Where There Is No Dentist Hesperian 2010

Where There Is
No Dentist

by Murray Dickson

updated and expanded
with information about HIV and AIDS
by Richard Bebermeyer,
Martin Hobdell and Gene Stevenson

Introduction by David Werner,
author of Where There lIs No Doctor

EULIEN GA
hesperian

Berkeley, California, USA
www.hesperian.org

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Copyright © 1983, 2006, 2010 by the Hesperian Foundation. All rights reserved.

Library of Congress
Catalog card No. 82-84067
Dickson, Murray
Where there is no dentist.
Includes index.
Berkeley, CA: Hesperian Foundation
ISBN: 978-0-942364-05-7

First edition, November 1983
13th printing (updated), September 2010

$

Printed in Canada on acid-free, 100% recycled paper by Transcontinental inne

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THANKS
Where There Is No Dentist, updated edition, 2010

Thanks from Hesperian

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

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

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

Editing and updating of the 2006 edition was coordinated by Kathleen Vickery
with assistance from Todd Jailer and Susan McCallister, production by lñaki
Fernandez de Retana and Leana Rosetti, and additional writing by Fiona
Thomson. For the 2010 edition, coordination by Dorothy Tegeler, with support
from Deborah Bickel, Matthew Crimp, Jacob Goolkasian, Shu Ping Guan, Todd
Jailer, Susan McCallister, and Kathleen Tandy.

Thanks from Murray Dickson, 1983

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

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

For their outstanding drawings, | am exceedingly grateful to: June Mehra,
Janet Elliott de Jacques, Michael Marzolla, Joan Thornpson, 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 Bali, Tom Coles, Sunil Mehra, and John Rogers. In particular,
thanks to Chris Lennox who, faced with stressful times in Papua New Guinea,
found time to read through two drafts; and to David Morley for his ideas for
improving the book and his assistance with its eventual publication.

For their financial help, | 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 (244 Camden Road, London NW1 9HE, U.K.)
for permission to use parts of David Halestrap’s book Simple Dental Care.

This book is based upon several years of practical experience, made possible
by the Canadian Organization CUSO. For this opportunity, and for CUSO's
active interest and involvement in this book, | 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 in a 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 love and a growing sense of understanding. It is my only
disappointment that they did not live to see this book in its final form.

CONTENTS

Introduction by David Werner

Part One: Learning and Teaching about Teeth and Gums

Chapter 1: Your Own Teeth and Gums .............0000 cece cence eee 1
Eat only good healthy foods .................... 3 Sore bleeding gums........................24. 7
Clean your teeth every day.................2.0. 4 More serious gum disease .................0005 8
Cavities, toothaches and abscesses ............. 6

Chapter 2: Teaching Family and Friends in YourCommunity .............. 9
Chapter 3: Teaching Children at School...............000 ccc eee eens 19
Chapter 4: School Activities for Learning about Teeth and Gums.......... 35
Why do we need teeth and gums?.............. 37 How do germs make holes in the teeth?......... 50
Why do some teeth look different? ............. 39 What makes the gums feel sore?............... 52
What holds the teeth?.........00..00...0000.. 41 What does it mean if a tooth is loose? .......... 54
How often do teeth growin? ..............00.. 43 How can we prevent cavities and

What makes teeth hurt?...................... Ag SNE GUMS iraran daersi ordeka hen 55
Chapter 5: Taking Care of Teeth and Gums................0000 ee eeeuees 61

Part Two: Treating Dental Problems

Chapter 6: Examination and Diagnosis ..........asua naana ee eee eee eens 73
Where to examine... n... 0... cece eee eee 75 Agooddiagnosis............. 002.0 cece cece ee 76
The instruments you need................0200- 75 Learn to tell similar problems apart............. 80
Chapter 7: Treating Some Common Problems...............0200000 eee 85
The first rule of treatment: stay clean! .. .. .. .. 86 Dislocated jaw...... 2.0.0... ........118
Problems you will see most often... ........ 92 Pain inthe joint.. .... 2... 0.0.0.0... 2.114
CAVITIES vo eins pardina wae Made sede D2 Swollen gums and epilepsy... ..........115
Abscess .. .. 2... 0. eee eee ee ee ee 9 Blood inthe mouth. ................ ..116
Infected sinus ...................... 95 After you take out a tooth ................116
Tooth injuries... 2.2... ......0....... 96 Swelling of the face ..................116
Loose tooth...... 0.2... ..0......... 99 Pain from the socket... ................117
New tooth growingin.................100 Bleeding from the socket... ............118
Gum disease... ....................101 Tetanus 0.2 118
Fever blisters... ....................104 Infection in the spit (saliva) gland. . .. .. .. .. ..119
Thrush... i pr nepr seca de 0.2.......105 Sores onthe face... 2.2.0.0... 120
Cankersores.......................106 Noma.... 0.00000. ee ee ee 121
Some special problems..................108 = Tumor.... 2... 0. ee ee 2125
Broken bone............-...-...-.+-108 Cancer. oo on ee ee 125

Chapter 8: Sealing Teeth... -rrei s5..40c eon denen s Se ee Keene Cae ees 127

Chapter 9: Injecting Inside the Mouth ................000c eee eens 135
Chapter 10: Cement Fillings ............. 00.0 cece eee eee eee 143
Chapter 11: Taking Out a Tooth............. 00 e eee tees 153
The instruments you need................0.5 154 False teeth... 163
Where you work is important................ 156 Problems that can OCCUr...............00008 165
How to take out the tooth................... 157 Clean your instruments after you finish........ 167
How to place a suture... 2.0... eee eee 161
Chapter 12: HIV and Care of the Teeth and Gums ...................0005. 169
What is HV recare eneses cece eee 171 White or yellow patches in the mouth....... 180
How is HIV spread?...................00. 72 Sores of the skin of the mouth............. 182
Who-gets HIV? .....¢.0csc0.cebsa cage ees 73 Infection of the gums ..................... 183
How HIV affects the mouth................ 173 Cold sores or fever blisters................ 186
How to examine the mouth for Red or purple patches in the mouth......... 188
signs of HIV or AIDS... 2.0.0.0... 202s 74 Dry or painful mouth and throat............ 189
Dental care fora person with HIV .......... 77 Helping people with HIV in
Common problems caused by HIV your community..................0000 eee 190
and how to treat them................... 178 Working for change in your community ...... 191
Appendices
Get Rid of Wastes Safely ...................... 0c eee eee 199
The Dental Kit n.n... nanna nunnana nanana rrara rrena 201

Medicines ...... n. nannan nanan raene erneer rreren 202

SUPPIIES:: anera a EE EEEE 205

Instruments ..... nnaou aonana aonana enerne reren 207
Records, Reports, and Survey$.............0. 2.000 cece eee 212
RESOUNCES+ 2). 258 c.22credenadeenteseaareqessgideemaeiaade 215
Vocabulary... 0... ccc ccc cnc ence cence neces 217
IND OX! sos ds we spleen ose bean cach sieeewing E Saleweed eaaeey ae 222

INTRODUCTION

by David Werner

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

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

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

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

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

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 help from dentists for
more difficult problems.

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

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

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

In other countries dentists and community dental workers work in closer
harmony. In Guatemala, Ecuador, Papua New Guinea, and Mozambique,
dental technicians are now recognized by the Ministries of Health. In Papua
New Guinea and Ecuador, professional dentists train and supervise them
to provide dental care to school children. In Ecuador, they work mostly

as dentist assistants, bringing high quality services to more people while
decreasing costs. The ‘dental therapists’ in Papua New Guinea are trained
to extract, drill, and fill teeth, as well as to work on prevention of dental
problems in school children.

In Guatemala and Mozambique, dentists from the dental school have trained
village health promoters as dental workers who work with people of all ages.
Their training includes community dental health education, cleaning of teeth,
extractions, and drilling and filling. These health workers are provided with
the few basic instruments needed to provide these services.

In Project Piaxtla Mexico (with which | 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. It begins by
encouraging the health worker to examine herself and her family. To be a
good example is the best way to teach.

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

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

The author has said:

| am sure some dentists will disagree with parts of this book.
Some points of disagreement may be small, like the failure to
use accepted dental terminology. Other ideas, particularly the
suggestion that non-dental people can be trained to provide
many kinds of treatments, may make some dentists angry.

