Where There Is No Dentist Murray Dickson

Where There
Is No Dentist

by Murray Dickson

with an Introduction by David Werner,
author of Where There Is No Doctor

Compiled by noonya

Library of Congress Cataloging in Publication Data
Catalog card No. 82-84067

Dickson, Murray

Where there is no dentist.

Includes index.
Palo Alto, CA: Hesperian Foundation
ISBN: 0-942364-05-8

First edition, November 1983
Seventh Printing, July 1996

PUBLISHED BY:

The Hesperian Foundation
P.O. Box 1692

Palo Alto, California 94302
U.S.A,

Copyright ©1983 by The Hesperian Foundation

This book is certainly not intended to be the last word in community
dental care. It is only a beginning. The author hopes to rewrite and
improve the book with suggestions from readers.

Note on the use, adaptation, and translation of this book:

Each country is special, with its own
particular customs, health needs, and
ways of caring for people.

This book, therefore, must be adapted
by dental workers in each country, using
the language that is common to the local
health workers there.

The author would be pleased to assist
in any way with those who would translate
or adapt the book.

The Hesperian Foundation encourages others to copy, reproduce or adapt
to meet local needs, any or all parts of this book, including the illustrations,
provided the parts reproduced are distributed free or at cost

—not for profit.

Any organization or person who wishes to copy, reproduce or adapt, any or
all parts of this book for commercial purposes, must first obtain permission
to do so from the Hesperian Foundation.

Please contact the Hesperian Foundation before beginning any transla-
tion or adaptation to avoid duplication of efforts, and for suggestions
about adapting the information in this book. The foundation would appreci-
ate receiving a copy of any materials in which text or illustrations from this
book have been used.

We would like to rewrite this book and incorporate many of your ideas.
If you have a suggestion, please write to Murray Dickson at The Hesperian
Foundation. Better yet, if you write your own manual, please set aside
two copies and send one to The Hesperian Foundation, Box 1692, Palo
Alto, California 94302, USA. Send the other to AHRTAG (Appropriate
Health Resources and Technologies Action Group), 29-35 Farringdon
Road, London EC1M 3JB, England. Both organizations would like to help
pass along your ideas to others.

THANKS

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 | 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, | was
able to take teaching notes and produce a suitable draft that was the basis for this
book. To you, David, for 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 The Hesperian Foundation 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 | sincerely appreciate it.

y 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, | 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.

| 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 Bail,
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, | am grateful to the Ella Lyman Cabot Trust, Muttart
Foundation, the Canadian Organization for Development through Education, and the
James C. Penney Foundation.

| 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 (6 Canonbury Place, London N1 2NJ, 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, | most gratefully say thanks.

Finally, | 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 ina
graduate study program. For much longer than | 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 Jove and a growing sense of understanding. It is my only disappointment that
they did not live to see this book in its final form.

CONTENTS

INTRODUCTION, by David Werner

Part One: Learning and Teaching about Teeth and Gums

Chapter 1: Your Own Teeth and Gums .. 2... .0.0.0 00000 ee eee 1

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

Chapter 3: Teaching Children At School. . 1... es 17

Chapter 4: School Activities for Learning About Teeth and Gums. ......... 33

Chapter 5: Taking Care of Teeth and Gums .......... 0.0000 eee ee 59
Part Two: Treating Dental Problems

Chapter 6: Examination and Diagnosis ......... 2.0.00 eee eee 7)

Chapter 7: Treating Some Common Problems .............00 00050 ee 81

Chapter 8: Sealing Teeth: 340. 2 aca eects Das hee bee ee ek Ad 12)

Chapter 9: Injecting Inside the Mouth ....... 0... cee eee 129

Chapter 10: Cement Fillings... 0... 0. ce ee 137

Chapter 11: Taking Out a Tooth... 2.0... es 147
REFERENCE PAGES: 4 nc..0 hac Seed eae a Sie en Ge SPE He 163

The Dental Kit

Records, Reports, and Surveys

Story Telling

Dental Health Teaching Materials

VOCABULARY? tos syece ted, be te at el nth tog LER oh sled ode tN Aes caan sols dan 182

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 ‘Hfe-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 /s 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:

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

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

e 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.

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
helo 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 foot-pedal
drills, who drill and fill teeth at remarkably low cost,

{n Honduras, dental technicians (who learn largely from each other,
starting as heloers) have formed their own union. Their political strength
recently 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 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 Jost.

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 | 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.

Where There Is No Dentist has 2 parts. The first part (Chapters 1-5)
discusses teaching and learning about preventive care. |t 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, Paoua 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:

| 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 pravide 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.

We hope that this will be only the first volume of Where There Is No
Dentist. \t takes the reader as far as simple extraction (pulling) of teeth
and placement of temporary fillings. As we have seen, village workers can
also learn a wide range of more difficult dental skills. We hope that later
volumes of Where There /s No Dentist will include permanent fillings,
homemade portable drilling equipment (many kinds have been developed),
the making of false teeth, and root canal treatment. There is no reason
why village workers cannot learn all of these skills and practice them at
low cost to serve the millions who are unserved today.

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.

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.

EEE
el Ze

mK
What can good
teeth give you?

e GOOD HEALTH
e GOOD LOOKS

e GOOD SPEECH
e GOOD EATING
e 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!

You can usually tell if your teeth and gums are healthy or not. Look at
the pictures on pages 71 and 72 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.

lf 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. ,

BY EATING ONLY
GOOD 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 wil! 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.

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

can drink from a cup. or fruit juice can easily make holes
in the child’s teeth.

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.

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.

grooves 1TOprevent problems you must take special
ontop —_ care to keep these protected places clean.

It is better to clean your teeth carefully
between

NEMEC ~ the teeth - Ne every day than to clean poorly many
_near the gums 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, 2. Cut a piece that is still
young bamboo, strong green and soft.
grass or the skin from ,
sugar cane or betel nut.

S
3. Chew one end to make 4. Sharpen the other end so
it stringy like a it can clean between the

teeth (see pages 69-70).

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 67).

Toothpaste is not necessary.
Charcoal or even just water is
enough. When your teeth are
clean, rinse away the loose
pieces of food.

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.
lf 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. A cental worker knows how to
fill the cavity so you can keep that tooth. Do this before the pain gets

If you do When decay touches When infection
not fill a cavity, the nerve inside, reaches the inside
it grows bigger. the tooth aches, of a tooth, it

It also grows even when you try is called a tooth
deeper. to sleep. abscess.

A tooth with an abscess needs treatment at once, before the infection
can go into the bone (page 87). In most cases the tooth must be taken out.
\f 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 for pain. See page 88 for
amount.

3. Reduce the swelling:
e hold warm water inside your mouth near
the bad tooth.

e Wet acloth with hot water and hold it
against your face. Do not use water hot
enough to burn yourself!

A tooth abscess can cause
swelling like this.

_ 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 48).

HEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE

Infection from gum disease can spread into the root fibers and bone (see
page 40). 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 (see p. 4) 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:
e Eat more fresh fruits and green leafy vegetables, and fewer soft
sticky foods from the store.
e 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.

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.

1. 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.

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

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

4. 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, 1/2 cup of hydrogen
peroxide with 1/2 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.

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 was NOW, more people are buying
their own, grown and prepared by softer and sweeter food from the
themselves. 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 as Everyone must be more careful
the sticky candy children eat today. to clean away soft, sweet food.
The sugar was bad for the teeth, but But many people do not know
the fiber in the cane helped rub how. Some, especially children,

them clean. do not even try.

10

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.

THERE MAY BE ANOTHER
REASON. EATING SWEET FOOD
AND NOT CLEANING YouR

M

TEETH CAN HURT o
A iy

UNCLE.
HIM ANGRY

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.

BUT WE CAN MAKE
FOR OURSELVES MANY
OF THE THINGS THE
STORE SELLS.

YES, AND WE CAN
MAKE OUR OWN
TOOTHBRUSHES FROM

OUR PEOPLE DO Not
USE TOOTHBRUSHES.
WE DO NOT HAVE MONEY
TO BUY SUCH THINGS
AT THE STORE.

