,
attach a
cardboard face
to the bag.

A puppet made from a sock looks alive.

1 . Fit the sock over your hand.

2 . Make the mouth by pushing in the
cloth between your thumb and
fingers.

3 . Add eyes, nose and hair to the
sock or to a box that fits over it.

Loosely fill a cloth bag with old cotton or paper. Put the end of a stick inside, and tie the bag to it with tape or string. Make a sad or happy face to fit the story. Dress the puppet with an old piece of cloth.

Where There Is No Dentist 2012 33

PUPPET SHOWS—AN EXAMPLE*

Above, school children in Ajoya, Mexico are holding puppets they made themselves. On the left, you see them in front of the stage and at right, the children show how they hold the puppets behind the stage.

1) They called their puppet show “Rotten

Teeth—And A Friend’s Advice.”

2) Pedro, a schoolboy, is sad. His friends
looked into his mouth and saw two
teeth with big holes in them. He tells
his brother he wants to walk home
alone.

3) On the way, Pedro meets Maria, a
friend who is a dental worker. “l’m not
sad because the others are laughing,”

says Pedro. “I know the real problem.

The holes in my teeth will get bigger.

My teeth will rot and fall out, and
maybe my permanent teeth coming in
will rot, too.”

Maria thinks she knows what to do. “We
will talk to your father,” she says.

* For another example of a puppet show, and more suggestions for making puppets, see pages 27-35 to 27-39 of Helping Health Workers Learn.

34 Where There Is No Dentist 2012

4) One day later.

(Note how the scene behind the puppets
changes. lt is a flipchart with pictures to
show the different places the puppets

‘go’.)

5) “I am a poor farmer,” Pedro’s father tells

Maria. “I only go to the city two times a
year to sell my crops. I cannot take the
boy to the city and pay for fillings in his
teeth.”

Maria answers, “But we can save his
teeth with a temporary cement filling.”*

6) “Then, when you have time and money,
you can go to the city. I know a dental
worker who will put in a permanent
filling. I trust him. I will send a note
with you, and it will not cost much.”

”Good!” says the father. “Come on,

Pedro,” says Maria, “l’II put some
cement in those holes!”

7) Four months later, Pedro visits the dental
worker in the city. “Maria’s good fillings
saved your teeth,” he says. “These
permanent fillings will last for years.”

“Terrific!” says Pedro.

8) After the show, the puppets played
a game. Throwing a ball into the
audience, they asked questions like

“How do you keep cavities from
happening?” Each child who caught
the ball answered the question and
threw it back. Then the children in the
audience began asking questions for the
puppets to answer. “Why did you get
rotten teeth?” one child asked Pedro.

The puppet looked down and said, “Too
much candy!”

* To learn how to make a temporary filling, see Chapter 10.

35

CHAPTER 4

School Activities for Learning

About Teeth and Gums

We can help school children in two ways. First, they need treatment now for problems they already have. Second, they need to learn how to prevent problems from hurting them (and their families) later.

Treatment and prevention go together. It is a mistake to emphasize only prevention and to forget about treatment. In fact, early treatment is the first step to prevention because it usually meets a person’s most strongly felt, immediate need .

As a community dental worker, you can visit a school and find out what the felt needs are. Begin with the teacher. Examine for cavities, bleeding gums, or other problems. Then look at the students.

Chapter 6 tells you how to examine a person. It also helps you decide what treatment to give, and who should give it.

Then teach how to prevent dental problems . Give the teacher ideas to help students learn why they have problems, and how to keep the problems from returning. The best way to learn is by doing—through activities, not lectures. This chapter has many suggestions for activities.

The best health practice is to prevent cavities and gum disease from even starting. With these activities, children can do something to guard their health.

Teacher, each day at school:

Suggest ways
for your
students to eat
good healthy
kinds of food.

AND

Give your
students time
to clean their
teeth.

35

36 Where There Is No Dentist 2012

A Note to Teachers:

Do not wait for a dental worker. This book, and especially this chapter, is written to help you learn and do things yourself. But do ask your dental worker to work with you. He probably has suggestions that would fit your situation. After examining the children, he can help you follow their progress.

You can then find out how much they are learning and how healthy they are becoming.

To begin, talk with your students to find out what they think and what they already know. What are their traditional beliefs? Some may be helpful, and others may need changing. At first it is best simply to discuss.

Ask the kind of questions that get students talking. Later they will take part in discussions more easily.

Add new information as you go along, changing some ideas but usually building upon what the students already know.

This chapter asks nine questions:

• Why do we need teeth and gums?

• Why do some teeth look different?

• What holds the teeth?

• How often do teeth grow in?

• What makes teeth hurt?

• How do germs make holes in the
teeth?

• What makes the gums feel sore?

• What does it mean if a tooth is
loose?

• How can we prevent cavities and
sore gums?

For each question, there is an activity to help students discover answers for themselves. The questions are not in any particular order, nor are they written for any particular grade level. Make your own lesson plan, using the main idea to help you. Shorten the lesson and make it easier for younger children. Add more information for older students and let them do more activities.

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37

Why Do We Need Teeth and Gums?

THE IDEA:

Your teeth and the gums around
them help you in many ways.

Teeth are important for:

Good Health . Infection from a bad
tooth can spread to other parts of
your body.

Good Looks . Healthy teeth that
look good help you feel good.

Good Speech. Your tongue and
lips touching the teeth help you
make many sounds.

Good Eating . Your teeth break food into small pieces so that you can swallow and digest it better.

Good Breath . If you leave food around your teeth, your breath will smell bad.

Your gums are important too .

They fit tightly around the teeth, and
help to keep them strong. Without
strong gums, your teeth are of no
use. Most old people lose teeth
because of bad gums, not bad teeth.

ACTIVITIES :

1 . Draw or cut pictures of people from magazines . Make posters to show that healthy teeth make a person happy, while bad teeth make a person sad. Use the posters for discussion.

Hang up a picture of a person the
students know and like. Put black on
one of her front teeth. Talk about it.

OR

Leave the picture for a few days. Then
put black on some of her teeth before
the students come to school. See who
notices first.

When someone sees the difference,
talk about how the person looks, how
teeth can be lost, how to prevent that,
and what she can do now.

38 Where There Is No Dentist 2012

Make a picture of a person who has
lost all of his teeth. He looks old.

Talk about how hard it is for him to
eat properly or speak clearly.

2 . Have the students say words that use teeth to make sounds .

“v” and “f” — friend, fever — the lower
lip touches the top teeth.

“th” — the, teeth — the tongue touches
the top teeth.

“s” — sun — air goes between the teeth.

Now, try saying the same words again,
but do not let the tongue or lips touch the
teeth.

3 . Have students draw pictures of good foods we use our teeth to eat.

Then draw foods that we can eat if we lose our teeth.

Need Teeth

No Teeth Needed
and
but not
many more!

much more!

Talk about this together. Try to eat a mango or some maize without using your teeth, or using only your front teeth.

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39

Why Do Some Teeth Look Different?

THE IDEA:

We need two different kinds of teeth to help us eat our food.

Front teeth . Another name for
them is incisors . Their sharp
edge cuts food into pieces.

Back teeth are called molars .

They chew and grind pieces
of food into bits small enough
to swallow.

The outside of a tooth is the hardest and strongest part of your body. When a tooth is healthy, it can chew hard food, even bone. The shape of a tooth allows us to swallow food when the small pieces can slide down its smooth sides.

Food that is not

Small bits of food
cleaned away
often get caught
from the grooves
inside deep lines, or
can make a cavity
grooves, in a tooth.

(hole) in them.

Look for them on the

A tooth with a
top and the sides of
cavity is weak and
back teeth.

often hurts.

40 Where There Is No Dentist 2012

ACTIVITIES:

1 . Ask the students to bring different kinds of food to class . Bring some yourself.

Eat the food using first the front and
then the back teeth.

Bite a guava using only the back teeth.

Chew completely a mango or piece of
maize, using only the front teeth.

2 . Collect teeth from different animals . Let the students discover from the shape of an animal’s teeth the kind of food it usually eats. For instance, a wild cat needs sharp pointed teeth to tear meat, but a goat needs flat teeth to chew grass.

Make a poster to show the animal, its teeth, and the kind of food it likes to eat.

3 . Have each student take a partner . Let each look at the shape of the front and back teeth in the other’s mouth.

Talk about the many different kinds of food we need to stay healthy.

Discuss which teeth we use to chew meat, fish, mango, and other good foods in your area. (For most foods, the answer is both front and back teeth!)

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41

What Holds the Teeth?

THE IDEA:

When you look inside someone’s mouth, you see only the top part of each tooth. The bottom part, its root, is inside the bone under the gum.

The roots of the tooth
hold it in the bone
just like the roots of a
root
tree hold it firmly in
the ground.

The roots of the tooth
do not actually touch
root
the bone. Root fibers
fibers
connect the root and
bone, holding the
tooth in place.

bone

The gums do not hold the teeth, but healthy gums will keep harmful germs from getting to the bone and root fibers. When the gums are not healthy, they form deep ‘pockets’ which collect germs. Soon, these germs will reach the root fibers and bone. The bone pulls away from the tooth in order to get away from the germs. With no bone to hold it, the tooth is lost. This is the most common reason why teeth fall out.

ACTIVITIES:

1 . Have the students look for
an old jaw bone from a dog
or other animal. Notice that
bone goes around every root
of every tooth and holds it
tightly. Break away some
of the bone and look at the
roots of the teeth.

Front teeth need only one root
because they are used for biting.

Back teeth have 2, 3, or even 4
roots. That makes them strong
enough to chew tough meat and
even break hard bone.

42 Where There Is No Dentist 2012

2 . Show your students how infected gums can cause teeth to fall out .

A

B

C
top of
gum
tartar
tooth
pocket
bone
pulling
root
away
bone

A. When gum disease is beginning, a small red `pocket’ forms where the tooth meets the gum. Germs and food collect in the gum and make acid. This makes the gums sore.

B. As a result, the gum pulls away and the pocket becomes deeper.

C. The bone moves away from the infection and no longer holds the tooth.

Try to think of other ways to teach how gum disease pushes the bone away from the tooth. In Jamaica, dental workers ask, “What do you do if someone attacks you with a machete (long knife)?” “I run away!” most people answer. “Exactly,” say the dental workers, “and when you have a lot of germs attacking the root of your tooth, the bone ‘runs away’ and leaves the tooth with nothing to hold it.”

Tell a story to show how, when the gum moves away from the top of the tooth, the root and bone are open to attack. For example: One day, a hen was sitting on the eggs in her nest. The hen was hungry, and when she saw a worm, she left the nest to catch the worm. Just then, a possum came along, saw the fresh, warm eggs, and ate them all up.

Explain to the students that the gums protect the teeth the way a hen protects her eggs. When she leaves the eggs unprotected and exposed, an animal can attack and destroy them. When gums around a tooth are red and sore, the tooth is exposed to germs that can attack not only the top of the tooth, but also the bone and root.

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43

How Often Do Teeth Grow In?

THE IDEA:

A child gets two sets of teeth. The first set, baby teeth, starts to grow when the child is a baby. The second and last set grows in at school age. They are the permanent teeth . Permanent teeth should last a lifetime.

A child grows his first baby tooth at about 7 months of age. It is usually a front one.

A baby who is poorly nourished, however, may not grow his first tooth until later. Do not wait for the first tooth before giving him the extra soft food he needs to grow and stay healthy.

The remaining baby teeth grow in over the next 24 months. By the time the child is 30 months old, there will be a total of 20 baby teeth in his mouth, 10 on top and 10 on the bottom.

Most permanent teeth form under the baby teeth. When the child is between 6 and 12 years old, the permanent teeth push against the roots of the baby teeth, making them fall out. Not all of the baby teeth fall out at once. One tooth at a time becomes loose, falls out, and then is replaced with a permanent tooth. The new tooth may not grow in immediately. Sometimes 2 or 3 months pass before the new tooth grows into the space.

In the 6 years between ages 6 and 12, the 20 permanent teeth replace the 20 baby teeth. In addition, 8 other teeth grow in behind the baby teeth.

At 6 years, the 4 first permanent
molars start to grow in at the back of
the mouth. This means an

8-year-old child should have

24 teeth, or spaces for them .

At 12 years, the 4 second
permanent molars grow in behind
the first molars. This means a

14-year-old child should have

28 teeth, or spaces for them .

Between 16 and 22 years, the 4 third
permanent molars grow in. This
means that an adult usually has a
total of 32 permanent teeth: 16 on
top and 16 on the bottom . *

*(Note: the third molars often do not grow in correctly. This is a very common cause of tooth pain. See page 66.)

44 Where There Is No Dentist 2012

THE ACTIVITY :

Have the students examine each other . * Help them learn which are baby teeth and which are permanent teeth. Look for the important 1st permanent molars at the back.

Show the students
how to count the
permanent tooth
teeth and the spaces
that are ready for new
loose baby tooth
teeth to grow in.

space for new tooth

Then have them count
their friends’ teeth, to find
out how many teeth should
be growing in different age groups.

Later, they can do this with their brothers and sisters at home.

• Wash your hands.

• Count the teeth.

• Count the spaces where new teeth have not yet grown in.

TOTAL = teeth + spaces

• Find out the person’s age.

Have the students first write their totals on the blackboard. Then make a chart for the children to remember and discuss the results.

* Here the children are only counting the teeth. They can also learn to check for cavities and gum disease (see p. 49).

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45

Discuss the number of teeth children have at different ages. Young children 6 to 12 years old, for example, have 24 teeth; older students, 28 teeth; and most adults, 32 teeth.

At home, students can count brothers’ and sisters’ teeth to learn how many teeth small children have. Count only the teeth and not the spaces.

Ask the students what other things they saw inside someone else’s mouth.

This is a good time for students to discover important things about good health practices. Encourage them to learn as much as they can from what they see, and then show them how to use a book like this to answer their own questions, For example, if students see cavities and red bleeding gums, you can start a discussion on tooth decay and gum disease. Use some of the activities on pages 55 to 60.

For another example, if the students see a baby who has only a few teeth, they may have some interesting questions. Show them this book and invite them to read pages 63 to 65 to find answers to questions like these.

• Can Chenia, who is 6 months old and has no teeth, eat soft foods?

Should she have more than just breast milk?

• When Chenia’s teeth grow in, will they give her diarrhea and fever?

• Will a 2-year-old girl get more baby teeth?

• Why do we care for baby teeth, when we only need them for a few years?

46 Where There Is No Dentist 2012

What Makes Teeth Hurt?

THE IDEA:

A tooth will hurt if it is broken, loose, or if it has a cavity. Cavities are the usual cause of toothaches.

Healthy teeth are alive .

Two thin strings enter each tooth. One, the nerve, comes from the brain and carries the message of pain. The other is the blood vessel . It comes from the heart and carries blood to the tooth.

If you could peel away
the gum and look inside
the bone, you would see
that a nerve and a blood
vessel go into each one
of a tooth’s roots.

They give the tooth life
and feeling.

The hard cover of the tooth protects the nerve and blood vessel inside it. But when tooth decay eats through that cover, the nerve and blood vessel are unprotected. A cavity lets food, water and air get closer to the nerve, and that can make the tooth hurt.

The sugar in food makes tooth decay possible. Sweet food that is also sticky is the worst of all because it glues itself to the teeth. Germs inside your mouth use the sugar to grow and to work harder at making cavities.

See the next section for more discussion of how germs and sugar combine to cause cavities.

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47

A cavity may look small on the outside, but it is much bigger inside. Decay spreads more easily in the soft part under the hard cover of the tooth.

A tooth with a cavity may hurt, but it usually does not hurt all the time. This is because the bottom of the cavity is close, but not yet on the nerve inside the tooth.

Fill a small cavity and save a tooth .

A small cavity that is not treated grows bigger and gets deeper. When the cavity finally touches the nerve, it causes a tooth abscess. Infection from the tooth decay going inside the tooth causes the tooth to ache all the time, even when you try to sleep.

Infection can pass from the tooth to the bone. As it spreads under the skin, there will be swelling of your face.

A tooth with an abscess must either be taken out or have its nerve treated .

An abscessed tooth is dying. When it dies the tooth changes color from white to dark yellow, grey, or even black. Pus from the end of its root can pass to the gum, making a sore called a gum bubble .

A tooth is like a light bulb.

When the bulb is alive from power inside, it is
bright and useful.

The little wires inside the bulb are like the nerves inside the tooth. When the bulb burns out, it is dark and not useful any more.

48 Where There Is No Dentist 2012

ACTIVITIES:

1 . Have each student look inside a partner’s mouth . Look for black spots that may be cavities, for dark teeth that are dead, and for sores on the gums, especially near a bad tooth.

2 . Discover how sweet food sticks to teeth .

• Cut several different kinds of food with a knife.

• Vegetables and meat do not stick to
the knife.

• Sweet foods, like chocolate and
jam buns, do stick to the knife.

They stick to your teeth the
same way.

Pour some cola or juice in a dish, and leave it outside overnight.

As water is lost, the juice left in the dish
becomes sticky. It attracts flies.

The air you breathe dries the cola and
causes a sticky, very sweet coating to
form on your teeth. It attracts germs.

Try to find some old teeth. Ask the
students to keep their own baby teeth
when they fall out. (Note: in some
countries this is not acceptable.) Your
dental worker can save you some
teeth that were taken out at the clinic.

Scrape the outer cover of the root with a knife. Feel how hard and smooth it is.

Then find out what happens
when the students leave a tooth
in cola, milk, or plain water.

After 3 days scrape each tooth
again with a knife. Students will
discover that sweet cola drinks
make teeth softer and darker
in color.

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49

3 . Look inside a tooth for the space where the nerve and blood vessel used to be. See how close they were to the tooth’s hard outer cover.

Look for a small hole at the end of the root. That is the place where the nerve and blood vessel enter the tooth.

Ask your dental worker to find an old tooth
with a cavity and cut it for you.

OR

• Take a hammer.

• Gently break open a tooth.

• Look inside.

See how much bigger the cavity is on the
inside. lt spreads under the hard cover.

Cut through a rotten yam. See how the
rotten part spreads under its skin in the
same way.

4 . Do a project in class .

• Count the number of students with cavities.

• Count the number of teeth having cavities. Show the students how to look for them on the tops, sides and between the teeth.

• Find out the person’s age.

Have the students write on the blackboard what they counted. Then make a chart or graph.

• Decide if tooth decay is a serious problem in your school. Ask your dental worker to look at your results and to come and treat the students, and help you prevent the problem from returning.

• Do the same with brothers and sisters at home. Find out if tooth decay is a problem with these young children. Tell your dental worker what you find.

50 Where There Is No Dentist 2012

How Do Germs Make Holes in the Teeth?

THE IDEA:

Acid makes holes in the teeth. The acid is made when sweet foods mix with germs in your mouth.

It is not possible to prevent cavities or gum problems by trying to kill all of the germs in your mouth. There are too many—and some germs are good for you. The important thing is to keep the germs from getting together and making a film or coating on your teeth.

This film on the teeth is called plaque , but you do not need to use this word.

Every morning we can all feel a ‘furry film’ on our teeth. This film must not be allowed to stay on the teeth! It will mix with sugar and make acid. Worse, if it stays in a group (or ‘colony’) for more than 24 hours, it will mix with saliva, harden, and make tartar (see page 52).

The main reason for cleaning teeth is to break up these colonies so they cannot make acid. Also, if you forget to clean your teeth, tartar will form, and you will need a dental worker to scrape it off. This is why it is important to clean your teeth at least every 24 hours, so the tartar can never form on your teeth.

THE ACTIVITY:

Here is a game called “Scatter!” that students can play outside. You need:

• Five ‘bases’ (a tree, rock, or
the corner of a house can
be a base) in a half circle,

12 meters apart. Each base
must have a ‘monitor’ who
stays at the base.

Note: children who cannot
run can be good monitors.

• One person with a
broom. This person is the

‘decolonizer’.

Children in Jocuixtita, Mexico, beginning a
game of “Scatter!” The ‘decolonizer’ is the
girl in the center with the broom.

The Game:

20 students called ‘colonizers’ stand facing the decolonizer. When the decolonizer says “go!” they try to ‘form colonies’ around the bases before the decolonizer can touch them with the broom.

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51

The colonizers win if they make
a colony. There are two kinds of
colonies: (1) 15 people touching
one monitor at a base, or (2) a
chain of 12 people holding
hands, touching two monitors.

Play two games: one with
children trying to form the first
kind of colony, one with the
second kind. These photos are

The ‘decolonizer’ (with broom) has lost the
from the second game.

game. The children behind him have formed
a ‘colony’.

The decolonizer tries to stop the
others by touching them with the
broom. When the decolonizer
touches a colonizer with the
broom, the colonizer must leave
the area for one minute. (Give
that child a task to do—run
around the school-house or lie
down and sit up 30 times.)

The decolonizer wins if no

Here the decolonizer stops a boy from
colonies form in 5 minutes.

completing a chain.

After The Game:

Talk to the students about germs
in their mouths and how small
they are. Can anyone see germs?

No, but they can feel them and
taste them. Ask the group what
their mouths feel like in the
morning when they wake up. You
may get these answers:

• My teeth feel mossy.

• My breath is bad.

• I feel a coating on my teeth,

To teach about things too small to see, look
but it goes away when I
at the suggestion on page 11-29 of Helping brush them.

Health Workers Learn.

Tell the students that this coating on the teeth is a ‘colony’ of germs. They are always trying to group together on the teeth or in spaces between the teeth—just as the ‘colonizers’ did in the game!

52 Where There Is No Dentist 2012

What Makes the Gums Feel Sore?

THE IDEA:

Healthy gums fit tightly around the teeth and help to hold them strongly.

Healthy gums also cover and protect the bone under them.

Healthy gums are pink in color, or
even blue or dark yellow in some people.

But healthy gums are never red .

Healthy gums are pointed between
the teeth . This lets food slide away and
be swallowed.

Healthy gums fold under, making a
little pocket around the tooth .

As we saw with the last activity (p. 50), when you have ‘colonies’ of germs on your teeth, they can make acid that makes holes on your teeth. The same coating of germs can make a different acid that makes the gums sore. This also happens when food mixes with the coating on your teeth. Soft food is the worst kind, because when it mixes with spit it sticks more and stays longer on your teeth. Juice from tea, betel nut, and meat color this food, making the tooth look dark.

Healthy gums become sore because of acid. When the coating on the teeth (p. 50) becomes hard, it is called tartar . Tartar can hurt the gums.

Also, the ‘colonies’ of germs can make a coating on top of tartar more easily than on a clean tooth. When the colonies are new, they make more acid which causes tooth and gum problems. After 24 hours, it hardens and makes a new layer of tartar. The tartar gets bigger and bigger.

Here is a larger picture of the

Sore gums are infected .

teeth in the box above:

Infected gums are red
and bleed easily .

Infected gums are round and
swollen between the teeth .

They are also loose instead of
tight against the teeth.

Infected gums have a deep gum pocket which catches even more food.

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53

Infection in the gums is called gum disease . It is important to treat gum disease early, before it can spread to the root fibers and the bone.

If you have sore, bleeding
gums, you can do much to
treat the infection yourself.

1 . Clean your teeth with a soft
brush gently and more often

(see pages 69 to 72).

2 . Eat more fresh fruits and
vegetables.

3 . Rinse your mouth with warm
salt water.

4 . Clean between your teeth
with dental floss or string. At
first your gums may bleed
when you do this. But when
the gums are stronger the
bleeding will stop (p. 71-72).

ACTIVITIES:

1 . Have the students look in each other’s mouths .

Can they see the coating on the teeth? Usually
they cannot. They may see food or ‘white stuff,’

but this is not the coating that makes acid.

However, if someone has been chewing betel nut
or eating berries, you will see stains on her teeth and the stains will be darkest where she has these colonies of germs on her teeth.

2 . Put something on the teeth to stain the colonies of germs . Try using food dye, betel nut or berry juices. Remember: first wash your hands!

Older students can rub berries on the teeth of the younger ones. Have them rinse with a little water and spit it out. After this, the colored areas on the teeth will show where the colonies of germs are forming. Where are they? Usually you will see the dark colors:

• between the teeth.

• in the pits or holes in the teeth.

• on the tops (biting surfaces) of the teeth.

The older students can show the younger ones the best way to clean teeth (see pages 69–72). Have them use a mirror to see if they are getting the colored juice from their teeth. They will learn that it is most difficult to get rid of the color between their teeth. Give them some string, dental floss, or the soft stem from a young palm leaf and show them how to use it between their teeth. Remind them to be gentle, or they will hurt their gums. Clean between your teeth every day .

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What Does It Mean if a Tooth is Loose?

THE IDEA:

Baby teeth become loose when children are between 6 and 12 years old.

This is normal. If a loose baby tooth does not have a cavity, and if the gums around it are healthy, there is probably a permanent tooth growing under it.

But a tooth might be loose because it is broken or because it is sick from an abscess or gum disease. Either can destroy the bone around the tooth’s roots.

When bone is lost, the tooth
becomes loose. A loose tooth hurts
and usually must be taken out.

There is no medicine to make bone
grow back around the roots of
loose teeth . All you can do is stop
the infection from getting worse.

ACTIVITIES:

1 . Let the students look into each other’s mouth for loose baby teeth.

Look carefully to see why a tooth is loose.

Touch the gum and bone beside the
loose tooth. You can feel a bump—it is
the new permanent tooth growing.

Save the baby tooth after it has fallen
out. Look to see how the permanent
tooth has eaten away its root by
pushing against it.

2 . Look for teeth that have cavities or gum
disease around them . The students can do
this with each other, and then later at home.

(Remember: they must wash their hands!)

A tooth that has some of its root showing
is probably loose.

Using your fingers or the handles of two
spoons, rock the tooth back and forth
gently. See how much it moves, and ask
how much it hurts.

Tell the person what he can do to
prevent other teeth from becoming
loose . (See the next section.)

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How Can We Prevent Cavities and Sore Gums?

Eating good food and carefully cleaning the teeth prevent both tooth decay and gum disease.

Food from your own garden and local food from the market is best .

These foods are good for your body, your teeth, and your gums.

Vegetables, especially

Peas and beans, like green

Oil, from palm nut
those with dark green
beans, soybeans, winged
kernels, ground nuts,
leaves.

beans, and mung beans.

and coconut.

Fruits, like banana,

Fish, meat and eggs.

Clean water, coconut
guava, oranges, and
water, and milk are best
papaya.

to drink.

Soft foods and sweet foods from the store
are not good for you . Soft foods stick to your teeth easily. They can work longer to cause
cavities and infected gums. Sweet foods have
mostly sugar in them, and it is ‘factory sugar,’

not the ‘natural sugar’ that is in the foods in
the pictures above.

This kind of sugar is quick to mix with germs
and make acid. Remember: natural sugar makes
acid slowly; factory sugar makes acid quickly.

Children who eat a lot of sugar lose their
appetite for other foods—the foods that help
them grow strong, stay healthy, and learn well
in school.

Store foods are also expensive. You can
usually get better food, and more of it, for the
same money in your garden or in the market.

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Cleaning your teeth carefully every day is another important way to take care of both teeth and gums. However, cleaning teeth is like building a house .

To do a good job, you need to work slowly and carefully . Once a day is enough, if you clean your teeth well every day.

Buy a brush from the store, or make one yourself (see p. 4). But be sure the cleaning end of the brush is soft so that it won’t hurt the gums.

Use your brush to clean all the teeth, especially the back ones with the grooves. Back teeth are harder to reach and so it is easy not to clean them well enough. Cavities start from sweet food and germs left together inside the grooves.

1 . Scrub the inside,
outside, and top of
each tooth.

2 . Push the hairs of
your brush between
two teeth. Sweep
the food away.

3 . Wash your mouth
with water, to
remove any loose
bits of food.

Small children are not able to clean their teeth carefully enough by themselves. They need help. Look at the pictures on the cover and p.18 to see how you can do this. Older children can care for younger brothers and sisters at home .

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ACTIVITIES :

One of the best ways to teach is by example.

Students will believe what their teacher says if they know he eats good food and cleans his teeth.

The reverse is also true. Learning is harder when students know that their teacher does not do those things himself.

Students can be a good example for their community, too. They can:

• draw pictures of foods that are both good and bad for teeth. Use them to make posters and flannel-board stories.

• make puppets and plays to discuss ways people can become healthier.

There are some other ways to make learning meaningful and fun.

1 . Make a garden at school . Divide the ground so that each class has its own space to plant a garden.

Use some of the garden’s food to prepare a meal for the students, perhaps once a week. Students can bring food from home if there is not enough ready in the garden.

2 . Organize a school lunch program . Each day the students can bring some good food from home. Cooked yams, or maize, nuts, fruit and fresh vegetables are all good. Often the students will exchange food and talk about the many different foods that can be grown locally.

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3 . Find the best way to clean teeth . Divide the class into groups. They will learn more easily in a small group of 4 to 8 students.

Give all the students something to eat that is sweet, sticky and dark in color, such as sweet chocolate biscuits. Ask the students to look in each other’s mouth, to see how easily the biscuit sticks to the teeth.

One or two of the students in a group can then try to clean away the pieces of biscuit, using a different method.

each person
eat a sweet
sticky food
and…

...do

...brush
nothing
and rinse

...rinse

...eat a
only
fibrous
food

When they are finished, the students can look at the teeth to decide if they are clean or not. Put your findings on a chart and talk about what you have learned.

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4 . Make cleaning part of a daily health activity . Older students can look after younger students. They can first check their hair for lice, then sores for infection, and teeth for old food or germs. (To see the coating of germs on the teeth, try the activity on page 53.) One partner can point out to the other where washing and brushing can be done better.

CLEANLINESS CAN BEGIN AT SCHOOL

At school, students can wash their hands before lunch and brush their teeth with flouride toothpaste afterward. Encourage them to keep a piece of soap and a toothbrush or brushstick (p. 4). A program in the Philippines called Fit for School (page 221) combines this with deworming 2 times a year to keep children healthier, develop good habits, and keep them in school.

The student
can keep the

OR
brush at her
own desk...

A piece of bamboo can hold a brush
nicely. Make two holes near the top
for some grass string, to hang the
bamboo brush holder.

... or on a
rack at the
back of the
room.

Let each student look after her
own soap and brush.

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Have the students score each other’s progress. Do not make it hard to judge, or they will not do it. In the example below, the tooth is either clean or not clean.

SCORING TEETH

Pick 4 teeth, a back tooth and
a front tooth—two on top and
two on the bottom.

Use the same 4 teeth for each
person. Look for food on each
tooth near the gums.

A clean tooth = 2 points.

A dirty tooth = 0 points.

Total possible points each day
is 4 teeth x 2 = 8 points.

In this example the score is:

Tooth 1 = 2 points

Tooth 2 = 0 points

Tooth 3 = 0 points

Tooth 4 = 2 points

Total = 4 points

Have each student put his daily score on a chart. At the end of the month he can see how much he has improved.

61

CHAPTER 5

Taking Care of

Teeth and Gums

We can prevent most tooth and gum problems . This chapter gives more information about how teeth grow in and how to keep teeth and gums healthy. Share this information and you will prevent problems from starting.

But remember that people are most interested in the problems they have now . Before listening to what you know about prevention, people will want treatment for the problems that are already causing them pain and discomfort.

Early treatment is a form of prevention .

It can prevent a tooth or gum problem
from becoming more serious .

When you treat a person’s problem, it shows that you care about him. It also shows that you know what treatment he needs. As his confidence in you grows, he will want to learn from you about preventing tooth or gum problems.

In order to help a person it is
important to know what the
problem is and what is the
best treatment. But just as
important is knowing what
you are not able to do, and
when to seek help.

In this chapter, you will learn
more about teeth, gums, and
problems affecting them,
but you must never be too
proud to get help from more
experienced dental workers.

Know your limits.

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TAKING CARE OF BABY TEETH

A child’s baby teeth are being made before birth while the baby is still inside the mother’s womb. During the last months of pregnancy and the first few months after the child is born, the baby teeth take their final form. Pregnant mothers and young children need good food and good health in order to have strong baby teeth .

Strong teeth

Weak teeth
are white and their
have yellow marks that
front surface is smooth.

are pitted and rough.

Baby teeth get marks on them when: 1) the pregnant mother is sick or does not eat good food; 2) the young baby is sick or does not eat good food; or, sometimes, 3) the baby’s birth was early or the delivery was difficult.

The marks are rougher than the rest of the tooth. Food sticks easily to them and turns the tooth yellow.

The marks are also soft. They need to be cleaned well every day (p. 63) to prevent them from becoming
cavities. A tooth with a cavity hurts. When children’s teeth hurt, they do not want to eat as much.

Cavities in baby teeth can make a child’s malnutrition worse .

Remember this whenever you see a weak, poorly nourished child. When you examine a child at the health clinic, lift his lip and look at his teeth. Do this as part of your routine examination .

You can fill cavities with cement (Chapter 10).

Cement prevents food and air from going inside
the cavity and hurting the child.

A sore on the gums may be a gum bubble. If so,
it means the tooth has an abscess (page 82).

That cavity should not be filled with cement.

Instead, the tooth needs to be taken out

(Chapter 11) before the infection gets worse.

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For baby teeth to grow strong, mother and baby must stay healthy.* Help her to understand how important this is. A pregnant mother should:

• Eat enough good kinds of foods, both for herself and her baby growing inside (page 68; also see Where There Is No Doctor, Chapter 11, and Helping Health Workers Learn, pages 25-39 to 25-44.)

• Attend health clinic each month, so the health workers can examine her regularly and she can receive important medicines (see Where There Is No Doctor, page 250).