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

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

CHAPTER 1

Your Own Teeth
and Gums

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

What can good teeth
give you?
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!

2

Where There Is No Dentist 2010

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

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

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

BY EATING ONLY
GOOD HEALTHY
FOOD AND CLEANING
YOUR TEETH
EVERY DAY!

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

Where There Is No Dentist 2010

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.

Sweet and GOOD

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.

REMEMBER:
BREAST

IS
BEST!

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.

Where There Is No Dentist 2010

CLEAN YOUR TEETH EVERY DAY

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

HIDING PLACES

Bits of food stay longer in
grooves and ‘hiding places’.
This is where both tooth and
gum problems start.

To prevent problems you

grooves must take special care to
on top keep these protected places
clean.
between It is better to clean your
the teeth teeth carefully once every
near the gums day than to clean poorly

many times a day.
Here are 3 places where problems start. r y

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

1. Use a small branch of young 2. Cut a piece that is
bamboo, strong grass, or the skin still green and soft.
from sugar cane or betel nut.

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

teeth (see pages 71-72).

Where There Is No Dentist 2010

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

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

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

5

6

Where There Is No Dentist 2010

CAVITIES, TOOTHACHES AND ABSCESSES

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

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

Each tooth has roots When decay When infection
that hold it in the touches the nerve reaches the
jaw bone. Inside inside the tooth inside of a root,
each root is a nerve. aches, even when it is called a

(p. 39 to 40 and 45) you try to sleep. tooth abscess.

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

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

2. Take aspirin or acetominophen for pain.
See page 95 for amount.

3. Reduce the swelling:

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

e Weta cloth 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.

Where There Is No Dentist 2010

SORE BLEEDING GUMS

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

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

f f £, y 4 7
a4 oF
1
Wi el Aa ha
HEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE

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

1. Even if your gums are sore and they bleed, you must still clean the
teeth beside them. If more food collects on the teeth, the gum
infection will get even worse. Get a soft brush (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.

8

Where There Is No Dentist 2010

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.

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).

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

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

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

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

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

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 their own, grown and
prepared by themselves.

Even sugar cane was not as bad
as the sticky candy children eat
today. The sugar was bad for the
teeth, but the fiber in the cane
helped rub them clean.

NOW, more people are buying
softer and sweeter food from
the store. This kind of food
sticks to the teeth more easily
so it has more time to attack
the teeth and gums.

Everyone must be more careful
to clean away soft, sweet
food. But many people do not
know how. Some, especially
children, do not even try.

10 Where There Is No Dentist 2010

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
TEETH CAN HURT
THEM AND MAKE

HIM ANGRY À
BEFORE HE DIED.
2 <<

N

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
THE TWIG OF A TREE!

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

Where There Is No Dentist 2010
BE A GOOD EXAMPLE

Other people like to watch what you do before they try something different.
First show members of your family and then they will be an example to
others in your community. For example:

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

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

2. Do not buy fizzy drinks like Coca-Cola or Fanta.
They have a lot of added sugar which quickly
makes children’s teeth rotten.

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

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

Clean, cool water, tea with little sugar, milk, or
water from a young coconut are best to drink.
Fresh fruits are delicious when you are thirsty.

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

3. Keep your children’s teeth clean.
Your friends will notice clean
teeth or teeth that are dirty or
have cavities. Remember, clean
teeth are healthy teeth.

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

A younger child cannot. He needs
help. Each day someone older
should clean his teeth for him
(page 18).

11

12 Where There Is No Dentist 2010

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 MARIE, PLEASE HELP

AND YOUR ME CLEAN BABY’S Fins. T
CHILDREN’S TEETH TEETH AND THEN Must CLEAN
HEALTHY BY BROTHER’S TEETH.

MY OWN
TEETH PROPERLY.

WE WILL DO IT
EVERY DAN,

CLEANING THEM,

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

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

USE A SOFT TOOTHBRUSH.
A SOFT BRUSH 15 BEST
BECAUSE IT WON'T
HURT YOUR GUMS.
TELL YOUR
FAMILY THAT.

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

WILL STAY STRONG UNTIL
YOU GROW OLD.

WHAT SHOULD
I DO IF MY
GUMS BLEED?

WISH L 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.

Where There Is No Dentist 2010
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 CARIES,

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 . oth =A m
about their customs, traditions RRN i LE ŽA
and beliefs. Respect them. i Ra SMR RY ie Ñ

ERA
Learn about their health habits. i Re oe
Improving health may require :

changing some habits and
strengthening others.

Aa

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. 214.

13

14 Where There Is No Dentist 2010

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

Be,

Sweeping the compound in the Brushing the teeth and gums

makes it a clean and same —» keeps them clean and healthy.
healthy place to live. way 7

at C

A small child cannot find in the A small child cannot see the
his own lice. Mother same — food on his teeth. He needs
knows she must help him. way. help with that also.

Eating different kinds of food

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

help each other to grow. your whole body, grow stronger.

Where There Is No Dentist 2010
STORY TELLING—AN EXAMPLE

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

many stories, and she wants to learn whatever she can from these stories.
Unfortunately, some traditional beliefs about pregnancy are partly
wrong. An example is the belief that one must always have dental problems
during pregnancy.

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

A Story: Bertine’s teeth
Bertine was the dental worker in her village. She was a young woman, but
the villagers respected her because she was such a careful worker, and
because she knew how to fill cavities and pull teeth without hurting people.
She also spent a lot of time teaching people how to avoid dental problems.
“Clean your teeth every day!” she often said, at her clinic, at the schools, at
village meetings. “Eat a mixture of foods,
especially a lot of fruits and vegetables!
Avoid candy and sweet, sticky foods!”

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

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

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

15

16 Where There Is No Dentist 2010

“The usual reasons?” asked Bertine.

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

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

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

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

{ “Yes, and you should!” said Lucie. “And

' me you can take better care of your teeth.

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

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

Zi

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

Where There Is No Dentist 2010

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 26 to 34 for ways to use
pictures, puppets, and plays.

. Teach Wherever People Get Together

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

Talk with people where they gather near their homes.

Talk to men
Talk to and women
women at at church
health clinics meetings,
and in the in parents’
market. Talk groups at their
to men at children’s
business school, and
and farming at community
meetings. meetings.

Teach men and women at reading groups.

17

18 Where There Is No Dentist 2010

5. Teach Something People Can Do Right Away

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

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

Pick out a child and clean his teeth yourself.
Let his mother watch.

Use a soft brush (or for a baby, a clean cloth).
Gently but quickly brush or wipe his teeth. Do
the best you can even if he cries.

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

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

of every tooth. how well the mothers are doing.

Give further help when needed.
Always praise and encourage
those who are doing well.

Teaching Children "3
at School

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

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

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

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

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

As school children continue to learn, they can share their new ideas

and information at home with brothers, sisters, mothers, fathers, and
grandparents. In this way, the circle of teaching and learning described on
page 12 comes back into the family and is complete.

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

19

20 Where There Is No Dentist 2010

PART 1:
TEACHING SO THAT LEARNING CAN TAKE PLACE

WHAT 15 THE MATTER, LI?
YOU ARE NOT

KEEPING UP WITH
THE OTHERS.

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

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

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

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

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

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

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

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

RIGHT SIR,

WHAT DO YOU THINK
ABOUT THAT?

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

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

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.

Where There Is No Dentist 2010

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
. Teach and learn together with your school children.
. Start with what the students already know.
. Let students see and then do.
. Let children help each other.
. Teach about teeth and gums together with other subjects.
. Be a good example.

. 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 PERMANENT SUCCESSOR LIES

APICAL To... PAY ATTENTION /
YOU NEED TO KNOW THIS FOR

YOUR TEST/... EACH PRIMARY

A lecture transfers
your own notes

to the children’s
notebooks without
ever passing
through their minds.
A discussion draws out
information and opinions.

It helps you | A LOOSE TOOTH
to learn more | aki T know À
f 00D WAY
about the To TAKE OUT
school children, epic
OOTH.
what they

already know
and believe to
be true.

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

21

22 Where There Is No Dentist 2010

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.

DEGLUTITIO
ATN,
This way
makes students
feel stupid.

AAA ESOMAYS

EATING Food

This way lets the yaa To Gaw ?
students feel good,
because it makes
sense and they know

something about it.