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 wil! 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.

Ss

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.
iF Your friends will notice clean
STN teeth or teeth that are dirty or

oe 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 16).

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

KEEP YOUR TEETH
AND YOUR
CHILDREN’S TEETH
WEALTHY BY

; CLEANING THEM,

MARIE, PLEASE HELP
ME CLEAN BABY’S
TEETH AND THEN

BROTHER’S TEETH.
WE WILL DO IT
EVERY DAY.

FIRST, I
MUST CLEAN
MY OWN
TEETH PROPERLY,

THEN MAYBE MY
TEETH WON'T HURT
LIKE VINCENT’S,

... TO THE SCHOOL... ... TO THE HOME

BROTHER, TRY To BRUSH
YOUR BACK TEETH BETTER.
IF YOU DO, THEN THEY

WILL STAY STRONG UNTIL
YOU GROW OLD.

USE A SOFT TOOTHBRUSH.
A SOFT BRUSH IS BEST
BECAUSE IT WON'T
HURT YOUR GUMS.
TELL YOUR
FAMILY THAT.

WHAT SHOULD
T 0O IF MY
GUMS BLEED?

WISH [ HAD
KNOWN ABOUT
THAT BEFORE.

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

13

FINDING THE BEST WAY TO TEACH

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

IMPROVING ORAL HYGIENE CAN
SIGNIFICANTLY REDUCE. THE

INCIDENCE OF DENTAL “<&
Bi

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 p. 176.

14

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

Just as sweeping the in the Brushing the teeth and gums
compound makes it a clean same way keeps them clean and

and healthy place to live.

aed Aa?

Asmall child cannot find his in the A small child cannot see the

own fice. Mother knows she same way food on his teeth. He needs
must help him. help with that also.

Eating different kinds of
food helps people to grow.

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

to grow. body, grow stronger.

15

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:

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

e 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.

e 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.

e Let people see what you mean. See pages 24 to 32 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 as they
sit together and
discuss important
issues, Also go to
their business and
farming meetings.

Talk to women at
health clinics, in the
market, and at their
church meetings.

Teach men and women
at reading groups.

16

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 Jearn 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 have lice -
removed from his hair.

Now let each mother clean her own Ask her to do the same at home

child’s teeth. Teach her to clean on each day. At the next clinic, look at

top and on both sides of every the children’s teeth and see how

tooth. : well the mothers are doing. Give
further help when needed. Always
praise and encourage those who are
doing well.

17

CHAPTER 3

Teaching Children
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 the 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 afl 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 grand-
parents. 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. |n Chapter 4 there are nine questions on
teeth and gums with specific activities for learning how to answer them.

18

PART 1: TEACHING SO THAT
LEARNING CAN TAKE PLACE

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

WHAT 15 THE MATTER, LI?
YOU ARE NOT
KEEPING UP WITH
THE OTHERS.
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.

“7LEARN THIS AND DON?T ASK ;
WHY | — BLA, BLA, BLA... A student learns not to question. What you
m™, teach may have no relation to his own
I ws he We experiences and needs.
is j
Se

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

WHAT DO YOU THINK
ABOUT THAT?

RIGHT SIR,

WELL, I WOULD LIKE TO
LOOK AT MY BROTHER'S
TEETH FIRST.

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.

19

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 your 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. Beagood 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 PERMANENT SUCCESSOR LIES

APICAL TO... PAY ATTENTION !
YOU NEED TO KNOW THIS FOR

YouR TEST!... EACH PRIMARY

A discussion draws
out information and
opinions.

A LOOSE TOOTH
MAY BE
ROTTEN.

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.

20

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.

DEGLUTITION

a Tm

This way makes students feel stupid.

el \
BINNe—EsoRHAQUS

WHAT pe
PARTS HE

you To CHEW
AND SWALLOW! ?

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

RE. something about it.

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

21
3. Let Students See and Do.

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

AN OLD CHINESE SAYING : You

CAN MAKE A
TOOTHBRUSH

PLHGART. <Veunc

| FORGET IT. | Twig.

F | SEE (T,
REMEMBER IT.

|
|

NOW, CHEW
ONE END

IF | DOIT TO MAKE JT

SOFT ANDO
| KNOW IT. STRINGY,

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.

22

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:

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

(2) They can do a play or puppet show
about care of teeth and gums.

(3} They can check the teeth and gums of:
the younger children and ‘score’ them
on how healthy they are (see p. 58).

Here a group of school children

(4) Best of all, they can actually clean the — in Ajoya, Mexico is putting a
teeth of the younger ones, and show high-fluoride paste (see p. 167)
them how to clean their own teeth on the teeth of the younger
when they are able. children.

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 same 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.

“STORE FOOD

Number sellin
hd

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
asurvey 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 Program,
Institute of Child Health, 30 Guilford Street, London WC1N 1EH, England.

23

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.
e Clean your teeth carefully every day. Also, help your children keep
their teeth clean.
e Make a garden near your house and plant a variety of vegetables and
fruits in it.
e 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:

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

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

e 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.

24

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 38). 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 177-179.

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 46.

25

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:
YNUTS fy al

VEISH em EGG ©

BRUSH 2G / ips

S
NY
TOOTH i GUMS GOOD
As you find each word, put a V beside it.

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

VILLAGE
CO-OP STORE

befrisvtesvy

ganprqxoami

uvxofeaorsn abscess cola
misg steof h
otenee uy hw ye Y sugar booths e
iycsocolaobec cavity Vv maize
scG/smpscufr\t f
206 Boldin ook vials V sore Beecn lee
afaelneertglo infection gum disease
scbpnusntiujn

e@aizer t disjb

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

26

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.

aot he) Deen Ld
TAK
at Youn

Ae
Let each child carry her poster home a

to show her family and friends. aa
Hang up other posters in the store, =|

church, or other places where peaple co
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 sand-
paper 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.

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

27

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.

This is part of a flip chart presentation on
mothers’ and children’s health. Notice the
rings at the top that hold the flip chart
together. They are made from old
electrical cords.

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 ‘flio chart
story’ to others.

There is also a
small copy of the
big picture on the
back of the page
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

28

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 asore 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.

29

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.

&
Qu )

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 Health 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
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.

30

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

Mr. Lyam, you should
feel shame for selling
that kind
of food/

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

Using puppets, it is often easier
to say things that people them-
selves 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 we J
cardboard face ZN
to the bag. G

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.

4) One day later.

(Note how the scene behind the
puppets changes. It is a flipchart with
pictures to show the different places
the puppets ‘go’.)

5) “| ama poor farmer,” Pedro’s father
tells Maria. ‘’l only go to the city two
times a year to sell my crops. | 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.’’*

oO

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

"Good!" says the father.

“Come on, Pedro,”’ says Maria, ‘‘l’ll
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.

ies

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!”

a
i
a

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

31

PUPPET SHOWS—AN EXAMPLE*

ated

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, aschoolboy, 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. ‘I’m
not sad because the others are
laughing,” says Pedro. ‘| 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.

33

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 famities) 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. BY

| EATING ONLY GOOD
HEALTHY FOODS
AND
2.CLEANING MY
TEETH CAREFULLY
EVERY DAY,

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.

34
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:
1. Why do we need teeth and gums?
2. Why do some teeth look different?
3. What holds the teeth?
4. How often do teeth grow in?
5, What makes teeth hurt?
6. How do germs make holes in the teeth?
7. What makes the gums feel sore?

8. What does it mean if a tooth is loose?

9. 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.

35

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,

Ow ey yr aie
Se Ve en nn not bad teeth.
THE ACTIVITY:

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.
EEKLY NE

caf
Mise,

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.

36

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.

snot

v’ and “'f" — friend, fever — the lower lip
touches the top teeth.

a “th'’ — the, teeth — the tongue touches the
in 2k, top teeth.
Coe)

sae

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.

37

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.

Small bits of food
often get caught
inside deep lines, or
grooves, in a tooth.

Food that is not
cleaned away from
the grooves can make
a cavity (hole) in

Look for them on the ~ them.

top and the sides of
back teeth.