• Not use the medicine tetracycline, because it can cause the teeth to turn dark. You, the health worker, must remember—do not give tetracycline or doxycycline to a pregnant woman or to a young child . If she needs an antibiotic, use a different one.

For baby teeth to stay strong, and to prevent marks from turning into cavities, mother should:

• Continue to breastfeed and never feed her
child juice or sweet tea from a bottle . Start giving soft foods, such as mashed banana or
papaya, when the child is 6 months old.

• Wipe her baby’s teeth with a clean cloth after
the baby eats. This cleans the baby’s teeth
and helps the baby get used to teeth cleaning.

Later he will be happy with a brush.

Around 1 year of age, there will be several baby teeth. At that time, mother should start using water—not toothpaste—on a soft brush or brushstick.

(With toothpaste, you cannot see the child’s teeth clearly because of the bubbles it makes.) She should scrub the sides and tops of each baby tooth as well as she can (page 69).

The child can also try to clean his own teeth. That should be encouraged.

However, since he is too young to clean properly, mother (or father, or older brother, sister) must clean his teeth once a day for him. Continue helping in this way until the child is old enough to go to school.

You can make a large brush smaller,
to fit more easily into a young child’s
mouth.

Pull out some of the back hairs, or
cut them out with scissors. Do not
cut the hairs in half, because the tops
are often rounded or softer, and that
is better for the gums.

*See the story about pregnancy and dental care on pages 15–16.

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Why Baby Teeth Are Important

Baby teeth are just as important to children as permanent teeth are to adults.

They help a child to eat, talk, and look good.

However, many people feel that it is not worth the effort to look after baby teeth. Nor is it worth fixing them. After all, parents think, the permanent teeth will take their place.

This kind of thinking is understandable. The problem is that we are forgetting one other useful purpose of baby teeth. Baby teeth keep space in the mouth for the permanent teeth to grow in. If there is not enough space, the new teeth will grow in crooked, and cavities grow faster around crooked teeth.

Permanent

Under each baby tooth a new
molars (PM)

permanent tooth is growing.

come in
behind the

At the same time, extra
baby molars
permanent molars are forming

(BM).

at the back of the mouth,
inside the bone (page 43).

Front baby teeth become
loose and fall out (usually

6–7 years, but sometimes as
young as 5 years) ahead of
back baby teeth (10–12 years).

This is because the front
permanent teeth are formed
and ready to grow in first.

The permanent molar (1 PM) is often the first of the permanent teeth to grow into the mouth. That happens at 6 years of age.

The first permanent molar grows into

Slowly but steadily the upper and
the mouth by sliding against the back
lower permanent molars grow until
of the second baby molar (2BM).

they meet and fit tightly together.

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65

Between the ages of 6 and 11, a child needs healthy baby molars to guide the first permanent molars into position and then to hold them there. When the first permanent molars grow into the right place, this is a good sign. It means the other permanent teeth will also grow in properly, because they will have enough space.

Note: Some people are born without enough space. But most people are not born with this problem—they lose the spaces when they remove baby teeth instead of fixing them.

help

HEALTHY BABY TEETH
t

o make

STRAIGHT PERMANENT TEETH

10 years
adult

help

SICK BABY TEETH

to make

CROOKED PERMANENT TEETH

10 years
adult

Tell mothers why baby teeth are important. Good food and regular cleaning keep them healthy. They should know that new teeth coming in do not cause diarrhea and fever, but that a child may have diarrhea or fever at the same time.

If there is a cavity, fix it so the tooth can be kept in the mouth to do its important work (see Chapter 10).

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TAKING CARE OF MOLAR TEETH

We often notice front teeth growing in, but not the back ones. Back teeth molars are not so obvious. Swelling on the face can be either a new molar growing in or an abscess. So, to help you to decide, look at the tooth for a cavity and at the gums beside it for a gum bubble.

When you see a swollen face, look for the two signs of an abscess.

But if the person is young (16–22 years), it often is not an abscess. The third permanent molar tooth may be growing in at the back of her mouth. As the tooth grows, it cuts through the skin. Just as a dirty cut on a person’s hand can get infected, the cut gum around her new tooth also can get infected, causing a swollen face.

See the red swollen skin on

Look behind her back teeth.

top of the new tooth.

If there is enough space for the tooth, it will grow in by itself. It only needs time. Before acting, decide how serious the problem is.

If there is no swelling and she can open her mouth, explain to her what is happening and what she can do herself to reduce infection and toughen the gums. The best medicine is to rinse warm salt water over the sore area. A good home remedy is to rinse until the tooth grows all the way into the mouth.

If it does appear serious (severe pain, swelling, not able to open the mouth), see pages 93 to 94 for further treatment.

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TAKING CARE OF ALL YOUR TEETH

This book often repeats an important message: eat good food and clean your teeth. It is repeated because this is the most important thing you can Iearn from this book. Later chapters will discuss what to do when problems occur, but if you follow these two suggestions, you will almost never have problems with your teeth and gums. This is true because good food keeps your whole body healthy, including your teeth. Also, with no

‘colonies’ of germs (page 50) or harmful factory sugar (page 55) on your teeth, your mouth cannot make the acids that cause both tooth and gum problems. So, remember:

1 . Eat Good Food

An easy-to-remember rule is the same foods that are good for the body are good for the teeth . A healthy body is the best protection against infection.

Good nutrition (eating well) means 2 things:

1) Eat a mixture of different kinds of foods
every time you eat . Look at the pictures
on page 55. There are several groups of
foods. Every time you eat, try to eat one or
two foods from each of the groups. This
way, you will get 3 important kinds of food:

grow food (body-building food) to give you
the protein you need; glow food (protective food) to give you vitamins and minerals; and

The MAIN FOOD is at
go food (concentrated energy food) to give
the center of every meal.

you calories to be active all day.

2) Be sure you eat enough
food to give your body the
energy it needs . This is even
more important than the first
suggestion. We get half or
more of our energy from our
main food. In most parts of the
world, people eat one low-cost

A spoonful of cooking oil
energy food with almost every
added to a child’s food means
he only has to eat about ¾ as
meal. Depending on the area,
much of the local main food
this main food may be rice,
in order to meet his energy
maize, millet, wheat, cassava,
needs. The added oil helps
potato, breadfruit, or banana.

make sure he gets enough

The main food is the central or
calories by the time his belly
is full.

‘super’ food in the local diet.

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Where There Is No Dentist 2012

Be sure always
to eat grow
foods and glow
foods to get the
vitamins and
protein you
need.

Your energy
foods give
you the most
important
part of your
diet—calories.

Half or more of
our
calories come
from the main
food, and most
of the other
calories come
from go foods.

WARNING ABOUT GO FOODS: Although go foods give us the energy we need, some go foods are worse than others. Honey, molasses, and especially white sugar can be very bad for the teeth, even though they have the calories we need. Fruits, nuts, and oils all give us energy (calories) without attacking the teeth.

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2 . Clean Your Teeth

Cleaning teeth requires time and care. If you hurry, you will leave food and germs behind, and they continue to make cavities and sore gums.

You may find that different dental workers recommend different ways of brushing teeth. Some ways are definitely better, but often they are harder to learn.

Teach a method of cleaning that a person can learn and will do at home.

Let him start by scrubbing his teeth (and his children’s teeth) back and forth, or round and round. Encourage him to improve his method only when you think he is ready.

Toothpaste is not necessary . Some people use charcoal or salt instead. But it is the brush hairs that do the cleaning, so water on the brush is enough.

Scrub the outside, inside, and top of each tooth carefully.

When you finish, feel the tooth with your tongue to make sure it is smooth and clean.

Finally, push the hairs of the brush
between the teeth and sweep away
any bits of food caught there. Do
this for both upper and lower teeth.

Sweep away in the direction the
tooth grows: sweep upper teeth
down and lower teeth up.

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Explain how important it is to use a brush with soft hairs. A brush that is stiff and hard will hurt the gums, not help them.

YES NO

You can make a hard brush softer
by putting the hairs into hot water
for a few minutes.

Do not put the plastic handle into
the hot water, or it will melt.

If your store has only hard brushes, tell the store keeper that hard toothbrushes do not help the people in the community. Ask him to order and sell only soft toothbrushes.

Note: Another important way to reduce cavities is by adding fluoride to teeth . Fluoride is a substance which, like calcium, makes teeth harder and stronger.

Fluoride in drinking water, toothpaste, salt, vitamins, and mouth rinses helps to prevent cavities. These methods are sometimes expensive. But treating teeth once a week with fluoride toothpaste is effective and inexpensive. See page 211.

Fluoride can also be found naturally in food and water. For example, tea leaves and most foods from the sea contain a large amount of fluoride.

So, your source of fluoride can be either:

OR

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CLEANING BETWEEN THE TEETH IS VERY IMPORTANT

Here are three ways to clean between the teeth:

1 . Push the hairs of a toothbrush between the teeth, and sweep the bits of food away.

2 . Remove the stem from a palm leaf. Use the thinner end and move it gently in and out between the teeth.

Rub the stem against
one tooth and then
the other. This way,
you clean the sides of
both teeth.

3 . Use some thin but strong thread or string. String can be the best method of all—but you must be careful with it.

Get some thin cotton rope

Buy and use dental floss. This
used for fishing nets. Unwind

OR
is a special kind of string for
and use one strand of it.

cleaning between the teeth.

Be careful! The string can hurt your gums if you do not use it correctly.

The next page shows how to use the string, but the best way to Iearn how to ‘floss’ your teeth is to have someone show you . Ask a dental worker who has experience.

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Wrap the ends of the
string around the middle
finger of each hand.

Use the thumb and finger to guide the string. Go back and forth to slide the string between two teeth. Be careful not to let it snap down and hurt the gums.

Upper teeth

Lower teeth

With your fingers pull the
string against the side of one
tooth. Now move the string
up and down . Do not pull
the string back and forth or
it will cut the gum.

Lift the string over the pointed
gum and clean the other tooth.

When you have cleaned both teeth, release the string from one finger and pull it out from between the teeth. Then wrap it around your two middle fingers once again, and clean between the next two teeth.

Remember: clean teeth and good food
will prevent almost all dental problems .

73

CHAPTER 6

Examination
and Diagnosis

Whenever you do an
examination, remember
to examine the mouth .

You can prevent much suffering
and serious sickness when
you notice and treat problems early.

Whenever you hold a health clinic, try
to find out how healthy each person’s
mouth is.

Ask if she is having a problem now, or
has had a problem recently.

Always write down what you find out,
so you remember what treatment that

When you look inside someone’s
person needs.

mouth, ask yourself these questions.

1. Are the teeth healthy? Look for:

Tell the person what is

1. A New
happening and how to

Tooth
keep the skin around
a new tooth healthy

(page 66).

They may be cavities
which should be filled

2. Black
when they are still

Spots
small (page 47).

Tell the person what is

3. A Loose
happening and how to prevent a

Tooth
loose tooth from getting worse or
affecting other teeth (page 54).

A tooth that is dark is dead and infection from

4. A Dark
its root can go into the bone (page 47). This

Tooth
can make a sore on the gums (page 74).

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2. Are the gums healthy?

Look at page 52 and compare the pictures of healthy and unhealthy gums.

Unhealthy gums often are red and they bleed when you touch them .

A bubble on the gums below the tooth
is a clear sign that the person has an
abscess. The abscess may be from the
tooth, or it may be from the gums. To
decide, look carefully at both the tooth
and the gum around it.

A bubble beside a healthy tooth is a sign of
infected gums. Scale the tooth carefully. See

Chapter 8.

A bubble beside a decayed tooth is a sign of
a tooth abscess. (See page 93.)

A sore on the gums from a badly decayed
tooth appears when a gum bubble breaks

GUM BUBBLE
open and lets out the pus from inside.

3. Are there any sores?

Look for sores under the smooth skin on the inside of the lips and cheeks. Look also under the tongue and along its sides.

1. A sore on the

2. Sores on the inside

3. Sores on the
gums may be
of the lip or cheek
lips or tongue
from an infected
may be from a
may may be
tooth (p. 93).

virus (p. 104).

cancer (p. 125).

After your examination, tell the person what you have found. If you notice a problem starting, explain what to do to prevent it from getting worse. If there are no problems and the mouth is healthy, congratulate the person.

Share your knowledge—explain things to people .

Help them Iearn how they can prevent and even
manage their own problems with their teeth .

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WHERE TO EXAMINE

Examine people in a light and bright place. It is dark inside a person’s mouth, so you need light to see the teeth and gums.

Use the sun. Examine outside, or inside a room facing the window. With sunlight alone, you will be able to see most places in the mouth well enough. If you cannot, set up a lamp or have someone hold a lamp for you.

Reflect the light off a small mouth mirror onto the tooth or gum.

If you have a low chair, lift up the
person’s chin so that you do not have to
bend over as far when you look into the
mouth. An even better way is to have the
person sit on some books. The person’s
head can lean back on a piece of cloth.

Use an old chair with a strong back.

Attach two flat sticks to the chair. Then
tie a strip of clean cloth to the sticks. Tie
it strong enough to support the head, but
loose enough to let the head lean back.

THE INSTRUMENTS YOU NEED

Three instruments are really enough:

1. A wooden tongue blade to hold back
the cheek, lips, and tongue.

2. A small mirror to let you look more
closely at a tooth and the gums
around it.

3. A sharp probe to feel for cavities
and to check for tartar under the
gum.

If you have many people to examine, it is helpful to have more than one of each instrument. But be sure they are clean.

Dirty instruments easily can pass infection
from one person to another . After you finish an examination, clean your instruments in soap
and water and then leave them in a germ-killing
solution like the ones described on page 89.

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A GOOD DIAGNOSIS

You are making a diagnosis when you decide what a person’s problem is and what is causing it. To do this, you need information. You need to make a careful examination to make a good diagnosis .

Learn all you can about the person’s problem:

1. Ask questions about the problem.

2. Look at the person’s face. Think about the person’s age.

3. Examine the mouth more carefully than before.

4. Touch the place that is sore.

1. Ask the person about the problem .

Give a sick person a chance to
describe how he is feeling.

Listen. Think about what possibly is
happening in his mouth.

You may have an idea about what
the person has. Now try to find out
more by asking questions:

•

What is the problem? Ask him
to talk about the pain, swelling,
bleeding, or whatever he is feeling.

•

Where does it feel that way? See if he can put his finger on the tooth or place that is bothering him.

•

When do you have the most pain? Find out if it happens all the time or only some of the time (for example, when he drinks something very cold).

•

When did it start? Find out if he has already had this problem before.

Ask how he took care of it.

•

Have you had an accident or injury lately? Infection still inside the bone from an old injury in the mouth can make a sore on his face, or can start swelling.

•

Are you having other problems? A head cold or fever can make the teeth hurt.

•

How old are you? Think about a new tooth coming into the mouth.

After you hear the answers to your questions, decide if your original idea is the correct diagnosis. If not, try to think of another possibility and ask more questions. This is the scientific method of making a diagnosis.

For a good explanation of scientific method, see Chapter 17 of Helping Health Workers Learn.

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When you talk to a woman, find
out if she is pregnant . A pregnant
woman’s gums can easily become
infected. The gums may bleed and
she may have more tooth decay.

But this does not have to happen.

If a pregnant woman takes extra
care of her teeth and gums, she can
prevent most dental problems. But
if she already has a problem, do not
wait for the baby’s birth before you
help her. You can treat a pregnant

Train midwives to examine
woman’s mouth problems now . In
women’s mouths. When
they send women to you for
fact, this may be an important way of
dental care, they can give
protecting her baby as well (see pages
you helpful information

15 to 16).

about the women’s health.

Caring for a pregnant woman—a guide for dental workers 1. Ask her how many months she has been
pregnant and find out if she has high blood
pressure. Any person with blood pressure over

150/100 may bleed excessively after extraction.

To get this information, encourage all women
to have regular check-ups with a midwife or a
trained health worker who has equipment for
measuring blood pressure.

2. Do not take X-rays of teeth unless absolutely
necessary. X-rays are dangerous to the unborn
baby inside. Before an X-ray, always cover the
mother’s chest, belly, and thighs with an apron
lined with lead.

3. Do not give her tetracycline or doxycycline while she is pregnant or breastfeeding.

4. Always give a careful and complete mouth examination. Tell her what treatment she needs and how to prevent tooth problems.

5. Be gentle. Show the woman that you care, that you want her to be comfortable, and that you can treat her without hurting her.

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2. Look at the person .

People have some problems more often at certain ages. When a person first comes in to see you, notice his age. Then, before you ask him to open his mouth, look at his face for a sore or swollen area.

SWELLING

CHILD

YOUNG PERSON

ADULT

Swelling can come from:

Swelling can come from:

Swelling can come from:

• mumps

• a new tooth growing

• a tooth abscess (p. 93)

• an infection in the spit
in (p. 100)

• a broken jaw (p. 113)

gland (p. 119)

• a tooth abscess (p. 93)

• a tumor (p. 125)

• a tooth abscess (p. 93)

A SORE

CHILD

YOUNG PERSON

ADULT

A sore can come from:

A sore can come from:

A sore can come from:

• impetigo

• fever blisters (p. 104)

• a tooth abscess (p. 93)

• Vincent’s infection

• a tooth abscess (p. 93)

• a bone infection

(p. 102)

(osteomyelitis)

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3. Examine inside the mouth .

Remember what the person said, the person’s age, and what you saw.

Now look more closely at the problem area.

Look at the teeth:

• Is a new one growing in?

• Is a tooth loose?

• Is there a dark (dead) tooth?

Look at the gums:

• Are they red?

• Is there any swelling?

• Do they bleed?

• Are the gums eaten away
between the teeth?

Look also for sores on the inside of the cheek or lips, and on the tongue.

4. Touch the sore place .

Touching is a good way to find out how serious the problem is. This will help you decide which treatment to give.

Push gently against each tooth in the area of pain to see if a tooth is loose. Rock the loose tooth backward and forward between your fingers, to see if it hurts when you move it.

Using the end of your mirror, tap against
several teeth, including the one you suspect.

There is probably
an abscess on a
tooth that hurts
when you tap it.

Press against the gums with cotton gauze. Wait a moment, and then look closely to see if they start bleeding. Then use your probe gently to feel under the gum for tartar. Carefully scrape some away. Wait and look again to see if the gums bleed. When gums bleed, it is a sign of gum disease .

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LEARN TO TELL SIMILAR PROBLEMS APART

If a person comes to you with a toothache or a sore or a loose tooth, there are many possible causes for each problem. The first thing you notice—the
toothache, sore or loose tooth—is your first step
to a diagnosis. To this you must add more information before you can point to the most probable cause.

Put together what you have found with what
you already know about teeth and gums. You
can make a good diagnosis of a problem without
knowing a special name for it.

Usually it is easy to make a diagnosis. However,
sometimes you will not be sure, and these are the
times to seek the advice of a more experienced dental worker. Never pretend to know something you do not . Only treat problems that you are sure about and have supplies to treat properly .

See Where There Is No Doctor, p. w4.

Use the charts beginning here to help you make the diagnosis. For more practice using charts to tell problems apart, see Chapter 21 of Helping Health Workers Learn.

IF THE PERSON

AND YOU FIND OUT

HE/SHE

SEE

HAS

THAT

MAY HAVE

PAGE

It hurts only after eating or
drinking. There is a cavity, but the
a cavity

92
tooth does not hurt when you tap it.

Part of the filling has fallen out, or is
a cavity
cracked and ready to fall out. Eating
under an

92
and drinking make the tooth hurt.

old filling

The tooth hurts when chewing food.

A TOOTHACHE
tartar

It may hurt when tapped, but there is
between

131
no cavity and the tooth looks healthy.

the teeth

It hurts all the time—even when
person tries to sleep. The tooth
hurts when you tap it and it feels a
an abscess

93
bit loose.

It hurts when person breathes in cold
a cracked
air. The tooth was hit recently.

or broken

96
tooth

He cannot open his mouth properly.

Steady pain and a bad taste are
a new tooth
coming from the back of the mouth.

growing in

100

Several top teeth hurt, even more
when you tap them. She had a head
an infected
cold and can only breathe through
sinus

95
her mouth.

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IF THE PERSON

AND YOU FIND OUT

HE/SHE SEE

HAS

THAT

MAY HAVE PAGE

He had a toothache recently.

a tooth

The bad tooth hurts when
abscess

93
you tap it.

A

SWOLLEN FACE

She is young, about 18 years
old, and has trouble opening
a new tooth
her mouth.

growing in

100

He was hit on the face or jaw.

The bone hurts when you
touch it. The teeth do not fit
a broken bone

108
together properly.

The swelling is under or
behind the jaw. It gets worse
an infection
when he is hungry and smells
inside the spit

119
food.

gland

The swelling has been there for
a long time. It does not seem to
a tumor

125
get better.

Food and tartar are attached
infection
to the tooth. The gums
inside the root
around it are loose and
fibers—from

101
swollen.

gum disease

There was pain in the tooth
before, but it does not hurt
infection in the

99
so much anymore. It has a
bone—from
and
cavity and there may be a
an old tooth

93
sore on the gums near it.

abscess

A

LOOSE TOOTH

The tooth was hit
a root broken
some time ago.

under the gum

96

When the loose tooth
moves, the bone around it
a broken bone

108
and the tooth beside it also
around the
to
move.

tooth’s roots

112

OR
infection inside

102
the bone from
and

Vincent’s

121

Infection

When you ask the person to
a tooth is out
slowly close his teeth, one
of position and
tooth hits another, before the
biting too hard

99
other teeth come together.

against another

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IF THE PERSON

AND YOU FIND

HE/SHE

SEE

HAS

OUT THAT

MAY HAVE

PAGE

The gums are red and
gum disease
swollen. They bleed when the
starting

101
teeth are cleaned.

Between two teeth the gums
something

A SORE MOUTH
are sore and swollen, like a
caught under

133
from
small tumor.

the gum

INFECTED GUMS

The gums between the teeth
have died and are no longer

Vincent’s
pointed. Pus and blood around

Infection (a

102
the teeth make the mouth
more serous
smell bad.

gum infection)

The gums are bright red and
fever blisters
sore, but between the teeth
on the gums—

104
they are still pointed.

from Herpes

Virus

A sore on the inside of the
cheek, lips, or under the
tongue, is yellow with the
skin around it bright red.

a canker sore

106

Food touching it makes the
sore hurt more.

a sharp place

A sore spot around or under
on a denture,
or
a denture hurts when you
or an old

106

A SORE MOUTH
touch it.

denture that
needs to be
from a
refitted

SMALL SORE
in another

A kind of white cloth seems
place
to be stuck to the top of the
mouth or tongue. It may
thrush

105
stop a baby from sucking.

The sore is near the root of

74
a bad tooth.

gum bubble
and

93

The corners of the mouth
are dry. The lips crack and
malnutrition

107
are sore.

Small painful blisters on the
fever blisters—
lips soon break and form dry
from Herpes

104
scabs.

Virus

A SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (see page 125).

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IF THE PERSON

AND YOU FIND OUT

HE/SHE MAY

SEE

HAS

THAT

HAVE

PAGE

Inside his mouth, he has a
abscessed tooth
tooth abscess or a broken
draining pus to

120
tooth near the sore.

the outside of
the face

A SORE

ON THE FACE

A dark sore is eating through
a condition
the cheek. Her gums are
called Noma—
badly infected. A bad smell is
starting from
coming from the dying skin on

Vincent’s

121
the face, and from inside the

Infection of the
mouth.

gums

A 1-month-old sore on the lips
is not healing with medicine.

cancer

125

He is young, between

16–24 years, with some
a new tooth
swelling behind his jaw.

growing in

100
a broken jaw—

TROUBLE

He recently had an accident.

probably in

108

OPENING THE
front of the ear

MOUTH

He had a toothache before
in a back tooth with some
an abscess in a
swelling.

back tooth

93

When she tries to open her
mouth, there is a clicking
pain in the
sound from in front of her
joint—where
ear. It also hurts in that place
the jawbone

114
whenever she tries to open
joins the head
her mouth or chew food.

Swallowing is difficult and
the jaw grows stiff. Germs
have gone into the body
tetanus

118
from dirty instruments or an
infected wound.

After opening wide to eat

TROUBLE
or yawn, his mouth became

CLOSING THE
a dislocated
stuck there. He has many

MOUTH
jaw

113
missing back teeth.

He had an accident and now
something is stopping the
a broken jaw

108
teeth from coming together.

85

Treating Some

CHAPTER 7

Common Problems

You must make a good diagnosis to treat a problem so it goes away and does not return. Why treat a sore on the face by cleaning it when the sore is from pus draining from a tooth with an abscess? You need to know the cause of the sore to give the best kind of treatment.

After you make the diagnosis, you must decide whether you or a more experienced dental worker should provide the treatment.

Know your limits . Do only
what you know how to do .

In the following pages, we describe the kinds of problems you as a health worker may see, and we also give the treatment for each problem.

Before you touch the inside of anyone’s mouth, learn how to keep clean . The next 6 pages explain how you can prevent infections by washing your hands, wearing gloves, and cleaning and sterilizing your instruments.

Germs in the mouth

The mouth is a natural home for germs. They usually do not cause problems because the body is used to them. In fact, many germs are helpful. For example, when we eat, some germs break down chewed food into parts small enough for the body to use.

There are problems when the number of these ordinary germs increases greatly, or when strange, harmful germs come into a healthy body from outside. Fever and swelling follow. It is an infection.

When we regularly clean the mouth, the number of germs stays normal.

You can teach others to clean teeth and gums, but cleaning is each person’s responsibility.

However, dental workers have one serious responsibility. You must not spread germs from a sick person to a healthy person . You must do everything you can to make sure your instruments are clean. An instrument with blood on it can spread hepatitis (a serious liver disease) or HIV, which causes AIDS.

85

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THE FIRST RULE FOR TREATMENT: STAY CLEAN!

No matter what problem you are treating, be sure that your workplace, your instruments, and you are always clean. For example, prevent infection by always washing your hands before you examine or treat someone.

Wash your hands with soap and water in front of the person, in the same room. You will show that you are a careful and caring health worker. Also, you will demonstrate just how important cleanliness really is.

Wear gloves

Latex or plastic gloves protect the people you
touch from germs that may be stuck under your
fingernails or on your skin, even after you wash
your hands. They also protect you from getting
infections. Wear clean gloves whenever you
touch someone’s mouth or any blood.

If you are filling or removing a tooth, or if you are touching any instruments that have been sterilized, you must wear sterile gloves.

If you do not have gloves, use plastic bags that
have been washed in disinfectant soap instead.

Bags are harder to use than gloves, but they are
better than nothing.

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87

Germs hide inside bits of old food, cement, or
blood on an instrument. There they can continue to live, even in boiling water.

This is why you must be sure to scrub the working
end of each instrument carefully with soap and
water. Rinse, and then look carefully to see that it is clean and shiny.

Remember that ‘clean looking’ is not necessarily ‘clean’. Truly ‘clean’ means free of germs. Unless you sterilize, that instrument may still have germs, the kind that cause infection in the next person that it touches.

Sterilizing means killing germs . The best way to sterilize is with heat. High heat kills almost all harmful germs—especially those that cause hepatitis, tetanus, and mouth infections. Wet heat (steam) is always more effective than dry heat from an oven.

Here is a simple rule to use in
deciding when to sterilize:

Boil or sterilize with steam
any instrument that has
touched blood .

That means always sterilize
all syringes, needles, and
instruments you use when
scaling teeth (Chapter 8)

or when taking out a tooth

Be safe: When in doubt, sterilize.

(Chapter 11).

Instruments need to boil in water for 30 minutes to become sterile. A pot with a cover to trap the steam can act faster. The inside becomes hotter.

But remember that water can rust metal instruments. To prevent rust:

• Add 5 spoonfuls (20 ml) of oil to every liter of water you boil.

• Then lay the hot instruments on a dry, clean (sterile, if possible) cloth, so the water can evaporate.

Never put an instrument away while it is wet .

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Sterilizing with steam under pressure is the surest method. It kills harmful germs in 30 minutes. You need a strong pot with a tight fitting lid. But be sure to make a small hole in the Iid so steam can escape when the pressure becomes too great .

A special pot called a pressure cooker is perfect for this. It even has a safety hole on it to release extra steam.

1 . Put 2 cups of water and

2 spoonfuls of cooking
oil into the pot.

2 . Place the handles together.

Put on high heat until a loud
hissing noise begins.

3 . Put on lower heat. Begin
timing now . Leave the hissing

DO NOT LET
pot on the low flame for

THE COOKER

30 minutes.

BOIL DRY!

4 . Cool the pot under water, open,
and lay the instruments on a
clean towel to dry.

The next time you use the pot,
you can use the same water that
was Ieft inside it.

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Sterilizing with heat is not necessary for instruments that do not touch blood. For example, after you examine a person or place a temporary filling, you can clean your instruments and then soak them in a solution of alcohol or bleach.

tight fitting

Alcohol solution
lid

1 . Mix in a large container each week:

7 parts alcohol (95%) with 3 parts
clean water. Keep the container
water
tightly covered to prevent

1
evaporation.

2 . Keep a covered pan half filled with
alcohol
this mixture. You will have to add
some more of the mixture from the
large container to the pan each day.

3 . Leave your clean instruments in the

2
pan, completely covered with the
liquid, for 30 minutes.

Bleach solution (sodium hypocholorite)

Find the cheapest brand name in your area for bleach.

Examples are Javex, Clorox, Purex, and Cidex. Make 1 liter of solution with a mixture of ½ cup

(125 ml) of bleach and 3½ cups (875 ml)

of clean water.

BLEACH & WATER

½ CUP

3 + ½ CUPS

Unfortunately, bleach rusts metal
instruments. To reduce rust,
add 1 large spoonful of baking
soda (sodium bicarbonate) to
the solution, and leave your
instruments in the solution for only

30 minutes.

Wipe each instrument with alcohol
to remove the film of bleach. Then
store it dry inside a clean cloth or in
another covered pan.

Change the solution each week.

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Where There Is No Dentist 2012

Keep your sterile instruments together in a clean place .

Wrap them in a clean cloth

OR

Leave them in disinfectant

(p. 89)

Before you use any instrument again,

Mark with tape the names
wash it with clean water—to remove
of the instruments inside.

the taste of the disinfectant.

Germs living in dirty cotton can easily go inside the socket and start an infection. It is important, therefore, to keep the cut pieces in a container that is clean and has a cover. Use clean tweezers to remove the cotton gauze when you need some.

Also, keep your room and work area clean. Sweep or mop the floor one or two times a day, and wipe down the chair and tables after every patient.

Staying clean is a part of staying healthy .

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NEEDLES

Many people get sick with serious illnesses like hepatitis or HIV from using unsterilized needles.

Reusable syringes and disposable syringes

Reusable syringes can be used again and again. Reusable syringes make less waste and can save money, but they must be washed very carefully and sterilized after every use .

Use each disposable needle only one time and then throw it away in a box like the one on pages 205–206. If you must reuse a needle, replace the cap very carefully and put the needle in a safe place (such as a pan full of bleach solution) until you are ready to clean and sterilize it.

HOW TO WASH AND STERILIZE A

SYRINGE AND NEEDLE FOR REUSE:

1 . Put on a pair of heavy gloves
to protect your hands from
germs and from sticking
yourself with the needle.

2 . Draw 5% bleach solution (see
page 89) up through the needle into the
syringe barrel.

3 . Squirt out the bleach solution.

4 . Repeat several times. Rinse everything
several times with clean water.

5 . Take the syringe and needle apart and boil or steam them. (See pages 87 to 88.)

Never reuse a needle or syringe without
cleaning and sterilizing it first .

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PART 1

PROBLEMS yOU WILL SEE MOST OFTEN

CAVITIES AND LOST OR BROKEN FILLINGS

A cavity can occur in any tooth. A cavity can also start around an old filling, especially if it is dirty. The deeper a cavity gets inside the tooth where the nerve lives, the more the tooth hurts.

SIGNS:

• Pain when drinking water or eating
something sweet.

• A hole (or black spot) on the tooth, or
between two teeth.

• Pain if food gets caught inside the hole.

• No pain when you tap the tooth.

TREATMENT (when there is no abscess):

Try to remove any loose piece of filling with a probe. Then, following the steps in Chapter 10, put in a temporary or permanent filling.

For a temporary filling:

1 . Fill the hole with cement. If you have no cement, put some cotton into the hole to keep food out.

2 . Look for cavities or broken fillings in the other teeth. Fill each one with cement before it gets worse and starts to hurt.

3 . Arrange for someone to replace the temporary filling with a permanent one.

For a permanent filling:

You will need a person who has experience doing Atraumatic Restorative Treatment (see page 152) or using a dental drill (see page 156).

A groove on the neck of a tooth is a more difficult cavity to fill. For the temporary cement to hold
properly, you need to shape the groove with a drill.

To help temporarily, you can put a little fluoride toothpaste on the groove (page 211). Do this once
each week until the inside part of the groove is stronger and the tooth hurts less. Or, you can paint the inside of the groove with oil of cloves (eugenol) to reduce the pain.

To avoid making the problem worse, (1) do not use a hard toothbrush; (2) do not brush back and forth along the gums; and (3) do not chew tobacco or betel nut and do not hold them against the teeth.

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TOOTH ABSCESS

A cavity that is not filled grows bigger and deeper until it touches the nerve.

Germs travel inside the tooth’s root and start an infection called an abscess .

Pus forms at the end of the root, inside the bone. As the pus increases, it causes great pressure. This is why an abscess causes severe pain.

SIGNS:

• Pain all the time, even when trying
to sleep.

• Tooth often feels longer, and even
a bit loose.

• Tooth hurts when it is tapped.

• A sore on the gums near where
the root ends (gum bubble).