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

Where There Is No Dentist 2010 23

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: rr

CAN MAKE A
TOOTHBRUSH

IFLHEAR IT, o

| FORGET IT. | Twie.

IF 1 SEE IT,
| REMEMBER IT.

NOW, CHEW
. ONE END
TO MAKE IT
Tee tie T, SOFT AND
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.

24 Where There Is No Dentist 2010

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:

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

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

e They can check the teeth and
gums of the younger children and
‘score’ them on how healthy they
are (see p. 60).

e Best of all, they can actually clean
the teeth of the younger ones,

Here a group of school children
in Ajoya, Mexico is putting a
high-fluoride paste (see p. 205)

on the teeth of the younger
children.

and show them how to clean their
own teeth when they are able.

5. Teach About Teeth and Gums
Together with Other Subjects
Teeth and gums are part of a bigger health picture. Teach about them in
class at the came time.

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

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

traditions and customs.

“STORE FOOD
A good way for school children to learn

the community.

The results will tell the children
something about health problems in
their community. For an example of a
survey of health problems, see page
3-14 of Helping Health Workers Learn.

pat | | Number selli
$ = 2 OyBundnsts
about using numbers is to do a survey in "Y y WV Ry A
iv)

dumber selling Cola
À arink
A HT UY JT Ieee Lo
j ee —

*For more ideas on how school children can help each other, write to CHILD-to-child Trust,
Institute of Education, 20 Bedford Way, London, WC1H OAL, UK. Tel: 44-207-612-6649.
Fax: 44-207-612-6645. E-mail: ccenquiries@ioe.ac.uk. Website: www.child-to-child.org

Where There Is No Dentist 2010

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.

. 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.

25

26 Where There Is No Dentist 2010

PART 2
MAKING LEARNING EXCITING, VISUAL, AND FUN

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

Tell a story about food or teeth. For example, tell a story about why a wild
cat's teeth are different in shape from a goat's teeth (page 40). Stories are
an excellent way to learn, both for the storyteller and for those listening.
Leave time at the end to discuss the story and to introduce new information.
See the example of storytelling on pages 15 to 16.

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

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

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

Do a demonstration using local resources.

Try, for example, the
‘tooth in the Coca-Cola’
test on page 48.

Where There Is No Dentist 2010 27

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:

VNUTS

ONIN
TOOTH GUMS G55

As you find each word, put a J beside it.

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

VILLAGE
CO-OP STORE

befrisvtesvyv

gasprqxoami

uvsofeaorsn abscess cola
misg steof

dtentéuhvye v sugar toothache
iyc@eolaobc cavity Vv maize
scG/smpscu(r\t

rae eons ee es V sore green leaf
afaelneerl|glo infection gum disease
scbpnusntluln

eĝa izor t d\s/b

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

28 Where There Is No Dentist 2010
You can use pictures on posters, flip charts, and on flannel-boards.

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

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

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

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

BK

Hang up other posters in = i
the store, church, or other T O W
places where people will on
see them. —]

U
Pictures can be made to =

stick to cloth and then used
to tell a story. Cover a board
with a piece of flannel cloth 4
or a soft blanket, to make a
flannel-board.* aS

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

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

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

Where There Is No Dentist 2010 29

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

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

But he can read a short message
written on the back of the page

before. There are
also examples of
questions to ask.

This way,

anyone who can
read can tell the
‘flip chart story’

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

with 2 thin pieces of wood with metal or wire rings

30 Where There Is No Dentist 2010

FLIP CHARTS—AN EXAMPLE

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

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

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

What color are his gums? Are they pointed?

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

Both cavities and gum disease can be treated.

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

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

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

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

4) Why does the boy have cavities and gum disease?
There are 2 reasons.

a) He eats too many sweet foods.
What foods do you see here?
What other foods hurt the teeth?

b) He does not clean his teeth regularly.
The germs in his mouth eat sugar from
his food and make acid. Acid causes
both cavities and gum disease.

Where There Is No Dentist 2010 31

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

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

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

store.

6) How can we clean our teeth?

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

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

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

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

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

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

Your copy is now
ready for coloring.
And you can use your
copy paper again to
make another copy.

32 Where There Is No Dentist 2010

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
themselves cannot. For example,
they can talk openly about the bad
food sold at the village store.

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

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

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

A puppet made from a sock looks alive.

1. Fit the sock over your hand.

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

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

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

Where There Is No Dentist 2010 33
PUPPET SHOWS—AN EXAMPLE*

a

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.”

LOS CONSEJOS
DE UN AMIGO

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

3) On the way, Pedro meets Maria, a
friend who is a dental worker. “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.”

nity

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

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

34 Where There Is No Dentist 2010

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’.)

“lam a poor farmer,” Pedro’s father
tells Maria. “I 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.”*

“Then, when you have time and
money, you can go to the city. | know
a dental worker who will put in a
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'Il put some
cement in those holes!”

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.

After the show, the puppets played

a game. Throwing a ball into the
audience, they asked questions like
“How do you keep cavities from
happening?” Each child who caught
the ball answered the question and
threw it back. Then the children in
the audience began asking questions
for the puppets to answer. “Why did
you get rotten teeth?” one child asked
Pedro. The puppet looked down and
said, “Too much candy!”

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

Aitaa dET.
www. hesperian .org

CHAPTER 4

School Activities for Learning
About Teeth and Gums

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

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

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

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

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

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

BY —
|. EATING ONLY GOOD
HEALTHY FOODS

AND
2. CLEANING MY

TEETH CAREFULLY
EVERY DAY,

Teacher, each day at school:

Suggest ways genie,

for your
students to eat
good healthy
kinds of food.

AND

Give your
students time
to clean their
teeth.

35

36 Where There Is No Dentist 2010

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:

e Why do we need teeth and gums?
e Why do some teeth look different?
e What holds the teeth?

e How often do teeth grow in?

e What makes teeth hurt?

e How do germs make holes in the
teeth?

e What makes the gums feel sore?

e What does it mean if a tooth is
loose?

e 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.

Where There Is No Dentist 2010

Why Do We Need Teeth and Gums?

THE IDEA:

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

Teeth are important for:

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

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

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

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

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

= Your gums are important too.

They fit tightly around the teeth, and

help to keep them strong. Without

strong gums, your teeth are of no

) use. Most old people lose teeth
because of bad gums, not bad teeth.

a

Con =a e i rot I~
O EE S E

ACTIVITIES:

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

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

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.

37

38 Where There Is No Dentist 2010

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

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

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

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

[EICD\ “th” — the, teeth — the tongue touches
in ~_\\ the top teeth. |
Osa) “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.

Where There Is No Dentist 2010 39

Why Do Some Teeth Look Different?

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

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

Back teeth are called molars.
They chew and grind pieces
of food into bits small enough
to swallow.

The outside of a tooth is the hardest and strongest part of your body. When

a tooth is healthy, it can chew hard food, even bone. The shape of a tooth
allows us to swallow food when the small pieces can slide down its smooth
sides.

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

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

A tooth with a
cavity is weak and
often hurts.

Look for them on
the top and the sides
of back teeth.

40 Where There Is No Dentist 2010

ACTIVITIES:

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

WHICH TEETH DID YOU USE
TO EAT THE MANGO?

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

Bite a guava using only the back teeth.

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

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

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

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

Talk about the many different kinds of food we need to stay healthy.
Discuss which teeth we use to chew meat, fish, mango, and other
good foods in your area. (For most foods, the answer is both front and
back teeth!)

Where There Is No Dentist 2010

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.

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

WZ
A

bone

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

ACTIVITIES:

1. Have the students look for
an old jaw bone from a dog
or other animal. Notice that ‘
bone goes around every root
of every tooth and holds it

SS
tightly. Break away some Ay A A we
f ull A

+

of the bone and look at the ik
roots of the teeth.

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

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

41

42 Where There Is No Dentist 2010

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

C

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 a story to show how, when the gum moves away from the top of
the tooth, the root and bone are open to attack. For example:

One day, a hen was sitting on the eggs in her nest. The hen was
hungry, and when she saw a worm, she left the nest to catch the
worm. Just then, a possum came along, saw the fresh, warm eggs,
and ate them all up.

Explain to the students that the gums protect the teeth the way a

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

Where There Is No Dentist 2010 43

How Often Do Teeth Grow In?