A tooth with a cavity
is weak and often
hurts.

38

THE ACTIVITY:

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

cae TEETH DID YOU USE
TO EAT THE MANGO? i

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.

oe:

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!)

39

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 tree hold it
firmly in the
ground.

root

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

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.

THE ACTIVITY:

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. Se
Break away some of the bone Hil | h we

and look at the roots of the f et A Ak
teeth.

») Front teeth need only one root
Se because they are used for biting.
COP aa

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

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

C

gum
pocket

bone-
pulling
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)?” ‘| 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 astory to show how, when the gum moves away from the top of
the tooth, the root and bone are open to attack. For example:

Enrique was sleeping on a cold night when suddenly he had diarrhea.
Still dreaming, he went outside, and afterward, he forgot to close his pants
tightly. Suddenly, he saw an ugly monster coming after him! He ran away
without thinking of his pants. Finally he could not run because his pants
were around his knees, and the monster caught him.

Explain to the children that when the gums are red near a tooth, they
are like Enrique’s pants—not tight enough around the tooth. When germs
come near the tooth, they will go inside and the gums will ‘fall down’ and
show part of the root of the tooth. When this happens, the germs attack
not only the top of the tooth, but also the bone and root.

41

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 four 1st 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 four 2nd permanent
molars grow in behind the 1st
molars. This means a 14-year-old
child should have 28 teeth, or
spaces for them.

Between 16 and 22 years, the four
3rd permanent molars grow in. This
means that an adult should have 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 64.

42
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.
ee

Show the students PERMANENT TOOTH
how to count the :
teeth and the spaces )

that are ready for LOOSE BABY TOOTH
new 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.
e Wash your hands.
e Count the teeth.
e Count the spaces where new teeth have not yet grown in,
TOTAL = teeth + spaces

e 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.

Lessow: Number of Tee#h We Should Have

ToTar = teeth now present (T) + spaces (§)

* Here the children are only counting the teeth. They can also learn to check for cavities and gum
disease (see p. 47).

43

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 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.

Lesson: Number of Teeth sn a Small Che led

under 1 year | ae years old | 2-3 years 0

e5oi I

CPELL. £
LAs
ypedd ri fis

@) —
Chenia
(sistev}
pete diddé
; reitt
ie So

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 53 to 58.

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 61 to 63 to find answers to questions like
these:

e Can Chenia, who is six months old and has no teeth, eat soft foods?
Should she have more than just breast milk?

e When Chenia’s teeth grow in, will they give her diarrnea and fever?
e Will a 2-year-oid girl get more baby teeth?

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

44

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. !t comes
from the heart and carries blood to the tooth.

onme NERVE
axa BLOOD VESSEL

\f 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.

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

y
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.

ye

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 net useful any more.

45

46

THE ACTIVITY:
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 4 sticky, very sweet coating
to form on your teeth. |t 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.

47

~ 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 asmall 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 grind it for you.
OR

. Take a hammer.

2, Gently break open a tooth.
3, Look inside.

See how much bigger the cavity is on
the inside. It 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.
e Count the number of students with cavities.
e Count the number of teeth having cavities. Show the students how
to look for them on the tops, sides and between the teeth.
e Find out the person’s age.

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

Toot] DECAY IN OUR SCHOOL
NUMBER OF STUDENTS AT SCHOOL

NUMBER OF STUDENTS WITH CAVITIES 1.6

Ny GEARS TyEars S years PysaRs \OyEAR il yeaes (Z years

WAT ogee La Lae tit

e 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: he!p you prevent the problem from returning.

e 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.

48

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 p/ague, 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 50).

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:

e 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.

e One person with a broom.
This person is the

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

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.

t

The ‘decolonizer’ (with broom) has fost the
game. The children behind him have formed
a ‘colony’.

Here the decolonizer stops a boy from
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 fee!
like in the morning when they
wake up. You may get these
answers:

e my teeth feel mossy!

e my breath is bad.

e | feel a coating on my teeth,
but it goes away when |
brush them.

THAT'S
RIGHT /
THEY ARE
MUCH TOO
SMALL TO
SEE!

49

The colonizers win if they make
a colony. There are two kinds of
colony: (1) 15 people touching
one monitor at a base, or (2) a
chain of 12 people haltding
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
from the second game.

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
colonies form in 5 minutes,

HOW MANY GERMS
DO You SEE IN
THIS CIRCLE ?

To teach about things too small to see, look at
the suggestion on page 11-29 of Helping 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!

50
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.

Se z

Wy

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. 48), 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.

i aN

VA /

Healthy gums become sore because of acid. Also, if the coating on the
teeth (p. 48) becomes hard, it is called tartar. Tartar can be very sharp
and 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 to cause tooth and gum problems. After 24
hours, they harden and make a new layer of tartar. The tartar gets bigger

and bigger.
; Here is a larger picture of the teeth in the box above:
Sore gums are infected.

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.

51

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

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

1. Clean your teeth with a
soft brush gently and more
often. (see page 69)

. Eat more fresh fruits and
vegetables,

. Rinse your mouth with
warm salt water.

. Clean between your teeth
with dental floss or string.
At first your gums may
bleed when you do this.

DE . But when the gums are

stronger the bleeding will

stop.

THE ACTIVITY:

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. c

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:

e between the teeth
e in the pits or holes in the teeth
e on the tops {biting surfaces) of the teeth.

The older students can now show the younger ones the best way to
clean teeth (see pages 67-70). Let the younger ones see in the mirror 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 even the soft stem from a young palm leaf,
and show them how to use it between their teeth (p. 70). Remind them to
be gentle, or they will hurt their gums. You should clean between your
teeth every day.

52

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
ABSCESS ‘
WITH BOIL teeth. All you can do is stop the
infection from getting worse.

GUM DISEASE

THE ACTIVITY:

1. Let the students look into each other's mouth for loose baby teeth.
Look carefully to see why a tooth ts 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.)

How Can We Prevent Cavities and Sore Gums?

Eating good food and carefully cleaning the teeth prevents 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.

ueMeF A & & & OO

Oil, from palm nut
kernels, ground nuts,

Vegetables, especially
those with dark green
leaves.

Hoof

Fruits, like banana,
guava, oranges, and
papaya,

Peas and beans, like green
beans, soybeans, winged
beans, and mung beans. and coconut.

yf Wing

Fish, meat and eggs.

7

i, ©DS

best 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, from your
garden or in the market.

Clean water, coconut
water, and milk are

54

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.

TEA

Reasearch nar naqurennageaaneaunr ruvamtvaan Teeemananenenerereeerera een Seay

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. 16 to
see how you can do this. Older children can care for younger brothers and
sisters at home.

THE ACTIVITY:

One of the best ways to teach is by example.

AND SO AT HOME WE
PUT BOTH DRIED FISH
AND GREEN LEAVES
INTO THE SOUP. MY
CHILDREN LIKE IT VERY
MUCH. YOU WILL TOO!

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.

55

56

3. Find the best way to clean teeth. Divide the class into groups. They
will learn more easily in asmall 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.

SARA

eat a sweet
sticky food
and

OR

rinse 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.

BETTER «=.

etitepiaty O

MARIE DID LAURA RINSED VINCENT ATE SARA BRUSHED
NOT CLEAN ONLY WITH WATER A CARROT AND RINSED

57

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
51.) 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 afterward. Encourage them to keep a piece of soap and a toothbrush
or brushstick (p. 4). One day a week, the whole class can rinse with
fluoride water (p. 167) to prevent cavities.

The student
can keep the

Ss brush at her
—— oe own desk...
A piece of bamboo can hold a brush
nicely, Make two holes near the er
top for some grass string, to hang
the bamboo brush holder.
prea -..orona
Sa, rack at the
= back of the
Say room.

Let each student look after her
own soap and brush.

58

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 1

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 point
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 point
Tooth 3 =0 point
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.

eo ee ee eo 2 2 830 5

Day 1224567 BPONM tH Horr

Month of 2 March

59

Taking Care of 5
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.