• Swelling of the gums around the
tooth, or swelling of the face on
the same side as the bad tooth.

TREATMENT:

If there is no swelling, take out the tooth immediately (unless you are able to give root canal treatment). This allows the pus to escape and relieves the pain. See Chapter 11.

If there is swelling, treat the swelling first. Take out the tooth only after the swelling goes down. This is necessary because an anesthetic (see Chapter 9) will not work if there is swelling.

To treat the swelling, give an antibiotic. Penicillin by mouth is best . Use an injection only when the person is in immediate danger. For example, inject penicillin when the person has a fever or if the swelling is pressing against the throat. But remember you can treat most serious infections with simple penicillin by mouth. For the doses for serious infections, look below the box on the next page. If you still think an injection is necessary, look at the section on procaine penicillin on page 210.

Adults and children over 25 kg (60 pounds) of weight should take the same amount of oral penicillin. Children under 25 kg should take ½ as much. For most infections, penicillin by mouth is taken 4 times a day for 5 to 7 days.

The first dose is double and then the regular dose is taken every 6 hours. The person should take all of the penicillin, even if the pain or swelling goes down . For the correct doses, see the next page.

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SECOND CHOICE

THE BEST CHOICE

(for those allergic to penicillin)

Penicillin: 1 tablet = 250 mg

Erythromycin: 1 tablet (or capsule) = 250 mg

Give enough tablets for 5 to 7 days

Give enough tablets for 5 days

First Dose (take all at once)

First Dose (take all at once)

Adults

4 tablets

Adults

4 tablets

and children over 25 kg

(1000 mg)

and children over 25 kg

(1000 mg)

Children under 25 kg

2 tablets

Children under 25 kg

2 tablets

(500 mg)

(500 mg)

Then every 6 hours for 5 to 7 days

Then every 6 hours for 5 days

Adults

2 tablets

Adults

2 tablets

and children over 25 kg

(500 mg)

and children over 25 kg

(500 mg)

Children under 25 kg

1 tablet

Children under 25 kg

1 tablet

(250 mg)

(250 mg)

IMPORTANT: to allow it to best fight infection, IMPORTANT: to avoid upset stomach, take
take penicillin before eating.

erythromycin with meals.

Note: If you do not have penicillin, use amoxicillin, 3 times a day for 7 days.

Adults and children over 25 kg take 500 mg each dose, and children under 25 kg take 250 mg each dose. To use ampicillin, see Where There Is No Doctor. People allergic to penicillin will also be allergic to amoxicillin and ampicillin.

For many infections, taking penicillin for 5 days should be enough. For serious infections, it may be necessary to take the antibiotics for 7 days.

For however long you take them, always take the double dose the first time, and then the regular dose 4 times a day (every 6 hours). If the infection does not heal, you may need a different medicine. Usually you can take out the tooth 1 or 2 days before the end of the antibiotic treatment, but the person must continue to take all of the tablets, even after you have taken out the tooth . If not, the infection might come back even stronger than before.

If the swelling is ‘pointing,’ open it with a sharp sterile knife to release the pus. Cover the wound with a sterile dressing to keep it clean. If you are not able to do that, explain how to reduce the swelling with heat . As often as possible until the swelling goes away:

• soak a cloth in warm water and hold it against the face.

• hold warm water inside the mouth near the swelling. It is not necessary to add salt to the water.

Finally, give the person medicine for pain. A 2-day supply will be enough, because the penicillin and the heat will reduce the pressure and that will reduce the pain. The best medicines for pain are aspirin, which usually comes in 300 mg tablets, and acetaminophen (paracetamol), which usually comes in 500 mg tablets. Aspirin is usually cheaper, but acetaminophen does not cause stomach pain and it is safer than aspirin for children. (To avoid stomach pain, take aspirin with food, milk, or water.) See doses at the top of the next page.

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95

EVERY 6 HOURS (4 times a day):

aspirin
or acetominophen
adults

600 mg

1000 mg
children

8 to 12 years

300 mg

500 mg

3 to 7 years

150 mg

250 mg

1 to 2 years
do not use

125 mg

INFECTED SINUS

A sinus is a hollow place inside the bone. There is a sinus under the eyes, on each side of the nose. Because the sinus is very close to the roots of the top teeth, these teeth may hurt if the sinus becomes infected.

SIGNS:

• Toothache in several top teeth. The
teeth look healthy, but hurt when you tap
them.

• A head cold, and plugged nose. She can
only breathe through her mouth.

• Hurts when you press against the bone
under her eyes.

• Tooth feels different when patient bends over forward.

TREATMENT:

Do not take out any teeth . They will feel better after you treat the sinus infection.

1 . Give penicillin for 5 days (page 94).

2 . Explain to the person that she should:

• drink lots of water.

• breathe steam from boiling water to clear
her nose.

• hold a warm wet cloth against her face, as
often as possible.

• not try to blow her nose, or else her ears will hurt. Wiping the nose is better.

3 . See the person again after 3 days, and

• examine her teeth closely, tapping them to be sure they are strong and healthy.

• if she is not better, get help from a more experienced health worker.

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TOOTH INJURIES

1 . Broken tooth

It is possible to save a broken tooth. It depends on where the tooth is broken and whether its nerve is still covered.

SIGNS:

• Pain when breathing air or drinking
water.

• Blood from the gums around the tooth.

• Tooth moves when you touch it.

TREATMENT:

Take out the broken tooth if:

• its nerve is not covered. If no one can give special root canal treatment, the tooth must come out. Germs from the saliva have already gone inside the tooth and started a small infection.

• its root is broken. To see if it is broken, push gently against the tooth as you feel the bone around its roots. The tooth’s root probably is broken if the tooth moves but the bone does not. The root probably is not broken if both the tooth and bone move.

However, the bone around the roots may be broken (page 109).

You can save a broken tooth if the nerve is still covered and the root is not broken . To do this, use a file on the sharp edges around the break. This makes them smooth so they do not cut the tongue. Later, an experienced dental worker who has the equipment can cover the broken part with a cap or a filling. Until this is possible, tell the person how to protect the tooth:

• Give the tooth a rest. Use other teeth to eat.

• Do not drink things that are very hot or cold, and do not eat spicy food.

• Watch the tooth. See if it changes color (gets darker). Also watch the gums near the root. See if a sore (gum bubble) develops.

A dark tooth and gum bubble are signs that the tooth is dying. Take it out, unless you can give special nerve treatment.

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2 . Tooth knocked out

When a tooth is knocked out of the mouth, you should ask two questions: (1) Was it a baby tooth? (2) How long ago did it happen?

Baby tooth . There is no reason to try to put a baby tooth back into the socket.

Tell the child to bite on some cotton to stop the bleeding. Then wait for the permanent tooth to replace it. Warn the mother that the permanent tooth may take more time than usual to grow into the mouth .

Similarly, there is no need for
treatment if the baby tooth is
pushed up under the gum.

The tooth may grow back into the
right place later, or it may turn dark
and die. If you see a darkened tooth
or a gum bubble (page 74), take out
the baby tooth before it hurts the
permanent tooth that is growing
under it.

Permanent tooth . A permanent tooth is worth saving. How long ago was it knocked out? If it was less than 12 hours ago, you can put a permanent tooth back into the socket. The sooner you do this the better, so do not wait. If you replace the tooth in the first hour, it has a much better chance of joining with the gum and bone . In order to heal and to join the bone, the tooth must be held firmly.

a) Wash the tooth
gently with saline,
milk, or clean water.

There should not be
any bits of dirt on the
root of the tooth.

Keep the tooth
damp with wet
cotton gauze.

Do not scrape away any skin from the
root or from the inside of the socket .

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Where There Is No Dentist 2012
b) If you can not use anesthetic, tell the patient that it will hurt somewhat. Gently push the tooth up into the socket. As you push it up, use a slight turning movement
back and forth.

The biting edge of the loose
tooth should be at the same
level as the teeth beside it.

Hold it in place with your
fingers for about 5 minutes.

c) Soften some beeswax and
form it into 2 thin rolls. Place 1
roll near the gums on the front
side of 5 teeth: the loose tooth
and the 2 teeth on each side
of it. Press the wax firmly, but
carefully, against these teeth.

Do the same with the second
roll of wax on the back side of
the same teeth, again near the
gums.

It is good if the wax on the
back side is touching the wax
on the front side. This helps
the wax hold the teeth more
firmly. To do this, you can

Keep the wax in its position
push the wax between the
for at least 3 weeks.

teeth with the end of your
cotton tweezers.

Tell the person with the injured tooth to return to see you several times . The tooth may die several months or even several years later (see page 47). If that happens, you must take out the tooth, unless you can do root canal treatment.

If it is possible, take an X-ray of the tooth 6 months later and then again each year. Look at the X-ray picture of the root to be sure an infection is not eating it away. To do this, compare the root with the roots of the teeth beside it.

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LOOSE TOOTH

A tooth may be loose for one of several reasons. Decide the reason before giving the treatment.

IF THE TOOTH IS LOOSE

THE BEST

BECAUSE

TREATMENT
a new permanent tooth is

1. Tell the mother and child what is happening.

growing under it.

2. Pull out the loose baby tooth, if it is hurting the child.

gum disease or an old abscess has

1. Take out the tooth, especially if it also hurts.

eaten the bone around its roots.

2. Explain to the person what to do to prevent this problem in other teeth. (See Chapter 5.)

its root has been broken.

Take out both parts of the tooth. If you have trouble taking out the broken root, leave it and try again a week later.

the bone around its root is cracked.

Do not take out the tooth . If you do, the bone will (The bone moves when you push
come out with it. Instead, hold the tooth with wires against the tooth.)

(page 110).

A tooth may also be loose because another
tooth is biting too hard against it.

SIGNS:

• You can feel the tooth move when
the upper and lower teeth meet.

• That tooth hurts.

TREATMENT:

You need to remove a bit of each of the teeth that are biting too hard. Use either a dental worker’s drill, a small file, or a hard stone.

1 . Smooth the inside edge
of the upper tooth.

2 . Smooth the outside edge
of the lower tooth.

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NEW TOOTH GROWING IN

A new tooth cuts through the gums when it grows into the mouth. Germs can easily go under the gums in that place and cause an infection. When the opposite tooth bites against the sore gum it can make an infection worse.

SIGNS:

• Toothache at the back of the jaw.

flap

• Mouth cannot open properly.

• A bad taste coming from the back
of the mouth.

• Sore throat.

• Skin over the new tooth is sore
and hurts when you touch it.

• The age of the person is the right
age for growing a new molar

Infection in the gums and pressure from
tooth (page 66).

the new tooth are painful. Notice the

‘flap’ of skin over the new tooth.

TREATMENT:

Do not take out a new tooth while there is still infection and pain . Wait for the infection to finish. Then decide if there is room for the tooth to grow in. A dental X-ray can help you make that decision. New molar teeth are often difficult to take out. Ask an experienced dental worker to take out the tooth, if it must be done.

What you can do

First, treat the infection. Then wait for the new tooth to grow more into the mouth. Tell the person what is happening. Tell him what he can do to keep the gums healthy while the tooth grows in:

• Rinse the area with warm salt water (page 7). Make 4 cups each day until the mouth opens normally again. Then make 1 cup each day to prevent the problem from returning. Keep rinsing this way until the tooth grows all the way in.

• Hold a warm wet cloth against the jaw as often as possible each day.

• Take aspirin for pain (page 94).

Give penicillin (pages 93–94) if there is fever, a swelling, or if he is only able to open his mouth a little.

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TEETHING

When babies and small children first get their teeth, it is called teething .

This can make the child unhappy, because his gums are sore.

Teething does not cause fever,
head colds, or cough.

But a child can have any of these
problems at the same time as he
gets a new tooth.

TREATMENT:

If the child has another sickness, do not blame it on teething. Look for another cause and treat it separately. Also, do not cut the gum over the new tooth. Let the tooth grow through the gum by itself.

1 . Give acetaminophen for pain and fever (page 94).

2 . Give the child something hard to bite against. This will help the tooth to grow through the gums faster. For example, let him chew on a dry hard biscuit.

GUM DISEASE STARTING

Infection can start in the gums whenever the teeth near them are not clean.

For example, there may be swelling between only 2 teeth or between many teeth. In addition, gums that are weak from poor nutrition are not able to resist the infection. This is why pregnant women and people living with HIV
must take special care to eat well and clean their teeth carefully. When a person has HIV, his body cannot fight infections well, so a gum infection can quickly get worse (page 189).

SIGNS:

• Gums are red instead of pink.

• Gums are loose instead of
tight against the tooth.

• Between the teeth, gums are
round instead of pointed.

Feel for tartar under the gum—or

• Gums bleed when the person
even a piece of fishbone.

brushes or flosses.

• Gums bleed when you press
against them, or when you scrape away food from under them.

• The person has bad breath and a bad taste inside the mouth.

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TREATMENT:

Explain to the person the cause of her gum problem and what she can do to help herself. The only way to stop gum disease is to remove plaque and tartar from the teeth and then to keep them clean.

1 . Show her how to clean her teeth better near the gums (page 69).

2 . Tell her to rinse her mouth with warm salt water (page 7). Make 4 cups each day until the bleeding stops. Then make 1 cup each day to keep the gums strong and tough.

3 . Tell her to eat fresh fruits and vegetables. Guavas, oranges, pineapples, papayas, tomatoes, peas, and green leaves give strength to gums.

4 . Gently reach under the gums and remove tartar (or loose piece of fishbone) that is caught there (see Chapter 8).

Sometimes a pregnant woman’s gums become swollen, and the swelling does not go down even after cleaning with a soft brush and rinsing with salt water. These swellings must be cut away. But she should wait to have this small operation until after the baby is born.

MORE SERIOUS GUM DISEASE

Vincent’s infection of the gums, also called trench mouth, affects both adults and children. In its worst form, it can eat a hole through the cheek of a weak child (page 121).

A person with Vincent’s Infection may not want to eat because his teeth hurt when he chews food. That can make a child’s malnutrition worse.

You must prevent this problem from starting, especially in a child who is weak from sickness. Teach mothers to clean their children’s teeth and to get their children to rinse their mouths with warm salt water.

SIGNS:

• Gums between the teeth are dying
and turning gray.

• Pus and old blood collect around
the teeth.

• Burning pain from the gums.

• Bleeding from the gums.

• The mouth smells bad.

TREATMENT:

You will need to see the person over a 2-week period. Start some treatment now:

1 . If the person is already sick, give penicillin for 7 days (page 94).

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2 . Clean away the pus, old food, and big pieces of tartar. Then:

• Tell the person to rinse his mouth with warm water.

• Wipe his gums with cotton soaked in a 3% solution of hydrogen peroxide, iodine, disinfectant mouth wash, or warm salt water. Rinse with warm water. For a child, use a weaker solution, such as 1 part hydrogen peroxide mixed with 5 parts water.

• Scrape away the bigger pieces of tartar. Do not try to remove all of it.

You can do that later. Put topical anesthetic on the gums if you have some (first dry the area with cotton so the topical anesthetic will stay longer). Rinse away any loose bits of tartar with warm water.

3 . Teach the person how to care for the gums at home:

• Rinse at home for 3 days with a weak solution of hydrogen peroxide (page 8), iodine, disinfectant mouth wash, or warm salt water. Try to hold the solution in the mouth for several minutes. The longer the solution touches the gums, the better it is for the gums. Rinse once every hour. After 3 days, change to salt water, 4 cups a day.

• Clean the teeth with a soft brush. Parents can clean children’s teeth.

Show them how (page 18), and ask them to do it even if the gums bleed.

For a young child who is not able to
rinse, Mother or Father can wipe his
gums with the weak solution 4 times a
day.

Show parents how to do this. Give
them some cotton gauze and hydrogen
peroxide, iodine, or disinfectant mouth
wash to take home.

4 . Cook food that is soft (like pounded yam) and not spicy (no pepper). Eat fresh fruits and vegetables that give strength to the gums (page 102).

If you cannot eat well because of pain, take a multi-vitamin, or at least vitamin C and zinc.

• Stop smoking and stop chewing betel nut.

One week Iater, scrape away the rest of the tartar from the teeth. Then with the person’s own brush show him how to do a better job of cleaning his teeth.

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FEVER BLISTERS

Herpes virus is a kind of germ that causes fever blisters. Fever blisters are sores that can form inside the mouth on the gums or outside on the lips. Blisters on the inside cheeks only are not from herpes (see canker sores, page 106).

Sores inside the mouth are a serious problem that usually affect children between 1 and 5 years old. A child with fever blisters in his mouth can become very sick. He will not be able to eat properly. If he does not drink enough fluids, he can become dehydrated (lose his body water). This is dangerous! Fever blisters are also a problem for people living with HIV. See pages 192 to 193.

SIGNS:

Inside the mouth

• Sore throat.

• Fever.

• Crying, stops sucking 2 to 3 days before sores appear.

• Spit spills from the mouth because it hurts to swallow.

• Painful swelling under the jaw.

• Bright red blisters on the gums, but not between the teeth . Blisters also may be on the roof of the mouth.

TREATMENT:

Medicine cannot kill the herpes virus. The sores will go away by themselves in about 10 days. The treatment is to help the person feel more comfortable and to be sure he gets enough to eat and drink.

1 . Give aspirin or acetaminophen for fever (page 94).

2 . Wipe milk or yogurt over the sores to protect them before eating. Wash your hands before touching the inside of someone’s mouth! (See page 86.) Then give food that is soft and not spicy. If the person cannot eat, prepare a special milk-oil drink, as on page 111.

3 . Give lots of fluids to drink.

Sores on the lips usually occur after the age of 5.

They often appear when the person is weak and
sick (for example, with diarrhea or pneumonia).

Usually there is no fever. The blisters soon break open and release water. When they dry, a crust
forms. The blisters often return. When sores leak

On the lips
water they can pass infection. If you or anyone else touches them, wash your hands immediately.

To prevent the blisters from becoming infected, put an antibacterial cream or petroleum jelly (Vaseline) on them. If you hold ice against the sores for several minutes each day, it may help them heal faster. See page 193 for more options.

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THRUSH

Thrush is an infection caused by a yeast fungus called Candida. It often appears when a person is weak and poorly nourished, or sick and taking medicine like tetracycline or ampicillin. In a baby, thrush usually appears on the tongue or top of the mouth. It can stop the baby from sucking. ln an adult, thrush often occurs under a denture. Thrush is a very common problem for people living with HIV (see pages 186 to 187).

SIGNS:

• White patches on the tongue, cheek, or
top of the mouth. Wipe the white area: If
there is no bleeding it is old milk . If there is bleeding, it is thrush .

• The child may not want to suck or eat.

TREATMENT:

There is usually something else present which is helping thrush to grow.

Try to find what it is and deal with it. For example, treat the malnutrition, diabetes, or anemia, change or stop the antibiotic medicine, or clean the denture and leave it out of the mouth for a while. Then: 1 . Cover the white patches with nystatin drops. Use a full dropper 4 or 5
times a day until the patches are gone. If you do not have nystatin you can soak a piece of cotton in gentian violet and use it to paint the white patches 2 times a day.

If the baby’s mother has sore, painful nipples, she may also have thrush in her breasts. She should treat her nipples the same way she treats the baby’s mouth.

Do not use penicillin or any other antibiotic unless you need to treat something different . Thrush can get worse when a person uses an antibiotic for a long time.

2 . For children, continue breastfeeding. For older persons, make their food soft and easy to chew.

IMPORTANT: Sometimes white lines appear on the inside of an adult’s cheek or on the roof of the mouth. If these lines become sore and do not get better with treatment, they can change into a cancer (page 125). To prevent this cancer, ask the person to stop smoking (especially pipes), stop chewing betel nut, and get dentures adjusted if they do not fit properly .

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CANKER SORES

The exact cause of canker sores is not known. Canker sores affect both adults and children, and are very common among youth.

One or more sores can appear at any time. These sores hurt, especially when pieces of food touch them.

SIGNS:

• A sore can appear on the cheeks,
inside the lips, on the tongue, or below
the gums on the smooth skin.

• The sore is white or yellow with the
skin around it bright red.

• The person may have had a similar kind
of sore before. It tends to come back.

Note: a sharp edge of a denture rubbing against the gums can make a similar kind of sore .

TREATMENT:

A canker sore goes away by itself in about 10 days. Medicine does not make that happen any faster. (However, smoothing a denture or fixing a broken tooth does help.) The treatment is simple. Tell the person how to feel more comfortable while waiting for the 10 days to pass:

• Eat foods that are soft and not likely to hurt the sore.

• Do not eat spicy food.

• Drink lots of water.

• Chew food on the other side of the mouth, away from the sore.

A denture which does not fit
should be remade.

In the meantime, leave the
denture out of the mouth for

2 or 3 days.

Ask the person to rinse with
warm salt water, 4 cups each
day until the sore is better.

If the sore continues after 10 days, it may be infected. Give penicillin (page 93).

A sore that does not heal after antibiotic treatment may be cancer (see page 125) . See a doctor immediately .

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SORES AT THE CORNERS OF THE MOUTH

Teeth support the lips. When they come together for chewing, the teeth stop the person’s chin from moving any closer to the nose.

A person without many teeth looks old. A person with a poor fitting denture also looks old.

The distance from his chin to his
nose is shorter than normal.

He must close his jaw further to
eat. That causes lines to form at
the corners of his mouth.

Poor health can make lines at
the corners of the mouth crack
and become sore . These cracks are
often infected with thrush and can be treated with nystatin (see page 105).

If sores are not at the corners but around the mouth, they could be due to a bacterial infection (see page 94).

A person with missing teeth needs dentures. Dentures will help him chew more food and make him look younger. They support his Iips and open his mouth more. (See page 170).

A child who has had a fever or measles often has dry lips. The corners of her mouth can crack and become sore.

Cracks and sores appearing at the
corners of a child’s mouth are signs of
dehydration and malnutrition.

The child needs to eat the kind of foods that give strength, energy, and protection. Feed her beans, milk, eggs, fish, oils, fruits, and green leafy vegetables (see pages 67 to 68).

TREATMENT (when sores occur):

1 . Wash the sores with soap and hot water.

2 . Mix 1 part sulfur with 10 parts of petroleum jelly (Vaseline).

3 . Smear some on the sores 3 to 4 times a day.

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PART 2

SOME SPECIAL PROBLEMS

You will find some problems that are too serious for you to treat. If you can, send the sick person to a more experienced dental worker as soon as possible.

Sometimes, however, it is better to start some of the treatment yourself.

Early treatment can prevent some problems from becoming more serious.

Also, if you know what to do when someone returns from the hospital, you can help that person to get well faster.

Sometimes, you will find it impossible to get help. Therefore, we will discuss each of these more serious problems in detail, so you can give as much help as necessary.

BROKEN BONE

Three main bones form the face and lower jaw.

1. cheek bone

2. upper jaw bone

(lower jaw joins
the head here)

3. lower jaw bone

A bone can break completely, or part of it can crack. In either case, the teeth are usually pushed out of position. Look for this as a sign of a broken bone.

SIGNS of a broken bone:

• The person has had an injury.

• When teeth are closed, some upper
teeth do not meet lower teeth.

• The person cannot open or
close the mouth properly.

• There is bleeding from between 2 teeth.

• There is swelling or a bruise on the face or jaw.

• There is bleeding into the eye.

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SIGNS of a cracked bone
around the tooth’s roots:

• When you move one tooth,
the tooth beside it also moves.

• When you move the loose
tooth, the bone moves with it.

• Blood is coming from
under the gums.

TREATMENT:

When a bone is broken or cracked, the treatment is to hold the broken parts together so that the parts can rejoin. The usual way to do this is to put wires around the teeth. An experienced dental worker should do this. There are two things you can do. First, provide emergency care. Later, show the person how to eat and how to keep his mouth clean.

Emergency care (pages 109–110):

1 . Be sure the person can breathe.

2 . Stop the bleeding.

3 . Put a bandage on the person’s head.

4 . Give penicillin to stop infection.

5 . Give aspirin or acetominophen for pain.

1 . Be sure the person can breathe .

Lie him on his side so
that his tongue and
jaw fall forward.

Later, carry him to the hospital in that position. If he goes in a car, be sure he sits with his head forward. His jaw and tongue will be forward and he will breathe more easily.

Look inside the mouth to see if any tooth is broken and very loose. A broken piece of tooth can fall out and block the person’s airway, so take out the broken part now . You can leave in the root, but if you do, tell the dental workers at the hospital (page 219). They will remove the root when they put on the final wires.

2 . Stop the bleeding .

Wipe away the dried blood from his face and from inside his mouth. Look for the place that is bleeding. Sew any deep cuts on his face (see Where There Is No Doctor, page 86). If you gently press cotton gauze against the bleeding gums, it will usually control the bleeding.

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Bleeding inside the mouth, from between the broken parts of the bone, is more difficult to stop . You must pull the two sides together and hold them in that position. To do this, you need wire that is thin, strong, and bends easily. ‘Ligature wire’ (0.20 gauge) is best.

Place a piece of wire around 2 teeth, one
on each side of the break. Choose the
strongest tooth on each side—the ones
with the longest or the most roots.

Tighten the wire around the two strong
teeth with pliers or a hemostat.

Ask the person to close his teeth. Lift up the broken part of the jaw and hold it so the lower teeth meet the upper teeth properly. This is the normal way the jawbone holds the teeth.

Now join the wires. Twist and tighten them
together. This may be painful.

You can inject local anesthetic—see

Chapter 9. You must twist the wire tight
enough to hold the broken parts together.

Bend the end of the twisted wire toward the teeth. Now it cannot poke the person’s lips or cheek.

3 . Put on a head bandage .

Gently close the person’s jaw so that his teeth come together. Support it in this position with a head-and-chin bandage.

Tie the bandage to support the jaw, not to pull it. Do not make it too tight. It is all right if his mouth stays partly open with the teeth slightly apart.

Be sure not to let the bandage choke the person.

4 . Give penicillin by injection (page 210) for 5 days to stop infection inside the bone.

5 . Give something for pain . Aspirin (page 94) may be enough. Give 600 mg by mouth, 4 times a day. For children, see doses on page 95. If there is a lot of pain and the person cannot sleep, give codeine. The dose for an adult is 30 mg, 4 to 6 times a day as needed.

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Send the person to the hospital as soon as possible. The person must have wires placed on his teeth within a week of the accident. The wires must remain there for 4 to 6 weeks. Every week, the person must return to the hospital to have the wires tightened. During this time he cannot open his mouth to chew food or brush his teeth.

CARING FOR A PERSON WHO CANNOT EAT PROPERLY

1 . Give Iiquid foods for strength and energy .

Prepare food in two ways: (a) First, a milk-oil drink to build strength and then (b) a special soup to keep him strong and give him energy.

To build strength: Milk-oil drink

Mix for him each day at your clinic:

• 9 cups of water

• 150 ml of peanut oil or coconut milk

• 3 cups of milk powder

• ½ cup of honey or 1 cup of sugar

Leave some near his bed, and keep the rest in a cool place.

To keep strength and give energy: Special vegetable soup Cut into small pieces and cook together in a pot of water:

• ½ tin of fish or a handful of dried fish

• 4 small spoonfuls of peanut oil or palm oil

• 6 sweet potatoes or small yams

• 1 large handful of green leaves

• 1 small spoonful of salt

Pour the soup into an empty tin with small holes made in the bottom.

Use the back of a spoon to press as much of the cooked food as you can through the holes. The person can suck the soup between the teeth to the throat and then swallow it. Clean the tin and set it in boiling water, so you can use it again the next day.

2 . Keep the teeth clean and the gums tough .

The person must learn to clean teeth and gums or the gums can quickly become infected and the mouth will feel sore. So:

• Scrub both the wires and the teeth with a soft brush after drinking soup.

• Rinse with warm salt water (page 7), 2 cups every day.

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LOOSE TEETH

If the bone around the roots of the teeth is cracked, those teeth will be loose. Do not take the teeth out until the bone is healed . Otherwise, bone will come out with the teeth and there will be a big hole in the jaw.

Instead, support the teeth, in order to hold both sides of the bone steady.

1 . With your thumb and finger, gently
move the loose teeth and bone back
into normal position.

2 . Cut a hypodermic needle and use it
as a splint. Make it long enough to fit
around two strong teeth on each side of
the loose teeth. Curve the needle so it
fits the curve of the teeth. To make the
sharp ends smooth, use a file or rub the
ends against a stone.

3 . Tie each tooth to the needle. Use short pieces of 0.20 gauge ligature wire (page 110).

Put one end of the wire under the needle.

Bring it around the back of one tooth and
out to the front again over the needle.

Use the end of a small instrument to
hold down the wire at the back of the
teeth. Then twist the ends together.

Tighten the wire around each one of
the 6 teeth.

4 . Cut the ends of the ligature wire. Turn them toward the teeth, so they will not
cut the lip.

5 . Tighten the wires the next day, and then once each week. But be careful. Only ½ a turn usually is needed. More, and the wire will break.

Always twist in the direction a clock moves. With this habit, you will remember which way tightens the wire and which way loosens it.

6 . Explain to the person that it takes 4 weeks for the bone to heal. The wires must remain on the teeth for this time. To help the teeth to heal, ask the person to:

• give these teeth a rest. Use other teeth for chewing.

• clean both the teeth and the wires with a soft brush.

• rinse with warm salt water, 2 cups every day (page 7).

• return to have the wires tightened every week.

7 . After 4 weeks, cut and remove the wires. Ask the person to watch those teeth. A dark tooth and gum bubble are signs that the tooth is dying. Take it out, unless you can give special nerve treatment.

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DISLOCATED JAW

If a person opens her mouth wide and then is unable to close it, we say her jaw is dislocated . It is stuck in the open position. This problem often happens to a person who does not have several of her back teeth. When she opens wide to yawn or shout, the part of her jaw that joins her head moves too far forward inside the joint. It is then unable to return to its normal position. You can also dislocate the lower jaw by accident while extracting a tooth.

SIGNS:

• She is unable to close her
teeth together.

• She cannot close her lips
easily.

• Her lower jaw looks long
and pointed.

• It hurts when you press on
the joint in front of her ear.

normal
dislocated

• She cannot speak clearly.

TREATMENT:

The treatment is to try to move the lower jaw back where it belongs. Then hold it in that position until the muscles can relax.

1 . Find a way to support the person’s head. For example, have the person sit on the floor with her head against a wall.

2 . Kneel in front of her. Put your fingers under her jaw, outside the mouth. Put your thumbs beside her last molar tooth on each side. Do not put your thumbs on the molars. The person may bite them!

Press down hard with the ends of your
thumbs. Force the jaw to move quickly
down and back into position. Be sure to
press down before you press back.

If the jaw will not move, perhaps the
muscles are too tight. A doctor or
dentist can put the person to sleep,
which will relax the muscles.

3 . Support the jaw with a head–and–chin
bandage for 3 to 4 days (page 110).

4 . Give aspirin or acetominophen for pain (page 94).

5 . Explain the problem to the person and tell her how to care for her jaw: (a) eat mostly soft foods for 2 weeks; (b) hold a warm wet cloth against the jaw; (c) remember not to open the mouth wide anymore. If possible, replace the missing back teeth with dentures (page 107) .

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PAIN IN THE JOINT

A joint is the place where one bone joins another. The jawbone has two joints, for it joins the head in front of each ear.

The mouth opens and closes because:

• muscles pull the jawbone; and

• the jawbone slides against the head
bone, inside the joints.

Pain in these joints may be because:

1 . The muscles are tight because the
the person is tense or nervous.

2 . The jawbone is fractured in the area
of the joint. (Also check the lower
jaw on the other side since a fracture
near the joint is often caused by a
blow to the other side of the face.)

3 . The teeth do not fit together properly.

TREATMENT:

Before you treat, decide what is causing the pain. We will discuss the three causes mentioned above.

1 . Tension .

Talk with the person and help, if you can, to find a solution to her personal problems. This can do much to help her and her muscles relax.

In addition, explain how to care for the sore joint: a . Eat only soft foods until it no longer hurts to chew.

b . Hold a hot, wet cloth against the jaw, to help relax the muscle.

Do this as often as possible, but be careful not to burn the skin.

c . Take aspirin or acetominophen (page 94) to reduce the pain.

2 . Fracture .

If an X-ray shows a fracture, the person needs expert help. A dentist can wire the teeth in a way that will allow the bone to heal.

3 . Teeth do not fit together properly .

Imagine a line that passes between the 2 middle upper teeth and the 2 middle lower teeth in the person’s closed mouth (see the next page).

When the person opens the mouth, this line becomes longer, but it is still a straight line. If it is not, this condition can, after a long time, cause pain in the joint.

Where There Is No Dentist 2012 115

These teeth are normal. The line formed between the two middle teeth does not shift when the mouth opens.

When you see teeth that do not fit
properly:

• Warn the person not to open his
mouth wide. Suggest, for example,
that he take his food in small bites.

• Tell the person what can be done
to help. Often a dentist can grind
the teeth in a special way and this
can end the pain.

These teeth do not fit properly. Because the line shifts, this means the jaw is also shifting.

This shift can cause pain in the joint.

SWOLLEN GUMS AND EPILEPSY

Many persons who suffer from epilepsy

(see Where There ls No Doctor, page 178) have a problem with swollen
gums. In severe cases, the gums are
so swollen they cover the teeth. This
problem is caused not by epilepsy but by
diphenylhydantoin or phenytoin (Dilantin),
a drug used to control epilepsy.

When you see swollen gums, find out what medicines the person is taking.

If possible, change to a different drug. If the person must continue using diphenylhydantoin, explain how to prevent this swelling of the gums. Show the person this book, especially pages 69 to 72. Persons who take this drug may be able to prevent the swelling by brushing the teeth carefully after each meal, and taking special care to clean between the teeth (page 71).