THE IDEA:

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

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

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

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

Most permanent teeth form under the baby teeth. When the child is
between 6 and 12 years old, the permanent teeth push against the roots

of the baby teeth, making them fall out. Not all of the baby teeth fall out at
once. One tooth at a time becomes loose, falls out, and then is replaced with
a permanent tooth. The new tooth may not grow in immediately. Sometimes
2 or 3 months pass before the new tooth grows into the space.

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

At 6 years the 4 first permanent
molars start to grow in at the back of
the mouth. This means an
8-year-old child should have

24 teeth, or spaces for them.

At 12 years, the 4 second
permanent molars grow in behind
the first molars. This means a
14-year-old child should have
28 teeth, or spaces for them.

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

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

44 Where There Is No Dentist 2010

THE ACTIVITY :

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

Show the students Caa

PERMANENT TOOTH
how to count the

teeth and the spaces )

that are ready for new LOOSE BABY TOOTH

teeth to grow in.

SPACE FOR NEW TOOTH
Then have them count

their friends’ teeth, to find
out how many teeth should
be growing in different age
groups. Later, they can do this with their brothers and sisters at home.
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.

Lesson: Number of Teeth We Should Have

TOTAL = teeth now present (T) + spaces (S)

Ambun (giri)

22 ;
PNE. 2y
Michael (bey) 25 Tatai

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

Where There Is No Dentist 2010 45

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

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

Lésson: Number of Teeth ina Small Che led
Deboi

under 1 year | 1-2 years old | 2-3 years o
21

(brother)

ae seed’ if ? fw

O ($ “aie I
sister)

Sthed Jiili
EEA

ERREI 29

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

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

e Can Chenia, who is 6 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 diarrhea and fever?

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

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

46 Where There Is No Dentist 2010

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, come from the brain and
carries the message of pain. The other is the blood vessel. It comes from
the heart and carries blood to the tooth.

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

aun NERVE
m> BLOOD VESSEL

=)

vee:

a

Ù

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.

Where There Is No Dentist 2010 47

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

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

Fill a small cavity and save a tooth.

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

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

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

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

vie

7 = A tooth is like a light bulb.
DES RA] When the bulb is alive from power inside, it is
bright and useful.
The little wires inside the bulb are like the nerves
CA) inside the tooth. When the bulb burns out, it is dark

and not useful any more.

48 Where There Is No Dentist 2010

ACTIVITIES:

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

2. Discover how sweet food sticks to teeth.

e Cut several different kinds of food with a knife.

e Vegetables and meat do not stick to
the knife.

e Sweet foods, like chocolate and
jam buns, do stick to the knife.
They stick to your teeth the
same way.

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

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

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

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

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

After 3 days scrape each tooth

again with a knife. Students will
discover that sweet cola drinks
make teeth softer and darker

in color.

Where There Is No Dentist 2010

3. Look inside a tooth for the space where the nerve and blood vessel

used to be. See how close they were to the tooth’s hard outer cover.
Look for a small hole at the end of the root. That is the place where
the nerve and blood vessel enter the tooth.

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

e Take a hammer.
e Gently break open a tooth.
e Look inside.

See how much bigger the cavity is on the
inside. It soreads under the hard cover.

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

. 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 they counted. Then
make a chart or graph.

=
TooTH DESAY IN OVA SCHOOL |
TOTAL

NUMBER OF STUDENTS AT SCHOOL
ê

i t
a wet

CY

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 help 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.

49

50 Where There Is No Dentist 2010

How Do Germs Make Holes in the Teeth?

THE IDEA:

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

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

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

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

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

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
game of “Scatter!” The ‘decolonizer’ is the
girl in the center with the broom.

The Game:

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

Where There Is No Dentist 2010 51

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 holding
hands, touching two monitors.

Play two games: one with

children trying to form the first
‘ kind of colony, one with the

The ‘decolonizer’ (with broom) has lost second kind. These photos are

the game. The children behind him have from the second game.

formed a ‘colony’.

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

The decolonizer wins if no

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

HOW MANY GERMS
DO You SEE IN
THIS CIRCLE ?

After The Game:

Talk to the students about germs
in their mouths and how small
they are. Can anyone see germs?
No, but they can feel them and
taste them. Ask the group what
their mouths feel like in the
morning when they wake up. You
may get these answers:

e My teeth feel mossy.
e My breath is bad.

e | feel a coating on my teeth, To teach about things too small to see, look
but it goes away when | at the suggestion on page 11-29 of Helping
brush them. Health Workers Learn.

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

52 Where There Is No Dentist 2010

What Makes the Gums Feel Sore?

THE IDEA:

Healthy gums fit tightly around the teeth and help to hold them strongly.
Healthy gums also cover and protect the bone under them.

Healthy gums are pink in color, or
even blue or dark yellow in some people.
But healthy gums are never red.

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

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

As we saw with the last activity (p. 50), when you have ‘colonies’ of germs
on your teeth, they can make acid that makes holes on your teeth. The same
coating of germs can make a different acid that makes the gums sore. This
also happens when food mixes with the coating on your teeth. Soft food

is the worst kind, because when it mixes with spit it sticks more and stays
longer on your teeth. Juice from tea, betel nut, and meat color this food,
making the tooth look dark.

T a lA à

WA

Healthy gums become sore because of acid. When the coating on the
teeth (p. 50) becomes hard, it is called tartar. Tartar can hurt the gums.
Also, the ‘colonies’ of germs can make a coating on top of tartar more
easily than on a clean tooth. When the colonies are new, they make more
acid which causes tooth and gum problems. After 24 hours, it hardens
and makes a new layer of tartar. The tartar gets bigger and bigger.

Here is a larger picture of the

Sore gums are infected. teeth in the box above:

Infected gums are red
and bleed easily.

Infected gums are round and
swollen between the teeth.

They are also loose instead of
tight against the teeth.

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

Where There Is No Dentist 2010 53

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
gums, you can do much to
treat the infection yourself.

1. Clean your teeth with a soft
brush gently and more often
(see page 71).

2. Eat more fresh fruits and
vegetables.

3. Rinse your mouth with warm
salt water.

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

ACTIVITIES:

1. Have the students look in each other’s mouths.
Can they see the coating on the teeth? Usually
they cannot. They may see food or ‘white stuff’,
but this is not the coating that makes acid.
However, if someone has been chewing betel nut
or eating berries, you will see stains on her teeth
and the stains will be darkest where she has
these colonies of germs on her teeth.

2. Put something on the teeth to stain the colonies of germs. Try using
food dye, betel nut or berry juices. Remember: first wash your hands!
Older students can rub berries on the teeth of the younger ones. Have
them rinse with a little water and spit it out. After this, the colored areas
on the teeth will show where the colonies of germs are forming. Where
are they? Usually you will see the dark colors:

e between the teeth
e inthe pits or holes in the teeth
e onthe tops (biting surfaces) of the teeth.

The older students can show the younger ones the best way to clean
teeth (see pages 69-72). Have them use a mirror to see if they are getting
the colored juice from their teeth. They will learn that it is most difficult

to get rid of the color between their teeth. Give them some string, dental
floss, or the soft stem from a young palm leaf and show them how to use
it between their teeth (p. 72). Remind them to be gentle, or they will hurt
their gums. Clean between your teeth every day.

54 Where There Is No Dentist 2010

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

ABSCESS z

WITH BOIL loose teeth. All you can do is stop

the infection from getting worse.

~<——. GUM DISEASE

ACTIVITIES:

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

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

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

2. Look for teeth that have cavities or gum
disease around them. The students can do
this with each other, and then later at home.
(Remember they must wash their hands!)

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

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

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

Where There Is No Dentist 2010 55

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.

hip A
DIE Ñ
So
Vegetables, especially Peas and beans, like green Oil, from palm nut
those with dark green beans, soybeans, winged kernels, ground nuts,
leaves. beans, and mung beans. and coconut.
A) © of) Nom (|, OOD
Fruits, like banana, Fish, meat and eggs. Clean water, coconut
guava, oranges, water, and milk are best

and papaya. to drink.

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

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

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

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

56 Where There Is No Dentist 2010

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.

— ~~ _ es

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.

LEY

nr pe ee ees

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.

—si_

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

Where There Is No Dentist 2010

ACTIVITIES:
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:

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

e 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.