I HAVE NEVER SEEN THIS PROBLEM,
BuT T HAVE A FRIEND IN THE CITY
WHO CAN HELP. LT WANT TO GO WITH
You TO LEARN WHAT f CAN.

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.

60

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. 61) 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 lio 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 78). That cavity should not be

filled with cement. Instead, the tooth needs
to be taken out (Chapter 11) before the
infection can get worse.

61

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

1. Eat enough good kinds of foods, both for herself and her baby
growing inside (page 66; also see Where There Is No Doctor, Chapter
11, and Helping Health Workers Learn, pages 25-39 to 25-44.)

2. 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).

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

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

1. Continue to breast feed and never feed her child juice or sweet tea
from a bottle. Start adding soft foods, mashed banana or papaya
when the child is 4 months old.

2. 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 67).

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 with scissors.

*See the story about pregnancy and dental care on pages 177-179.

62

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.

Under each baby tooth a new permanent
tooth is growing.

At the. same time, extra permanent
molars are forming at the back of the
mouth, inside the bone (page 41).

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
Permanent molars (PM) come in ready to grow in first.

behind the baby molars (BM).

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

26n 26™

LPM
1PM

The first permanent molar grows into Slowly but steadily the upper and
the mouth by sliding against the lower permanent molars grow until
back of the second baby molar (2BM). they meet and fit tightly together.

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—— to make—» STRAIGHT PERMANENT TEETH

10 years adult

help
SICK BABY TEETH ————— to make > CROOKED PERMANENT TEETH

i}

MOVING INTO NOT ENOUGH
THE CAVITY SPACE

10 years

adult

Tell mothers why baby teeth are important. Good food and regular
cleaning keeps 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).

64

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.

CAVITY

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 ona
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.

\f 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.

\f it does appear serious (severe pain, swelling, not able to open the
mouth), see page 88 for further treatment.

65

TAKING CARE OF ALL YOUR TEETH

This book often repeats an important message: eat good food and clean
your teeth. |t is repeated because this is the most important thing you
can learn from this book. Later chapters will discuss what to do when
problems occur, but if you follow these two suggestions, you wil! 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 48) or harmful factory sugar (p. 53) on your
teeth, your mouth cannot make the acids that cause both tooth and gum

problems. So, rermember:

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 two things:

One, eat a mixture of different kinds of foods
every time you eat. Look at the pictures on page
53. 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 three important
kinds of food: GROW FOOD (body-building food)
to give you the protein you need; GLOW FOOD

The MAIN FOOD is (protective food) to give you vitamins and
at the center of minerals; and GO FOOD (concentrated energy
every meal. food) to give you calories to be active all day.

Two, 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 energy food with almost
every meal. Depending on the area,
this MAIN FOOD may be rice, maize,
millet, wheat, cassava, potato, bread-
fruit, or banana. The MAIN FOOD is
the central or ‘super’ food in the local
diet.

A spoonful of cooking oil added to a
child’s food means he only has to eat
about 3% as much of the local main food
in order to meet his energy needs. The
added oil helps make sure he gets enough
calories by the time his belly is full.

66

GROW FOODS

cD
o
oOo

Be sure THE MAIN
always to eat oops AND
GROW FOODS ‘GO FOODS’
and GLOW GIVE US THE
FOODS to get ENERGY TO
the vitamins RUN, WORK
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 FOOD gives 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.

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.

67

68

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.

NO

You can make a hard brush softer by ee ee mee ee
putting the hairs into hot water for a y

few minutes. 9

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

\f your store has only hard brushes, tell the storekeeper 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, vitamins, and mouth rinses,
helps to prevent cavities. These methods are sometimes expensive.
Perhaps the most effective and inexpensive method is the weekly
rinse at school, described on page 167.

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:

69
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
Zz y 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.

Buy and use Dental Floss.

Get some thin cotton rope This is a special kind of
used for fishing nets. Unwind OR | string for cleaning
and use one strand of it. 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 learn how
to ‘floss’ your teeth is to have someone show you. Ask a dental worker
who has experience.

70
Wrap the ends of the string around the middle finger of each hand.

0,

es

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.

iw

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.

71

CHAPTER 6
Examination
and Diagnosis

CARE THE TEETH HEALTHY? Oo

ise

fous 7“

Whenever you do an examination, Gee Tie ums wenerae DO" \

remember to examine the mouth. ewe S
<p

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 When you look inside
remember what treatment that person needs. someone's mouth, ask
yourself three questions.

1. Are the teeth healthy?

Look:tor: Tell the person what
, is happening and how
1. A New Tooth (SS to keep the skin
around it healthy
/ (page 64).

They may be
cavities, which
should be filled
when they are
still small
(page 45).

Tell the person what

is happening and how
to prevent it from

fi: getting worse or

ogee affecting other

teeth (page 52).

A tooth that is dark is dead.
Infection from its root can
go into the bone (p. 45).
This can make a sore on the
gums (p. 72).

72

2. Are the gums healthy?

Look at page 50 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 ry ame _—
gums. Scale the tooth carefully. See Chapter 8.
A bubble beside a decayed tooth is a sign of a tooth se hs
abscess. See page 87. oS ag OF
1 Ss py
A sore on the gums from a badly decayed tooth ~ Le 2
appears when a gum bubble breaks open and lets out /
the pus from inside. GUM BUBBLE

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.

}¥ @

i Yon am on Fae
WAC

1. Asore on the gums | 2. Sores on the inside | 3. Sores on the lips
may be from an of the lip or cheek or tongue may be
infected tooth may be from a virus cancer (p. 119).
(p. 87). (p. 98).

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. {f there are no problems and the mouth is healthy, congratulate
the person,

Share your knowledge—explain things to people.
Help them learn how they can prevent and
even manage their own problems with their teeth.

73

WHERE TO EXAMINE

Examine people in a light and bright place. !t 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 asmall 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 fean back.

THE INSTRUMENTS YOU NEED

Three instruments are really enough:

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

EEE ee) 2. Asmall 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 85.

74

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.

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 what the
person has, Now try to find out
more by asking questions:

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 sarahalls than before. |

4. Touch the place that is sore.

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.

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 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.

75

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 is not necessary. 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 woman’s mouth
problems now. In fact, this may be an important way of protecting her
baby as well. See pages 177-179.

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.

CHILD

Swelling can come from

e mumps

ean infection
in the spit
gland (p. 113)

@a tooth abscess
(p. 87)

CHILD
A sore can come from
e impetigo
e Vincent’s

Infection
(p. 96)

SWELLING

SS
f \

YOUNG PERSON
Swelling can come from
anew tooth

growing in
(p. 94)
ea tooth abscess

(p. 87)

YOUNG PERSON
A sore can come from

e fever blisters

(p. 98)
a tooth abscess

(p. 87)

ADULT
Swelling can come from

ea tooth abscess

(p. 87)
ea broken jaw

(p. 107)
ea tumor (p. 119)

ADULT
A sore can come from

ea tooth abscess

(p. 87)
ea bone infection

(osteomyelitis)

76

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:

e@ Is anew one growing in?
e Isa tooth loose?
e Is there a dark (dead) tooth?

TiME
2. SWOLLEN FACE
3 LARGE CAVITY
IN MOLAR

ABSCESS 2

Look at the gums:

e Are they red?

e Is there any swelling?

e Do they bleed?

e 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 helo 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.

1 MUST TAKE OUT
YOUR TOOTH. iT
HAS AN ABSCESS.

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

There is probably
an abscess ona
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 !ook
again to see if the gums bleed. When gums bleed, it is a sign of gum disease.

77

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 /s 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

HAS
>

A TOOTHACHE

AND YOU FIND OUT
THAT

Ppeee
It hurts only after eating ae
or drinking. There is a ~{RY a as
: wan
cavity, but the tooth does
AD a

not hurt when you tap it.

Part of the filling has fallen
out, or is cracked and ready > vs) (
to fall out. Eating and yyy
drinking make the tooth hurt.

The tooth hurts when chewing

food. it may hurt when tapped,

but there is no cavity and

the tooth looks healthy.