116 Where There Is No Dentist 2012

BLOOD IN THE MOUTH

Use wet cotton gauze to wipe away the old blood from inside the mouth.

Then you can see where it is coming from. Treat the cause of the bleeding.

IF YOU SEE:

TO STOP THE BLEEDING:

SEE PAGE
a large red clot growing out

1. Remove the clot with

118
of a socket where you have
cotton tweezers.

taken out a tooth

2. Ask the person to bite on
a piece of cotton.

sore and bleeding gums

1. Rinse with a mixture of

8
and the mouth smells bad
hydrogen peroxide and water.

(Vincent’s infection)

2. Remove as much tartar as you can.

127
a red, bleeding growth

Take out the tooth; it

93
inside the cavity in a tooth
has an abscess.

a loose tooth with bleeding

Hold the tooth with wires, or if the

112
gums around it
root is broken, take out the tooth.

163
torn gums with broken

1. With wire, hold the broken

110
bone and bleeding
parts of the bone together.

2. Send the person to an
experienced dental worker.

PROBLEMS AFTER YOU TAKE OUT A TOOTH

Problems such as swelling, severe pain, and bleeding can occur after you take out a tooth. Tetanus (page 118), a more serious problem, can also occur, especially if your instruments were not clean.

Swelling of the Face

You can expect some swelling after
you take out a tooth. But if the
swelling continues to grow, and it is
painful, this is not normal. Probably an
infection has started. The treatment
is the same as for a tooth abscess:

penicillin for 5 days to fight infection,
heat to reduce the swelling, and
aspirin or acetominophen for pain.

See page 94 for the proper doses.

Where There Is No Dentist 2012 117

Pain from the Socket

There is always some pain after a tooth is taken out. Aspirin is usually enough to help.

However, sometimes a severe kind of pain starts inside the tooth’s ‘socket’

(the wound) 2 to 3 days after you take out the tooth. This problem is called dry socket and it needs special care.

TREATMENT:

1 . Place a dressing inside the socket. Change it each day until the pain stops.

First, clean out the socket .

Squirt warm water inside the socket with
a clean syringe. After the person spits out
the water, squirt water inside once more.

Use a blunt needle so that it does not
hurt the gums or bone if it touches them.

Third, place the dressing
gently inside the socket .

Place one piece of dressing

Second, prepare the dressing .

into each root space. Push

Soak 1 to 2 small pieces
it down into the root space
of cotton in eugenol (oil of
gently.

cloves).

Cover the socket with plain

Squeeze each piece so that it
cotton gauze, and send
is damp but not wet.

the person home bitting

Note: There may be local
against it. He can remove
medicine in your area that
the plain cotton in an hour.

relieves pain. Use it instead of

The dressing should remain
eugenol.

inside the socket.

2 . Give aspirin or acetominophen for pain (page 94).

118 Where There Is No Dentist 2012

Bleeding from the Socket

When you take out a tooth it leaves a wound, so you can expect some blood. However, if the person bites firmly against a piece of cotton, it usually controls the bleeding. To help the wound heal (from a clot), tell the person not to smoke, rinse with salt water, or spit for 1 or 2 days after you take out the tooth.

When the first bleeding occurs, put a new piece of cotton on top of the wound and ask the person to close her teeth against it for an hour. Keep her there with you, to be sure she continues to bite on the cotton. (If it is too painful, you may want to inject anesthetic. See Chapter 9.) Change the cotton if it becomes soaked with blood.

TREATMENT (if the bleeding continues):

1 . Take her blood pressure (see Where

There Is No Doctor, pages 410-411). If it is high, you may need medicine to bring
it down. That can help slow the bleeding.

2 . Look carefully at the wound.

If the gum is torn or loose,
put in a suture (pages 167–168).

3 . Wrap tea leaves in cotton gauze. Soak the bundle in water and then put it on the socket. Have the person bite against it. Or, have her bite against cotton gauze soaked with cactus juice.

Let the person go home only when the bleeding stops. Give her some clean cotton to use in case the bleeding starts again later (see page 169).

TETANUS

This is a very serious infection. Tetanus germs enter the body when a wound, like a wound on the bottom of the foot, gets dirty. Germs can also be carried to the socket when you use a dirty instrument to take out a tooth.

To avoid this, carefully read pages 86 to 91 .

SIGNS:

• the jaw becomes stiff and tight
not

• it is hard to swallow
cleaning

• the whole body becomes tight,
properly
with sudden spasms

TREATMENT:

A person with signs of tetanus requires immediate medical help. See Where There Is No Doctor, pages 182 to 184, if you cannot get help immediately.

Where There Is No Dentist 2012 119

INFECTION INSIDE THE SPIT (SALIVA) GLAND

Spit glands are places where the spit or saliva is made. They are located in front of the ear and under the jaw, on each side of the head. If there is an infection inside a spit gland, the face will become swollen and the area will hurt.

Spit is sent from the gland to the mouth through a thin pipe called a duct.

Ducts open into the mouth in two places: on the inside of each cheek and under the tongue.

A small stone can often block a duct and cause an infection in the spit gland and swelling of the face. You may be able to feel the stone near where the duct enters the mouth.

SIGNS:

• swelling in the area of the spit gland.

• pain which gets worse when the person is hungry, and when he sees or smells food.

• the opening of the duct is red, swollen, and hurts when you touch it.

spit from
this gland
enters on
the inside of
the cheek
tongue
spit from
this gland
enters under
the tongue

TREATMENT:

Reduce the infection and swelling first. Later try to remove the stone.

1 . Give penicillin for 5 days (page 94). If the swelling is large and the infection serious, start with short-acting crystalline penicillin (see page 210).

2 . Give aspirin or acetominophen for pain (see page 94).

3 . Apply a wet hot cloth to the swelling as often as possible.

4 . Give enough soft food to prevent the person from feeling hungry.

The pain will be less then.

5 . When the person feels better, a dentist or doctor can remove the stone that is blocking the duct.

120 Where There Is No Dentist 2012

SORES ON THE FACE

Whenever you see a sore on a person’s cheek or under his chin, remember there may be a tooth or gum problem. If it is a gum problem, it may be Noma. See the following pages.

A bad tooth:

Ask him to open his mouth.

Look for an infected tooth in
the area of the sore.There
may be a large cavity and the
tooth may be loose.

Or the tooth may be darker
in color than the others.

This is because it is dead.

The pus is draining onto
the skin, so the pressure
is reduced and the person
does not complain of pain.

TREATMENT:

1 . Take out the tooth (see Chapter 11).

2 . Give penicillin for 7 days (see page 94).

3 . After the penicillin treatment, check the sore. If it has healed, there is no longer infection inside. The treatment is finished.

But if the sore is still open and you can squeeze out pus, you will need the help of experienced health workers who can:

• test the pus to see if it is resistant to penicillin. The person may need to take a different antibiotic .

• take an X-ray to see if there are dead pieces of bone which are keeping the infection alive. If there are, they must be removed.

If infected gums (and not a bad tooth) are the cause of a sore on the cheek or chin, the problem is more serious. See the next 4 pages.

Where There Is No Dentist 2012 121

NOMA

When a child is sick, a simple gum infection can get out of control and spread through the cheek to the face. When that happens the condition is called Noma or Cancrum Oris . Noma is a complication of Vincent’s Infection of the gums (page 102).

You will usually see Noma in children. It will only develop if these 3 things are true:

1 . The child’s general resistance is low.

Usually, he is undernourished and anemic

(lacks iron). He may have tuberculosis.

2 . The child has Vincent’s Infection.

3 . The child has recently had a serious
illness such as measles or malaria.

Noma can also be a problem for adults living with HIV. See page 191.

SIGNS:

The infection starts in the mouth .

Then it passes to the gums .

1 . Sore mouth with itching gums.

2 . Swollen, sore gums.

3 . Gums bleed when eating or
when teeth are cleaned.

4 . Bad breath, spits a lot.

Then it reaches the jaw .

5 . Loose teeth.

6 . Loose pieces of bone
around the teeth.

Finally, it affects the cheek .

7 . Skin is tight with dark red
swelling.

8 . Black spot on the cheek
breaks open, leaving a hole
into the mouth.

9 . A line separates dead
tissue from healthy tissue.

122 Where There Is No Dentist 2012

TREATMENT:

You must start treatment for Noma immediately in order to prevent the hole from getting bigger. The bigger the hole, the tighter the scar that forms after you close the hole. A tight scar will prevent the child from opening his mouth and chewing the food he needs to grow stronger.

1 . Give fluids .

The child needs to overcome both
the lack of body water (dehydration)

and his lack of resistance to disease.

Start giving the milk-oil drink
described on p. 111.

If he cannot drink by himself, help
him. Use a spoon or syringe.

Place the fluid on the inside of the
healthy cheek and ask the child to
swallow.

2 . Treat the anemia .

Start giving iron (ferrous sulfate) now. The child should continue taking the tablets or mixture for 3 months, with food.

Ferrous Sulfate Tablets
over 6 years

200 mg (1 tab) 3 times a day

3–6 years

100 mg (½ tab) 3 times a day
under 3 years

50 mg (¼ tab) 3 times a day

You can also use ferrous fumarate . Advise the mother that the iron will make the child’s stool black.

Also give food rich in iron: meat, fish, eggs, dark green leafy vegetables, peas and beans.

Note: A child may have anemia because he has worms. It is a good idea to do a stool analysis to find out. If he has worms, give him medicine right away. Mebendazole, albendazole, and thiabendazole treat many different worm infections. Piperazine treats roundworm and pinworm infections, and there are other medicines for tapeworm and blood flukes. Also give folic acid . For doses, see Where There Is No Doctor, pages 373 to 376, and page 392.

Where There Is No Dentist 2012 123

3 . Start antibiotics .

Metronidazole is the best medicine to use. Give 200 mg by mouth 3 times a day for 10 days. You can also use clindamycin. To decide how much to give, weigh the child. For adults, see the medicines and doses on page 191.

Weight

Dose for clindamycin (give 3 times a day for 5 days) 5 to 10 kg

50 mg by mouth or 60 mg by injection

10 to 17 kg

100 mg by mouth or 130 mg by injection

17 to 25 kg

150 mg by mouth or 225 mg by injection
over 25 kg

250 mg by mouth or 333 mg by injection

4 . Treat the other illness that helped Noma to develop .

It is wise to assume that the child has malaria and to begin treating with antimalarial drugs (see Where There Is No Doctor, pages 364 to 367).

Look for any other illnesses and treat them, too, especially measles and tuberculosis.

5 . Clean the sore .

Gently pull away any dead skin with tweezers. Wash the inside of the sore with hydrogen peroxide. (Be sure you measure the hydrogen peroxide carefully. See page 8.) Then put in a wet dressing. (You can also clean the sore with an iodine solution.)

The dressing:

• Soak cotton gauze in salt water. Squeeze out the extra water so that it is damp but not wet.

• Put it in the hole and cover it with a dry bandage.

• Every day, remove the bandage, wash the hole with hydrogen peroxide, and put in a new dressing. Do this until the hole does not smell anymore and there is no more dark dead skin.

6 . Remove the loose teeth and dead bone .

You can use a local anesthetic (Chapter 9). Usually there is not much bleeding. If gums are loose, join them with a suture (see pages 167 to 169).

124 Where There Is No Dentist 2012

7 . Keep the mouth clean .

• Use a soft brush gently to clean the remaining teeth. Do this 3 times a day for the child.

• Wipe the gums with a weak solution of hydrogen peroxide. Use cotton gauze that is damp with the solution. Do this every 2 hours for 5 days.

• Then after 5 days, start rinsing with warm salt water, 3 cups a day.

8 . Get advice on whether surgery is needed .

Unfortunately, the child will probably need surgery, to release the scar. Without this surgery, the child will not be able to open his mouth properly.

Send the child for medical help when the
infection is finished and the wound starts
to close.

You may also need a dentist’s help at this
time. The child’s jaws may need to be
wired. The wires are put on the healthy
teeth in a way that holds the mouth open
while the tight scar is forming. When the
wires are removed, the child will be able to
open and close his mouth to chew food.

PREVENTION OF NOMA:

Noma need not occur . We can prevent it. Always give special attention to the mouth of a sick child, to be sure to keep his teeth clean.

Whenever someone is nursing or caring for a sick child, that person should clean the child’s teeth as a normal activity. This is especially true for a child who is weak, undernourished, and with little body water (dehydration).

Such a child should always:

• have his teeth carefully cleaned
each day with a soft brush.

• rinse his mouth with a warm salt
water solution (page 7), 2 times
a day.

• eat fresh fruits and vegetables,
especially the kind that have
vitamin C: guavas, oranges,
pineapples, papayas, tomatoes,
peas, and dark green leaves.

Where There Is No Dentist 2012 125

TUMOR

A tumor is a lump that grows under the skin or inside the bone. It grows slowly but steadily, usually without any pain.

If the swelling does not get better after 5 days of antibiotics and heat treatment (page 94), it may be a tumor .

TREATMENT:

Do not waste any more medicine or any more time. A tumor may be cancer . Send for medical help. Surgery is needed to remove a tumor.

CANCER

Any sore or bump that does not
heal within 2 weeks may be cancer.

The lips and tongue are the 2
places in the mouth where cancer
starts most often. Also check
the floor of the mouth under the
tongue, the soft part of the roof of
the mouth, and the gums.

Cancer is deadly .

Cancer can spread quickly to the inside of the person’s body where you cannot see it. This can lead to the person’s death. But cancer can be treated if you notice it early.

TREATMENT:

Whenever you treat a sore and it does not get better, send the person for medical help immediately. A doctor can cut out a piece from the sore, look at it under a microscope, and decide if it is cancer. If it is cancer, you will need specialized treatment.

126 Where There Is No Dentist 2012

“METH MOUTH”

The drug methamphetamine (also called meth, speed, yabaa, and other names) is used by increasing numbers of people around the world. This very addictive drug is harmful to the brain, the body, and especially the teeth and gums. People who abuse methamphetamine develop “meth mouth,” a condition where most of their teeth are badly decayed and appear stained, blackened, and rotting. If left untreated, these teeth can not be saved.

SIGNS:

•

Dry mouth (xerostomia). Meth use stops the mouth from making saliva which helps to buffer the teeth from sugar and acids in the mouth after eating and drinking. This can cause tooth decay.

•

Many cavities in the teeth from the drug itself and from sugary foods and drinks craved by meth users.

• Gum disease. Meth use shrinks the blood vessels in the mouth, and lack of blood flow causes the gums to break down and prevents the healing of cuts and sores in the mouth.

• Tooth grinding caused by the drug causes cracked teeth and other increased damage and wear to the teeth.

•

Bad oral hygiene, common among meth users.

TREATMENT:

If someone with meth mouth comes to you for care, you can do your best to clean his teeth, fill cavities, and treat for gum disease. But if he continues to use the drug, his teeth will quickly get bad again. The most important thing you can do is help the person get treatment for his drug addiction. The international organization Narcotics Anonymous has programs in more than 131 countries and may be able to help. Find a chapter near you by looking on the internet: www.na.org.

127

CHAPTER 8

Scaling Teeth

Scaling means ‘scraping away.’ You can scale old food, tartar, or even a fish bone caught under the gum. You usually scale teeth to remove tartar.

We get tartar when the coating
of germs on our teeth (page 50)

becomes hard.

Gums that press against tartar
become sore and infected.

Clean teeth keep our gums healthy. Scaling a person’s teeth gives infected gums a chance to become normal again.

However, gums remain healthy only when we keep the teeth beside them clean . If we are not careful about cleaning our teeth after they are scaled, tartar will soon return. Instead of being healthy, the gums will become sore and infected again.

Scale a person’s teeth, but also teach how to keep teeth clean .

You must remove something caught under the gums (page 133) before it causes more pain and swelling. Remove a piece of fish bone or piece of mango string now .

If the person has a mild gum problem (gums that bleed), wait a week or so before scaling. If the person uses this time to clean his teeth better and to rinse with warm salt water (page 7), the gums will improve. The person’s teeth will be easier for you to scale, and he will learn that he can do much by himself to care for the gums.

Use a mirror to show the person gum infection inside his own mouth .

Later he can see the improvement he has made. He can learn about how to keep gums healthy as he follows his own progress.

Scale a person’s teeth only when he really wants to try to keep them clean . If he does not want to clean his teeth, the tartar will soon return. Do not waste your time scaling the teeth of a person who does not want to learn.

127

128 Where There Is No Dentist 2012

THE INSTRUMENTS YOU NEED FOR SCALING

We scale teeth with special instruments called scalers . There are many different kinds of scalers for different teeth, to make scaling easier. It can be a problem to know which ones to buy.

Scalers are expensive instruments. For that reason, it is better to order only a few instruments that you can use to clean most teeth.

You need only 2 double-ended scalers, or 4 single-ended scalers.

For instance:

1 . One with two pointed tips—to remove tartar from the part of the tooth near the gum.

Its proper name is
lvory C -1 scaler.

2 . Another with two blunt, rounded ends—to remove tartar from the part of the tooth under the gum.

Its proper name is

G-11 and 12 curette.

The ends of the scaler are the important parts. One end is bent to the left and the other end is bent to the right, so you can reach more easily around all sides of the tooth.

The blade at each end of the scaler is sharp. You must keep the blade sharp.

A sharp blade can break more of the tartar away than a blunt blade.

You also need these:

Sharpening stone

Mirror

Probe

Tweezers

(Arkansas stone)

(explorer)

(cotton pliers)

Note: When you order an instrument, use both its common and proper name. Then you have a better chance of receiving the instrument you want.

You can also make some of your own instruments. See pages 214-216.

Keep everything in a Scaling Kit .

Where There Is No Dentist 2012 129

HOW TO SCALE TEETH

Tartar starts to form inside the gum pocket. There it builds up, because the gums protect it. So you often must feel rather than see the tartar when you scale a tooth.

You must remove all of the tartar so the gums can heal. New tartar grows faster when there is old tartar Ieft behind for it to build upon .

Lay out what you need ahead of time:

your instruments: scalers, mirror, probe, tweezers sharpening stone
cotton gauze

Your light must be good enough to see the tooth and gums around it clearly.

Scaling teeth requires time and practice. Make yourself and the person comfortable. You can sit next to a special chair that lets the person lean back (see page 75).

The steps in scaling teeth are these (pages 129–133): 1 . Explain to the person what you are going to do.

2 . Feel under the gum for rough spots (tartar).

3 . Place the scaler under the tartar.

4 . Pull the scaler against the side of the tooth.

5 . Check to be sure the tooth is smooth.

6 . Explain what you have done and what the person should now do.

1 . Explain what you are going to do . Tell the person what to expect.

There will be some bleeding and possibly some pain. However, you can stop and rest, or inject local anesthetic, if it is painful. Remember: first wash your hands and your instruments! (See pages 86–89.) 2 . Feel under the gum for tartar . Tartar feels like a rough spot on the root of the tooth. Since tartar can form anywhere inside the gum pocket, feel for it on all sides of the tooth.

You can check for tartar two ways:

a . Use your probe . Slide the point up and down along the root surface under the
gum. Feel for places that are rough.

Teeth without tartar are smooth.

b . Use cotton gauze . Twist a corner and press it between the teeth. The gauze
lowers the gum and soaks up the spit.

You can then see more tartar.

130 Where There Is No Dentist 2012

3 . Place the scaler under the tartar . You must learn two important things: how to hold the scaler and how to slide the scaler into the gum pocket.

Hold the scaler almost as you
would hold a pen. You can
then pull it against the tartar
with both power and control.

Control is very important . The ends
of the scalers are sharp. If you are not
careful, the blades can cut the gums.

Be gentle and do not hurry. Always hold
the tip of the scaler on the tooth to avoid
poking the gums.

Rest your 3rd finger against a tooth. This
will steady your hand and let you slide the
sharp scaler under the gum with care.

FOR AN UPPER TOOTH

FOR A LOWER TOOTH

Where There Is No Dentist 2012 131

The edge of the gum, near the tooth, folds under to form a pocket. This gum pocket goes completely around each tooth. The gum pocket can be shallow or deep. A deep pocket means there has been an infection for a while.

Tartar starts forming deep
inside the gum pocket. If
tartar
you remove tartar that you
can see above the gum,
it is helpful, but not good
gum pocket
enough. You must remove
root fibers
the rest of the tartar, or the
infection will continue. If
bone
part of the tartar stays on
the tooth, the infection will
root
continue.

First, use the pointed-

Then, go back with your
tip scaler to remove
rounded-tip scaler and
the tartar that you
scrape away the
can see.

remaining tartar.

Be careful when you place the rounded end of
the scaler inside the gum pocket .

a) Put the sharp face of the blade
b) You can feel the edge as it goes over
against the tooth. Slide it along the
the rough tartar. Stop when you feel
tooth down into the gum pocket.

the bottom of the gum pocket.

132 Where There Is No Dentist 2012

4 . Hold the end tight against the side of the tooth and pull the scaler .

Try to break free as much tartar as possible at once. It is a bad idea to remove the tartar a bit at a time, because the remaining tartar becomes smooth and harder to scrape away.

1. Tighten your fingers on

2. Pull the scaler with a
the scaler.

firm short stroke.

ALWAYS KEEP THE TIP OF

THE SCALER ON THE TOOTH—

NOT POKING THE GUM.

3. Wipe the end of the

4. Press against the gums to
scaler with cotton gauze.

stop the bleeding.

5 . Check to be sure the tooth is smooth .

With your probe, feel under the gum
for any place that is still rough.

When all the sides of the tooth feel
smooth, move to the next tooth.

Do not hurry. It is more important to take your time and carefully remove all the tartar. If the person has a lot of tartar, scale only half the mouth now. Do the other half on another day, as soon as the person can return.

Finally, make the tooth look clean . Use the sharp edge of either scaler.

Scrape away the dark material on the front and back sides of the tooth.

The tooth itself has not turned dark. It is just a stain. People most often get these stains when
they eat meat, drink tea or smoke tobacco.

You can scrape away this old food and uncover
the white tooth. But remember: the teeth will turn dark again if not cleaned carefully every day.

Where There Is No Dentist 2012 133

6 . Talk to the person about what you have done and what to expect . The gums will be sore for the next few days. That is normal.

Then explain to the person what to do to make the gums strong and tough again.

• Clean your teeth better with a soft brush . Reach with the brush into the gum pocket, and behind your front teeth. That is where tartar collects most often (page 69).

• Clean between your teeth . Use your brush, the stem from a palm leaf, or a piece of strong, thin thread (page 71).

• Rinse your mouth with warm salt water . Start with 4 cups a day, to make the gums strong. Then use 1 cup a day to keep them strong (page 7).

• Eat local foods that give strength to gums . Fresh fruits like guava and oranges, and fresh vegetables with dark green leaves are good for the gums.

REMOVING SOMETHING FROM UNDER THE GUM

If the gum between two teeth is red and swollen, something may be caught inside the gum pocket. Ask what the person has been eating. The object may be a fish bone, mango string, or a sharp piece of tartar.

First try to feel the object with your probe. Then remove it using a scaler or a piece of strong thread.

Use the rounded-tip scaler in the same
way as you would to remove tartar.

Feel the object, go under it gently,
and then lift it out.

OR

Tie a knot in a piece of thread. Then slide
the thread between 2 teeth (page 71).

However, do not move the thread up and
down. Instead, pull it and the knot out
the side. The knot can pull the object out
with it.*

* If the gum has grown into a kind of tumor (epulis), an experienced dental worker should cut it away.

134 Where There Is No Dentist 2012

KEEP YOUR SCALING INSTRUMENTS

SHARP AND CLEAN

A sharp scaler bites into tartar better than a blunt one. Sharpen the edge whenever you feel it sliding over the tartar.

From time to time, feel the cutting edge to be
sure it is sharp.

Scrape it against your fingernail. If the cutting
edge is not able to cut your nail, it will not be
sharp enough to break the tartar free.

Sharpen the cutting edge of the scaler on a fine-grain stone (Arkansas stone). Put a few drops of oil or water on the stone first, so the scaler can slide against it more easily.

Rest your 2nd or 3rd finger against the side
of the stone. This is for control.

Rub the cutting edge against the stone. Move
it back and forth.

Turn the round scaler as you sharpen it. This
helps to keep the scaler’s round shape.

Scalers must be more than clean—they must be sterile. This is because there may be spots of blood on them. Hepatitis (Where There Is No Doctor, page 172) and other diseases can pass from the blood of one person to the blood of another person. To learn how to sterilize, see pages 87 and 88.

Your mirror, probe, and canon tweezers do not need sterilization. A disinfectant (see page 89) will clean them. Dry all the instruments with a towel. Then wrap them inside a clean cloth and put them in your scaling kit.

They are now ready for use whenever you need them again.

Remind each person: scaling is not
a cure. Rather it is a way of giving
her a new start. Only she can give
herself the care she needs to keep
her gums healthy. You have removed
the hard material from her teeth,
and if she brushes carefully, the
tartar will not return!

135

Injecting Inside

CHAPTER 9
the Mouth

It is possible to treat a tooth without pain. You do this with an injection of local anesthetic. You must inject near the nerve, so to give good injections, you must know where the nerves are .

Injecting is a skill that develops with experience. The best way to learn is not from a book, but from a person who has experience giving injections.

Watch an experienced dental worker give injections . That person can then watch you and show you how to inject carefully and safely .

Local anesthetic is an injectable medicine. When it touches a nerve, the tooth joined to that nerve feels numb or dead for about an hour. This usually gives you enough time to take out a strong tooth or to put a cement filling into a deep cavity.

WHAT YOU NEED TO INJECT

There are two kinds of syringes for injecting local anesthetic inside the mouth. One is made of metal and the other is made of glass. The metal syringe uses local anesthetic in a cartridge. The glass syringe uses local anesthetic from a bottle.

DENTAL (METAL) SYRINGE

GLASS SYRINGE

This is a dental syringe. It uses special

This kind of syringe is for injections of
needles, and the local anesthetic is sealed
medicine like penicillin, but you can use
inside a glass cartridge. After injecting,
it in the mouth. Sterilize the syringe and
safely dispose of the needle and the
needles (pages 88 and 138) before and
cartridge. See pages 205 to 206.

after each use. When sterile, the needles
are ready for another person.

Before you inject, be sure
the local anesthetic is able
to come out of the needle.

Use a new needle and a new cartridge of local
anesthetic for each person .

Be careful! Do not touch the needle.

135

136 Where There Is No Dentist 2012

It is safer to use the metal dental syringe but it depends on the local anesthetic you can get. Order needles to fit your particular kind of syringe.

METAL SYRINGE

PLASTIC OR GLASS SYRINGE

Order:

Order:

1 . syringe: aspirating dental cartridge

1 . syringe: standard syringe that
syringe, 1.8 ml (1ml=1cc)

holds around 3 ml (1ml=1 cc)

2 . needles: disposable needles for dental

2 . needles: 24 gauge, long (40 mm
cartridge syringe (27 gauge, long)

x.56 mm or similar)

one box contains 100 needles, each

3 . local anesthetic: 20 ml bottle of
one inside a plastic cover.

lidocaine (lignocaine) 2%

3 . local anesthetic: local anesthetic
or, if not available: order
cartridges for a dental syringe

2 ml ampules of procaine
one sealed tin contains 50 cartridges
hydrochloride 1%.

of lidocaine (lignocaine) 2%.

Note: Lidocaine will keep the teeth numb longer if there is epinephrine in it.

But this is more expensive, and you should not use it on persons with heart problems (see the bottom of the next page).

WHERE TO INJECT

You can deaden a nerve with an
injection of local anesthetic:

1 . near the small nerve branch
going inside the root of a tooth.

2 . near the main nerve trunk before it divides into small branches.

Smaller nerves ‘branch’ off from the main nerve—much like branches of a tree leave its main trunk.

One small nerve then goes to each root of every tooth.

Inject an upper tooth near its roots .

Bone in the upper jaw is soft and spongy.

Local anesthetic placed near the root of
an upper tooth can go inside the bone
and reach its nerve easily.

The same injection also makes the gums
around that side of the tooth numb.

Where There Is No Dentist 2012 137

It is more difficult to inject the lower teeth .

The lower jaw bone is thicker. When you inject near the roots of a lower tooth, the anesthetic is not able to reach its nerve as easily.

Note: You can inject lower front teeth in young children, or very loose lower
nerve (a)

front teeth in adults, near their roots.

enters
jawbone here

To make a lower tooth
completely numb, you must
nerve (a)

block the main nerve (a) before
it goes inside the jaw bone.

nerve (b)

goes to 3

If you are treating a back
back teeth
tooth, you must give a
second injection for nerve (b).

These 2 injections also make the

See page 140.

gums around the teeth numb.

WHEN TO INJECT

Inject local anesthetic whenever the treatment you give may hurt the person. If, after you inject, the person says the tooth still hurts, be kind. Stop and inject again.

Inject local anesthetic slowly and carefully .

You can then treat a bad tooth and not hurt the person .

HOW TO INJECT*

For a good, safe injection, remember these 5
things!

1 . Do not inject local anesthetic
into an area that is swollen .

This can spread the infection.

swelling

Also, pus inside the swelling
stops the local anesthetic from
working properly.

Instead, treat the swelling first (page 94) and take out the tooth later.

2 . If the person has a heart problem, do not inject more than 2 times in one visit . Also, it is best not to use an anesthetic with epinephrine on persons with heart problems. Use lidocaine only, or mepivacaine 3% only.

* Local anesthetics are the only injections given in the mouth. To learn about injecting antibiotics, see page 210.

138 Where There Is No Dentist 2012

3 . Before you push the needle under the skin, be sure its pointed end is facing in the correct direction .

The local
anesthetic must
come out against
the bone, where
the nerve is.

YES

NO

4 . Before you inject the local anesthetic, wait a moment to see if any blood enters the syringe . ( Note: only an aspirating syringe will do this.) blood

Pull back on the plunger. If
blood comes inside, it means
you have poked a blood vessel.

Pull the needle part way out
and gently move it over to a
different place.

If you inject local anesthetic into the blood vessel, there will be more swelling afterward, and the person may faint. If the person faints:

• Lie him on his back.

• Loosen his shirt collar.

• Lift his legs so they are higher than his head.

5 . Be sure your syringe and needles are clean and sterile (see pages 86
to 91). Do not pass an infection from one person to another by using dirty needles.

FOR GLASS SYRINGES:

Boil the syringe and needle in water (page 88)

for at least 30 minutes in a covered pot . It is also a good practice to boil your metal syringe.

FOR METAL SYRINGES:

• Use a new cartridge for each person who
needs an injection . Do not use local anesthetic from a cartridge that you have used on another person.

• Use each disposable needle only 1 time and then throw it away in a box like the one on pages 205 to 206. If you must reuse a needle, replace the cap very carefully and put the needle in a safe place (such as a pan of bleach solution) until you are ready to clean and sterilize it (see pages 87–88).

Where There Is No Dentist 2012 139

Injecting the Upper Teeth

Inject local anesthetic near the root of
the tooth you want to treat.

Front teeth have one root. Back teeth
have more than one.

For a tooth to become completely numb,
the local anesthetic must touch the small
nerve going to each one of its roots.

1 . First decide where to inject .

Lift the lip or cheek. See the
line that forms when it joins
the gum.

The needle enters at the
line where the lip or cheek
meets the gum .

2 . Push the needle in, aiming
at the root of the tooth. Stop
when the needle hits bone.

Inject about 1 ml of local
anesthetic (½ of a cartridge).

Pull the needle part way out
and move it over to the next
root. Inject again.

If the tooth is to be taken out, leave .25 ml for the next step.

3 . If you are taking out a tooth, also inject the gums on the inside .

Ask the person to open wide. Inject the remaining
anesthetic (.25 ml) directly behind the back tooth that must come out.

One injection can numb
the gum behind the

6 front teeth. Inject into
the lump of gum behind
the middle front teeth.

( Note: This injection hurts! It may help to use

‘pressure anesthesia.’ See page 141.)

4 . Wait 5 minutes for the tooth to become numb.

140 Where There Is No Dentist 2012

Injecting the Lower Teeth

When you block the nerve, it affects all of the teeth as well as gums on that side. However, it takes practice to do this successfully. Ask an experienced dental worker to help you learn how to give this injection properly .

Stand in such a way that you can see clearly where you need to inject. Ask the person to open wide.

1 . First feel for the place to be injected .

Put your thumb beside the last molar tooth. (Wash your hands first!

See page 86.) Feel the jawbone as it turns up towards the head. Rest your thumb in the depression there.

2 . Press against the skin with the end of your thumb .

The skin forms a ‘v’ shape. Your needle must go into the ‘v’.

Hold the syringe on top of tooth
number 4 and aim the needle at the ‘v’.

Push the needle in until it hits the
jawbone, (about ¾ of the length of a
long needle). Pull back on the plunger
of the aspirating syringe to check for
blood (page 138).

Inject 1.5 ml of local anesthetic (¾ of a cartridge).

Try to feel your way: If you hit bone too early, pull the needle part way out and move it over so that it points more toward the back of the mouth. Try again.

If you do not hit bone, the needle is too far back. Pull it part way out, and point it more toward the front. Push it in again.

Where There Is No Dentist 2012 141

3 . Give a second injection BESIDE the back teeth .

If you are going to fill or remove a
back tooth, inject beside that tooth,
where the cheek joins the gum.

Inject .5 ml of local anesthetic

(¼ of a cartridge).

This injection is not needed for front
teeth . It is enough to block the main nerve.

4 . Wait 5 minutes for the tooth to become numb.

Take time with children

1 . Put some topical anesthetic on the
gum before you inject. But be sure
the gums are dry in that place. If you
wipe the gum with cotton, the topical
anesthetic will stay on longer. Give
the anesthetic time to work: wait a
minute before injecting.