57

58 Where There Is No Dentist 2010

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

Give all the students something to eat that is sweet, sticky and dark in
color, such as sweet chocolate biscuits. Ask the students to look in each
other's mouth, to see how easily the biscuit sticks to the teeth. One or
two of the students in a group can then try to clean away the pieces of
biscuit, using a different method.

each person

eat a sweet
MARIE sticky food SARA
and...
...do «brush
nothing and rinse
LAURA

VINCENT

...rinse ..eata
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 1

stitL Dirty O

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

Where There Is No Dentist 2010 59

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

CLEANLINESS CAN BEGIN AT SCHOOL

At school, students can wash their hands before lunch and brush their
teeth afterward. Encourage them to keep a piece of soap and a toothbrush
or brushstick (p. 4). One day a week, the whole class can treat their teeth
with fluoride (p. 205) to prevent cavities.

The student
can keep the
brush at her
own desk...

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

bamboo brush ea |

.. Orona

rack at the
iro back of the

room.

Let each student look after
her own soap and brush.

60 Where There Is No Dentist 2010

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 net clean.

1 SCORING TEETH

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

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

r

y A clean tooth = 2 points.
A dirty tooth = 0 points.
Total possible points each day
is 4 teeth x 2 = 8 points.

In this example the score is:
Tooth 1 = 2 points
Tooth 2 = 0 points
Tooth 3 = 0 points
Tooth 4 = 2 points
Total = 4 points

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

"Err I ETO e Cele ee eee ese saa

Month of? March

CHAPTER 5

Taking Care of
Teeth and Gums

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

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

Early treatment is a form of prevention.

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

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

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

61

62 Where There Is No Dentist 2010
TAKING CARE OF BABY TEETH

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

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

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

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

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

Cavities in baby teeth can make a child’s malnutrition worse.
Remember this whenever you see a weak, poorly nourished child. When
you examine a child at the health clinic, lift his lip and look at his teeth. Do
this as part of your routine examination.

You can fill cavities with cement (Chapter 10).
Cement prevents food and air from going inside
the cavity and hurting the child.

A sore on the gums may be a gum bubble. If so,
it means the tooth has an abscess (page 81).
That cavity should not be filled with cement.
Instead, the tooth needs to be taken out
(Chapter 11) before the infection can get worse.

Where There Is No Dentist 2010

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

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

e 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).

e 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. If she needs
an antibiotic, use a different one.

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

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

e Wipe her baby’s teeth with a clean cloth after
the baby eats. This cleans the baby’s teeth,
and helps the baby get used to teeth cleaning.
Later he will be happy with a brush.

Around 1 year of age, there will be several baby teeth. At that time, mother
should start using water—not toothpaste—on a soft brush or brushstick.
(With toothpaste, you cannot see the child’s teeth clearly because of the
bubbles it makes.) She should scrub the sides and tops of each baby tooth
as well as she can (page 69).

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

1 You can make a large brush smaller,
` to fit more easily into a young
_—T child’s mouth.

“ite — Pull out some of the back hairs, or
A cut them out with scissors. Do not
cut the hairs in half, because the

tops are often rounded or softer, and
that is better for the gums.

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

63

64 Where There Is No Dentist 2010

Why Baby Teeth Are Important

Baby teeth are just as important to children as permanent teeth are to adults.
They help a child to eat, talk, and look good.

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

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

Permanent Under each baby tooth a new
molars permanent tooth is growing.
(PM) come

in behind At the same time, extra

the baby permanent molars are forming
molars at the back of the mouth,
(BM). inside the bone (page 43).

Front baby teeth become
loose and fall out (usually

6-7 years, but sometimes as
young as 5 years) ahead of
back baby teeth (10-12 years).
This is because the front
permanent teeth are formed
and ready to grow in first.

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

t dem

26”
iPm
LPM
The first permanent molar grows into Slowly but steadily the upper and
the mouth by sliding against the back lower permanent molars grow until

of the second baby molar (2BM). they meet and fit tightly together.

Where There Is No Dentist 2010

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.

HEALTHY BABY TEETH —— help > STRAIGHT PERMANENT TEETH

a

to ma

10 years

SICK BABY TEETH ———— ee —> CROOKED PERMANENT TEETH

4pm 2am {

TAKEN OUT
BEFORE

26"
apm
MOVING INTO NOT ENOUGH
THE CAVITY SPACE

10 years adult

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

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

65

66 Where There Is No Dentist 2010
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 Can

GUM BUBBLE

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

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

See the red swollen skin on
Look behind her back teeth. top of the new tooth.

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

If there is no swelling and she can open her mouth, explain to her what is
happening and what she can do herself to reduce infection and toughen the
gums. The best medicine is to rinse warm salt water over the sore area.

A good home remedy is to rinse until the tooth grows all the way into the
mouth.

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

Where There Is No Dentist 2010

TAKING CARE OF ALL YOUR TEETH

This book often repeats an important message: eat good food and clean
your teeth. It is repeated because this is the most important thing you
can learn from this book. Later chapters will discuss what to do when
problems occur, but if you follow these two suggestions, you will almost
never have problems with your teeth and gums. This is true because good
food keeps your whole body healthy, including your teeth. Also, with no
‘colonies’ of germs (page 50) or harmful factory sugar (page 55) on your
teeth, your mouth cannot make the acids that cause both tooth and gum
problems. So, remember:

1. Eat Good Food

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

Good nutrition (eating well) means 2 things:

1) Eat a mixture of different kinds of foods
every time you eat. Look at the pictures
on page 55. There are several groups of
foods. Every time you eat, try to eat one or
two foods from each of the groups. This
way, you will get 3 important kinds of food:
grow food (body-building food) to give you
the protein you need; glow food (protective
food) to give you vitamins and minerals; and

The MAIN FOOD is at go food (concentrated energy food) to give

the center of every meal. you calories to be active all day.

2) Be sure you eat enough

food to give your body the a=
energy it needs. This is even cat 3
more important than the first = ney

suggestion. We get half or
more of our energy from our
main food. In most parts of the ee
world, people eat one low-cost oe oe
energy food with almost every a a ea

; means he only has to eat
meal. Depending on the area,
hi inf about 3⁄4 as much of the
t IS mam ood may be rice, local main food in order to
maize, millet, wheat, cassava, meet his energy needs. The
potato, breadfruit, or banana. added oil helps make sure
The main food is the central or he gets enough calories by
‘super’ food in the local diet. the time his belly is full.

68 Where There Is No Dentist 2010

Be sure always
to eat grow
foods and
glow foods

to get the
vitamins and
protein you
need.

Your energy
foods give

you the most
important

part of your
diet—calories.
Half or more
of our

calories come
from the main
food, and most
of the other
calories come
from go foods.

WARNING ABOUT GO FOODS: Although go foods give us the energy

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

Where There Is No Dentist 2010

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.

69

70 Where There Is No Dentist 2010

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

YES

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

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

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

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

Fluoride in drinking water, toothpaste, salt, vitamins, and mouth
rinses helps to prevent cavities. These methods are sometimes
expensive. But treating teeth once a week with fluoride toothpaste
is effective and inexpensive. See page 205.

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:

Where There Is No Dentist 2010 71
CLEANING BETWEEN THE TEETH IS VERY IMPORTANT

Here are three ways to clean between the teeth:
1. Push the hairs of a toothbrush between the teeth, and sweep the bits
of food away.

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

Rub the stem against
4 $2 y one tooth and then
= the other. This way,
you clean the sides
of both teeth.

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

Get some thin cotton rope Buy and use dental floss.This
used for fishing nets. Unwind OR is a special kind of string for
and use one strand of it. cleaning between the teeth.

Be careful! The string can hurt your gums if you do not use it correctly.
The next page shows how to use the string, but the best way to learn
how to ‘floss’ your teeth is to have someone show you. Ask a
dental worker who has experience.

72 Where There Is No Dentist 2010

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

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

Upper teeth
—

Lower teeth

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

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

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

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

CHAPTER (

Examination
and Diagnosis

Whenever you do an CARE THE TEETH HEALTHY 2) Oo

i i o e
examination, remember 5 .
to examine the mouth. olen Gu

You can prevent much suffering Dg 5
and serious sickness when
you notice and treat problems early.
Whenever you hold a health clinic, try
to find out how healthy each person's
mouth is.

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

Always write down what you find out,
so you remember what treatment that When you look inside someone's
person needs. mouth, ask yourself these questions.