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

it hurts when person breathes
in cold air. The tooth was
hit recently.

He cannot open his mouth
properly. Steady pain and

a bad taste are coming from
the back of the mouth.

Several top teeth hurt, even
when you tap them. She had
a head cold and can only
breathe through her mouth.

HE/SHE MAY | SEE
HAVE PAGE
a cavity 86

a cavity under
an old filling

tartar between
the teeth

a cracked or
broken tooth

a new tooth
growing in

an infected
sinus

78

IF THE PERSON

HAS

——

A
SWOLLEN FACE

A
LOOSE TOOTH

AND YOU FIND OUT
THAT

He had a toothache recently.
The bad tooth hurts when you
tap it.

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

He was hit on the face or
jaw. The bone hurts when
you touch it. The teeth

do not fit together properly.

The swelling is under or
behind the jaw. It gets
worse when he is hungry
and smells food.

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

Food and tartar are
attached to the tooth,
The gums around it are
loose and swollen,

There was pain in the tooth
before, but it does not hurt
so much anymore. It has a
cavity, and there may be

a sore on the gums near it,

The tooth was hit some
time ago.

When the loose tooth moves,
the bone around it and the
tooth beside it also move.

BONE BROKEN ‘ ;
UNDER THE GUM _s"

When you ask the person to
slowly close his teeth, one
tooth hits another, before

the other teeth come together.

HE/SHE MAY
HAVE
=

a tooth abscess

a new tooth
growing in

a broken bone

an infection
inside the spit
gland

a tumor

infection inside
the root fibers—
from gum disease

infection in the
bone—from an
old tooth abscess

a root broken
under the gum

a broken bone
around the
tooth’s roots

OR

infection inside
the bone from
Vincent's
Infection

a tooth is out of
position and
biting too hard
against another

IF THE PERSON
HAS
—————

A SORE MOUTH
from
INFECTED GUMS

or
A SORE MOUTH
froma
SMALL SORE
in another
place

AND YOU FIND OUT
THAT

The gums are red and swollen.
They bleed when the teeth are
cleaned.

Between two teeth the gums
are sore and swollen, like
a small tumor,

The gums between the teeth
have died and are no longer
pointed. Pus and blood
around the teeth make the
mouth smelt! bad.

The gums are bright red and
sore, but between the teeth
they are stil! pointed.

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

A sore spot around or
under a denture hurts
when you touch it.

A kind of white cloth seems
to be stuck to the top of

the mouth or tongue. It

may stop a baby from sucking.

The sore is near the root
of a bad tooth.

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

Small painful blisters on
the lips soon break and
form dry scabs.

HE/SHE MAY
HAVE
——

gum disease
starting

something
caught under
the gum

Vincent's
Infection
{a more serious
gum infection)

fever blisters on
the gums—from
Herpes Virus

a canker sore

a sharp place on
a denture, or an .
old denture that
needs to be
refitted

thrush

gum bubble
enone [oe

fever blisters
—from Herpes
Virus

A SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (See page 119).

79

80

\F THE PERSON
HAS
$= —

A SORE
ON THE FACE

TROUBLE
OPENING THE

| CAN NOT

OPEN ANY

MORE THAN
THIS,

TROUBLE
CLOSING THE

AND YOU FIND OUT
THAT

- Inside his mouth, he has
a tooth abscess or a
broken tooth near the sore.

A dark sore is eating through
the cheek. Her gums are badly
infected. A bad smell is coming
from the dying skin on the face,
and from inside the mouth.

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

He is young, between 16-24
years, with some swelling
behind his jaw.

He recently had an accident.

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

When she tries to open her
mouth, there is a clicking
sound from in front of her
ear. It also hurts in that

piace whenever she tries to
open her mouth or chew food.

Swallowing is difficult, and %> OR BLP
the jaw grows stiff. Germs

have gone into the body from

dirty instruments or an

infected wound.

After opening wide to eat or
yawn, his mouth became stuck
there. He has many missing
back. teeth,

He had an accident, and now
something is stopping the
teeth from coming together.

HE/SHE MAY
HAVE
——_

abscessed tooth
draining pus to
the outside of
the face

a condition called
Noma-starting
from Vincent's
Infection of the
gums

cancer

a new tooth
growing in

a broken jaw—
probably in front
of the ear

an abscess in a
back tooth

pain in the joint
—where the
jawbone joins
the head

81

CHAPTER 7

Treating Some
Common Problems

You must make a good diagnosis to treat a problem so it finishes 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.
Use the table below to help you find the right page.

Before you touch the inside of anyone’s mouth, learn how to keep
clean. See the next 4 pages.

PART 1: PROBLEMS YOU WILL SEE MOST OFTEN

Cavities: sic bho seen Ye aes Sore gums

lost filling... ......004. page 86 gum disease starting ..... page 95
broken filling... 2.0.2.0. page 86 something caught under

Abscess... . ee ee page 87 _ the gums fepulis) -- page 95, 127

; Vincent's Infection... ... page 96

Infected sinus ........... page 89 fever blusters (from

Tooth injury Herpes virus)........ page 98
1. broken tooth ,........ page 90 GT HIPIGSFit dscns face tey Ne needa page 99
2. tooth Knocked out. .... page 91

Other sores in the mouth

Loose tooth .........--. page 93 Canker SOreS ik 6 ee ek a page 100
New tooth growingin....... page 94 fromadenture......... page 100
babies’ teething ........ page 95 at the corners of the mouth . page 101

Broken bone...........-. page 102 PMROTAAUUS: oie: cece ibe aaa See aaa page 112
Distocated jaw. .......... page 107 Infection in the spit gland . . . . page 113
Paininthejoint.......... page 108 Sores on the face

Swollen gums and epilepsy . . . . page 109 from atooth abscess ..... page 114

Noma \cancrum oris), a

Bleeding from the mouth. .... page 110 complication of Vincent's

After you take out a tooth (NIBSTLON: SS. aa Be page 115
swelling of the face ...... page 170 STOR dt CASh nor ete page 119
pain from the socket ..... page 111

bleeding from the socket . . . page 112 Cancer»... see eee eee page 119

82

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 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.

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. {t 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.

83

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 any instrument that
has touched blood.

That means always sterilize with
steam all syringes, needles, and
instruments you use when scaling

teeth (Chapter 8) or when taking
out a tooth (Chapter 11). Be safe: When in doubt, sterilize!

Instruments left in boiling water need 30 minutes to become sterile. A
pot with a cover to trap the steam can act faster. The inside becomes
hotter and 20 minutes is enough. But remember that water can rust metal
instruments. To prevent rust:

e 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.

Sterilizing with steam under pressure is the fastest and surest method.
It kills harmful germs in 15 minutes. You need a strong pot with a tight
fitting lid. But be sure to make a small hole in the lid 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 oil .
into the pot. cree ie

ese ee _ - =
22 ee
° @

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
pot on the low flame for 15
minutes.

DO NOT LET

THE COOKER oy)
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 left inside it.

85

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,

Alcohol solution tight fitting
ED lid

1. Mix in a large container each week: #1 ——S

7 parts alcohol (95%) js
and 3 parts clean water. water
Keep the container tightly covered CATT
to prevent 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 (#1) to the pan each
day.

#2
3. Leave your clean instruments in the QV

pan, completely covered with the
liquid, for 30 minutes.

Bleach (sodium hypochlorite) solution

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
1/2 cup (100 ml) of bleach and 3 1/2 cups (900 ml)
of clean water.

P esvorsnoe» DBDDD

aud 3 + % 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.

86

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

e ahole (or black spot) on the tooth, or
between two teeth

e 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 filling.

Now:

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.

Soon (within a few months):

3. Arrange for someone to replace the temporary filling with a
permanent one. You will need a person who has experience using
a dental drill (see p. 145).

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 paint the groove with fluoride water (page 167). 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
betel nut and do not hold it against the teeth.

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

e tooth often feels longer, and even a
bit loose

e tooth hurts when it is tapped

¢ asore on the gums near where the
root ends (gum bubble)

e 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. If the anesthetic works, then
it is safe to take out the tooth.