If you do not have topical
anesthetic, try using pressure.

You can use ‘pressure anesthesia’

whenever you have to give an
injection in a sensitive place, like the
roof of the mouth.

Wind some cotton around the end
of a match-stick. Press firmly for
a minute behind the bad, tooth. Then inject quickly into the depression that formed where you pressed.

2 . Be sure the anesthetic is warm when you inject it. Hold the cartridge or bottle in your hands for a few minutes before you use it.

3 . Use a new, sharp needle.

4 . Have someone pass you the syringe out of sight of the child. Then the child will not have to look at it and be frightened.

5 . Be ready to stop the child from grabbing the syringe.

6 . Inject the anesthetic slowly. Do not hurry. A too-quick injection can cause sudden pressure, which hurts and frightens the child.

142 Where There Is No Dentist 2012

AFTER YOU GIVE AN INJECTION

Before you begin treatment, test the tooth and gums to be sure that they are numb. Wait 5 minutes for the anesthetic to start working. Ask the person how his lips feel—they should feel ‘heavy’ or numb. Then test the area.

Poke the gums between the teeth
with a clean probe.

Watch the person’s eyes—you will
see if you are hurting. If the person
still feels pain, stop. Think about your
injection technique, and inject again.

After you finish treatment, always talk to the person about what you have done. Tell the person what to expect, and how to be careful with the numb area of the mouth:

• The area will feel normal again in about 1 hour.

• Do not bite or scratch the area while there is no feeling.

• Do not drink anything hot. It can burn the skin inside the mouth.

With a child, always place a ball of cotton between the teeth on the side where you injected. The child should leave it there for 2 hours, until the area feels normal again. Explain this to the mother, and give her a bit of extra cotton to take home. It is much better for the child to chew cotton instead of the numb lip or cheek!

Try not to hurt anyone . You can treat a bad tooth easier, faster, and without pain if you inject local anesthetic slowly and carefully into the right place .

143

1

CHAPTER

0

How to Fill a Cavity

When someone’s tooth hurts, you do not always need to take it out. There may be a way to treat it and keep it. Always ask yourself whether a bad tooth really needs to come out.

This chapter is about filling cavities. Cavities are the holes that tooth decay makes in the teeth.

From this chapter, you can learn:

• When to fill the cavity, or when
to take out the tooth.

• How to place a temporary
cement filling.

• How to place a permanent filling
using Atraumatic Restorative

Treatment (ART).

WHEN NOT TO PLACE A FILLING

Do not fill a cavity if you think there is an abscess in the tooth . Look for these signs of an abscess:

• The face is swollen.

• There is a gum bubble near the
root of the tooth (page 74).

• The tooth hurts constantly, even
when the person tries to sleep.

• The tooth hurts sharply when you tap it gently.

An abscess occurs when germs from tooth decay start an infection on the inside of the tooth. If you cover up an abscess with filling material, it will make the problem worse. Pressure builds up inside the filled tooth, causing even more pain and swelling.

If a tooth has an abscess, take it out (see the next chapter), unless you can give special nerve treatment (root canal treatment).

143

144 Where There Is No Dentist 2012

WHEN TO PLACE A FILLING

You can fill a cavity if the tooth does not have an abscess . There is probably not yet an abscess if:

• there is no swelling of the face or gums
near the bad tooth.

• the tooth hurts only once in a while —
for example, if it hurts only when eating
or drinking something cold or sweet, or
when breathing cold air.

• the tooth feels the same as the others
when you tap it gently.

These signs mean that the decay is deep
enough for the nerve to feel temperature
changes, but not near enough to the nerve to be infected. So there is not an abscess . You can save the tooth by filling the cavity as soon as possible .

WHAT A FILLING CAN DO

A filling can help a person in three ways:

• It stops food, air, and water from entering the cavity. This will stop much discomfort and pain.

• It stops the decay from growing deeper. This can prevent a tooth abscess.

• It can help save the tooth, so the person can use it for many more years.

TWO KINDS OF FILLINGS

A permanent filling is made to last for many years. A dental worker trained in Atraumatic Restorative Treatment (ART) can fill the cavity with a sticky material called glass-ionomer. (See pages 152–155 for how to do ART.) Or an experienced dental worker can shape the cavity with a dental drill and fill it with a combination of materials called amalgam or composite (see pages 156–157).

A cement filling is a temporary filling meant to last only for a few months.

It helps the person feel more comfortable until it is possible to get a permanent filling.

Replace a temporary filling with
a permanent filling as soon as possible .

Where There Is No Dentist 2012 145

This chapter shows how to place cement fillings first, and then explains how to place permanent fillings using ART. It does not explain how to use a dental drill because most readers do not have the expensive equipment needed. Remember that many people can benefit from the extra time that a temporary filling gives them before they get a permanent filling.

A cement filling is often the first step to saving a tooth .

THE INSTRUMENTS AND FILLING MATERIAL YOU

NEED FOR CEMENT FILLINGS

In many places, government medical stores can provide most of the instruments as well as cement filling material. If this is not possible, a dentist may be able to help you to order what you need.

Instruments

Most dental instruments look alike, but the small end of each instrument is shaped to do a special task. Try to get instruments similar to these and keep them in a kit.

OR
mirror
probe
tweezers
spoon
filling tool
mixing tool

(explorer)

(cotton pliers)

(spoon excavator)

(filling

(wooden

(metal or
instrument)

spatula),
plastic
for cement spatula),
only
for cement

Some instruments have more than one name.

or ART

The second one, in parentheses ( ), is the proper
name. Use the proper name when you order.

146 Where There Is No Dentist 2012

Cement Filling Material

Many companies make temporary filling material. The names on the packages are different. This makes it hard to know which one to order.

However, the basic material of each product is the same—zinc oxide and oil of cloves (eugenol). To save money, order these two main ingredients in bulk, instead of an expensive kind of dental cement filling material.

Oil of cloves is a liquid.

Zinc oxide is a powder.

You may be able to buy a special kind of zinc oxide powder called I .R .M .

(Intermediate Restorative Material). Fillings with I.R.M. are stronger and harder, so they last longer. But it is more expensive than zinc oxide and eugenol.

HOW TO PLACE THE CEMENT FILLING

Lay out on a clean cloth:

your syringe, needle,
oil of cloves
and local anesthetic

(eugenol) and

(in case a tooth hurts)

zinc oxide
your instruments:

lots of cotton:

mirror, probe,
cotton rolls,
tweezers, spoon,
gauze, or
filling tool,
cotton wool
mixing tool
smooth glass to
mix cement

To place a cement filling, follow these 5 steps (pages 147–150): 1 . Keep the cavity dry.

2 . Lift out the soft decay.

3 . Mix the cement.

4 . Press the cement into the cavity.

5 . Remove the extra cement from around the cavity and the tooth.

Where There Is No Dentist 2012 147

1 . Keep the cavity dry . The cavity and the area around it must be dry so you can see what you are doing. Just as important, cement stays longer inside a dry cavity .

Place cotton between the cheek and
gums to keep the area dry. Put some
cotton under the tongue when you
work on a lower tooth.

Use whatever kind of cotton you
have: gauze, wool, or even rolls.

Change the cotton whenever it
becomes wet .

Keep the cavity dry while you work.

Wipe the inside of it every now and
then with a bit of cotton.

Then leave a piece of cotton inside
the cavity while you mix the cement.

2 . Lift out the decay . You do not need to remove all of the decay on the bottom of the cavity. If you try to clean out all of the decay, you might touch the nerve.

However, you must remove all of the decay from the edges of the cavity . Otherwise, germs and food can go between the cement and the cavity and keep the decay growing inside. For ART

(pages 152–155), it is especially important to remove all the decay from the edges so the filling will stick well.

Use the spoon tool to scrape clean
the walls and the edge of the cavity.

If you find that the part of the tooth at
the edge of the cavity is thin and
weak, break it deliberately. That
makes for stronger sides to hold
onto the cement. You can use the
end of your filling tool to break
the edge but it is much easier with a dental hatchet, which is less likely to bend.

Use the spoon tool to lift out soft decay from inside the cavity. Be careful not to go too deep and touch the nerve at the very bottom of the cavity. This
takes practice. If the tooth hurts when you do this, stop and inject some local anesthetic.

148 Where There Is No Dentist 2012

Use cotton gauze to collect the bits of decay so that the person does not swallow them. Use your mirror and look closely around the edges of the cavity for any decay that you may have missed. Put some cotton inside the cavity and leave it there to keep the area clean and dry while you mix the filling.

3 . Mix the cement on a piece of smooth glass. Place separately onto the glass a pile of zinc oxide powder and a few drops of eugenol liquid.

Pull a small amount of the powder to the liquid with the mixing tool and mix them together. Add more powder in this way, until the cement mixture becomes thick.

Suggestion: Practice mixing the cement ahead of time.

You can then find out the time it takes to become hard.

Cement is much easier to use when it is
thick and not too sticky . Roll a bit between your fingers. If the cement sticks, it is not yet
ready. Add more powder and then test again.

Now take the cotton out of the cavity. Check to
be sure the cavity is dry. If the cotton around
the tooth is wet, change it.

Where There Is No Dentist 2012 149

4 . Press some cement into the cavity . Put a small ball of cement on the end of your filling tool. Carry it to the cavity. Spread it over the floor of the cavity and into the corners.

Then add another ball of cement, pressing it against the other cement and against the sides of the cavity.

REMEMBER: Decay stops growing only when the
cement covers it completely and tightly .

Keep adding cement until the cavity is over-filled. Smooth the extra cement against the edge of the cavity.

If a cavity goes down between two teeth, one other step is necessary. You need to take care that the cement does not squeeze and hurt the gum.

Before you spread
the cement, place
something thin
between the teeth.

before
after

You can use the soft stem from
a palm leaf, a toothpick, or a
tooth from a comb. Be sure it
has a rounded end to prevent
damage to the gums.

150 Where There Is No Dentist 2012

5 . Remove the extra cement before it gets too hard . Press the flat side of the filling tool against the cement and smooth it towards the edge of the cavity.

As you smooth the cement, shape it to look like the top of a normal tooth. This way, the tooth above or below it can
fit against the filling without breaking it.

After you take out the stem or toothpick, smooth
the cement (p.149). Gums are easier to clean,
and stay healthier, when the cement beside
them is smooth .

Cement that sticks out and is not smooth can
hurt the gums. It can also later break off. When
that happens, spit and germs are able to go
inside and start the decay growing again.

It is also important to look closely around the tooth for loose pieces of cement and to remove them before they make the gums sore .

Use the end of your probe. Gently
reach into the gum pocket and lift
out any pieces of cement caught
there.

Wipe off your probe with cotton
gauze each time.

Now remove all the cotton and ask the person to gently close the teeth. The teeth should come together normally and not hit first against the cement filling. Too much pressure against the cement filling will crack and break it .

Always check to see if part of the filling is high: (1) lf the cement is still wet, you can see the smooth place where the opposite tooth
bit into it. Scrape the cement away from
this place.

(2) If the cement is dry, have the person bite on If you do not have carbon a piece of carbon paper. If there is too much paper, darken some paper cement, the carbon paper will darken the
with a pencil.

cement. Scrape away that extra cement.

The person must not leave your clinic until the filled tooth fits properly against the other teeth .

Where There Is No Dentist 2012 151

AFTER YOU FINISH PLACING THE FILLING

Explain to the person how to take care of the filling so it will not break:

• Do not eat or drink anything for 1 hour—let the filling get hard and strong.

• Try not to use that tooth for biting or chewing after getting a cement filling. Until there is a permanent filling, the cement and sides of the cavity are weak. They cannot take much pressure.

If the tooth hurts more after you place the filling, there is probably an abscess. Take out the tooth. If you cannot take out the tooth immediately because of swelling, take out the filling to relieve the pressure, and take out the tooth after you treat the swelling (page 93).

Clean your instruments after you finish .

First scrape the dried filling from the tools. Then, after you scrub them with soap and water, leave them for 20 minutes in disinfectant (see page 89).

Finally wrap the instruments together in a clean cloth so they are ready for use when you need them again.

REMEMBER: A cement filling is only a temporary measure .

A good one can last up to 6 months. During this
time, the person must see a dental worker who has
the equipment to put in a permanent filling using

ART (see the next page) or a dental drill. For this, the person may have to travel to a dental clinic, or wait for a dental worker to visit your area.

152 Where There Is No Dentist 2012

HOW TO PLACE A PERMANENT FILLING

USING ART

Atraumatic Restorative Treatment (ART) is a way to place a permanent filling without using an expensive dental drill. This method was invented in Tanzania, East Africa, and it is now being used by dental workers in many parts of the world.

The process for placing a permanent filling using ART is similar to placing a temporary cement filling, but instead of cement you use a sticky material called glass ionomer. Once glass ionomer is in the cavity, it releases fluoride (page 226) and helps prevent new cavities from forming.

THE INSTRUMENTS AND FILLING MATERIAL YOU NEED FOR ART

The dental instruments you need for ART are the same as the ones for cement fillings shown on page 145. You will also need petroleum jelly (such as Vaseline) and a material called glass ionomer. Glass ionomer comes in “low viscosity,” “medium viscosity,” and “high viscosity” forms (“viscosity” means ‘thickness’). High viscosity glass ionomer works best for ART because it is the strongest and lasts
for a long time.

Glass ionomer is expensive, but
sometimes local governments will provide
it at lower cost. A package of glass
ionomer usually comes with a bottle of
liquid and a bottle of powder that you mix
together for ART.

It is important to store glass ionomer in a cool place.

To place a filling using ART, follow these 6 steps: 1 . Keep the cavity dry (see page 147). This is especially important in ART because the glass ionomer sticks much better to a dry cavity.

2 . Lift out the soft decay (see page 147).

3 . Clean the cavity (see page 153).

4 . Mix the glass ionomer just before using it (see page 154).

5 . Right away, fill the cavity with the glass ionomer (see page 154).

6 . Remove any extra glass ionomer from the tooth before it gets too hard (see page 155).

Where There Is No Dentist 2012 153

Follow steps 1 and 2 on pages 147 to 148 . Then return here for steps 3 to 6 .

3 . Clean the cavity . After you have
removed the decay, clean the cavity so
that the glass ionomer will stick well.

The best way to do this is with the liquid
from the glass ionomer.

Put one drop of glass ionomer liquid
on the glass slab. Using the tweezers,
pick up a piece of cotton, dampen
it in water, then dip it into the glass

Be sure that the glass ionomer
ionomer liquid. Use the cotton to
liquid you are using has acid
clean the cavity.

in it and is not just water. If
your glass ionomer liquid is

Use another piece of cotton dipped only
just water, clean the cavity
in water to wash the cavity out. Use
with polyacrylic acid or cavity
a new piece of cotton to wipe out the
conditioner instead.

cavity and dry it.

Put a piece of cotton inside the cavity while you mix the glass ionomer. This will keep the cavity dry.

If a cavity goes down between two teeth, one other step is necessary.

You need to take care that the glass ionomer does not stick to the other tooth or squeeze and hurt the gum.

Before you mix the glass ionomer, place something thin between the teeth such as the soft stem from a palm leaf, a toothpick, or a tooth from a comb. A small strip of tin foil or a strip of plastic cut from a plastic bottle will also work. Be sure it has a rounded edge to prevent damage to the gums.

before
after

154 Where There Is No Dentist 2012

4 . Mix the glass ionomer on a piece of smooth glass just before using it.

The package of glass ionomer should have a bottle of liquid, a bottle of powder, a measuring scoop, and instructions for how much to use of each. Place a level scoop of the powder onto the glass, then close the powder bottle right away.

Put a drop of liquid separately on the glass. It is important for this liquid to have no air bubbles, so if your first drop has bubbles, keep holding the bottle upside down and place a second drop somewhere else on the glass to use for mixing.

Spread the liquid around a little, pull half of the powder to the liquid with the mixing tool, and mix them together quickly but carefully.

Add more powder until you have used the full amount instructed. It is important to mix in all the powder and not add extra liquid so the filling is strong. The mixture should become thick and smooth like chewing gum.

Some dental
workers
use the first
drop with
air bubbles
to clean the
cavity for
step 3.

Now, take the cotton out from inside the cavity. Check to be sure the cavity is dry. If the cotton around the tooth is wet, change it.

5 . Fill the cavity with the glass ionomer right away. Use your filling tool to carry a small amount of the glass ionomer mixture to the cavity.

Carefully press the mixture against the sides of the cavity. Then add more glass ionomer to fill the center of the cavity.

Where There Is No Dentist 2012 155

Keep adding glass ionomer

Remove your
until the cavity is over-filled.

finger carefully

Put extra glass ionomer in any
from the side
other pits on the surface of
so you do not
the tooth near the cavity. Rub
lift out the
filling.

petroleum jelly on your finger
and press down firmly onto the
filling for a few seconds, rolling
your finger from side to side.

This will make the filling smooth.

6 . Remove extra glass ionomer from the tooth before it gets too hard . Use the spoon tool or the filling tool to quickly and carefully remove any loose pieces of glass ionomer.

Let the glass ionomer harden for less than 1 minute, then ask the person to gently close the teeth. The teeth should come together normally and not hit first against the filling.

Check to see if part of the filling is too high
by having the person bite on a piece of
carbon paper. If there is too much filling, the
carbon paper will darken it. Scrape away the
extra filling from that place using the filling

If you do not have carbon
paper, darken some paper
tool and check again.

with a pencil.

The person must not leave your clinic until the filled tooth fits properly against the other teeth .

Once the teeth fit together, spread petroleum jelly over the filling with your finger. Petroleum jelly will protect the filling from water and saliva for at least an hour while the filling fully hardens. Take out all the cotton.

After you have finished placing the filling, explain to the person how to take care of it, and clean your instruments. See page 151.

156 Where There Is No Dentist 2012

PERMANENT FILLINGS USING A DENTAL DRILL

This chapter has shown how to place a temporary filling with cement and a permanent filling with ART. This book does not give full instructions for placing permanent fillings with a dental drill, but if you have been trained to use a dental drill, see pages 217 and 221-222 for ideas about getting equipment and resources.

Some Simple Dental Drills

We use a dental drill to remove all
decay from a cavity and to change
the shape of the hole in the tooth
so it can firmly hold the permanent
filling material. The most expensive
drills use electricity, but some drills
are powered by people instead of
electricity.

In India and Guatemala, health
workers use a foot treadle to power
a drill, the same way they operate a
sewing machine. This kind of drill is

Village dental workers in the mountains
slower than a compressed-air drill,
of western Mexico use bicycle power to
and the grinding produces a lot of
make compressed air, which runs a high
heat, so one must take care not to
speed drill.

let the tooth get so hot that it kills

Local young people or family members
the nerves (see page 157). Still, this
volunteer to pump the air while they
is one of the simplest and cheapest
wait to have their own teeth fixed.

ways to place a permanent filling.

Where There Is No Dentist 2012 157

How a Dental Drill Works

Even if you have the equipment, it is essential that you learn how to make permanent fillings from a person who has experience using a dental drill .

The tip of the drill (drill bit) is
sharp. Some drills spray water on
the tooth to keep it cool. Cooling
is especially important with a
slower treadle-powered drill. An
assistant can spray water on the
tooth if the drill does not have a
sprayer.

As the drill bit moves slowly back and forth, it opens the cavity further. This makes it easier to see all of the decay. The decay is later removed with a spoon instrument (page145).

The drill bit also changes the shape of the cavity. The hole in the tooth is shaped so that it will keep the permanent filling material in place.

The filling material, which is made
of metal or plastic, must be very
strong. It must not break apart
when the person chews food or
when saliva washes over it.

Unfortunately, the best kinds of
filling material often require special
instruments to prepare and place
them in the cavity.

Where There Is No Dentist 2012

159

CHAPTER 11

Taking Out a Tooth

Not every painful tooth needs to come out. You must decide how serious the problem is, and then decide if you can treat and save the tooth. Some problems—such as root canal treatment for a tooth with an abscess, or wiring for a loose tooth—require the skills of an experienced dental worker.

Even if you cannot treat every person, a more experienced worker can help you by taking care of the more difficult tooth problems.

Remove a tooth only when it is necessary. Here are three reasons to take out a tooth:

• It hurts all the time or hurts enough to wake the person at night.

• It is loose and hurts when you move it.

• It has a broken root (p. 96) or a broken top with an exposed nerve.

It is important to learn from another person, not just from a book. Find an experienced dental worker who can show you how to take out a tooth and who can then watch you as you try it yourself.

Before You Begin: Ask Questions!

Before you take out a tooth, you need to learn about the person’s health.

Tell the person what to expect, and then ask:

• Do you bleed a lot when your skin is cut? (If so, you may bleed a lot when your tooth comes out.)

• Do you have swollen feet and difficulty breathing? (You may have heart disease.)

• Do you have any allergies? (You may be allergic to some medicines we give when we take out a tooth.)

• Are you a diabetic? (If you have diabetes, your wound will take a long time to heal.)

• Are you pregnant? (Some problems can be treated during pregnancy, but sometimes it is better to wait. See pages 15–16, 77, 102, and 160.)

If the person answers “yes” to any of these questions, you must take special precautions. See the next page.

159

160 Where There Is No Dentist 2012
fIvE PROBLEMS TO WATCH fOR

1. A person who bleeds a lot must know how to prevent bleeding afterward.

Explain very carefully the steps given on page 167. You may also want to place a suture (pages 167-168) to hold the gums tightly together.

2. Persons with heart disease often take aspirin or medicines called anticoagulants that do not allow the blood to clot normally. Ask what medicine the person takes. Heparin and warfarin are examples of anticoagulants. Another heart medicine, digitalis, is not an anticoagulant. If the medicine is not an anticoagulant, you can take out the tooth. But do not use more than 2 cartridges of local anesthetic. The epinephrine inside the anesthetic can harm a weak heart. (See page 137, #2).

3. A person with allergies may be allergic to aspirin, penicillin, erythromycin, or other medicines you often use. find out which medicine has caused problems and give a different medicine, one that will not cause a reaction.

4. A diabetic’s wound may become infected. Watch carefully the place where you took out the tooth and give antibiotics (page 94) if an infection begins.

5. During the last month of pregnancy, a woman may be too uncomfortable to have a tooth taken out. Control the infection with a 5-day course of penicillin (page 94), and take out the tooth after the baby is born. It is also better to wait if the woman has high blood pressure, because she may bleed too much when you take out the tooth. for more information about treating pregnant women, see page 77, and the story on pages 15 to 16.

Be Patient, Careful, and Considerate

• Inject local anesthetic slowly in the right place, so the tooth becomes numb and you do not hurt the person when you remove it. If the person says the tooth still hurts, it is probably true! Inject again.

• Use the correct instrument in the correct way. If you are careful you can avoid breaking the tooth. When you take out a baby tooth, be extra careful not to hurt the new tooth growing under it.

• Explain everything to the person. Tell the person if something is going to hurt, even a little. When you take out the tooth, you can explain, for example, that there will be a feeling of pressure. Press on the person’s arm to demonstrate what it will be like. When you finish taking out the tooth, explain what you have done and what the person can do at home to help the mouth heal.

THE INSTRUMENTS YOU NEED

Buying instruments can be confusing, because there are so many. Only a few of them are really necessary. You can take out most teeth with the 4 basic instruments on page 161.

Where There Is No Dentist 2012 161

When you order, use the proper name. Many companies use numbers to describe the instruments, but a different company may use a different number. If you use the proper name along with the number given here, most companies will understand what you want. (See page 213.) The Four Basic Instruments

You can take out most teeth with these 4 instruments: A spoon or probe…

… an elevator…

… and two forceps

150
upper universal forcep

151
lower universal forcep

Use this to

An elevator will

Use forceps to pull out the
separate the gum
loosen a tooth, or lift
tooth. There is one for upper
from the tooth.

out a broken root.

teeth and one for lower teeth.

Other forceps can be useful, especially for taking out a strong back tooth.

They have pointed beaks that are made to fit between the roots of a back molar. As a result, you can hold onto the larger tooth better.

87

‘cowhorn’

forcep

73
lower molar

‘hawk’s bill’

forcep

18R

18L left
right
upper
upper
molar
molar
forcep
forcep

162 Where There Is No Dentist 2012

Curved elevators are good for taking out broken roots. You can force their pointed ends more easily between the root and the bone that is holding it.

30

31

Cryers elevators

Unfortunately, forceps and elevators are expensive. If you want to order more than the 4 basic instruments (page 161), remember the cost.

WHERE YOU WORK IS IMPORTANT

Work wherever it is light and bright. You must be able to see what needs to be done. Sunlight or light from a lamp is usually enough. Use a dental mirror (page 145) to direct more light into the mouth.

Use a chair that has a back high enough to support the person’s head.

Think about how you can stand and work the most easily.

To take out a lower tooth, you need to

To take out an upper tooth, you need to
push down and then pull up.

push up and then pull down.

So the person should be sitting

So the person should be
down low.

sitting up high.

If you stand on a box, he will be lower.

If he sits on cushions, he will be higher.

Where There Is No Dentist 2012 163

HOW TO TAKE OUT THE TOOTH

Once you are certain which tooth must come out, decide which instruments you will need. Lay them out ahead of time on a clean cloth: a syringe,
needle, and
local anesthetic
forceps
an elevator
cotton gauze
spoon instrument

Before you touch your instruments, be sure your hands are clean. Wash with soap and water, and put on clean plastic or rubber gloves. See pages 85 and 86.

Be sure, also, that your instruments are clean. See pages 87 to 90. Prevent infection—keep clean!

To take out a tooth, follow these

8 steps (pages 163–170):

1. Explain what you are going to do.

2. Inject local anesthetic.

3. Separate the gum from the tooth.

4. Loosen the tooth.

5. Take out the tooth.

6. Stop the bleeding.

7. Explain to the person what to do at
home to look after the wound.

8. Help the person to replace the tooth
with a false tooth.

1. Always begin by talking to the person. Explain why you must take out a tooth (or teeth) and tell how many teeth you will take out. Begin working only when the person understands and agrees.

2. Inject some local anesthetic slowly, in the right place. Remember from Chapter 9 that the injection for a lower tooth is different from the injection for an upper tooth.

Wait 5 minutes for the anesthetic to work, and then test to be sure the tooth is numb. Be kind—always test before you start. If the person still feels pain, give another injection.

164 Where There Is No Dentist 2012

3. Separate the gum from the tooth.

The gum is attached to the tooth inside

Use this
the gum pocket. Separate the gum and
tooth before you take out the tooth. If
you do not, the gum may tear when
or this
the tooth comes out. Torn gums bleed
more and take longer to heal.

Slide the end of the instrument along the
side of the tooth into the gum pocket. At the
deepest part of the pocket, you can feel the

Front Side
place where the gum attaches to the tooth.

Push the instrument between this
attached part and the tooth. Then
separate the tooth from the gum by
moving the instrument back and forth.

Do this on both the cheek side (outside)

Back Side
and the tongue side (inside) of the tooth.

The attached gum is strong, but it is also thin. Control your instrument carefully so that it only cuts through the part that is attached to the tooth. Do not go any deeper.

4. Loosen the tooth. A loose tooth is less likely to break when you take it out. Before you take out a strong tooth, always loosen it first with a straight elevator.

Caution: if you do not use it properly, a straight elevator can cause more harm than good.

It is important to hold a straight elevator properly.

Place your first finger against the next tooth while you turn the handle. This will control it.

Remember that the sharp blade can slip and hurt the gums or tongue.

The blade goes between the bad tooth and
the good one in front of it. Put the
curved face of the blade against
the tooth you are removing.

Slide the blade down the side
of the tooth, as far as possible
under the gum.

Turn the handle so that the
blade moves the top of the

Put pressure on the bone, not the tooth
bad tooth backward.

beside it. Do not loosen the good tooth!

Where There Is No Dentist 2012 165

5. Now, take out the tooth. Push your forceps as far up the tooth as possible. The beaks of the forceps must hold onto the root under the gum.

YES

NO

Use your other hand to support the bone around the tooth. Your fingers will feel the bone expanding a little at a
time as the tooth comes free.

With practice, you will be
able to decide how much
movement the tooth can
take without breaking.

To decide which way
to move a tooth,
think about how
many roots it has.

If a tooth has 1 root, you can turn it.

If a tooth has 2 or 3 roots,
you need to tip it back and forth.

Take your time. If you hurry and squeeze your
forceps too tightly, you can break a tooth.

Removing a tooth is like pulling a post out of the ground. When you move it back and forth a little more each time, it soon becomes loose enough to come out.

166 Where There Is No Dentist 2012

Front teeth come

Back teeth usually come
straight out
out toward the cheek

When you remove lower molars with the lower molar ‘cow-horn’ forcep, you use it in a different way:

• fit the points under the gum,
between the tooth’s roots.

• Squeeze the handles gently
and move them up and down,
then side to side. This will force
the points of the forcep further
between the roots and lift the
tooth up and out.

Note: some lower molars come out
toward the tongue.

WARNINg: Do not use the

‘cowhorn’ forcep to take out a baby
molar. Its points can damage the
permanent tooth growing under it.

When the tooth comes out, look carefully at its roots to see if you have broken any part off and left it behind. Whenever possible, take out broken roots so that they do not cause infection Iater inside the bone.

Where There Is No Dentist 2012 167

6. Stop the bleeding. Squeeze the sides of the socket (the hole that is left after you take out the tooth) back into place. Then cover the socket with cotton gauze and ask the person to bite firmly against it for 30 minutes. A child should bite firmly on the gauze for 2 hours. See page 142.

Whenever the gums are loose, join them together. To stop the bleeding and heal the wound, you must hold the gums tightly against the bone under them.

HOW TO PLACE A SUTURE

When you remove 2 or more teeth in a row, it is a good idea to join the gums with a suture (needle and thread). If you need more than one suture, place the first one nearest the front of the mouth and work toward the back.

The needle and thread you use must be sterile.

Boil both for 30 minutes. See page 88.

You will need an instrument to hold the needle firmly (hemostat) and scissors to cut the thread.

a) Pass the needle through the loose gum—the one you can move most easily. Then pass it through the more firmly attached gum.

If the looser gum is on the outside,
you will bring the needle toward the
tongue. Protect the tongue with a
tongue blade or your dental mirror.

You must suture both the upper and
the lower gums in this way.

After this you must tie 2 knots and cut
the thread. See the next page.

168 Where There Is No Dentist 2012
b) Pull the thread until about 4 cm of thread is left loose on the starting side.

Wrap the longer end of thread 2 times
around the beaks of the needle holder.

Then grab the shorter free end of the
thread with the tip of the needle holder.

With the needle in your fingers, pull the
needle holder in the opposite direction.

The thread will slide off the beaks and
form the first knot.

Tighten the knot onto the side of the wound, not on top of it.

c) Tie a second knot, to keep the first one tight.

Wrap the thread once around the beaks of
the needle holder.

Grab the free end with the tip of the
needle holder as you did before. Pull the

2 ends in opposite directions. The second
knot will form over the first knot.

d) Cut the threads so that about .5 cm is left free. If the ends are too long, they will bother the person’s tongue. If they are too short, the knot may come open.

Then cover the area with cotton gauze.

Tell the person to:

• bite against the cotton for 1 hour
to stop the bleeding, and

• return in 1 week for you to
remove the thread.

There is a special kind of suture material that disappears by itself, which is good to use because the person does not have to return for you to remove sutures. Unfortunately, it is expensive. If you cannot afford it, use sewing thread and remove it 1 week later.

Where There Is No Dentist 2012 169

7. Explain to the person what you have done, and what to do at home to look after the wound. Remember that her mouth is numb, so she cannot feel what is happening.

Taking out a tooth is like a small operation. There will be bleeding and later some pain and swelling. This is normal and should be expected.

Tell the person this. Then give the following advice:

• Bite firmly on cotton gauze for an hour, and again later if blood comes from the socket.

Always give the person some extra cotton gauze to
carry home, in case bleeding starts again later.

Show her how to use the cotton gauze.

• Take aspirin or acetominophen for pain as soon as you need it, and then every 3 to 4 hours (pages 94-95).

• Keep your head up when you rest. This
reduces bleeding because it is harder for
blood to flow uphill. It also hurts less.

• Do not rinse your mouth. In some places people believe they should immediately rinse
with salt water and spit a lot after a tooth comes out, but this is harmful! It is important for the blood clot to stay inside the socket and not wash away.

• Do not drink hot Iiquids like tea or coffee, because they encourage bleeding. However, cool Iiquids are good for you.

Drink a lot of water.

• Continue to eat, but be sure the food is soft and easy to chew.

Try to chew food on the side opposite the wound.

• Keep your mouth clean. Start on the second day and continue until the socket is well. To do this, rinse your mouth with warm salt water (page 7) and keep your teeth clean (pages 69–72), especially the teeth near the socket.

FALSE TEETH

After a tooth comes out, it is a good idea to
replace it with a false tooth. If you do not,
the other teeth soon start to shift into the
open space.

This weakens the bone around their roots.

After some years, they too become loose
and sore, and they have to be taken out.

170 Where There Is No Dentist 2012

WHY FALSE TEETH ARE HELPFUL

When you take out a tooth, it is like removing a brick from the center of a wall. The area around the space becomes weaker and begins to crumble.

To prevent this, a plastic tooth can fit into the space. This tooth is not for chewing food but to hold the remaining teeth in their normal, healthy position.

A full set of teeth allows a person to chew the foods needed to stay healthy and feel good. Moreover, teeth help you look good!

A person
without many
teeth looks old.

With a new set of
plastic ‘false teeth’,
the same person
looks and feels
much younger.