1. Are the teeth healthy? Look for:
Tell the person what is
1. A New S happening and how to
keep the skin around it
healthy (page 66).

They may be cavities
which should be

filled when they are
still small (page 47).

Tell the person what is
happening and how to prevent
it from getting worse or
affecting other teeth (page 54).

A tooth that is dark is dead and infection
from its root can go into the bone (page 47).
This can make a sore on the gums (page 74).

73

74 Where There Is No Dentist 2010

2. Are the gums healthy?

Look at page 52 and compare the pictures of healthy and unhealthy gums.
Unhealthy gums often are red and they bleed when you touch them.

A bubble on the gums below the

tooth is a clear sign that the person

has an abscess. The abscess may be

from the tooth, or it may be from the

gums. To decide, look carefully at Z T -Z
both the tooth and the gum around it. 1 a

A bubble beside a healthy tooth is a sign

of infected gums. Scale the tooth carefully. x jz
See Chapter 8. So ae
A bubble beside a decayed tooth is a sign E + z

of a tooth abscess. (See page 93.)

A sore on the gums from a badly decayed GUM BUBBLE

tooth appears when a gum bubble breaks
open and lets out the pus from inside.

3. Are there any sores?

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

A
LASET

1. A sore on the 2. Sores on the inside . Sores on the
gums may be of the lip or cheek lips or tongue
from an infected may be from a may may be
tooth (p. 93). virus (p. 104). cancer (p. 125).

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

Share your knowledge—explain things to people.

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

Where There Is No Dentist 2010 75

WHERE TO EXAMINE

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

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

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

Use an old chair with a strong back.

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

THE INSTRUMENTS YOU NEED

Three instruments are really enough:

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

K 2 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.

AEE PE CNRS RS 5 A,

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

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

76 Where There Is No Dentist 2010

A GOOD DIAGNOSIS

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

Learn all you can about the person’s problem:
1. Ask questions about the problem.

2. Look at the person's face. Think about the person's age.
3. Examine the mouth more carefully than before.
4. Touch the place that is sore.

1. Ask the person about the problem.

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

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

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

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

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

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

e When did it start? Find out if he has already had this problem before.
Ask how he took care of it.

e 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.

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

e« 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.

Where There Is No Dentist 2010

When you talk to a woman, find
out if she is pregnant. A pregnant
woman's gums can easily become
infected. The gums may bleed and
she may have more tooth decay.
But this does not have to happen.

If a pregnant woman takes extra
care of her teeth and gums, she can
prevent most dental problems. But
if she already has a problem, do not
wait for the baby’s birth before you
help her. You can treat a pregnant
woman's mouth problems now. In
fact, this may be an important way of dental care, they can give
protecting her baby as well (see pages you helpful information

15 to 16). about the women’s health.

| TRANSFER To
DENTAL CLINIC
Maria Antonio

Train midwives to examine
women’s mouths. When
they send women to you for

Caring for a pregnant woman—a guide for dental workers

. Ask her how many months she has been
pregnant and find out if she has high blood
pressure. Any person with blood pressure over
150/100 may bleed excessively after extraction.
To get this information, encourage all women
to have regular check-ups with a midwife or a
trained health worker who has equipment for
measuring blood pressure.

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

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

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

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

78 Where There Is No Dentist 2010

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:

* mumps

e an infection in the spit
gland (p. 119)

e a tooth abscess (p. 93)

CHILD

A sore can come from:

* impetigo
e Vincent's infection
(p. 102)

SWELLING

YOUNG PERSON

Swelling can come from:

e anew tooth growing
in (p. 100)
e a tooth abscess (p. 93)

YOUNG PERSON

A sore can come from:

e fever blisters (p. 104)
e a tooth abscess (p. 93)

Swelling can come from:

e a tooth abscess (p. 93)
e a broken jaw (p. 113)
e a tumor (p. 125)

A sore can come from:

e a tooth abscess (p. 93)
e a bone infection
(osteomyelitis)

Where There Is No Dentist 2010

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

LET ME THINK
L PAIN ALL THE
TIME
2. SWOLLEN FACE

3 LARGE CAVITY
IN MOLAR

ABSCESS ?

Look at the gums:

Are they red?

Is there any swelling?

Do they bleed?

Are the gums eaten away
between the teeth?

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

4. Touch the sore place.

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

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

1 MUST TAKE OUT
YOUR TOOTH. 1T
HAS AN ABSCESS.
Using the end of your mirror, tap against

several teeth, including the one you suspect.

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

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

80 Where There Is No Dentist 2010

LEARN TO TELL SIMILAR PROBLEMS APART

If a person comes to you with a toothache or a sore
or a loose tooth, there are many possible causes for
each problem. The first thing you notice—the
toothache, sore or loose tooth—is your first step

to a diagnosis. To this you must add more information
before you can point to the most probable cause.

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

Usually it is easy to make a diagnosis. However,
sometimes you will not be sure, and these are the
times to seek the advice of a more experienced dental
worker. Never pretend to know something you do not. Only treat
problems that you are sure about and have supplies to treat properly.
See Where There Is No Doctor, p. w4.

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

IF THE PERSON AND YOU FIND OUT HE/SHE
HAS THAT MAY HAVE

y It hurts only after eating or

drinking. There is a cavity, but the a cavity
tooth does not hurt when you tap it.

Part of the filling has fallen out, or is a cavity
cracked and ready to fall out. Eating 8 under an
and drinking make the tooth hurt. old filling

A TOOTHACHE The tooth hurts when chewing food. tartar
t may hurt when tapped, but there is between
no cavity and the tooth looks healthy. : the teeth

t hurts all the time—even when ae |
person tries to sleep. The tooth i
: S ` an abscess
hurts when you tap it and it feels a
bit loose.

t hurts when person breathes in cold a cracked

air. The tooth was hit recently. or broken
tooth

He cannot open his mouth properly.
Steady pain and a bad taste are a new tooth
coming, from the back of the mouth. growing in

Several top teeth hurt, even when

you tap them. She had a head cold “ an infected
and can only breathe through her i sinus
mouth.

IF THE PERSON

HAS
Y

A
SWOLLEN FACE

We

-om

A
LOOSE TOOTH

Where There Is No Dentist 2010 81

AND YOU FIND OUT

THAT
vy

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
ouch it. The teeth do not fit
ogether properly.

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

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.

f

BONE BROKEN ‘
UNDER THE GUM Ta

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

HE/SHE MAY| SEE
HAVE PAGE
—y
a tooth
abscess

3
00
08
19

5
01

a new tooth
growing in

an infection
inside the spit
gland

aad a

99
and
93

9
1

1

1
12
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
aganist another

82 Where There Is No Dentist 2010

IF THE PERSON
HAS

y

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
smell bad.

The gums are bright red and
sore, but between the teeth
they are still 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 serous
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

gum bubble

fever blisters—
from Herpes
Virus

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

Where There Is No Dentist 2010 83

IF THE PERSON AND YOU FIND OUT HE/SHE MAY
HAS THAT HAVE

y

nside his mouth, he has a } abscessed tooth
ooth abscess or a broken draining pus to
ooth near the sore. the outside of

the face
A SORE

ON THE FACE ; .
A dark sore is eating through a condition

he cheek. Her gums are Lal ® called Noma—
badly infected. A bad smell is | starting from
coming from the dying skin on Vincent's

he face, and from inside the Infection of the
mouth. gums

A 1-month-old sore on the lips

; : $ SS cancer
is not healing with medicine.

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

a new tooth
growing in

TROUBLE a broken jaw—
OPENING THE He recently had an accident. probably in

front of the ear

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

an abscess ina
back tooth

1 CAN NOT When she tries to open- : o

OPEN ANY her mouth, there is clicking pain in the

MORE THAN sound from in front of her Mt joint—where
ear. It also hurts in that place AM the jawbone
whenever she tries to open joins the head
her mouth or chew food.

Swallowing is difficult and %2.prx 8.0

the jaw grows stiff. Germs

have gone into the body A tetanus
from dirty instruments or an /

infected wound.

TROUBLE After opening wide to eat
CLOSING THE or yawn, his mouth became j: a dislocated
stuck there. He was many j jaw
missing back teeth.

He had an accident and now
something is stopping the € 2 a broken jaw
teeth from coming together.