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 ‘aqueous procaine penicillin’
on page 166.

Adults and children over 25 kg. (60 pounds) of weight should take the
same amount of oral penicillin. Children under 25 kg. should take 1/2 as
much. For most infections, penicillin by mouth is taken 13 times: a very
large first dose and 12 smaller doses every 6 hours for 3 days. The person
should take all of the penicillin, even if the pain or swelling goes down.
For the correct doses, see the next page.

87

88

-—

THE BEST CHOICE

Penicillin G or V:
1 tablet = 250 mg.
Give enough tablets for 3 days

First Dose (take all at once)

Adults 8 tablets
and children over 25 kg. (2000 ma.)
Children under 25 kg. 4 tablets
{1000 mg.)

Then every 6 hours for 3 days (12 doses)
Adults 2 tablets
and children over 25 kg. (500 ma.)
Children under 25 kg, 1 tablet
(250 mg.)

IMPORTANT: to allow it to best fight

SECOND CHOICE
(for those allergic to penicillin)

Erythromycin:
1 tablet (or capsule) = 250 mg.
Give enough tablets for 3 days

First Dose (take all at once)

Adults 4 tablets
and children over 25 kg. (1000 mg.}
Children under 25 kg. 2 tablets
(500 mg.)

Then every 6 hours for 3 days (12 doses)
Adults 2 tablets
and children over 25 kg. (500 mg.)
Chijdren under 25 kg. 1 tablet
(250 ma.)

IMPORTANT: to avoid upset stomach,
take erythromycin with meals.

infection, take penicillin before eating.

For serious infections, it may be necessary to take the antibiotics for a
longer time. Take the same first dose as above, then take 1/2 the first
dose every 6 hours until the condition begins to improve. Then take the
second, smaller dose every 6 hours until the end of five days, or seven
days if it is very serious.* 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 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:

e soak a cloth in warm water and hold it against the face.
e 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 two-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
comes in 300 mg. tablets, and acetaminophen (paracetamol), which
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.)

Take aspirin or acetaminophen 4 times a day. Every 6 hours, adults
can take 2 tablets, children 8 to 12 years take 1 tablet, and children 3 to
7 take 1/2 tablet. Children 1 to 2 years should only take acetaminophen,
1/4 tablet 4 times a day. See page 165.

*|f the infection does not heal, penicillin may not be the best antibiotic. Take some pus from the
infection and have it tested, to see which antibiotic is best.

89

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.

®@ ahead cold, and plugged nose. She
can only breathe through her mouth.

® hurts when you press against the bone
under her eyes.

TREATMENT:

Do not take out any teeth. They will feel better after you treat the sinus
infection.

1, Give penicillin for 3 days (page 88).

2, Explain to the person that she should:

® drink lots of water.

* breathe steam from boiling water—
to clear her nose.

@ hold awarm 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.

90

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:

e pain when breathing air or drinking
water

e blood from the gums around the tooth

e tooth moves when you touch it

TREATMENT:

Take out the broken tooth if:

e its nerve is not covered. If no one can give special root canal
treatment, the tooth must come out. Germs from the spit have
already gone inside the tooth and started a small infection.

e 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 103).

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:

e Give the tooth a rest. Use other teeth to eat.

e Do not drink things that are very hot or cold, and do not eat spicy
food.

e 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.

91

2. Tooth knocked out

When a tooth is knocked out of the mouth, you should ask two
questions: (1.) Was it a baby tooth? and (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 (p. (72), 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. |n order to heal and to
join the bone, the tooth must be held firmly.

1, Wash the tooth gently
with 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.

92

3, Soften some beeswax and form it

2. 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.

into 2 thin rolls. Place-1 roll near the
gums on the front side of five teeth:
the loose tooth and the two 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 push the wax between the teeth
with the end of your cotton tweezers.

Keep the wax in its position for at
least 3 weeks.

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 45). 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.

LOOSE TOOTH

A tooth may be loose for one of several reasons. Decide the reason
before giving the treatment.

-———

IF THE TOOTH IS LOOSE BECAUSE THE BEST TREATMENT:
anew permanent tooth is 1. tell the mother and child what is
growing under it. happening.

2. pull out the loose baby tooth, if it is
hurting the child.

gum disease or an old abscess . take out the tooth, especially if it

has eaten the bone around its also hurts.

roots. . 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 Do not take out the tooth. If you do,
cracked, (The bone moves when the bone will come out with it. Instead,
you push against the tooth.) hojd the tooth with wires (page 104),

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.

e 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.

94

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:

e toothache at the back of the jaw
© mouth cannot open properly

e abad taste coming from the back of
the mouth

e sore throat

e skin over the new tooth is sore and
hurts when you touch it Infection in the gums and

e the age of the person is the right age pressure from the new tooth are

for growing a new molar tooth painful. Notice the ‘flap’
(page 64). 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:

e 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.

e Hold a warm wet cloth against the jaw as often as possible each day.
e Take aspirin for pain (page 88).

Give penicillin (page 87) if there is fever, a swelling, or if he is only able
to open his mouth a little.

95

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 or aspirin for pain and fever (page 88).

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 (called an epulis) between
only 2 teeth or between many teeth. tn addition, gums that are weak
from poor nutrition are not able to resist the infection. This is why a
pregnant woman must take special care to eat well and clean her teeth
carefully.

SIGNS:

e Gums are red instead of pink.

e Gums are loose instead of
tight against the tooth.

e Between the teeth, gums are
round instead of pointed.

e Gums bleed when you press
against them, or when you
scrape away food from under

Feel for tartar under the gum—

them. or even a piece of fishbone.
e The person has bad breath

and a bad taste inside the mouth.

96

TREATMENT:

Explain to the person the cause of her gum problem and what she can do
to help herself.

1, Show her how to clean her teeth better near the gums (page 67).

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).

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 115).

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 toclean 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 two-week period. Start some
treatment NOW:

1. If the person is already sick, give penicillin for 3 days (page 88).

97

2. Clean away the pus, old food, and big pieces of tartar. Then:
® Tell the person to rinse his mouth with warm water.

e Wipe his gums with cotton soaked in a 5% solution of hydrogen
peroxide. Rinse with warm water. For a child, use a weaker solution.
Mix 1 part hydrogen peroxide with 5 parts water and wipe the
child’s gums with it.

e Scrape away the bigger pieces of tartar. Do not try to remove ail 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. Give Vitamin C (ascorbic acid), 2 tablets a day for 7 days.
(1 tablet = 500 mg.)

4, Teach the person how to care for the gums at home:

e Rinse at home for 3 days with a weak solution of hydrogen peroxide
(page 8). 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. If you have no hydrogen peroxide, rinse with salt
water from the beginning.

For a young child who is not able to rinse, Mother or
Father can wipe his gums with the weak solution of
hydrogen peroxide 4 times a day.

Show parents how to do this. Give them some cotton
gauze and hydrogen peroxide to take home.

e Clean the teeth with a soft brush. Parents can clean children’s teeth.
Show them how (page 16), and ask them to do it even if the gums
bleed,

e 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
96).

e Stop smoking and stop chewing betel nut.
One week later, scrape away the rest of the tartar from the teeth. Then

use the person’s own brush and show him how to do a better job of
cleaning his teeth.

98

FEVER BLISTERS

Herpes virus causes fever blisters. Herpes virus is a kind of germ. Fever
blisters are sores that can form either inside the mouth on the gums, or
outside on the lips.

When the sores are inside the mouth, it is a serious problem. It usually
affects 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!

SIGNS:

© sore throat

e fever

e crying, stops sucking 2-3
days before sores appear

e spit spills from the mouth
because it hurts to swallow

e painful swelling under the jaw.

e 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 them-
selves 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.

Inside the mouth

1. Give aspirin or acetaminophen for fever (page 88).

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
82.) Then give food that is soft and not spicy. If he cannot eat, prepare
a special milk-oil drink for him, as on page 105.