If possible, after you take out a tooth, encourage the person to replace the tooth with a plastic tooth. find out where they are made and how much they cost. Then explain:

• how to clean the remaining teeth to prevent them from going bad (pages 69–72), and

• how it is possible to get a replacement plastic tooth.

Where There Is No Dentist 2012 171

PROBLEMS THAT CAN OCCUR

Sometimes a problem develops even though you have tried to be careful.

give help whenever you can. If you are not able to help, refer the person to a doctor or dentist as soon as possible.

BROkEN ROOTS

If you can see the root, try to remove it. If you leave a broken root inside the bone, it can start an infection.

Removing a broken UPPER root. Use your straight elevator. Slide the blade along the wall of the socket until it meets the broken root.

1. Force the blade between

2. Move the root away
the root and the socket.

from the socket wall.

3. Move the root further

4. Grab the loose root and
until it is loose.

pull it out.

Removing a broken LOWER root. Use a straight elevator (or a curved elevator if you have one). If the broken root is from a molar tooth, slide the blade into the socket beside the broken root.

1. Break away the bone between

2. Force the blade between
the root and the blade.

the root and the socket.

3. Move the root away

4. Grab the loose root and
from the socket wall.

pull it out.

WARNINg: It is better to leave a small broken root inside the socket.

In a week or so, it will loosen itself and be easier to remove.

172 Where There Is No Dentist 2012

ROOT PUSHED INTO THE SINUS

An upper root that seems to disappear may have gone into the sinus (page 95). Do not try to find it. Instead, cover the socket with cotton gauze and send the person to the hospital. A special operation is needed to open the sinus, find the root, and take it out.

Ask the person not to blow his nose. That forces air through the opening and prevents it from healing.

BONE CHIPS AND TAgS Of fLESH

Small pieces of bone that lie loose inside the socket can cause bleeding and delay healing.

Gently reach into the socket with the end of
an elevator or spoon instrument. Feel for the
piece of bone and carefully lift it out.

Give local anesthetic if needed.

When you are finished, ask the person to bite on cotton gauze until the bleeding stops.

Small tags of flesh are not serious, but they bother the person. Hold the tag steady with cotton tweezers and use sterile scissors carefully to cut the bit of flesh free.

Rinsing with warm water makes gums tough and helps them heal. But do not rinse for the first 24 hours. See page 169.

BLEEDINg

If the first cotton gauze (page 161) does not stop the bleeding in the socket, place more cotton gauze. Wait 5 minutes to see if the bleeding stops. If this does not work, follow the steps on pages 167–168 for placing a suture.

SWELLINg

Hold a cloth wet with cold water against the face. This helps to prevent swelling. This is a good thing to do if the tooth was hard to take out, or if it took a long time.

If there already is swelling, heat against the face will help to reduce swelling. Hold a cloth wet with hot water against the swollen area, 30
minutes on and 30 minutes off. Be careful not to burn the skin!

A large swelling usually means there is an infection. The person needs additional treatment. See page 116.

Where There Is No Dentist 2012 173

PAINfUL SOCkET

The socket area often hurts for a day or so after the tooth has been removed. Aspirin or acetominophen (page 94) is usually enough to relieve the pain.

A strong, steady pain that lasts for several days is a sign that the person is having a problem called dry socket. The treatment for this special kind of problem is given on page 117.

DISLOCATED JAW

When you press against a person’s jaw while taking out a tooth you can sometimes dislocate it. The jaw has been pushed out of position and it is not able to go back again.

We describe the care for a dislocated jaw on page 113.

MOST IMPORTANT: Be sure to tell each person you treat, “If your problem gets worse, you can come back to see me immediately!”

CLEAN YOUR INSTRUMENTS AFTER YOU FINISH

If your instruments are dirty, they can pass on germs that cause tetanus (page 118) or hepatitis (see page 172 in Where There Is No Doctor).

germs on dirty instruments can also go into the socket and start an infection.

Dental instruments must be not only clean, but also sterile. This means they need to be both scrubbed and then boiled before they can be used again.

See pages 86 to 89.

Use a brush and clean each

Then kill the germs by
instrument with soap and water.

placing the instruments into

Be careful to scrub away all bits of
a covered pot of boiling
old dried blood.

water for 30 minutes.

HIV and Care
chapter12
of the Teeth and Gums

Many things in the world have changed since Where There Is No Dentist was first published in 1983. One of the most profound changes has been the spread of HIV and AIDS worldwide. Although millions of people are now infected with HIV, the illness is still surrounded by fear and disinformation.

This chapter explains HIV and AIDS, what they mean for people who are infected and for oral health workers, and how we can all work together to prevent the spread of HIV.

For people with HIV, good
dental care can mean the
difference between living
and dying.

If a person with HIV has a
clean and healthy mouth,
he or she will be able to eat
well, be stronger, feel better,
and live longer.

Mary and David

Mary was 17 years old. She and her boyfriend David were expecting a baby.

David was Mary’s first boyfriend and he was very attentive and kind to her. But David had not been well lately. His mouth had been very sore and smelled bad all the time. Although he did not seem to have problems with his teeth, it was hard to chew or swallow, and white spots appeared on the roof of his mouth. Mary thought he should go to see the dental worker at the health center. At first David refused. He said he did not want to talk about it in a nervous voice. Finally David agreed to go if Mary would go too.

David said he wanted to see the dental worker by himself. So Mary sat in the waiting room while David saw the dental worker.

175

176 Where There Is No Dentist 2012

After a while the dental worker came out and asked Mary to come into the room. David was sitting on a chair looking worried. He tried to give Mary a smile, but she could see his heart was not in it. The dental worker asked David if she could tell Mary what she had found in David’s mouth. David agreed, so the dental worker explained to Mary that David did not have any problems with his teeth. He had infections in his mouth, gums, and throat.

This was why his mouth was sore and smelled bad all the time.

The dental worker said she would give David the dental care he needed.

But she also said she thought David’s problem might be caused by a much more serious infection called HIV. That would explain why his body is weak and he is unable to fight off the infection in his mouth. But to be sure, David should get a blood test for HIV. And because HIV can be passed from one person to another she encouraged Mary to get tested too. She explained that the sooner you find out if you have HIV, the sooner you can start taking medicines that help you and your baby live long and healthy lives.

I can treat the

It would be good for you
problem in David’s
both to get tested so
mouth, but I think he
that if you have HIV you
has a serious infection.

can protect youselves
and your baby.

The right information will help dental workers give good dental care to everyone.

This story shows why it is important for dental workers to know about infections in the mouth that may be caused or made worse by HIV. With correct and up-to-date information, dental workers can give the good dental care everyone deserves, and can help prevent HIV from spreading to other people or to themselves.

Health and dental workers must give people with HIV
the care they need . Make sure your health system provides the resources (equipment, medicines) you need to give good care .

Where There Is No Dentist 2012 177

WHAT ARE HIV AND AIDS?

HIV (Human Immunodeficiency Virus) is a germ that causes AIDS (Acquired Immune Deficiency Syndrome) by weakening the immune system, the part of the body that fights off infection and disease.

A person is said to have AIDS when he or she starts to get many common health problems more often than usual and stays sick longer. Some of these problems are losing weight, sores that will not heal, a bad cough, sweating at night, diarrhea, skin rashes, a fever, or feeling very tired all the time.

Without treatment the immune system of a person with AIDS gets weaker and weaker and the person is less able to fight these health problems.

Most people with AIDS die from diseases their bodies are no longer strong enough to fight.

Many people who are infected with HIV do not get sick for several years.

This means that a person can be infected with HIV and not know they have it because they feel healthy. But HIV can be passed from one person to another as soon as a person is infected. So, the only way to know if you are infected is to take a blood test called an HIV test. This test can be done at many clinics, hospitals, and other locations.

Medicines called anti-retrovirals, or ARVs,
can help people with HIV regain their
health or stay healthy for many years.

ARVs can also help prevent the spread
of HIV to a baby or to people who are
exposed accidentally. ARVs cannot cure

HIV, however. So these medicines must be
taken every day, for life.

Medicines for HIV are expensive, though
people affected by HIV have organized to
make them available in more countries and
at lower prices. Many governments and organizations provide ARVs for free either through their own funding or with the support of international donors.

Talk to a health worker who has experience working with HIV to find out where to go for treatment for HIV.

178 Where There Is No Dentist 2012

HOW IS HIV SPREAD?

HIV lives in certain body fluids, such as blood, semen (sperm), and the fluids in the vagina. The virus is spread when these fluids get into the body of another person. This means that HIV can be spread by:

• having unsafe or risky sex with someone who has the virus (see page 198).

• using injection needles or syringes that have not been sterilized (see page 87).

• using dirty instruments that cut the skin for injecting drugs, scarring, piercing, circumcision, or dental care. Even if instruments have been washed and look very clean, they can still have germs on them and can spread HIV if they have not been sterilized (see page 87).

• touching or receiving the blood of an infected person.

• mother to child during pregnancy, birth, or breastfeeding.

• splashing of blood into the eyes or mouth.

HIV does not live outside the
human body for more than a
few minutes. It cannot live on
its own in the air or in water.

This means you cannot give
or get HIV from everyday
contact, such as play, working
with someone, shaking hands,
sharing meals, or from spitting,
sneezing, coughing, sweating,
from tears, or from insect bites.

HIV is not spread by casual contact.

Where There Is No Dentist 2012 179

WHO GETS HIV?

Millions of people all over the world are
infected with HIV. If the body is strong,
the HIV virus can grow quietly for several
years, slowly weakening the immune
system before it turns into AIDS. If the
body is weak, the diseases of AIDS may
develop more quickly.

Both rich and poor people can be infected with HIV, but the sickness is worse for the poor. This is because poor people get more infections, which weaken the body, because they do not have access to:

• low-cost health care.

• enough nutritious food.

• clean, safe drinking water.

• safe, uncrowded living conditions.

• good sanitation.

Most mouth infections

Working to change these
are not caused by
conditions is an important

HIV, but all mouth
part of preventing the
infections are serious
when a person is
spread of HIV and
infected with HIV.

improving the lives of
people who have HIV.

HOW HIV AFFECTS THE MOUTH

People with HIV are likely to have more problems inside the mouth than people who do not have HIV. Because their bodies are weaker, any sores and infections may spread more quickly than they do for healthier people.

So people with HIV may need more regular and careful help from dental workers than other people in the community.

Most people with HIV will get at least one kind of infection or problem in the mouth at some time during their illness. If this is not treated, it can be painful, can affect how much food the person eats, and can cause more serious health problems.

Infections in the mouth related to HIV affect the soft skin (tissue)—the lips, the cheeks, the tongue, the lining of the roof of the mouth, under the tongue, and the skin around the teeth (the gums). HIV does not directly affect the teeth themselves. In the final stages of AIDS, the gums and the jaw bone, which hold the teeth in place, may be destroyed. Also, HIV can cause “dry mouth,” especially for people using ARVs (anti-retroviral drugs), which makes it easier to get cavities (tooth decay).

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HOW TO EXAMINE THE MOUTH

FOR SIGNS OF HIV OR AIDS

IMPORTANT: You cannot tell from looking at a person if he or she has HIV .

Dental workers must always be careful to make sure they do not pass the virus from one person to another during dental care.

Also, dental workers must protect themselves to make sure the virus does not pass to them from someone they are treating. So always use precautions against HIV infection with every person you see .

The best precautions are to always wear clean latex gloves or plastic bags on the hands, a face mask, eye protection, and to use only clean, sterile instruments. For information on how to clean and sterilize instruments, see pages 86 to 91 .

When you examine someone, alWays try to:

Wear glasses or goggles. Make sure you
can see through them clearly.

Wear a clean cloth or mask over
your nose and mouth. Try to change
the cloth several times a day. Before
wearing a cloth again, wash it in
clean soapy water, rinse, and hang it
in the sun to dry.

Wear clean gloves or plastic
bags on your hands.

If possible, dental workers should always be protected so they can prevent HIV from passing to themselves, the people they are treating, their families, and their sexual partners.

Where There Is No Dentist 2012 181

Always examine the lips, face,
and inside the mouth of someone
who wants advice about a dental

Before you examine
problem. Look for any swelling,
someone, always
explain carefully
broken skin, sores, redness,
what you are going
infection, or unusual color
to do.

changes. For information about the
most common problems caused
by HIV, see page 184.

Look carefully inside the cheeks and lips. Ask
the person to lift up her tongue so you can look
underneath it. Also, ask her to stick her tongue out.

Wrap a small piece of clean cloth around the tip of the tongue and gently pull it forward so that you can see the sides of the tongue, the back part of the mouth and tongue, and as far down the throat as possible.

For more information on how to examine the mouth
and teeth, see Chapter 6, pages 73 to 83 .

It is important to ask about the person’s general
health too. There may be other signs of HIV such as fevers, night sweats, feeling very tired all the time, weight loss, or diarrhea. Many people with HIV also become ill with tuberculosis or cancers. If the person has any of these problems, make sure he or she goes to see a health worker or doctor who is experienced with HIV.

Feel along the jaw, underneath the jaw bone, and on the upper neck to see if there are any lumps or pain.

182 Where There Is No Dentist 2012

Always tell the person what treatment you would like to give. After your examination, explain what you found and what can be done to help or prevent it from getting worse. Always ask the person for permission before you do any treatment, just as you should for any person you see.

No one else should know if
someone has HIV, except for
those the person wants to know.

If you think it is important
to tell others, always ask for
permission first.

If you know or think
someone is infected with

HIV, do not tell anyone
else—even the person’s
family.

Respect the privacy of a person with HIV as you would anyone who comes to you for dental care .

(See page 192, “Treat everyone with respect .”)

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DENTAL CARE FOR A PERSON WITH HIV

In general, there is no need to change dental treatment because a person is infected with HIV. This is especially true if the person has no signs of HIV. If there is already an infection in the mouth, use a mouth wash before treatment (see the “General Treatment” box on pages 184 and 185). This will help prevent the infection from getting worse.

Anyone with HIV has the
right to get good dental
care and to be treated
with respect.

There are no special problems in doing simple fillings, or fitting false teeth (dentures) for a person infected with HIV. But as the HIV infection advances to AIDS, you will be able to give better dental care if you know about any health problems the person may have. For example, if you need to take out a tooth, you must be extra careful not to cause an infection (see page pages 85 to 90). Remember, always use clean, sterilized instruments, and when you give injections use only clean, sterilized needles and syringes, or disposables, so you do not cause infections. If you have any concerns about someone’s health, it may help to speak with a health worker.

Taking out a Tooth

To take out a tooth, follow all the guidelines in Chapter 11, page 163. In addition, to prevent infection for someone with HIV, before you remove the tooth, make sure the person’s mouth is as clean as possible. A mouth rinse can help (see the “General Treatment” box on pages 184 and 185).

To prevent infection and to help with healing, gently scale or scrape away the tartar (see Chapter 8) from all the teeth. Be careful to do as little damage as possible to the gum and bone around the tooth you are taking out. An infected tooth socket (the hole that is left after you take out the tooth) in a person with HIV can be a serious problem. For problems after you take out a tooth, see pages 171 to 173.

In the later stages of HIV infection when the person has AIDS, the blood may not clot as quickly as normal. Be very gentle when you take out the teeth. Take only one tooth out at a time, and wait until bleeding is controlled before taking another one out.

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COMMON PROBLEMS CAUSED BY HIV

AND HOW TO TREAT THEM

There are many infections that occur in the mouth, such as a cold sore or gum infection. Most of these infections are not caused by HIV and do not usually cause serious problems. But all infections are serious when a person has been infected with HIV because the virus makes the person’s body weak and unable to fight off infection. Smoking or chewing tobacco can also make problems in the mouth worse. Many infections for people with HIV, including mouth infections, can be prevented by taking 480 mg of cotrimoxazole 2 times a day with lots of water.

The main problems in the mouth
for persons with HIV are:

1 . white or yellow patches

4 . cold sores or blisters

2 . open sores

5 . dark-colored skin patches

3 . gum infections

6 . dry or painful mouth and throat

General treatment

Always remove false or plastic teeth (dentures) before using any of these treatments.

Most of the problems in this chapter can be helped:

• if the teeth are kept clean by brushing or
using a chewing stick every day, including
false or plastic teeth.

• by rinsing the mouth several times a day
with a simple mouth wash made with salt
and clean water (see page 7).

1

2

3

Where There Is No Dentist 2012 185

• by gently cleaning any infection or sores with a clean cloth that has been moistened with salt water.

• by gently wiping inside the mouth (teeth, gums, all the soft inside skin) with a clean cloth.

Be careful if you use a chewing stick. Some wood is very hard and can hurt and damage the gums. The soft wood from the neem tree (which grows in many tropical countries) works well. You can also wrap clean cloth around the pointed end of a small stick or tooth pick and use it to carefully clean the teeth one at a time.

other treatments that can help are:

• chlorhexidine gluconate, 0.2%—a mouth wash that has no alcohol in it. Hold some in the mouth for 1 minute, 2 times a day. Make sure it covers the whole mouth inside, and then spit it out. This mouth wash reacts badly with some kinds of toothpaste. So wait 30 minutes between using this mouth wash and brushing your teeth.

• gentian violet, 0.5%—a purple-colored liquid that kills germs. Paint it onto the parts of the mouth that are infected.

Sometimes it may be necessary to paint the whole inside of the mouth. Try not to swallow any.

• povidone iodine, 1%—a brown-colored liquid that kills germs.

Hold some in the mouth for 1 minute, 2 times a day. Make sure it covers the whole mouth inside, and then spit it out (do not swallow any). Do not use for more than 14 days. Do not use if you are pregnant or breastfeeding.

• hydrogen peroxide, 3% and clean water—(see page 8) .

1

2

3

4

Mix hydrogen peroxide

Hold some

Spit it out and
evenly with water—that is
in the mouth
repeat. Do this

½ cup of hydrogen peroxide
for about
every hour when
with ½ cup of water.

2 minutes.

awake for 3 days.

186 Where There Is No Dentist 2012

1 . White or yellow patches in the mouth

(thrush, oral candidiasis)

White, yellow,
or (sometimes)

red patches. The
patches in this
picture are behind
the bottom, front
teeth, but they
most often appear
on the roof of the
mouth and the top
of the tongue.

Thrush is the most common infection in the mouth seen in people with HIV infection. Thrush can also be a problem for people who do not have HIV. For more information about this, see page 105.

SIGNS:

• A burning or swelling feeling in the mouth, especially when eating spicy foods. Because of pain, eating and swallowing become more and more difficult.

• The skin inside the mouth is usually covered with white, yellow, or red patches. If you try to remove the white patches with a clean cloth, they will come off, but sometimes leave a bleeding red surface underneath. In some people they may not come off easily.

In a few people, there are no white patches. Instead, the skin of the mouth is red and blotchy. It may look very rough.

• Sometimes there are painful cracks
at the corners of the mouth that
will not heal and sometimes bleed.

Where There Is No Dentist 2012 187

TREATMENT:

Gently scrub the tongue and gums with a clean
cloth or soft toothbrush 3 or 4 times a day.

Then rinse the mouth with salt water and
spit it out (do not swallow). In addition,
if possible, use any ONE of these
remedies:

• Put 2.5 ml (½ teaspoon) of nystatin
solution in the mouth and hold it there

2 minutes and then swallow it. Do this 5 times
a day for 14 days. OR,

• Use either gentian violet or chlorhexidine gluconate mouthwash, as described in the “General Treatment” box on page 184 and 185. OR,

• Cut or break a 100 mg clotrimazole vaginal insert into 2 pieces. In the morning, put 1 piece in the mouth and let it slowly melt there. Use the second piece at night. The package may say: “Do not take by mouth.”

This means do not swallow it. It is safe to let it melt in the mouth, making sure it covers the whole inside of the mouth, and then spit it out. Do this 2 times a day for 7 days (14 days if the infection is very bad). OR,

• Depending on how bad your problem is, suck one or two 100,000 Unit nystatin lozenges, 4 or 5 times a day for 10 to 14 days.

If thrush is very bad, or if it moves into your throat and makes it hard to swallow, you may try one of these stronger medicines instead of the remedies above. (But do not take either of these medicines if you are pregnant or breastfeeding):

• Take 400 mg of fluconazole by mouth. The next day take 200 mg of fluconazole once each day for 14 days. But if you do not feel better in 3
to 5 days, increase the dose to 400 mg once each day. OR,

• Take one 200 mg tablet of ketoconazole, by mouth, once a day with food for 14 days.

Some people get relief from thrush
when they paint the inside of the
mouth with a little tea tree oil or yogurt.

tea tree

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2 . Sores of the skin of the mouth (ulcers)

Open sores (ulcers) that
can appear anywhere in
the mouth. Usually the skin
around the sores is red. The
sores in this picture are on the
inside of the top lip.

Most people from time to time have had a small open sore (ulcer) in the mouth caused by an infection that has destroyed the skin in that area. It is usually painful and can make eating and speaking difficult for 1 or 2 weeks.

The ulcer heals if the mouth is kept clean. For people with HIV infection, the healing process can be very slow and sometimes the sore area in the mouth becomes very large. This is especially true if the person is taking anti-retroviral medicines to weaken HIV, such as zidovudine (AZT).

SIGNS:

The skin lining the mouth or on the tongue is broken and will probably look much redder than the skin that is not broken.

TREATMENT:

Keep the area clean to control the infection and to help the skin heal. Clean the sores with a cotton swab dipped in 1% povidone iodine. Or use any of the methods described in the “General Treatment” box on pages 184 and 185.

Also give antibiotics if:

• the skin around the ulcer is very swollen, AND

• you feel soft lumps (lymph glands) underneath the lower jaw bone.

Give 500 mg of amoxicillin by mouth, 3 times a day for 7 days. (Not safe for people allergic to penicillin. Anyone who is allergic to penicillin will also be allergic to amoxicillin and ampicillin).

OR 100 mg of doxycycline by mouth, 2 times a day for 7 days. (Not safe for women who are pregnant or breastfeeding).

OR 500 mg of tetracycline by mouth, 4 times a day for 7 days. (Not safe for women who are pregnant or breastfeeding).

OR 500 mg of erythromycin, 4 times a day for 7 days.

Where There Is No Dentist 2012 189

3 . Infection of the gums

(Vincent’s Infection, trench mouth)

The skin around the teeth

(the gums) is painful, red and
puffy with oozing yellow
liquid (pus).

Many people have some infection of the gums around their teeth. The amount of infection depends on how clean the mouth is kept and how well a person’s body can fight off disease. If the mouth and gums are not kept clean, the infection may get so bad that it will spread to the jaw bone and other tissues nearby and the teeth will eventually loosen and fall out.

Because the body of someone with HIV infection is less able to fight off disease, any gum infection will quickly get worse if the person does not keep his mouth and teeth clean. This can be very serious. If a person with HIV loses his teeth and cannot eat, he will become even more ill.

SIGNS:

• The gums are red, puffy, and very painful.

• There may be yellow liquid (pus) oozing from the gum around one or more teeth.

• The gums between several teeth have sores (ulcers).

• The person’s mouth smells very bad.

If the infection of the gums is very bad and advanced (as it can be for a person with HIV), the signs may include:

• red, raw ulcers of the gums.

• the roots of the teeth will show.

• pieces of the jaw bone can be seen at the bottom of the ulcers.

• some teeth are loose.

190 Where There Is No Dentist 2012

TREATMENT:

• Keep the area clean to control the infection
and to help the skin heal. Use any of
the methods described in the “General

Treatment” box on pages 184 and 185.

• Very gently remove the tartar around the
teeth. Be especially careful not to cause
damage to the gums (see “Scaling Teeth”

on pages 127 to 133).

Also give antibiotics if:

• the neck is sore or stiff, and there are soft lumps just underneath the lower jaw bone.

Give 500 mg of amoxicillin by mouth, 3 times a day for 7 days.

Women who are pregnant or breastfeeding can use this treatment.

OR for persons allergic to amoxicillin, give 100 mg of doxycycline by mouth, 2 times a day for 7 days.

OR give 500 mg of tetracycline by mouth, 4 times a day for 7 days.

Do not give tetracycline to pregnant women because it can harm a baby’s developing teeth.

OR for women who are pregnant or breastfeeding, and are allergic to amoxicillin, give 500 mg of erythromycin by mouth, 4 times a day for 7 days.

• the gums between the teeth have ulcers, and the person’s mouth smells bad.

Give 500 mg of metronidazole by mouth, 2 times a day for 7 days.

Once the area is clean and the infection is controlled, take out any teeth that are very loose (see pages 163 to 167).

Where There Is No Dentist 2012 191

More serious gum infection

(gangrene of the face, Noma, Cancrum Oris)

SIGNS:

In the most severe gum infection, the jaw bone will become infected and this can spread through the cheek to the face. This will be very easy to see, as parts of the face and jaw rot away and smell bad. It happens mainly to very sick children (usually one to four years old), but can also happen to adults with HIV infection.

TREATMENT:

Get medical help as quickly as you can—in a hospital if possible .

In the meantime, use the information on pages 122 to 124 for cleaning and treating the gangrene.

The medicines (antibiotics) listed on page 123 are for children. For an adult, give the following:

For an adult who is able to swallow:

• give 400 mg of

• OR if you cannot get
metronidazole by mouth,
metronidazole give 450 mg of

3 times a day for 10 days,
clindamycin by mouth, 4 times a
day, for 5 days.

• OR if clindamycin is not available give 500 mg of erythromycin by mouth, 4 times a day, for 10 days.

NOTE: Clindamycin, erythromycin, and metronidazole are OK to use for women who are pregnant or breastfeeding.

For an adult who cannot swallow:

• inject 2,000,000 (2 million) Units of penicillin G into a large muscle, 3 times a day, for 7 days.

For an adult who is allergic to penicillin,

• inject 600 mg of clindamycin into a large muscle, 4 times a day, for 5 days.

If you give the medicines by injection, change to medicines by mouth once the person starts to feel better. But do not stop giving the medicines until the 7 to 10 days have passed.

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4 . Cold sores or fever blisters

Painful red blisters on
the gums that have burst
open and become small,
open sores.

Many people get cold sores or fever blisters caused by the herpes virus.

People who become infected with herpes carry the virus forever. Most people are infected as children. The herpes sores can come and go. For more information, see page 104.

The herpes sores usually heal after 1 or 2 weeks. But for persons infected with HIV, the sores come more often and last much longer.

SIGNS:

1 . One or more small, sometimes painful, red blisters appear on the lips and skin around the mouth. In people with HIV infection, they also appear just inside the lips, and on the gums and the roof of the mouth.

2 . The blisters burst and become small open sores that often spread into each other.

3 . After the blisters on the lips burst, a yellow crust forms over them.

The herpes sores can pick up other infections,
particularly in people with HIV infection. Also, the liquid inside the sores and blisters can spread
infection. If herpes is spread to the eyes, it can cause blindness . Keep fingers and hands away from sores because they contain very active
virus. It is very important to wash the hands
before and after touching the face or eyes.

Where There Is No Dentist 2012 193

TREATMENT:

Medicine cannot kill the herpes virus. Keep the area clean to control any infection in the sores and to help them heal. Keep fingers and hands away from the sores, and drink lots of fluids. Use any of the methods described in the “General Treatment” box on pages 184 to 185.

Also:

• Begin treatment as soon as you feel a
tingling, before the cold sore appears. This
may stop the sore from developing or
developing so severely.

• A medicine called acyclovir may also help.

Give 200 mg by mouth, 5 times a day
for 7 to 10 days. You can also apply a
small amount of acyclovir ointment on
the sores 6 times a day for 7 days. It is

OK to use them both at the same time.

Acycolvir works best if taken or used early
in the infection, before the blisters burst, if
possible.

• If the sores are infected, give 500 mg of amoxicillin, 3 times a day for 7 days.

OR for persons allergic to amoxicillin, give 100 mg of doxycycline, 2 times a day for 7 days.

OR for a woman who is allergic to penicillin, and is pregnant or breastfeeding, give 500 mg of erythromycin, 4 times a day for 7 days.

• Antibacterial ointments such as neomycin or bacitracin can also help to prevent and control other infections that get into the sores. Stop using the acyclovir and spread a small amount of anti-bacterial ointment on the infected skin outside the mouth (not in the mouth) 2 to 5 times a day for about 5 days.

• To help ease the pain of sores outside the mouth, stop using acyclovir and cover the area with a dry powder, like baby powder, talc, or cornstarch. Do not use medicated powders as they can make the open sores sting very badly. Wash hands carefully before and after using powder.

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5 . Red or purple patches in the mouth

(Kaposi’s sarcoma)

Painless, red-, brown-,
or purple-colored patches

(that look like swollen
bruises). They can appear
anywhere in the mouth.

The patches in this picture
are on the top (roof) of
the mouth.

Some people infected with HIV will get red- or purple-colored patches in the mouth. These patches are called Kaposi’s sarcoma and they can also appear elsewhere on the body. Kaposi’s sarcoma can be an early sign of HIV infection.

SIGNS:

Painless patches that look like swollen bruises around or inside the mouth. The red or purple color is more obvious in the mouth. The patches rarely become infected and painful, usually only if they burst.

TREATMENT:

Get advice from a health worker
or doctor who is experienced
with the problems of HIV.

People who are taking anti-
retroviral medicines (ARVs) tend
not to get this kind of cancer.

And starting treatment with

ARVs can keep it from getting
worse. Sometimes very strong
anti-cancer medicines are used.

Also, some medicines for
treatment of varicose veins can
be helpful.

Where There Is No Dentist 2012 195

6 . Dry or painful mouth and throat

Many people with AIDS have difficulty eating near the end of their lives because of a dry or painful mouth and throat. But it is important to eat nutritious food during a sickness, even a serious sickness like AIDS. The person will feel much more comfortable and have less pain and infection if he or she can eat well.

A dry mouth can be caused by an infected swelling in the glands of the mouth that usually make spit (saliva). This is most common for people taking ARVs (anti-retroviral medicines). A painful mouth can be caused by other infections and problems that come with HIV and AIDS.

For information about how to treat an infection of the spit gland, see page 119. For help with eating if the mouth is very dry or sore, try the following:

• Eat soft foods in small pieces that are easy to chew and swallow.

• Cook foods until they are soft and tender.

• Mix foods with liquids to make them easier to swallow.

• Keep a small bottle of drinking water with you all the time.

• Use a straw to drink fluids.

• Do not eat hot or spicy foods. They can irritate a sore mouth and throat.

• If it is difficult to swallow, tilt the head back a little, or move it forward.

• Rinse the mouth with clean water often. This
will remove food and germs, and help with
healing.

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HELPING PEOPLE WITH HIV

IN YOUR COMMUNITY

As a dental worker or health worker, you can make a great difference in the well-being of both the person with HIV and his or her family. Take a special interest in them and help them find ways to get the care and companionship they need.

Care During the Final Days

During the final days of their illness, most people with AIDS prefer to be at home with their families. Both the sick person and the family need a lot of care and help during this time. This includes care for health problems and personal needs, as well as help with social and legal issues.

You can support the family if you organize volunteers in the community to:

• provide food and cook meals.

• help with daily household chores.

• look after babies and children whose parents are dying, or who may have already died.

• help with funeral arrangements.

It may also help to ask other family members, friends, or a religious leader to visit the family and the person who is dying. This support can help the sick person to die with dignity, and the family to cope with losing a loved one.

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WORKING FOR CHANGE IN YOUR COMMUNITY

By teaching and talking about HIV, dental workers can play an important role in helping to stop the spread of the disease.

Treating people with HIV infection helps to prevent its spread .

You can help if you:

• Learn as much as you can about HIV, how it is spread, and how to prevent it.

• Share your knowledge about HIV with others in community meeting places—like schools, stores, religious meetings, restaurants and bars, and military bases.

• Teach people how to practice safer sex to stop the spread of HIV. Safer sex is when no body fluids pass from one person to another during sex.

• Educate people about the importance of using clean needles for injections. In hospitals and health centers, make sure your needles come out of a sealed, sterile packet. Set up needle exchange programs for IV drug users in your community.

Practice Safer Sex

Safer sex means to:

• have sex with only one partner who has sex
only with you.

• always use condoms during sex, and help
women learn how to ask men to use them.

• think of other ways to have pleasure, such
as touching genitals with the hands, and
rubbing or massaging different parts of the
body.

• not have sex with someone who shares
drug injection needles.

If the whole community has good information about HIV and safer sex, men and women and their partners may feel more comfortable making changes in their sex lives to protect themselves. No one has become infected with HIV because he or she spoke openly and honestly about safer sex.

198 Where There Is No Dentist 2012

Although it can be difficult to speak openly about sex, to help prevent the spread of HIV it is necessary to talk about what is risky sex and what is safer sex.

How risky are different kinds of sex?

sex in the anus without a condom
sex in the vagina without a condom
sex with many people
sex when the vagina is dry
sex with someone who has had sex
with many people
sex without ejaculation

(“pulling out”)

sex using a diaphragm
sex with only one person who
only has sex with you
oral sex

(mouth on penis or vagina)

sex using a condom
kissing or touching
mutual masturbation

Treat Everyone with Respect

All people have a right to be respected, including people who have HIV. Set an example in your community by supporting people with HIV, their partners, and their families. Some people think AIDS is a “disease of outsiders“ or of

“bad” people. They think HIV does not affect “good” people like them. But HIV affects rich and poor people, men and women, people of all races and religions, health workers, and religious leaders.

Many people are afraid to take the HIV test or seek treatment because they think they will be treated badly. We must all take care not to let our fear of HIV and AIDS make us treat people unfairly. Anyone who is ill should be cared for with kindness and respect.

Where There Is No Dentist 2012 199

As a health and dental worker, you and other
community and religious leaders can help people
with HIV get health services, housing and jobs.