Where There Is No Dentist 2010

CHAPTER 7

Treating Some
Common Problems

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

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

Know your limits. Do only

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

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

Germs in the mouth

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

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

When we regularly clean the mouth, the number of germs stays normal.
You can teach others to clean teeth and gums, but cleaning is each person's
responsibility.

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

85

86 Where There Is No Dentist 2010
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.

Wear gloves

Latex or plastic gloves protect the people you
touch from germs that may be stuck under your
fingernails or on your skin, even after you wash
your hands. They also protect you from getting
infections. Wear clean gloves whenever you
touch someone's mouth or any blood.

If you are filling or removing a tooth, or if you are touching any
instruments that have been sterilized, you must wear sterile gloves.

ees hee, If you do not have gloves, use plastic bags that
have been washed in disinfectant soap instead.
Bags are harder to use than gloves, but they are
better than nothing.

Where There Is No Dentist 2010 87

Germs hide inside bits of old food, cement, or
blood on an instrument. There they can continue
to live, even in boiling water.

This is why you must be sure to scrub the working
end of each instrument carefully with soap and
water. Rinse, and then look carefully to see that it
is clean and shiny.

Remember that ‘clean looking’ is not necessarily ‘clean’. Truly ‘clean’ means
free of germs. Unless you sterilize, that instrument may still have germs,
the kind that cause infection in the next person that it touches.

Sterilizing means killing germs. The best way to sterilize is with heat. High
heat kills almost all harmful germs—especially those that cause hepatitis,
tetanus, and mouth infections. Wet heat (steam) is always more effective
than dry heat from an oven.

Here is a simple rule to use in
deciding when to sterilize:

Boil or sterilize with steam
any instrument that has
touched blood.

That means always sterilize
all syringes, needles, and
instruments you use when
scaling teeth (Chapter 8)

or when taking out a tooth
(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.

e 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.

88 Where There Is No Dentist 2010

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 cooking
oil into the pot.

2. Place the handles together.
Put on high heat until a loud
hissing noise begins.

3. Put on lower heat. Begin
timing now. Leave the hissing
pot on the low flame for
15 minutes.

4. Cool the pot under water, open,

and lay the instruments on a
clean towel to dry.

DO NOT LET
THE COOKER
BOIL DRY!

The next time you use the pot,
you can use the same water that
was left inside it.

Where There Is No Dentist 2010 89

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
1. Mix in a large container each week: cH lid

7 parts alcohol (95%) with 3 parts LLL
clean water. Keep the container Een, water
tightly covered to prevent 1 AHH
evaporation.
2. Keep a covered pan half filled with alcohol

this mixture. You will have to add
some more of the mixture from the
large container to the pan each day.

3. Leave your clean instruments in the 2
pan, completely covered with the Se

liquid, for 30 minutes.

Bleach solution (sodium hypocholorite)

Find the cheapest brand name in your area for bleach.
Examples are Javex, Clorox, Purex, and Cidex. Make
1 liter of solution with a mixture of % cup
(125 ml) of bleach and 3% cups (875 ml)
of clean water.

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.

90 Where There Is No Dentist 2010

Keep your sterile instruments together in a clean place.

Wrap them in a clean cloth OR Leave them in disinfectant
(p. 89)

Before you use any instrument
again, wash it with clean water—to
remove the taste of the disinfectant.

Mark with tape the names
of the instruments inside.

Germs living in dirty cotton can easily go inside the socket and start an
infection. It is important, therefore, to keep the cut pieces in a container that
is clean and has a cover. Use clean tweezers to remove the cotton gauze
when you need some.

Also, keep your room and work area clean. Sweep or mop the floor one or
two times a day, and wipe down the chair and tables after every patient.

Staying clean is a part of staying healthy.

Where There Is No Dentist 2010 91
NEEDLES

Many people get sick with serious illnesses like hepatitis or HIV from using
unsterilized needles.

Reusable syringes and disposable syringes

Reusable syringes can be used again and again. Reusable syringes make
less waste and can save money, but they must be washed very carefully and
sterilized after every use.

Use each disposable needle only one time and then throw it away in a box
like the one on pages 199-200. If you must reuse a needle, replace the cap
very carefully and put the needle in a safe place (such as a pan full of bleach
solution) until you are ready to clean and sterilize it (p. 138).

HOW TO WASH AND STERILIZE A SYRINGE AND
NEEDLE FOR REUSE:

1. Put on a pair of heavy gloves
to protect your hands from
germs and from sticking
yourself with the needle.

2. Draw 5% bleach solution (see page 89) up i
through the needle into the syringe barrel. :

3. Squirt out the bleach solution.

4. Repeat several times. Rinse everything
several times with clean water.

5. Take the syringe and needle apart and boil or
steam them. (See page 138.)

Never reuse a needle or syringe without

cleaning and sterilizing it first.

92 Where There Is No Dentist 2010

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:

e Pain when drinking water or eating
something sweet.

e A hole (or black spot) on the tooth, or
between two teeth.

e Pain if food gets caught inside the hole.

e 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 page 151), or doing Atraumatic Restorative Treatment (ART), a
way to remove cavities without drilling..

A groove on the neck of a tooth is a more difficult
cavity to fill. For the temporary cement to hold hye
properly, you need to shape the groove with = J

a drill. To help temporarily, you can put a little BES A
fluoride toothpaste on the groove (page 205). Do

this once each week until the inside part of the groove is stronger and the
tooth hurts less. Or, you can paint the inside of the groove with oil of cloves
(eugenol) to reduce the pain.

To avoid making the problem worse, (1) do not use a hard toothbrush;
(2) do not brush back and forth along the gums; and (3) do not chew tobacco
or betel nut and do not hold them against the teeth.

Where There Is No Dentist 2010 93
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:
e 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.

e A sore 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.

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 204.

Adults and children over 25 kg (60 pounds) of weight should take the same
amount of oral penicillin. Children under 25 kg should take % as much. For
most infections, penicillin by mouth is taken 4 times a day for 5 to 7 days.
The first dose is double and then the regular dose is taken every 6 hours. The
person should take all of the penicillin, even if the pain or swelling goes
down. For the correct doses, see the next page.

94 Where There Is No Dentist 2010

THE BEST CHOICE SECOND CHOICE PSY
(for those allergic to penicillin)

Penicillin: 1 tablet = 250 mg
Give enough tablets for 5 to 7 days

Erythromycin: 1 tablet (or capsule) = 250 mg

Give enough tablets for 5 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 5 to 7 days
Adults 2 tablets
and children over 25 kg (500 mg)
Children under 25 kg 1 tablet
(250 mg)

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 5 days
Adults 2 tablets
and children over 25 kg (500 mg)
Children under 25 kg 1 tablet
(250 mg)

IMPORTANT: to allow it to best fight infection,
take penicillin before eating.

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

Note: If you do not have penicillin, use amoxicillin, 3 times a day for 7 days.
Adults and children over 25 kg take 500 mg each dose, and children under
25 kg take 250 mg each dose. To use ampicillin, see Where There Is No
Doctor. People allergic to penicillin will also be allergic to amoxicillin and
ampicillin.

For many infections, taking penicillin for 5 days should be enough. For
serious infections, it may be necessary to take the antibiotics for 7 days.
For however long you take them, always take the double dose the first time,
and then the regular dose 4 times a day (every 6 hours). If the infection does
not heal, you may need a different medicine. Usually you can take out the
tooth 1 or 2 days before the end of the antibiotic treatment, but the person
must continue to take all of the tablets, even after you have taken out
the tooth. If not, the infection might come back even stronger than before.

If the swelling is ‘pointing’, open it with a sharp sterile knife to release the
pus. Cover the wound with a sterile dressing to keep it clean. If you are not
able to do that, explain how to reduce the swelling with heat. As often as
possible until the swelling goes away:

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 2-day supply will be enough,
because the penicillin and the heat will reduce the pressure and that will
reduce the pain. The best medicines for pain are aspirin, which 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.) See doses at the top of the next page.

Where There Is No Dentist 2010 95

EVERY 6 HOURS (4 times a day): aspirin or acetominophen
adults 600 mg | 1000 mg
children 8 to 12 years 300 mg 500 mg

3 to 7 years 150 mg 250 mg
1 to 2 years do not use 125 mg

INFECTED SINUS

A sinus is a hollow place inside the bone. There is a sinus under the eyes, on
each side of the nose. Because the sinus is very close to the roots of the top
teeth, these teeth may hurt if the sinus becomes infected.