3. Give lots of fluids to drink.

Sores on the lips usually occur after the age Co a)
of 5. They often appear when the person is {
weak and sick (for example, with diarrhea or s—
pneumonia.) Usually there is no fever. The
blisters soon break open and release water.
When they dry, a crust forms. The blisters often

Panui. On the lips

These sores go away in about 1 week. To prevent them from becoming
infected, paint the sores with gentian violet, tincture of benzoin, or
petroleum jelly. !f you hold ice against the sores for several minutes each
day, it may help them heal faster.

99

THRUSH

Thrush is a kind of infection. 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. In an adult, thrush often occurs
under a denture.

SIGNS:

e 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.

e 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,
change or stop the antibiotic medicine, or leave the denture out of the
mouth for a while. Then:

1. Put some nystatin creme on top of the white patch with a bit of cotton.

adults: put some on 4 times a day
children 5-12 years: put some on 3 times a day
children up to 5 years old: put some on 2 times a day

Show the mother how she can do this in her child’s mouth at home. If
you have no nystatin creme, paint gentian violet on the white area. The
mother should paint the child’s mouth 2 times a day.

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. Continue breast feeding. 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, they can
change into a cancer (page 119). 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.

100
CANKER SORES

A virus can cause canker sores, as with fever blisters. Unlike fever
blisters, canker sores usually affect adults rather than children.

One or more sores can appear at any time. These sores hurt, especially
when pieces of food touch them.

SIGNS:

e Asore can appear on the tongue,
roof of the mouth, or below the
gums on the smooth skin.

e The sore is white or yellow with the
skin around it bright red.

e 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 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 food
with a lot of pepper. 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 2-3 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 87).

A sore that does not heal after antibiotic treatment may be cancer.
See a doctor immediately.

101
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. eo a } |4/
He must close his jaw further

to eat. That causes lines to \ y,

form at the corners of his “a
mouth,

Poor health can make lines at
the corners of the mouth crack
and become sore.

A person with missing teeth needs dentures. Dentures will help him
chew more food and make him look younger. They support his lips and
open his mouth more.

Note: Making dentures is not easy. We hope to write a book
in the future that will tell more about dentures.

A child who has had a fever or measles often has pl 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 page 65).

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 3-4 times a day.

102

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:

e The person has had an injury.
e When teeth are closed, some upper
teeth do not meet lower teeth.
e The person cannot open or close
the mouth properly, .
e There is bleeding from between 4} )
2 teeth.
e There is swelling or a bruise on
the face or jaw.
e There is bleeding into the eye.

103

SIGNS of a cracked bone around
the tooth’s roots: @ AND THE OTHER

e When you move one tooth, the f TOOTH ALSO MOVES

tooth beside it also moves.
e When you move the loose tooth,

the bone moves with them. ge @) BECAUSE THE
e Blood is coming from under BONE AROUND
the gums. @ PUSH GENTLY THEIR, ROOTS
AGAINST ONE IS CRACKED.
TREATMENT: TOOTH

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
out 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 103-104):

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 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 (p. 175). 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, p. 86). If you gently press cotton gauze against
the bleeding gums, it will usually control the bleeding.

104

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 two 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 hem :
P he ostat BLEEDING FROM THE BONE

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 8. 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 166) for 5 days to stop infection
inside the bone.

5. Give something for pain. Aspirin (o. 88) may be enough. If there is a
lot of pain and the person cannot sleep, give codeine. The dose for an
adult is 30 mg.

105

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 (see below):

1. Give him liquids containing food for both strength and energy.
2, Show him how to keep his teeth clean and his gums tough.

1. Give liquid foods for strength and energy.

Prepare food in two ways: (1) First, a milk-oil drink to build strength;
and then (2) 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
e 3 cups of milk powder
@ 150 ml of peanut oil or coconut milk
e 1/2 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:

e 1/2 tin of fish, or a handful of dried fish

e 4small spoonfuls of peanut oil or palm oil
> @ 6 sweet potatoes or small yams

e 1 large handful of green leaves

# 1 small spoonful of Salt is :

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:

e 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.

106

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 BEND THE NEEDLE
splint. Make it long enough to fit around two AROUND THE TOOTH
strong teeth on each side of the loose teeth. $0 IT DOES NOT

Curve the needle so it fits the curve of the Pa OUT
teeth. To make the sharp ends smooth, use a

file or rub the ends against a stone. Chpesy

3. Tie each tooth to the needle. Use short pieces
of 0.20 gauge ligature wire (page 104).

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 asmall instrument to hold USE A STRONG
down the wire at the back of the teeth. Then HEMOSTAT OR

twist the ends together. Tighten the wire NEEDLE HOLDER
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 1/2 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 (p. 8).
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.

DISLOCATED JAW

107

If a person opens her mouth wide and then is unable to close it, we say
her jaw is dislocated. |t 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.

SIGNS:

NORMAL DISLOCATED
TREATMENT:

She is unable to close her teeth
together.

She cannot close her tips easily.
Her lower jaw looks long and
pointed.

It hurts when you press on the
joint in front of her ear.

She cannot speak clearly.

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 104),

4. Give aspirin for pain (page 88).

5. Explain the problem to the person and tell her how to care for her
jaw: (1) eat mostly soft foods for 2 weeks; (2) hold a warm wet
cloth against the jaw; (3) remember not to open the mouth wide
anymore. If possible, replace the missing back teeth with dentures

(page 101).

108
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:
e muscles pull the jawbone; and

e 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.

(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 (page 88) 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 two middle upper teeth and the
two 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.

109

; 1
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:

(a) Warn the person not to open
his mouth wide. Suggest,
for example, that he take
his food in small bites.

| (b) Tell the person what can
be done to help. Often

a dentist can grind the teeth These teeth do not fit properly.
in aspecial way and this Because the line shifts, this means
can end the pain. 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 Is No Doctor, page
78) have a problem with swollen gums.
In severe cases, the gums are so
swollen that they cover the teeth. This
problem is caused not by epilepsy but by
diphenylhydantoin (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 67 to 70.
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 69).

110

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:
SESE Ene
a large red clot growing
out of a socket where you
have taken out a tooth

sore and bleeding gums
and the mouth smells bad
(Vincent's infection)

a red, bleeding growth inside
the cavity in a tooth

a loose tooth with bleeding

gums around it

torn gums with broken bone
and bleeding

TO STOP THE BLEEDING:

. Remove the clot with cotton

tweezers.

. Ask the person to bite on a

piece of cotton.

, Rinse with a mixture of

hydrogen peroxide and water.

. Remove as much tartar as you can,

Take out the tooth; it has an
abscess.

Hold the tooth with wires,
or if the root is broken,
take out the tooth.

. With wire, hold the broken

parts of the bone together.

. Send the person to an

experienced dental worker.

PROBLEMS AFTER YOU TAKE OUT A TOOTH

Problems like swelling, severe pain, and bleeding can occur after you
take out a tooth. Tetanus (p. 112), 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 3 days to
fight infection, heat to reduce the swelling,
and aspirin for pain. See page 88 for the

proper doses,

111

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.

Second, prepare the dressing. Place one piece of dressing into

each root space. Push it down into
the root space gently.

Soak 1-2 small pieces of cotton
in eugenol (oil of cloves).
Squeeze each piece so that it

; i i n
is damp but not wet. Cover the socket with plain cotto

gauze, and send the person home
biting against it. He can remove
the plain cotton in an hour. The
dressing should remain inside the
socket.

Note: There may be a local
medicine in your area that
relieves pain. Use it instead of
eugenol.

2. Give aspirin for pain (page 88).

112

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 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.
({f 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 Helping Health
Workers Learn, page 19-13). 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 155-
157).

. 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 157).

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 82 to 85.

SIGNS: = OLD, DRY BLOOD
ot

e the jaw becomes stiff and tight cleaning
e itis hard to swallow property,
e the whole body becomes tight, with sudden
spasms ON

TREATMENT:

A person with signs of tetanus requires immediate medical help. See
Where There Is No Doctor, page 182, if you cannot get help immediately.