You can help people treat each other with
respect, and you can encourage people who
have HIV to become involved in their treatment
and in their community’s activities.

Remember, you can help support the human rights of people living with HIV or someone who people think is living with HIV. Discriminating against them violates HIV is not a curse or a their human rights.

punishment.

Set an Example and Share Good Information

The example you set and the information you share will help fight the fear people have of knowing, touching or living with someone who has HIV.

Make sure people know that HIV is not spread by ordinary daily contact. HIV
is not spread by hugging, touching, holding or shaking hands, by dancing, using the toilet after someone with HIV, or eating food prepared by a person with HIV. People can share dishes, towels, and bed sheets and not become infected with HIV. Also, it is not possible to get infected from someone’s tears, sneeze or spit, or from a mosquito bite.

Other viruses such as measles or chicken pox are spread easily through the air. But HIV spreads only if certain body fluids of a person with HIV get inside another person.

As a health worker, you can help people make decisions based on good information and not fear. A good way to begin is to plan a meeting to discuss HIV with other health workers in your area or region and with someone from a regional HIV organization. He or she can help health workers learn about HIV so they will be able to provide accurate, consistent information to the people in their communities. They can also learn about the best ways to treat the infections that people with HIV often get.

A person with HIV can get sick very easily
with many common health problems such as
pain, cough, skin rashes, fever and diarrhea.

For information about these problems,
see Where There Is No Doctor, or another
general medical book.

200 Where There Is No Dentist 2012

FOLLOW YOUR OWN ADVICE

As a dental worker and health leader, you can have a great impact on your community’s health and well-being if you set a good example. It is not enough just to give health education talks and tell people how to behave. As you talk to people about the importance of practicing safer sex, you must remember to also practice safer sex with your own sexual partner. A dental worker who does not practice safer sex can become infected with HIV and pass the virus to others.

Here is an example of what can happen to dental workers if they do not follow their own advice:

Two years ago, in one region of a country, there were 15
health centers that provided dental services. Today, 5 of the centers can no longer provide these services because their dental workers—all men—have died from AIDS. Also, 2 of the 15 students in a recent dental training course—a man and a woman—have HIV. No one knows exactly how each one got infected with HIV, but most people believe it was because they were not careful with their sexual partners. The dental workers and students gave many health education talks to tell people how to behave, but people in the community could see that they did not follow the advice themselves.

Where There Is No Dentist 2012 201

Think of Yourself as a Teacher

As a dental worker, you will be able to improve the health of the people in your community and help prevent the spread of HIV if you think of yourself as a teacher. The knowledge you share can have a more lasting impact on the health and well-being of a community than your skills as a dental worker.

By making connections with people and organizations working on different aspects of HIV, you will learn new information that can help you and your community. Contact local, regional, and national groups who work on HIV
education and prevention, on providing service for people with HIV, and on expanding access to ARVs and other medicines.

Help people with the
resources you have, and
think about where you
might find more resources
to help meet people’s
needs.

If all health workers can give the same correct, up-to-date information, it will help prevent the fear caused by wrong ideas about AIDS. If their neighbors are not afraid of them, people with HIV—as well as those who care for them —
can become more accepted in the community. Then they can help others understand every person’s real risk of getting HIV. So learn as much as you can about HIV and share the information with everyone.

Remember to:

• Give advice to the people you treat, especially those most at risk for getting infected, such as young people, migrants and refugees, sex workers, drug users who share needles, and anyone having sex with more than one faithful partner.

• Fight for improvements in the social and legal services available for people with HIV. Remember, the fight is against the conditions that lead to the spread of HIV, and not against people who have HIV.

Fight to end discrimination against those infected with HIV. Discrimination is an obstacle to care. It may stop people from coming for treatment and it may stop people from learning how to prevent the spread of infection.

Where There Is No Dentist 2012

203

APPENDICES

Get Rid of Wastes Safely . . . . . . . . . . . . . . . . . . . . . . 205

The Dental Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Records, Reports, and Surveys . . . . . . . . . . . . . . . . . 218

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Vocabulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Other Books from Hesperian . . . . . . . . . . . . . . . . . . . 237

205

Get Rid of Wastes Safely

Every time you examine a person’s mouth, fill a cavity, or extract a tooth, you are left with some waste. For example, used cotton or gauze, disposable needles and syringes, plastic gloves, and other materials must be thrown away. But do not put them in the trash . These wastes carry germs and can spread infections to you and to people in the family and community. Wear gloves when you touch wastes, and get rid of them carefully.

HOW TO DISPOSE OF SHARP

WASTES

Sharp wastes must be put into a container so
they will not injure anyone who finds them. A
container made of metal or heavy plastic, with a
lid or tape to close it, works well.

When the container is half full, add 5% bleach
solution, then seal it closed and bury it deep in
the ground.

Make a box to dispose of needles safely

Find a metal or hard plastic box. Make a long hole in the lid of the box that is wide on one side and gets narrower on the other side.

(continued on next page)

206  Where There Is No Dentist 2012

When you have finished using a disposable syringe, put the needle into the box and slide it down to the narrowest point.

Then pull up on the syringe and the needle will fall off into the box. The plastic syringe can be sterilized and thrown into a waste pit (see below).

When the box is half full, pour 5% bleach
solution into the box, seal it closed, and
then bury it deep in the ground.

OTHER WASTES

Other wastes, like plastic gloves, syringe barrels, or cloth soaked in blood, should be sterilized and then buried deep in the ground. You can sterilize them by soaking them in bleach for 20 minutes.

WARNING: Do not burn plastic gloves, syringes, or any other plastics . Burning plastic wastes is dangerous—when plastic burns, it makes smoke and ash that is very poisonous.

BURYING WASTES

Find a place away from where
people get their drinking water
and away from where children
play. Dig a safe waste pit to
bury wastes.

207

The Dental Kit

In the next 10 pages, there are lists of medicines, instruments, and other supplies recommended in this book. Keep them together in a kit. You may want to change some of them, or add others to meet your own needs .

As a dental worker, you will be able to get many of the items on the lists from your government medical stores. Some things you will have to buy yourself. That can be expensive, so we make several suggestions to help you save money.

Before you order, decide how many of each thing you need. Ask yourself: How many persons do I treat each day? For what problems? Then order enough medicines and supplies for three months.

Note: As more people learn about the treatment you can give, more will come to ask for your help . Remember this when you order .

Remember, also, that some persons may need more than one treatment .

On pages 208 to 209 we give an example. We recommend how many medicines, supplies, and instruments you will need if you see 10 people a day—200 a month. You cannot be exact, of course, because you cannot predict exactly what problems will arise. However, we can say that, on the average: In a group of 10 persons with urgent problems:

• 6 persons need you to take out 1 or more teeth (so you must inject)

• 2 persons need cement fillings

• 2 persons need medicine before you can treat them.

Many of these persons must return for another visit:

• 5 persons need you to scale their teeth and teach them how to care for them better

• 1 person will need a cement filling

• 2 persons will need treatment after taking medicine.

208  Where There Is No Dentist 2012

MEDICINES
local name

Amount you

Amount to

See

Use

Proper Name

(write in here) need in 3 months
keep in kit

Page

For

1 . aspirin,

2,000

100

94

Pain

300 mg tablets
tablets
tablets

2 . acetaminophen

(paracetamol)

500

10

94

500 mg tablets
tablets
tablets

For

1 . penicillin,

2,000

100

94
infections

250 mg tablets
tablets
tablets

2 . erythromycin,

500

40

250 mg tablets
tablets
tablets

94

3 . nystatin
drops or

12 small

2 small

105
gentian violet
bottles
bottles

Another antibiotic, tetracycline, is not recommended for any of the treatments in this book because it is a broad-spectrum antibiotic. Narrow spectrum antibiotics (see ‘antibiotics,’ page 225) are usually safer and just as effective for most dental problems. If you do use tetracycline, read page 355 of Where There ls No Doctor and remember, do not give tetracycline to a pregnant woman or to a young child . Tetracycline can make young, developing teeth turn yellow.

SUGGESTIONS:

1 . Compare prices before you buy medicines. Often the same medicine has many different names. The generic name (the name we use on this page) usually is cheapest, and the medicine is just as good as the

‘brand-name medicines’. Use the generic name to order and buy, not the brand name.

2 . Always look for a date on the package. It is called the expiration date (or expiry date). If today is Iater than that date, do not buy or use that medicine .

3 . Be careful to give the correct dose. Read the next two pages carefully, as well as the ‘Treatment’ section of each problem in Chapter 7. If pages 209 and 210 are not clear to you, read Chapter 8 (pages 59 to 64) of Where There ls No Doctor.

4 . For serious infections, see page 210.

Where There Is No Dentist 2012 209

THE CORRECT DOSE

Before you give medicine, think about the sick person’s weight and age. The smaller children are, the less medicine they need. For example, pain medicine such as aspirin (300 mg tablets) or acetaminophen (500 mg tablets) can be broken up into smaller tablets:

Four times a day:

Babies take

Adults

Childen 8–12

Children 3–7
acetaminophen
take 2 tablets
take 1 tablet
take ½ tablet
only, ¼ tablet

Note: Do not hold aspirin on the bad tooth. Aspirin has acid that can hurt the tooth. Always swallow aspirin immediately. For severe pain, when aspirin does not help, an adult can take 30 mg of codeine 4 to 6 times a day, as needed.

ANTIBIOTICS: TO FIGHT INFECTION

Antibiotics kill bacteria that cause infections. Some antibiotics work better than others on certain bacteria. If you can, test the pus (page 220) to find which antibiotic works best.

Do not give penicillin to a person who is allergic to it . Ask about the person’s allergies before you give penicillin pills or injections. When you inject penicillin, always keep epinephrine ( Adrenalin) ready to inject if the person shows signs of allergic shock. Stay with the person for 30 minutes. If you see these signs…

• cool, moist, pale, gray skin (cold sweat)

• difficulty breathing

• weak, rapid pulse (heartbeat)

• loss of consciousness

… immediately inject epinephrine: .5 ml for adults or .25 ml for children.

If necessary, inject the same dose again after 20 or 30 minutes. For more information on allergic shock, see Where There Is No Doctor, pages 70 to 71.

Always give the full dose of penicillin or any antibiotic, even if the person feels better. See page 94 for the correct dose of penicillin or erythromycin. Erythromycin also comes in liquid form. It has 125 mg in 5
ml, so 10 ml of liquid (about 2 large teaspoons) is the same as one 250 mg tablet.

It is important to take a strong first dose of penicillin or erythromycin, and then smaller doses 4 times a day for 3 to 5 days after that. Carefully read the instructions on page 94.

210  Where There Is No Dentist 2012

INJECTIONS: FOR SEVERE INFECTIONS

It is always safer to take medicine by mouth.

Sometimes, however, an infection is so bad that
you need to give medicine by injection. Learn
how to give injections from an experienced
health worker . The injections described on this

.5

1

1.5 2 2.5

3
page are not like the anesthetic injections in

Chapter 9 of this book—you must inject these

3 ml syringe
medicines into a large muscle in the buttocks or
arm. For more instructions on this kind of injection, see Chapter 9 (pages 65-74) of Where There Is No Doctor.

For severe infection: There are 2 kinds of penicillin to inject.

You will usually use

For very severe infections, give

‘aqueous procaine

‘crystalline penicillin’ every
penicillin’. Give only 1

6 hours for the first day. It acts
injection per day.

quickly and for a short time only.

INJECTABLE MEDICINES

SUPPLIES

DOSE

Adult

Child 6–12

Child 1–6

Amount you need Amount to
years old
years old

Proper Name
in 3 months
keep in kit

(over 40 kg)

(22–39 kg)

(10–22 kg)

1 . procaine

200

4 bottles

4 ml

2 ml

1 ml
penicillin,
bottles

2 times/

2 times/day

2 times/day
bottle with
day

300,000

Units per ml

2 . crystalline

50

3 ml

1.5 ml

1 ml
penicillin,

1 bottle
bottles

4 times/

4 times/

4 times/
bottle with
day
day
day

1,000,000

Units per ml

Where There Is No Dentist 2012 211

SUPPLIES

Local name

Amount you need in

Amount to

See

Use

Proper Name

(write in here)

3 months
keep in kit

Page

To make

1. clean

8 packages
dressings
cotton gauze
of 100

20 pieces

225

2. clean

10 packages
cotton rolls
of 50

8 rolls

147

To

3. oil of
fill
cloves

1 small
cavities

(eugenol)

50 ml
bottle

146

4. zinc oxide

1 small
powder

500 grams
bottle

146

To treat

5. flouride
sensitive
toothpaste
teeth

211

1 tube

1 tube

(below)

To give

6. lidocaine

injections

2% 1.8 ml

8 boxes of 100

10
of local
cartridge
cartridges
cartridges

136
anesthetic

7. disposable
needles,

8 boxes of

10

27 gauge long

100 needles
needles

136

8. lidocaine
topical

5 small

1
anesthetic
tubes
tube

141

FLUORIDE

You can use a special solution of fluoride (if available) or any fluoride toothpaste, which is much cheaper and more common (see above, number 5), in 2 ways: To treat a sensitive tooth: Put cotton rolls between the lip and gum on each side of the bad tooth. Dry the bad tooth with cotton and look for the small groove that is causing the pain. Cover the groove with a smear of fluoride toothpaste and tell the patient not to spit or rinse it out for several minutes. One week later, give the same treatment again, or have the patient do it himself.

To help prevent cavities, in children who do not clean their teeth with fluoride toothpaste, once a week have children bring their toothbrushes or toothsticks to school. Put some fluoride toothpaste on each child’s brush or stick and have them brush and coat their teeth, leaving the paste in their mouths for at least one minute. Then they can spit it out. Do not eat or drink for 30 minutes.

On page 24, children are shown using a twice-yearly application of a special paste, a ‘topical fluoride gel’. This is good, but the weekely treatment with fluoride paste is even better for the teeth.

212  Where There Is No Dentist 2012

Weight (how heavy something is)

Volume (how full something is)

1liter

1 cup

1 teaspoon

1

10 x 100

1000 ml = 1 liter
kilogram

=
grams

(kg)

(equals)

(g)

236.5 ml = 1cup

5 ml = 1 teaspoon

1 kilogram = 1000 grams

1 ml = 1 cubic

1 gram = 1000 mg
centimeter (cc)

local name

Amount you need

Amount

See

Use

Proper Name

(write in here)

in 3 months
to keep in kit

Page

To make
rinses

1. salt

2 kilograms

100 grams

7

2. hydrogen
peroxide

3 liters

500 ml

8

To keep

1. 95% alcohol
instruments
disinfectant solution

18 liters

1.5 liters

89
clean

2. bleach for
disinfectant solution

2.5 liters

125 ml (½ cup)

89

To keep

Arkansas
instruments
sharpening stone

1 stone

1 stone

134
sharp

For
wooden tongue

8 boxes of
examining
depressors

50 per box

10

75

SUGGESTIONS:

If you order your supplies in bulk long before you need them, you probably will pay lower prices. If you have a place to store supplies that is clean, dry, and free from cockroaches and rats, consider ordering enough for one year instead of only 3 months.

Where There Is No Dentist 2012 213

INSTRUMENTS

When you are treating several people on the same day, you will need to clean some instruments (see pages 86 to 89) at the same time that you are using others. Therefore, it is necessary to have several of each kind of instrument, to be sure that the instrument you need will be ready (clean or sterile) when you need it.

There are 3 instruments you will need for each person who comes to you, no matter which treatment is needed. They are: a mirror, probe, and cotton pliers. Keep them together. Below we recommend that you have 15 of each of these, so you can keep one in each treatment kit. You do not need to buy all of these instruments . You can make several of them—see pages 214–216. If you like, buy only one example of each of the instruments below, and use them as models to copy when you make your own extra instruments.*

Number

Local name
to buy or

See

Use

Proper Name

(write in here)

make

Page

To examine

1. dental mouth
or to
mirror

15

75
give any

2. explorer

15

75
treatment

3. cotton pliers

15

128

To inject

Aspirating dental
syringe to use with

1.8 ml cartridges)

3

135

To scale

1. lvory C-1 scaler

1

128
teeth

2. Gracey 11–12
curette

1

128

To place

1. spoon excavator

1

145
cement

2. filling instrument

1

145
fillings

3. cement spatula

1

145

To remove

1. spoon excavator

3

161
teeth

2. straight elevator

(No. 34)

3

161

3. upper universal
forcep (No.150)

3

161

4. lower universal
forcep (No.156)

3

161

Note: See pages 161–162 for recommendations of other elevators and forceps that are good to have if you can afford them.

*If you want the help of a charitable organization in buying instruments, see page 217.

214  Where There Is No Dentist 2012

MAKING YOUR OWN DENTAL INSTRUMENTS*

Here are a few ideas for making instruments at low cost. Try to use materials that are available where you live.

Can you think of any other materials you can use?

Each instrument has two parts: a handle and a working piece at the end.

Join them together:

… with wire:

… with glue or even wax:

If you make the end flat, it can prevent the working piece from turning.

Pound the working piece with a hammer and make a flat slot in the handle so the working piece cannot turn.

bottom of
working
piece
goes in
this slot

*I am grateful to Aaron Yaschine for the ideas in this section.

Where There Is No Dentist 2012 215

MAKING THE THREE INSTRUMENTS YOU USE MOST

Mirror: Use old pieces of mirror or a shiny piece of tin. You even can use a polished silver coin. A tongue depressor is the handle.

Probe: Use the end of a paper clip, pin or needle for the working piece. Rub it against a smooth stone to sharpen it. Bend it so it can reach around to the back of a tooth. Attach the working piece to a smooth stick handle (p. 214).

Tweezers: Draw the shape on a piece of tin and then cut it out with strong scissors. Use a file or a smooth stone to make the edges smooth. Bend in half to make the tweezers.

216  Where There Is No Dentist 2012

MAKING OTHER INSTRUMENTS AND SUPPLIES

Spoon: Bend a paper clip or needle. Flatten the end. Then pound a small stone against the end, to make it hollow. Make 2 bends and attach to a stick handle.

Filling Tool: Remove the heads from 2 long screws. With a file and hammer, make the end of one screw flat and the end of the other screw round. Bend each end in the direction of the edge (not the face) of the flat side. Attach both working pieces to a small stick handle.

Dental Floss: When using string to clean between your teeth (pages 71–72), you may have trouble getting this string down in between your teeth. Sometimes, also, the string gets caught there, forming a kind of

‘bird’s nest’. Three things can cause problems with dental floss: 1 . An incorrectly made filling—flat and
rough instead of round and smooth.

Replace the filling.

2 . Teeth too tight together . Use the floss on a tooth. Then pull the string out from
between the teeth as you press the
free end down against the gum with the
fingers of your other hand. If there is a
sharp filling on a tooth, the string will
pass under the filling as it comes free.

3 . String that is too thick . Make thinner but stronger floss by waxing as in this
picture. The wax also will make the floss
easier to slide between your teeth.

(1) Soak thin string in hot wax.

(2) To remove the extra wax, pull
the string between your fingers.

Where There Is No Dentist 2012 217

BUYING DENTAL SUPPLIES

When you do not have much money,

Other organizations that may
you must spend wisely. Dental
be able to help:

instruments are very expensive,
especially when you buy them at

World Dental Relief
commercial prices. Ask other health

PO Box 747
workers in your area where you can get

Broken Arrow, OK 74013-0747
instruments at lower prices. You can

USA
also try contacting the national dental
tel: 1-918-251-2612
association in your country. If you do not
fax: 1-918-251-6326
know how to locate your national dental
website: www.worlddentalrelief.com
association, contact the World Dental
e-mail: dentalreliefinc@aol.com

Federation:

Project HOPE

FDI – World Dental Federation

255 Carter Hall Lane

Tour de Cointrin, Avenue Louis Casaï

Millwood, VA 22646 USA

Case Postal 3
tel: 1-540-837-2100

1216 Geneve-Cointrin

1-800-540-4673

SWITZERLAND
fax: 1-540-837-1813
tel: 41-22-560-81-50
website: www.projecthope.org
fax: 41-22-560-81-40
e-mail: HOPE@projecthope.org
website: www.fdiworldental.org

Direct Relief International
e-mail: info@fdiworldental.org

27 S. La Patera Lane

Santa Barbara, CA 93117 USA

There are many organizations that
tel: 1-805-964-4767
donate health supplies—including dental
fax: 1-805-681-4838
instruments—or that distribute them at
website: www.directrelief.org
low cost. Some of these organizations
e-mail: info@directrelief.org
prefer to help church-sponsored
kkaufman@directrelief.org
health projects, but others will provide
instruments to anyone who needs

MAP International
them.

4700 Glynco Parkway

Brunswick, GA 31575-6800

Durbin PLC, a company in England, may

USA
sell the instruments mentioned in this
tel: 1-800-225-8550
book at lower than commercial prices.

website: www.map.org

For more information, contact:

e-mail: map@map.org

Durbin PLC

Dentaid

180 Northolt Road

Giles Lane, Landford,

South Harrow, Middlesex HA2 0LT

Salisbury, Wilts SP5 2BG

UK

UK
tel: 44-20-8869-6500
tel: 44-1794-324249
fax: 44-20-8869-6565
fax: 44-1794-323871
website: www.durbin.co.uk
website: www.dentaid.org
e-mail: cataloguesales@durbin.co.uk
e-mail: info@dentaid.org

218  Where There Is No Dentist 2012

Records, Reports, and Surveys

For record keeping, you can divide the
mouth into 4 parts:

• Upper Right (UR)

• Upper Left (UL)

• Lower Left (LL)

• Lower Right (LR )

In each part there are 8 teeth (fewer in
children—see page 43).

You can call each tooth by its short name,

Here are the short names of 4 teeth.

Can you find the tooth named LL5?

for example, UR3.

Keep a record of each person you see. Write some brief information about the person and the problem. This way, if the person returns, you remember what you did to help.

When a person needs to come more than once to take care of a problem, it is better to keep a special record for that person. With all the treatments on one page, you can follow that person’s progress more easily. Below is an example for a person named Yupere. Yupere has a bad tooth that has hurt from time to time for 2 months. One day when he woke up, his face was swollen. Yupere decided to wait a day to see if the swelling would go away.

The next day it was worse, so he went to the medical post for treatment.

Where There Is No Dentist 2012 219

Reports

You need to write a report whenever you send a person for medical help.

Give as much information as possible so that your treatment can continue and new treatment starts as quickly as possible. If you cannot go along, always send a report with a sick person .

The story of Niame: After drinking for several hours, Niame’s husband returned home asking for money. She had none and told him so. He did not believe Niame, so he beat her with his hands and then a knife. Naime’s friends carried her, unconscious and bleeding, to the aid post. The front part of her lower jaw was hanging out of position.

220  Where There Is No Dentist 2012

Surveys

It is a good idea to know how many persons in your community have cavities and gum disease. Look in the mouths of children and adults and make a record of what you see. Here is an example that is used in Mozambique: Put a line through the circle for each person with:

• cavities Ø

• red, swollen gums Ø

The dental workers in Mozambique do a quick
survey in 2 schools, 2 mother-and-child health
clinics, and 2 cooperatives or factories in their
community.

In each place, they examine 50 persons. This
is enough to give an idea of the general health
of teeth and gums in the community.

They make a paper for each age group.

Each paper has 3 sections. They make
a mark for each person they see, until
all 50 circles have marks in them. They
make extra marks if they see a tooth
and/or gum problem.

In this example, you can see that
children have more problems with
cavities, while adults suffer more from
gum disease. This is often true.

This survey helps the dental worker
in three ways:

1 . it shows how serious tooth
decay and gum disease are in
the community.

2 . it shows which age group is
suffering the most. To these
people the dental worker must
plan to give the most attention.

3 . it gives the dental worker
something to show the people
when they are discussing why
to change some old habits and
adapt some new ideas.

221

Resources

TEACHING MATERIALS

A Teacher Resource to Support Dental

Health Education, an illustrated manual

Common Oral Diseases, slide set.

for teachers of Kindergarten through

An introduction to oral disease including

Grade 5. Includes lesson plans and
periodontal disease and dental caries and activities.

their prevention. Also describes how a

Can be downloaded from the web here:

health worker should examine a patient’s www.health.gov.sk.ca/dental-health-mouth and gives details of the common
teacher-resource
problems that a dental worker meets.

Order from:

More information from:

T.C. Douglas Building

TALC

3475 Albert Street

PO Box 49, St Albans

Regina, SASK S4S 6X6

Herts, AL1 5TX

CANADA

UK
tel: 44-1727-853869
fax: 44-1727-846852

Fit for School, a program for
e-mail: info@talcuk.org
day care centers and schools in
website: www.talcuk.org
the Philippines, promotes daily
handwashing, toothbrushing, and

Guide for Safety and Infection Control
twice-yearly treatment for worms to
for Oral Healthcare Missions
improve child health and educational

This is a practical guide to providing safe
achievement. Their website offers
dental care in low-resource settings.

helpful materials for teachers:

Available from:

7th floor, PDCP Bank Centre

OSAP — Organization for Safety &

Cor. V.A.Rufino/L.P.Leviste Sts.

Asepsis Procedures

Salcedo Village, Makati City

A Global Dental Safety Organization

Metro Manila

P.O. Box 6297

PHILIPPINES

Annapolis, MD 21401
tel: 63-2-840-5035

USA
tel: 63-2-812-1078
tel: 1-800-298-6727; 1-410-571-0003
website: www.fitforschool.ph
fax: 1-410-571-0028
e-mail: info@osap.org
website: www.osap.org

222  Where There Is No Dentist 2012

OTHER ORAL HEALTH RESOURCES

FDI World Dental Federation

Regional Centre for Oral Health

Tour de Cointrin, Avenue Louis Casaï

Research & Training Initiatives

Case Postal 3

No 3c CBN Road

1216 Geneve-Cointrin

PMB 2067, Jos

SWITZERLAND

Plateau State,
tel: 41-22-560-81-50

NIGERIA
fax: 41-22-560-81-40
tel: 234-73-462-901
e-mail: info@fdiworldental.org
fax: 234-73-462-901
website: www.fdiworldental.org
e-mail: rcorti@rcortiafro.org

World Health Organization (WHO)

Basic Package of Oral Care is a

Oral Health Programme

WHO-affiliated program that aims to

Avenue Appia 20
include preventive and curative oral

1211 Geneva 27
health into the primary health care

SWITZERLAND
system in a way that is affordable and
tel: 41-22-791-2111
achievable for low-income communities.

fax: 41-22-791-3111

It includes urgent treatment (pain relief
website: www.who.int/oral_health
and emergency treatment), affordable

WHO has a Focal Point for Oral Health
fluoridated toothpaste, and Atraumatic
in each of its regional offices around

Restorative Treatment (ART) which
the world. This web page gives contact
removes cavities and diseased parts
information for each regional office, as
of teeth without drilling. For more
well as other resources:

information:

http://www.who.int/oral_health/partners/en/

Department of Global Oral Health,

Nijmegen

WHO Collaborating Centre for

Radboud University

Promoting Community-based Oral

Nijmegen Medical Center

Health Models, Intercountry Center

P.O. Box 9101
for Oral Health (ICOH)

6500 HB Nijmegen

Ministry of Public Health

THE NETHERLANDS

548 Ban Nong Hoi,
e-mail: info@globaloralhealth-nijmegen.nl

Chiang-Mai-Lamphun Road,
tel: 31-24-361-6995

Muang, Chiang Mai 50000
fax: 31-24-354-1971

THAILAND
website: www.globaloralhealth-
tel: 66-53-801160, 66-53-277027
nijmegen.nl
fax: 66-53-281909
e-mail: icoh@icoh.org

International No-Noma Federation
website: www.icoh.org
c/o Winds of Hope Foundation

20 avenue de Florimont
www .hivdent .org

CH 1006 Lausanne

This website includes treatment

SWITZERLAND
information and training resources to
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Where There Is No Dentist 2012 223

TRANSLATIONS OF WHERE THERE IS NO DENTIST

Arabic

Spanish

Arab Resource Collective (ARC)

Hesperian Health Guides

P.O. Box 13-5916

1919 Addison Street #304

591 Emil Edde (ex Lyon) Street, Dakik Bldg Berkeley, California 94704 USA Beirut, LEBANON
tel: 1-510-845-4507
tel: 961-1742075
fax: 1-510-845-9539
fax: 961-1742077
e-mail: bookorders@hesperian.org
website: www.mawared.org
website: www.español.hesperian.org
e-mail: arcleb@mawared.org

Please write to Hesperian or visit our

Burmese
website (www.hesperian.org/books-

Myanmar Christian Health Workers/CDC
and-resources/language-list/) for other

No 14 Daw Hla Pan Lan -Ka We Chan
translations of Where There Is No

Tha Maing Ma Yan Gone Myo Ne

Dentist, including:

Yangon (City), BURMA (MYANMAR)

e-mail: marieklaipo@gmail.com

• Farsi

• French

Also distributed in the US by

• Iban

Friends of Burma:

• Japanese
http://friendsofburma.org/fob/2011/06/

• Nepali
translation-of-where-there-is-no-dentist.

• Pashto
html

• Portuguese

• Sindhi

Korean

Basic Health Commission,

Yein Dental Clinic

Kwanak-gu, Shillim 2 dong, 404-1

Youngchang Plaza 4F

Seoul, 156-012 KOREA
tel: 82-2-511-1040
fax: 82-2-511-1049
e-mail: jsogood@hanmir.com

Available for download on Hesperian’s
website:

www.hesperian.org/books-and-
resources/resources-in-korean

Where There Is No Dentist 2012

225

VOCABULARY

This vocabulary is listed in the order of the alphabet: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Most names of sicknesses are not in this vocabulary. Find the name of a sickness in the Index and read about it in the book.

There are many words in this vocabulary that are not in the rest of the book, but you may see them in other books or hear dentists use them.

A

B

Abscess A sac of pus caused by an infection.

Baby teeth

The first set of teeth. There are

For example, a boil.

20 baby teeth, which are also called milk

Acid A strong liquid that is produced from teeth or primary teeth.

certain foods left in the mouth. Acid causes

Bacteria

Tiny germs that you can only
both tooth decay and gum disease.

see with a microscope and that cause many

Acute Sudden and short-lived. An acute illness different infectious diseases.

is one that starts suddenly and lasts a short

Beeswax Wax made by honey bees.

time. The opposite of ‘chronic’.

Bicuspids

The teeth between the canine

Adrenaline Also called epinephrine. A drug teeth and the molars; premolars.

which stimulates the heart, used for severe

Bite (1) To cut with the teeth. (2) The way the allergic shock.

upper and lower teeth fit together when

Adult teeth See

Permanent teeth.

they close.

Allergy A bad reaction after breathing in, Blood pressure

The force, or pressure, of the
eating, touching, or being injected with
blood flowing through the blood vessels
something. The reaction may be itching,

(veins and arteries).

sneezing, or difficult breathing.

Blood vessels

Tubes that carry blood through

Analgesic Medicine to calm pain. Aspirin,
the body. Veins and arteries.

acetaminophen (paracetamol), and codeine

Boil (1) To heat water until it bubbles. (2) A are all analgesics.

swollen, inflamed lump with a pocket of

Amalgam A special metal used in permanent
pus under the skin. A kind of abscess.

fillings.

Brand name

Trade name, the name

Anemia A disease in which the blood gets
a company gives to its product. A
thin. Signs include tiredness, pale skin, and
brand-name medicine is sold under a
lack of energy.

special name and is often more expensive

Anesthetic A drug that causes the mouth or than the same generic medicine.

other part of the body to feel numb.

Bridge

False teeth that are glued onto

Antibiotic

Medicine that fights infections
several nearby healthy teeth.

caused by bacteria. A broad-spectrum

Buccal

Of the cheek. The buccal face of a
antibiotic such as tetracycline kills many
tooth is the side facing the check.

kinds of bacteria, while a narrow-spectrum

Bulk

Large quantity or amount.

antibiotic like penicillin kills only a few
kinds of bacteria.

Appropriate Something that is the easiest, C
safest, and most likely to work in a
particular situation or condition.

Calcium

A nutritional element which makes

Arkansas stone A special stone used to
teeth strong and hard.

sharpen dental instruments.

Calculus Tartar.

Aspirate To breathe. An ‘aspirating syringe’ is Calories

Units of heat found in food, giving
one that can ‘breathe’, or allow liquid to go
energy for the body to use.

both in and out of the needle tip.

226  Where There Is No Dentist 2012

Cancer A tumor or lump that grows and may

Drill

An instrument used to change the
keep growing until it causes death.

shape of a cavity before placing a filling.

Canine teeth

Also called cuspids, dog teeth,

Duct

A tube that carries liquid. For
and eye teeth. These teeth have the longest
example, ducts carry spit from the spit
roots of any tooth.

gland to the mouth.

Carbohydrates Starches and sugars—foods

E
that give energy. In this book they are
called GO foods.

Elevator An instrument used to loosen a tooth Caries Cavities; tooth decay.

before you take it out.

Cavity A hole in a tooth where bacteria have Enamel The protective layer that covers the entered.

crown (top part) of a tooth. The enamel is

Cement filling A temporary filling, which
the hardest part of the body.

may protect a tooth for up to 6 months. Also

Epulis A tumor of the gums, usually found see Filling.

between the teeth.

Cementum The outer covering of the tooth’s Eruption The moment when a new tooth cuts root.

through the gums and becomes visible in

Chronic Long-term or frequently recurring
the mouth.

(compare with ‘acute’). A chronic disease is

Evaluation A study to find out the value of one that lasts for a long time.

something, or to find out what has been

Colony Germs grouped together in one
accomplished. Evaluations often compare
place.

different conditions before and after a new

Contagious disease A sickness that can be
activity begins.

spread easily from one person to another.

Examination A careful look at something; an investigation.

Contraindication A situation or condition
when a particular medicine should not

Expiration date The month and year
be taken, or a certain treatment not
marked on a medicine that tells when it
given. For example, many medicines are
will no longer be good. Throw away most
contraindicated during pregnancy.

medicines after this date.

Crown The top 1/3 of the tooth, the part that Explorer See

Probe.

is protected with hard enamel.

Extraction Taking out a tooth.

Curette A scaling instrument.

F

Cuspids Canine teeth.

Cyst An abnormal, sac-like growth in the

False tooth A ‘tooth’ made of plastic or other body which is often filled with water.

material, used to replace a tooth that has
been taken out.

Fever A body temperature higher than

D
normal.

Decay See Tooth Decay.

Fiber A fine, threadlike piece. A fibrous food like coconut contains a lot of fiber.

Dentition A whole set of teeth.

Filling Material put into the cavity in a tooth Dental floss See Floss.

to prevent further decay.

Dental worker A health worker who works
for healthy teeth and gums.

First aid Emergency care or treatment for someone who is sick or injured.

Dentist A professional who has advanced
formal education in care of teeth and gums.

Floss Special string used to clean between the teeth.

Dentures False teeth.

Fluoride A chemical which strengthens the Diagnosis A decision made by a health
teeth. Painted on the teeth, as an ingredient
worker about what a person’s illness is.

in toothpaste, or added to water for drinking

Diet

The kinds and amounts of foods that a
or rinsing, fluoride enters and hardens the
person should eat or avoid eating.

enamel. It is especially good for children’s

Dislocation

A bone that has slipped out of
teeth.

place at a joint.

Forceps Instruments used to pull teeth.

Distal

The side of the tooth that faces the

Fracture A broken bone.

back of the mouth. The opposite side from
the ‘mesial’ side.

Where There Is No Dentist 2012 227

G

Infection A sickness caused by bacteria or other germs. Infections may affect part of

Gauze A material made of cotton, woven into the body only (such as a sinus infection) or
an open mesh.

all of it (such as measles).

Generic name The scientific name of a

Infectious disease A disease that is easily medicine. Usually different from the brand
passed from one person to another;
names given it by the different companies
contagious disease.

that make it.

Inflammation An area that is red, hot, and Germs Very small organisms that can grow
painful, often because it is infected.

in the body and cause some infectious

Inject To give a medicine such as an
diseases; bacteria.

immunization or anesthetic, using a syringe.

Gram A metric unit of weight. There are
about 28 grams in an ounce. A paper clip
weighs about 1 gram.

J

Groove A long, narrow cut on the surface of Joint The place where two bones meet.

back teeth. Grooves are ‘protected areas’

When this book talks about the ‘pain in
because food and germs can hide and
the joint’, it means the joint (called the
remain in them longer.

‘temporomandibular joint’) where the cheek

Gum bubble Also called a gum boil. A small and jaw bones meet.

abscess on the gums.

Gum disease Illness that causes gums to

K
become loose, red, and swollen, and to
bleed when the teeth are cleaned.

Kilogram (kg) One thousand grams. A ‘kilo’

Gum pocket The space between the tooth
weighs a little more than 2 pounds.

and the flap of gums around it, forming a
small pocket.

L

Gums The skin around the teeth.

Labial Of the lips. The labial side of a tooth is H
the face of the tooth nearest the lips.

Ligature wire A thin, strong wire that bends Hemorrhage Bleeding.

easily, used to attach a loose tooth to a

Hemostat A needle holder, used for putting in strong tooth.

sutures.

Lingual Of the tongue. The lingual side of a Herb A plant, especially one valued for its tooth is the face of the tooth nearest the
medicinal or healing qualities.

tongue.

History (Medical history) What you can learn through asking questions about a person’s

M
sickness—how it began, when it gets better
or worse, what seems to help, whether

Malnutrition Health problems caused by not others in the village or family have it, etc.

eating enough of the foods that the body

Hydrogen peroxide A liquid used to clean
needs.

wounds and kill certain bacteria.

Mandible The lower jaw bone.

Hypertension High blood pressure.

Maxilla The upper jaw bone.

Mesial The side of the tooth that faces the front of the mouth; the opposite of ‘distal’.

I

Milligram (mg) One thousandth of a gram.

Immunizations (vaccinations) Medicines that Molar The back teeth, used for grinding.

give protection against specific diseases. For

Molars are the largest teeth in the mouth,
example, there are immunizations against
with 2 or even 3 roots each.

diptheria, tetanus, polio, tuberculosis, and
measles.

Incisors The four front teeth on the top and bottom.

228  Where There Is No Dentist 2012

N

Pus A yellow-white liquid found inside
infections.

Nerves Thin threads or strings that run from R
the brain to every part of the body and carry
messages for feeling, pain or movement.

Records, reports

Written information about

There is a nerve, along with a blood vessel,
sick persons and the treatment they receive.

in every root of every tooth.

Records are for the personal use of the

Numb Without feeling; anesthetized. When
health worker, reports are written by one
teeth and the gums around them are numb,
health worker to another to describe an
they cannot feel pain.

illness and ask for further treatment.

Nutrition The mixture of foods the body

Resistance The ability of something to defend needs to grow, be healthy, and fight off
itself against something that would normally
disease.

harm or kill it. Many bacteria become
resistant to the effects of certain antibiotics.

O

Rinse

To hold a liquid in the mouth, moving
around inside the mouth.

Occlusal The biting surface, or top, of the Risk

The possibility of injury, loss, or harm.

tooth.

Danger.

Oral Of the mouth. An oral medicine is one Root

The lower part of the tooth, under the
taken by mouth.

gum, connected to the bone.

Organisms Living things (animals or plants).

Root canal

The hollow part of every root of a
tooth, which has a blood vessel and a nerve

P
inside.

Root canal treatment

A special operation

Palate The roof or top part of the mouth.

on a dead tooth to remove material from

Permanent filling A filling using a special the root canal and replace it with filling
metal or ceramic material which lasts for
material.

years.

Root fibers

Tiny fibers which hold the root of

Permanent teeth The 32 adult teeth which
the tooth to the jaw bone.

grow into the mouth to replace the baby
teeth.

S

Petroleum jelly (petrolatum, Vaseline) A grease-like jelly used in preparing skin

Saliva

Spit. Saliva helps us to swallow our
ointments.

food.

Plaque A film or coating of germs that can Scab The crust of dry blood that forms over a form on the teeth, mix with food and make
wound.

acid. You cannot see plaque unless you

Scale To scrape the tartar off the teeth. A scaler stain it.

is an instrument for scaling.

Plate A set of false teeth.

Scientific method A way of learning

Premolars

The teeth between the molars and
something. It begins with information, then
the canine teeth; bicuspids.

an idea, and then the idea is tested against

Prenatal

Before birth.

the information available.

Prevention

Action taken to stop sickness

Side effects Problems caused by using a
before it starts.

medicine.

Probe

An instrument for examining teeth for

Signs The things or conditions to look for tartar or other problems.

when you examine a sick person, to find out
what sickness the person has. In this book

Protective foods

Foods that are rich in
the symptoms (the problems a person feels)

vitamins and minerals. They help build
are included with signs.

healthy bodies and make people more able
to resist or fight diseases. ln this book they

Sinus

A hollow place inside the bone.

are called GLOW foods.

Socket The wound left after you take out a Proteins

Body-building foods necessary for
tooth.

proper growth and strength. In this book

Soft drinks

Fizzy, carbonated drinks like
they are called GROW foods.

Coca-Cola.

Where There Is No Dentist 2012 229

Spatula

An instrument used for mixing cement

Top of the tooth

The part of the tooth that
for fillings.

bites on food. For both upper and lower

Starches Energy foods like maize, rice, wheat, teeth, the biting surface is the ‘top’ and the
cassava, potatoes, and squash.

root is at the ‘bottom’.

Sterile Completely clean and free from living Topical On top of the skin. A topical
micro-organisms. Things usually are not
medicine is put on the skin.

sterile until you boil them or steam them.

Traditions Practices, beliefs, or customs

Sterilize To make things sterile by boiling or handed down from one generation to
steaming for 30 minutes.

another by example or word of mouth.

Sugars Sweet foods like honey, sugar, or fruit Treatment Care given by a health worker
that give energy but often cause tooth and
to fight an illness, attend to an injury, or
gum problems.

prevent a new problem.

Survey A collection of facts about a small Tropical Having to do with the tropics—the group of persons or things in the community.

hot regions of the world.

If the small group is not unusual, the survey

Tumor An abnormal mass of tissue without
results will describe the whole community.

inflammation. Some tumors are due to

Suture A stitch made with needle and thread cancer.

to sew up an opening or wound.

Tweezer Small metal instrument for picking up cotton or small objects. Some persons

Swelling An area of the skin that is abnormally use the word forceps for tweezers, but in
large, puffed up. A swollen area is one that
this book, forceps are instruments for taking
has swelling.

out a tooth.

Symptoms The feelings or conditions that
sick persons report about their sickness.

U
ln this book, symptoms are included with
signs.

Ulcer A break in the skin or mucus

Syringe An instrument with a small sharp
membrane; a chronic open sore that can
needle, for giving injections.

appear on the skin, gums, or gut.

T

V

Tablespoon

A measuring spoon that holds 3

Vaccinations See

Immunizations.

teaspoons or 15 ml.

Vaseline See

Petroleum jelly.

Tartar A hard, rocky coating on the tooth near Vessels See

Blood vessels.

the gums, also called calculus or toothstone.

Tartar forms when old plaque mixes with

Virus Germs smaller than bacteria, which
calcium in the spit.

cause some infectious diseases, like measles

Teaspoon A measuring spoon that holds 5 ml.

or the common cold.

Three teaspoons equal one tablespoon.

Vitamins Ingredients in fruits and vegetables Teething The action of new teeth cutting
that our bodies need to work properly.

through the gums. Also see Eruption.

Volume The amount of space a thing occupies.

Temperature The degree of heat of something, We measure volume in liters, ml, gallons, etc.

such as the air or a person’s body.

Temporary filling A filling meant only to last W
until a permanent filling can be placed.

Weight The heaviness or lightness of a thing.

T.M.J.

The temporomandibular joint. See

We measure weight in kilograms, mg,

Joint.

pounds, etc.

Tooth abscess See

Abscess.

Wisdom teeth

The 3rd molars, which grow

Tooth decay

Damage to the tooth caused by
into the mouth when a person is 16-22 years
acid; cavities.

old.

Toothache Pain in a tooth.

X

Toothpaste A paste for cleaning teeth.

Tongue depressor A tongue blade; a piece

X-ray A special photograph that allows you to of wood used to keep the tongue out of the
see bone, roots of teeth, etc., under the skin.

way when examining or treating the teeth.

230  Where There Is No Dentist 2012

Index A-B-C

INDEX

A

do not cause diarrhea and fever, 65

how baby teeth grow and stay strong, 63

Abscess, 93, 225

knocked out: diagnosis and treatment, 97

and gum bubble, 74

loose, 54

begins with a cavity, 6, 47

make space in mouth for permanent teeth, 64

diagnosis and treatment, 93

marks on baby teeth, 62

flip chart presentation, 30-31

why baby teeth are important, 64

treat at once before infection reaches the

Bacteria (See Germs)

bone, 6

Bandage, head, for a broken jaw, 110

treat pregnant women, now, 15-16

Berry juice

Acetaminophen (paracetamol)

used to show coating of germs on teeth, 53

dental kit supply, 208

Bicycle-powered dental drill, 156

dose for pain, 94-95

Bleeding

Acid

and extractions, 77, 159-160

causes tooth decay and gum disease, 7, 50,

from socket: diagnosis and treatment, 118

225

how to place a suture, 167-168

some sugars make acid more easily, 55

in the mouth: possible causes (chart), 116

Adrenaline (epinephrine), 136, 137, 209

Bleach, for disinfecting without heat, 89

AIDS, Chapter 12, 175

Blood

(See HIV)

boil any instrument that has touched blood,

Alcohol, for disinfecting without heat, 89

87

Allergies to medicines

(Also see Bleeding)

and extractions, 159-160

Blood pressure, 77, 118

penicillin warning, 209

Blood vessel, 46

Amoxicillin, 94,188,190,193

Bone

Ampicillin, 94, 105

bone chips inside tooth socket, 172

Anemia, 16, 105, 123, 225

broken: diagnosis and treatment, 108-112

Anesthetics, local, 135-142

damage from gum disease, 42

dental kit supply, 211

three main bones in the face, 108

Antibiotics, 94, 225

Bones of animals, 41

dental kit supply, 208, 210

Books on dental care, 221-223

doses for tooth abscesses and other

Bottle feeding, 3, 63
problems, 94

Breast feeding, good for teeth, 3

injections, 209-210

Broken bone, 108-112

precautions, 209

Broken root, 171

sulfadimidine, 123

Broken tooth, 96

warning on tetracycline, 63

Brushing teeth (See Cleaning teeth)

Anti-retrovirals (ARVs), 177, 194

Brushstick (homemade toothbrush), 4

Arkansas stone, 128

Bubble (See Gum bubble)

Aspirating syringe, 136, 213, 225

Aspirin, 94

correct dose for pain, 94-95, 209

C

dental kit supply, 208

do not hold against teeth, 209

Cancer, 125, 226

Atraumatic Restorative Treatment, 92, 144, can begin with white lines inside mouth, 105

152-155

diagnosis, 125

Kaposi’s Sarcoma, 194

look for a sore that does not heal, 106

B

Candy, 9

(Also see Sweet foods)

Baby teeth, 62-65

ages when baby teeth come in, 43, 64

Cancrum oris (noma)

begin forming before birth, 62

diagnosis and treatment, 121-124, 191

Canker sores, diagnosis and treatment, 106

Index C-D-E

Where There Is No Dentist 2012 231

Cartridges of injectable anesthetic, 135-136, Cola drink, in experiment on decay, 48

211

Cold sores (fever blisters)

Cavities (caries), 226

diagnosis and treatment, 104, 192-193

can begin as marks on baby teeth, 62

‘Colonies’ of germs on the teeth, 50, 226

can become abscesses, 47

Comparative diagnosis (telling similar problems can make teeth hurt, 46
apart), 80-83

caused sometimes by baby bottles, 3

Cotrimoxazole, 184

diagnosis and treatment, 92

Cotton rolls, 147, 211

fill cavities before abscess forms, 6

‘Cowhorn’ forceps, 161

flip chart presentation, 30-31

do not use on baby teeth, 166

on neck of tooth, 92, 211

Curette (for scaling teeth), 128

puppet show about, 33-34

school survey, 49

D

Cement fillings (See Fillings)

Chair for examinations and extractions, 75, 162

Demonstration, 26, 48

Cheek bone, 108

Dental floss, 71-72, 216

Child-to-Child program, 24

Dental kit, supplies for, 207-217

Children

Dental mirror, 75, 215

as health workers, 24

Dental tools (See Instruments)

can clean their own teeth, 58

Dental workers, can visit schools, 35

cannot learn well if their teeth hurt, 20

Dentures, 169-170

want to learn, 19
bad dentures cause sore mouth, 107

young children should not take aspirin, 94, 209
sores under, diagnosis and treatment, 106

Chlorhexidine gluconate, 185, 187

Diabetes

Cleaning instruments, 75, 87-91

and extractions, 159-160

after extractions, 173

and thrush, 105

after filling a tooth, 151

Diagnosis (See Examination and diagnosis)

after scaling, 134

Diagnosis charts, 80-83

disinfecting without heat, 89
loose tooth, 81

how to sterilize syringes, 138
sore mouth, 82

pressure cooker, 88
sores 82-83

sterilizing with steam, 87-88
swelling, 81

wash your hands, too, 86
toothache, 80

Cleaning teeth, 56, 69-72
trouble opening or closing mouth, 83

can help sore gums, 7

(Also see Comparative diagnosis)

Child-to-Child activities, 24, 53

Diet (See Nutrition)

especially important for persons who take

Dilantin (diphenylhydantoin), 115
certain medicines, 115

Dislocated jaw

experiment to find the best way, 58
after extraction, 173

flip chart presentation, 31
diagnosis and treatment, 113

how to clean a baby’s teeth, 63

Disinfectant, cold

how to clean between teeth, 71-72
for cleaning certain instruments, 89, 212

how to make a brushstick, 4

Doxycycline, 77, 188, 190, 193

how to make a child’s toothbrush, 63

Drama, for teaching about tooth problems, 26

how to make waxed floss, 216

Drawing pictures, 31

make it part of a daily school activity, 59

Drill, dental, 156-157

parents should clean children’s teeth, 11,

Dry socket, diagnosis and treatment, 117

18, 63

pregnant women must take special care,16

‘protected areas’ that are hard to clean, 4

E

soft toothbrush is best, 4, 70

(Also see Gum disease, Scaling teeth)

Elevators for extractions, 161-162, 213

Clindamycin, 123, 191
how to use, 164

Clotrimazole, 187

Epilepsy

Coating of germs on the teeth, 50

and swollen gums: diagnosis and treatment,

115

232  Where There Is No Dentist 2012

Index E-F-G

Epinephrine (adrenaline), 136, 209

Fish bone

Epulis, 133

can get caught under gums, 133

Erythromycin, 94, 188, 190, 191, 193

Flannel-boards, 28, 226

dental kit supply, 208-209

Flesh, left inside socket after extraction, 172

Eugenol (oil of cloves), 146, 211

Flip charts, 29-31, 226

Examination and diagnosis, Chapter 6, 226

example, 30-31

bleeding in the mouth (chart), 116

Flossing (cleaning between teeth), 71-72, 216, different problems come at different ages, 78

226

examining inside the mouth, 79

Fluconazole, 187

four steps to a good diagnosis, 76

Fluoride, 24, 70, 226

and HIV, 180-182

on neck of tooth, 92, 211

how to check the gums, 74

rinse and paste to prevent cavities, 211

look for sores, 74

Food (See Nutrition)

questions that help you make a diagnosis, 73, 76

Forceps for extractions, 161, 213

telling similar problems apart, 80-83

Fracture (See Broken bone, tooth, root)

tetanus, 118

touch the sore place, 79

wear protective equipment, 180

G

where to examine, 75

(Also see Diagnosis charts)

Game (‘Scatter!’), 50-51

Excavator, 145

Generic name, 208

Gentian violet, 105, 185, 187, 208

Expiration date, 226

Extractions, Chapter 11

Germs, 227

before you begin—ask questions! 159

discussion about, 51

four problems to watch for, 160

health workers must not spread germs,

how to take out a tooth, 163-169

85-87

instructions: what to do afterward, 169-173

impossible to kill all germs in mouth, 50

instruments needed, 160-162

where they hide, 87

for people with HIV, 183

Gingivae, gingivitis (See Gums, Gum disease) pregnant women need not wait, 15-16, 77

Glass ionomer, 152

problems afterward, 116-117, 171-173

Gloves, 86, 180, 206

three reasons to take out a tooth, 159

‘Go foods’ (energy foods), 67-68

warning about, 68

Grooves on teeth, 92, 211, 227

F

Gum boil (See Gum bubble)

Gum bubble, 47, 74

False teeth, 169-170

Gum disease, 52-53

(Also see Dentures)

description, 42, 52

Fever blisters,

diagnosis and treatment, 101-103

diagnosis and treatment, 104, 192-193

flip chart presentation, 30-31

Filing teeth to correct a bad bite, 99

home care for, 53

Filling tool, 145

how gum disease makes teeth fall out, 42

Fillings, Chapter 10

learning activity about, 53

cement filling material, 146, 211

noma: diagnosis and treatment, 121-124

glass ionomer filling material, 152

picture of, 7

how to place a permenent filling, 152-155

possible cause of a sore mouth, 82

how to place a temporary filling, 146-151

prevent gum disease during pregnancy, 16

instructions for after you place a filling, 151

serious gum disease: diagnosis and

instruments needed, 145

treatment, 8, 102-103, 121-124

lost or broken: diagnosis and treatment, 92

Gum pocket, 52, 131, 227

permanent fillings, 152-157

Gums

puppet show about, 33-34

definition, 227

two kinds, 144

importance of, 1, 37

what a filling can do, 144

infected gums (noma): diagnosis and

when not to place a filling, 143
treatment, 121-124

when to place a filling, 144

healthy and unhealthy gums: description, 52

Index G-H-I-J-K-L-M

Where There Is No Dentist 2012 233

how to examine, 74

Instruments, 213-217, 227

swollen gums and epilepsy medicine, 115

boil any instrument that has touched blood, 87

swollen gums and pregnancy, 16, 77, 102

buying instruments, 217

why gums can feel sore, 7, 52

for examination, 75

for extractions, 161-164

for filling teeth, 145

H

for scaling, 128

Hands

making your own instruments, 214-216

wash before you touch someone’s mouth, 86

(Also see Cleaning instruments)

Hatchet, 147

Iodine Solution, 103, 123, 185, 188

Head bandage for a broken jaw, 110

I.R.M. (Intermediate Restorative Material), 146

Heart disease, and extractions, 159-160

Heat, can lower swelling, 94

J

Hemorrhage, and extractions, 159-160

Hemostat, 167

Jamaica

Herpes virus, can cause fever blisters, 104, dental workers’ description of gum disease,

192-193

42

High viscosity glass ionomer, 152

Jaw bone, 41

HIV, Chapter 12, 175

broken: diagnosis and treatment, 108-112

common problems, 184

dislocated: after an extraction, 173

definition, 177

dislocated: diagnosis and treatment, 113

dental care, 183

three main bones in face, 108

and food, 195

Joint, 227

how it spreads, 178

pain in: diagnosis and treatment, 114

general treatments, 184-185

prevention, 197-201

Hydrogen peroxide, 8, 185

K

warning: do not use too much, 8

Hygiene (keeping clean), 82-85, 86-90, 184-185

Kaposi’s Sarcoma, 194

Ketoconazole, 187

I

L

Incisors, 39

Infection, 227

Learning (See Teaching)

can pass from tooth to bone, 47

Lidocaine (lignocaine), 136

dental workers can infect others, 85

dental kit supply, 211

description of infected gums, 52

Ligature wire, 110, 227

during pregnancy, 15-16, 77, 96

Loose teeth, 54

in sinus: diagnosis and treatment, 95

diagnosis and treatment, 99

in spit gland: diagnosis and treatment, 119

possible causes (charts), 81, 99

Injections, Chapter 9, 210, 227

how to give injections to children, 141

injections of antibiotics, 210

M

instructions for after you give an injection, 142

Main food, 67-68

safe disposal, 205

Malaria, can contribute to noma, 121

sterilization of syringes, 138

Malnutrition, 227

two types of syringe, 135-136

cavities can help cause, 62

use an aspirating syringe, 138

often made worse by Vincent’s Infection, 102

Instructions

(Also see Nutrition)

what to do after extracting, 169-173

Mango string, can get caught under gums, 133

what to do after injecting, 142

Measles

what to do after placing a temporary

can cause dry, sore lips, 107
filling, 151

can contribute to noma, 121

what to do after scaling, 133

234  Where There Is No Dentist 2012

Index M-N-O-P-R

Medicines in dental kit, 207-210

O

Mepivacaine, 137

Methamphetamine use, effects on teeth and

Oil

gums, 126

prevents rust when sterilizing instruments, 87

‘Meth Mouth’, 126

Oil of cloves, 146

Metronidazole, 123, 190, 191

Milk-oil drink

P

for persons who cannot eat properly, 111

Mirror, 75, 215

Pain

Molars, 39, 43, 66, 227

aspirin or acetaminophen can help, 94

ages when molars grow in, 43

mouth and throat, 195

baby molars, 64

Patches (red or purple) in the mouth, 194

first permanent molar is often the first

Penicillin, 93-94, 208-210
permanent tooth, 64

almost always taken by mouth, 93

infection in new molar: diagnosis and

dental kit supply, 208
treatment, 100

dose taken by mouth, 94, 208

new molar can cause face to swell, 66

injectable, 210
often grow in badly, 43

precautions, 209

taking care of, 66

take entire dose, 93, 209

Mouth

Permanent teeth, 43, 54, 228

dry or painful, 195

knocked out: diagnosis and treatment, 97

trouble opening and closing (chart), 83

need good baby teeth before them, 64

white lines inside the mouth can be

Phenytoin (See Dilantin)

cancer, 105

Pictures

Mouth wash, 103, 183-185, 187

as a teaching aid, 28, 37-38

tracing, 31

Plaque, 50, 228

N

disclosing solution (berry juice), 53

Plays, 26

Neck of a tooth, grooves in, 92

Posters, 28

Needle, hypodermic

Povidone iodine, 103, 123, 185, 188

disposable, for oral anesthetic, 211

Pregnancy, 15-16

safe disposal, 199-206

and dental problems, 15-16, 77, 102, 160

used to wire a broken jaw, 112

women must take special care, 101

Nerve of a tooth, 46, 228

story about, 15-16

main trunks and small branches, 136-137

Pressure cooker for sterilizing instruments, 88

Noma (cancrum oris)

Prevention, 35, Chapter 5, 228

diagnosis and treatment, 121-124, 191
prevention, 124

early treatment is a form of prevention, 61

foods that are good and bad, 55

Nutrition, 67-68, 228

HIV, 197-201

eat a mixture of foods, 11, 67-68

(Also see Cleaning teeth, Nutrition)

eat enough food, 67

Probe, 75, 215

flip chart presentation, 30-31

Pronunciation, why teeth are important for, 37

foods for persons who cannot eat properly,

Puppet shows, 32-34

111, 195

example, 33-34

foods that make gums stronger, 7, 8

Puzzles, 27

foods that we cannot eat without teeth, 38
good and bad foods, 55

good and bad sweets, 3

R

grow foods in your own garden, 11

and HIV, 195

Records, 218, 228

pregnant women need Vitamin C, 16

Reports, 219, 228

tooth pain can interfere with nutrition, 62

Rinsing the mouth

Nystatin, 105, 107, 187, 208

during pregnancy, 16
with hydrogen peroxide, 8, 185

Index R-S-T

Where There Is No Dentist 2012 235
with salt water, 7, 184

Spit gland
various rinses, 184-185

infection in: diagnosis and treatment, 119

Root of the tooth, 41

Spoon
broken: diagnosis and treatment, 171

for extractions, 161
count roots before taking out a tooth, 165

for fillings, 145
has a nerve and blood vessel, 46

making your own, 216
pushed into sinus, 172

Sterilization, 87-89, 217

Root fibers, 41, 228

with steam, 88

Story telling, 15, 26

about pregnancy and dental care, 15-16

S

Sugar

some kinds make acid more easily, 55

Safe disposal of dental waste, 199-206

sugar cane is not as bad as candy, 9

Safer sex, 197-198

(Also see Sweet foods)

Salivary gland (spit gland)

infection in: diagnosis and treatment, 119

Sulfadimidine, 123

Salt water rinse, 7, 184

Surveys, 220, 229

Scalers, 128

as a way of learning numbers, 24, 25

Scaling teeth, Chapter 8

counting cavities, 49, 220
instruction for after you scale teeth, 133-134

counting teeth, 44-45
instruments for, 128, 213

to find the best way to clean teeth, 58
only scale teeth of someone who will keep

Sutures, 167-168
teeth clean, 127

Sweet foods, 9, 46, 55

‘Scatter!’ (game), 50-51

avoid fizzy drinks, 11

School

can cause cavities and gum disease, 6-7
cleaning teeth can be a daily health activity,

learning activities, 48

59-60, 211

some are called ‘go foods’, 67-68
school lunch program, 57

Swelling

(Also see Teaching)

and epilepsy medicine, 115

Scientific method for making diagnosis, 76

and pregnancy, 102

Sewing up a wound (suturing), 167-169

after extractions, 116, 172

Sharpening stone, 128

different problems come at different ages, 78

Shots (See Injections)

from a tooth abscess, 6, 47

Sinus

heat can lower swelling, 94
infected, diagnosis and treatment, 95

may be a new molar coming in, 66
root pushed into sinus, 172

possible causes (chart), 81

Slides for teaching about dental health, 221

Syringes

Socket, 228

aspirating, 136, 213
broken root inside, 171

for injections: two kinds, 135-136
painful (dry socket): diagnosis and

(Also see Injections)

treatment, 117
painful, 173

T

Soreness in mouth, possible causes (chart), 82

Sores

Tartar, 52, 229
around the mouth, 107

can be a sign of gum disease, 79
at corners of mouth: diagnosis and

how to scale, 129
treatment, 107

makes gums sore, 8
different problems come at different ages, 78

Teachers
from a denture: diagnosis and treatment, 106

can teach without dental worker’s help, 36
on the face, 120

Teaching
on lips, cheek, and tongue, 74, 188

‘association of ideas’, 14
types of face sores (chart), 83

by example, 57, 199-200
types of mouth sores (chart), 82, 188

community can be part of classroom, 25

Spatula, for fillings, 145

each person can teach another, 12

finding the best way to teach, 13-18

236  Where There Is No Dentist 2012

Index T-V-W-X-Z

finding the best place to teach, 17

Tooth decay

learn from the people, 13

can touch nerve and cause an abscess, 6

let students discover for themselves, 20, 24

flip chart presentation, 30

repetition helps people remember, 17

(Also see Cavities)

teach yourself before teaching others, 2, 201

Tooth injuries

teaching family and friends, Chapter 2

broken tooth: diagnosis and treatment, 96

teaching school children, Chapters 3, 4

tooth knocked out: diagnosis and treatment

teaching so that learning can happen, 20-24

97-98

with demonstrations, 26

Toothpaste, 5, 69

with drama, 26

Tracing pictures, 31

with posters and pictures, 28

Traditional beliefs, 10, 13, 229

with puzzles, 27

about pregnancy, 15

with story telling, 15-16, 175-176

building new traditions from old ones 14

(Also see School)

Treadle-powered dental drill, 156

Teeth

Treatment, Chapter 7

and gums, 1

can be given during pregnancy, 15-16, 77,

broken, 96

102, 160

four problems to watch for, 73

early treatment prevents serious problems, 2

how many teeth we should have, 43

Trench mouth:

importance of, 1, 37

diagnosis and treatment, 102, 189

injuries to: diagnosis and treatment, 96-98

Tumor, diagnosis and treatment, 125

learning about anatomy, 49

Tweezers, how to make, 215

loose: diagnosis and treatment, 54, 99

naming teeth with numbers, 218

new tooth coming in:

V

diagnosis and treatment, 100, 101

rotting in cola drink (experiment), 48

Vegetable soup (special drink)

what holds teeth, 41

for those who cannot eat properly, 111

what makes teeth hurt, 46

Vincent’s Infection of the gums

why some teeth look different, 39

can worsen and become noma, 121-124

(Also see Baby teeth, Loose teeth)

diagnosis and treatment, 102-103, 189-190

Teeth, false, 169-170

Vitamin C, 16, 103, 124

(Also see Dentures)

Teeth, taking out, Chapter 11

(Also see Extractions)

W

Teething: diagnosis and treatment, 101

Wax, to replace a knocked-out tooth, 98

Tension

Wire ligature, 110

can cause pain in joint, 114-115

Wisdom teeth (3rd Molars) (See Molars)

Tetanus

diagnosis, 118

Tetracycline, can hurt baby teeth, 63, 77, 208

X

Theater, 26

Thrush: diagnosis and treatment, 105, 186-187

X-rays

Tongue blade (tongue depressor), 75, 212

for knocked-out teeth, 98

Tools (See Instruments)

to look at new tooth growing in, 100

Tooth (See Teeth)

warning about pregnant women, 77

Tooth abscess (See Abscess)

Toothache

possible causes (chart), 80

Z

why teeth hurt, 46

Zinc, 103

(Also see Abscess)

Zinc oxide, 146, 211

Toothbrushes

how to make your own, 4-5, 23

how to make a brush smaller for a child, 63

soft is best, 4

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To order books in English or Spanish, or to learn more about Hesperian Health Guides, contact:

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Document Outline

- Copyright Information
- Thanks
- Contents
- Introduction
- Chapter 1: Your Own Teeth and Gums

- Chapter 2: Teaching Family and Friends in Your Community

- Chapter 3: Teaching Children at School

- Chapter 4: School Activities for Learning About Teeth and Gums

- Chapter 5: Taking Care of Teeth and Gums
- Chapter 6: Examination and Diagnosis
- Chapter 7: Treating Some Common Problems
- PART 1: Problems You Will See Most Often
- PART 2: Some Special Problems
- Chapter 8: Scaling Teeth
- Chapter 9: Injecting Inside the Mouth
- Chapter 10: How to Fill a Cavity
- Chapter 11: Taking Out a Tooth

- Chapter 12: HIV and Care of the Teeth and Gums

- Appendices
- Resources
- Vocabulary
- Index
- Other Books from Hesperian

Table of Contents

- Copyright Information
- Thanks
- Contents
- Introduction
- Chapter 1: Your Own Teeth and Gums

- Chapter 2: Teaching Family and Friends in Your Community

- Chapter 3: Teaching Children at School

- Chapter 4: School Activities for Learning About Teeth and Gums

- Chapter 5: Taking Care of Teeth and Gums
- Chapter 6: Examination and Diagnosis
- Chapter 7: Treating Some Common Problems
- PART 1: Problems You Will See Most Often
- PART 2: Some Special Problems
- Chapter 8: Scaling Teeth
- Chapter 9: Injecting Inside the Mouth
- Chapter 10: How to Fill a Cavity
- Chapter 11: Taking Out a Tooth

- Chapter 12: HIV and Care of the Teeth and Gums

- Appendices
- Resources
- Vocabulary
- Index
- Other Books from Hesperian