113

INFECTION INSIDE THE SPIT GLAND

Spit glands are places where the spit 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:

e swelling in the area of the spit gland.

e pain which gets worse when the person is hungry, and when he sees
or smells food.

e 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 3 days (page 88). If the swelling is large and the
infection serious, start with short-acting crystalline penicillin (see
p. 166).
2. Give aspirin for pain (page 88).
. 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.

OO

114

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 agum problem,
it may be Noma. See p. 115.

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 5 days (see page 88).

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:

e test the pus to see if it is resistant to penicillin. The person may
need to take a different antibiotic,

e 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.

lf 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.

115
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 96).

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 like
measles or malaria.

~_—

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.

116
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. 105.

If he cannot drink by himself,
helo 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 now. The child should continue taking the tablets or
mixture for 3 months.

Ferric Ammonium OR Ferrous Sulfate
Citrate Mixture Tablets (200 mg.)

over 6 years: 11/2 ml. (30 drops) daily 200 mg. (1 tab) 3 times a day
3-6 years: 1 ml. (20 drops) daily 100 mg. (1/2 tab) 3 times a day
under 3 years: 1/2 ml. (10 drops) daily 50 mg. (1/4 tab) 3 times a day

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 hookworm. It is wise not
to wait for a test for hookworm. Begin now giving hookworm medicine such
as thiabendazole and folic acid (see Where There /s No Doctor, pages 142,
363, and 376).

117

3. Start antibiotics.

Penicillin is the best antibiotic to use. As the child may not be able to
swallow pills easily, it is best to start with penicillin injections (page 166).

If you do not have penicillin, you can give sulfadimidine 4 times a day.
it comes in 500 mg. tablets or in syrup that has 500 mg. in 5 ml. To
decide how much to give, weigh the child.

Weight Dose (give 4 times a day)

5 to 10 kg.
10 to 17 kg.
17 to 25 kg.
over 25 kg.

1/2 tablet or 1/2 teaspoon of syrup
1 tablet or 1 teaspoon of syrup

1 1/2 tablet or 1 1/2 teaspoon of syrup
2 tablets or 2 teaspoons of syrup

4. Treat the other illness that helped noma to develop.

It is wise to assure that the child has malaria and to begin treating
with antimatarial drugs (see Where There Is No Doctor, pages 357 and
358).

Look for any other illnesses and treat them, too.

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.

The dressing:

e Soak cotton gauze in salt water. Squeeze out the extra water so that
it is damp but not wet.

e Put it in the hole and cover it with a dry bandage.

e 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 155-157).

118

7. Keep the mouth clean.

# Use asoft brush gently to clean the remaining teeth. Do this 3 times
a day for the child.

e 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 asick 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:

(1) have his teeth carefully cleaned each
day with a soft brush.

(2) rinse his mouth with a warm salt
water solution (page 7), 2 times a
day.

(3) eat fresh fruits and vegetables,
especially the kind that have Vitamin
C—guavas, oranges, pineapples,
papayas, tomatoes, peas, and dark
green leaves.

119

TUMOR

A tumor is a lump that grows under the skin or inside the bone.
grows slowly but steadily, usually without any pain.

t

If the swelling does not get better after 5 days of antibiotics and
heat treatment (page 88), 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
Y
Y Any sore that does not heal may be

cancer. The lips and tongue are the

two places in the mouth where
cancer starts most often.

Cancer is deadly.

Medicine cannot help.
It wastes time to use it.

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.

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.

121

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 (p. 48)
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. |f 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 keer ceeth clean.

You must remove something caught under the gums (page 127) 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. |f 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. |f 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.

122

THE INSTRUMENTS YOU NEED FOR SCALING

We scale teeth with special instruments called sealers. 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.

Sores ae Its proper name is
\\ f/ a SS Ivory 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:

Probe Tweezers Sharpening stone
Mirror (explorer) (cotton pliers) (Arkansas stone)

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 170-172.

Keep everything in a Scaling Kit.

123

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 left behind for it to build upon.

Lay out what you need ahead of time.

Jf your instruments: scalers, mirror, probe, tweezers

/_ sharpening stone

vA

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 73).

The steps in scaling teeth are these (pages 123-127):

. Explain to the person what you are going to do,

. Feel under the gum for rough spots (tartar).

. Place the scaler under the tartar.

. Pull the scaler against the side of the tooth.

. Check to be sure the tooth is smooth.

. Explain what you have done and what the
person should now do.

OarwWwNn—

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 82-85.)

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.

1. 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.

2. 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.

124

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 gently 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.

125

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.

GUM POCKET

ROOT FIBERS

9,

— BONE

ROOT

First, use the pointed-tip
scaler to remove the tartar
that you can see.

Be careful when you place the rounded end of the scaler in

pocket.

1. Put the sharp face of the
blade against the tooth.
Slide it along the tooth
down into the gum pocket.

Tartar starts forming deep
inside the gum pocket. If
you remove tartar that you
can see above the gum, it
is helpful, but not good
enough. You must remove
the rest of the tartar, or
the infection will continue.
If part of the tartar

stays on the tooth, the
infection will continue.

Then, go back with your rounded-
tip scaler and scrape away the
remaining tartar. Ae

side the gum

: \
an
at

2. You can feel the edge as it
goes over the rough tartar.
Stop when you feel the
bottom of the gum pocket.

126

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 2. Pull the scaler with
on the scaler. a 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
scaler with cotton gauze. to 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. {t 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.

127

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.
A. 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 67).

B. Clean between your teeth. Use your brush, the stem from a palm
leaf, or a piece of strong, thin thread (page 69).

C. 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).

D, 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

lf 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. ——s

Feel the object, go

under it gently, and
then lift it out.

— ce Tie a knot in a piece of
thread. Then slide the thread
between 2 teeth (page 69).

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.*

*|f the gum has grown into a kind of tumor fepulis), an experienced dental worker should cut
it away.

128

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, fee! 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 /s No
Doctor, page 172) can pass from the blood of one person to the blood of
another person. To learn how to sterilize, see pages 83 and 84.

Your mirror, probe, and cotton tweezers do not need sterilization. A
disinfectant (see page 85) 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.

I HAVE TAKEN OFF ALL
THE HARD STUFF. NEVER
LET IT COME BACK/ g

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!

Injecting Inside
the Mouth

129

CHAPTER 9

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 puta

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.

METAL SYRINGE

This is a dental syringe. It uses special needles,

and the local anesthetic is sealed inside a
glass cartridge. You must throw away both
needle and cartridge after. injecting. %

;

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.

GLASS SYRINGE

This kind of syringe is for injections of
medicine like penicillin, but you can use it in
the mouth. Boil the syringe and needles (p. 84)
before and after each use. When sterile, the
needles are ready for another person.

Be careful! Do not touch the needle.

130

Your choice of which syringe to use depends on the local anesthetic you
can get. Order needies to fit your particular kind of syringe.

————$—_
METAL SYRINGE GLASS SY RINGE
Order: Order:
1. syringe: aspirating dental cartridge syringe, 1. syringe: standard glass syringe that holds
1.8 ml. (Iml=1cc) around 3 ml! (1ml=1cc)
2. needles: disposable needles for dental 2. needles: 24 gauge, long (40 mm x.56 mm
cartridge syringe (27 gauge, long) or similar)
One box contains 100 needles, each one | 3. local anesthetic: 20 ml! bottle of lidocaine
inside a plastic cover (lignocaine) 2%
3. local anesthetic: local anesthetic cartridges Or, if not available: order 2 ml ampules
for a dental syringe of procaine nydrochloride 1%

One sealed tin contains 50 cartridges

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
…[truncated]

Summary: Where There  Is No Dentist    by Murray Dickson    with an Introduction by David Werner,  author of Where There Is No Doctor    Compiled by noonya    Library of Congress Cataloging in Publication Data  Catalog card No. 82-84067    Dickson, Murray   Where there is no dentist.   Includes index.  Palo Alto, CA: Hesperian Foundation  ISBN: 0-942364-05-8    First edition, November 1983  Seventh Printing, July 1996    PUBLISHED BY:    The Hesperian Foundation  P.O. Box 1692   Palo Alto, California…

Copyright © 1983, 2006, 2010 by the Hesperian Foundation