SIGNS:

e Toothache in several top teeth. The
teeth look healthy, but hurt when you tap
them.

e Ahead cold, and plugged nose. She can
only breathe through her mouth.

e Hurts when you press against the bone
under her eyes.

e Tooth feels different when patient bends over forward.

TREATMENT:

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

1. Give penicillin for 5 days (page 94).

2. Explain to the person that she should:

e drink lots of water.

e breathe steam from boiling water to clear
her nose.

e hold a warm wet cloth against her face, as
often as possible.

e 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

e examine her teeth closely, tapping them to be sure they are strong
and healthy.

e if she is not better, get help from a more experienced health worker.

96 Where There Is No Dentist 2010
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 saliva 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 109).

You can save a broken tooth if the nerve is still covered and the
root is not broken. To do this, use a file on the sharp edges around the
break. This makes them smooth so they do not cut the tongue. Later, an
experienced dental worker who has the equipment can cover the broken
part with a cap or a filling. Until this is possible, tell the person how to
protect the tooth:

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.

Where There Is No Dentist 2010

2. Tooth knocked out

When a tooth is knocked out of the mouth, you should ask two questions:
(1) Was it a baby tooth? (2) How long ago did it happen?

Baby tooth. There is no reason to try to put a baby tooth back into the socket.
Tell the child to bite on some cotton to stop the bleeding. Then wait for the
permanent tooth to replace it. Warn the mother that the permanent tooth
may take more time than usual to grow into the mouth.

Similarly, there is no need for
treatment if the baby tooth is
pushed up under the gum.

The tooth may grow back into the
right place later, or it may turn dark
and die. if you see a darkened tooth
or a gum bubble (page 74), take out
the baby tooth before it hurts the
permanent tooth that is growing
under it.

Permanent tooth. A permanent tooth is worth saving. How long ago was
it knocked out? If it was less than 12 hours ago, you can put a permanent
tooth back into the socket. The sooner you do this the better, so do not
wait. If you replace the tooth in the first hour, it has a much better
chance of joining with the gum and bone. In order to heal and to join the
bone, the tooth must be held firmly.

a) Wash the tooth
gently with saline,
milk, or clean water.
There should not be Y
any bits of dirt on the

root of the tooth. Kor’)

Keep the tooth
damp with wet
cotton gauze.

Do not scrape away any skin from the
root or from the inside of the socket.

97

98 Where There Is No Dentist 2010

b) If you can not use anesthetic, tell the patient that it will hurt
somewhat. Gently push the tooth up into the socket. As you push it
up, use a slight turning movement
back and forth.

lt sm,
sgt ule, Pay
sats ity time
PT SON R

The biting edge of the loose
tooth should be at the same
level as the teeth beside it.

Hold it in place with your
fingers for about 5 minutes.

c) Soften some beeswax and
form it into 2 thin rolls. Place 1
roll near the gums on the front
side of 5 teeth: the loose tooth
and the 2 teeth on each side
of it. Press the wax firmly, but
carefully, against these teeth.

Do the same with the second

roll of wax on the back side of
the same teeth, again near the
gums.

It is good if the wax on the
back side is touching the wax
on the front side. This helps
the wax hold the teeth more
firmly. To do this, you can
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 47). If that happens, you must take out the tooth, unless you can do
root canal treatment.

If it is possible, take an X-ray of the tooth 6 months later and then again each
year. Look at the X-ray picture of the root to be sure an infection is not eating
it away. To do this, compare the root with the roots of the teeth beside it.

Where There Is No Dentist 2010

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

3

a new permanent tooth is . tell the mother and child what is happening.
growing under it. . pull out the loose baby tooth, if it is hurting the
child.

gum disease or an old abscess has . take out the tooth, especially if it also hurts.
eaten the bone around its 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 cracked. Do not take out the tooth. If you do, the bone will
(The bone moves when you push come out with it. Instead, hold the tooth with wires
against the tooth.) (page 110).

A tooth may also be loose because another
tooth Is biting too hard against it.

SIGNS:

e 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.

99

100 Where There Is No Dentist 2010
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.
e 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.

e The age of the person is the right
age for growing a new molar

tooth (page 66). Infection in the gums and pressure from

the new tooth are painful. Notice the
‘flap’ of skin over the new tooth.

TREATMENT:

Do not take out a new tooth while there is still infection and pain. Wait
for the infection to finish. Then decide if there is room for the tooth to grow
in. A dental X-ray can help you make that decision. New molar teeth are
often difficult to take out. Ask an experienced dental worker to take out the
tooth, if it must be done.

What you can do

First, treat the infection. Then wait for the new tooth to grow more into the
mouth. Tell the person what is happening. Tell him what he can do to keep
the gums healthy while the tooth grows in:

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 94).

Give penicillin (pages 93-94) if there is fever, a swelling, or if he is only able
to open his mouth a little.

Where There Is No Dentist 2010 101
TEETHING

When babies and small children first get their teeth, it is called teething.
This can make the child unhappy, because his gums are sore.

Teething does not cause fever,
head colds, or cough.

But a child can have any of
these problems at the same
time as he gets a new tooth.

TREATMENT:

If the child has another sickness, do not blame it on teething. Look for
another cause and treat it separately. Also, do not cut the gum over the
new tooth. Let the tooth grow through the gum by itself.

1. Give acetaminophen for pain and fever (page 94).

2. Give the child something hard to bite against. This will help the tooth to
grow through the gums faster. For example, let him chew on a dry hard
biscuit.

GUM DISEASE STARTING

Infection can start in the gums whenever the teeth near them are not clean.
For example, there may be swelling between only 2 teeth or between many
teeth. In addition, gums that are weak from poor nutrition are not able to
resist the infection. This is why pregnant women and people living with HIV
must take special care to eat well and clean their teeth carefully. When a
person has HIV, his body cannot fight infections well, so a gum infection can
quickly get worse (page 183).

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 the person
brushes or flosses.

Feel for tartar under the gum—or
even a piece of fishbone.

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

e The person has bad breath and a bad taste inside the mouth.

102 Where There Is No Dentist 2010

TREATMENT:
Explain to the person the cause of her gum problem and what she can do

to help herself. The only way to stop gum disease is to remove plaque and
tartar from the teeth and then to keep them clean.

1. Show her how to clean her teeth better near the gums (page 69).

2. Tell her to rinse her mouth with warm salt water (page 7). Make 4 cups
each day until the bleeding stops. Then make 1 cup each day to keep
the gums strong and tough.

3. Tell her to eat fresh fruits and vegetables. Guavas, oranges, pineapples,
papayas, tomatoes, peas, and green leaves give strength to gums.

4. Gently reach under the gums and remove tartar (or loose piece of
fishbone) that is caught there (see Chapter 8).
Sometimes a pregnant woman's gums become swollen, and the swelling
does not go down even after cleaning with a soft brush and rinsing with salt
water. These swellings must be cut away. But she should wait to have this
small operation until after the baby is born.

MORE SERIOUS GUM DISEASE

Vincent’s infection of the gums, also called trench mouth, affects both
adults and children. In its worst form, it can eat a hole through the cheek of a
weak child (page 121).

A person with Vincent's Infection may not want to eat because his teeth
hurt when he chews food. That can make a child’s malnutrition worse.

You must prevent this problem from starting, especially in a child who is
weak from sickness. Teach mothers to clean their children’s teeth and to get
their children to rinse their mouths with warm salt water.

SIGNS:

e Gums between the teeth are dying
and turning gray.

e Pus and old blood collect around
the teeth.

e Burning pain from the gums.
e Bleeding from the gums.

e The mouth smells bad.

TREATMENT:

You will need to see the person over a 2-week period. Start some
treatment now:

1. If the person is already sick, give penicillin for 7 days (page 94).

Where There Is No Dentist 2010 103

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

e Wipe his gums with cotton soaked in a 3% solution of hydrogen
peroxide, iodine, disinfectant mouth wash, or warm salt water. Rinse
with warm water. For a child, use a weaker solution, such as 1 part
hydrogen peroxide mixed with 5 parts water.

e Scrape away the bigger pieces of tartar. Do not try to remove all of it.
You can do that later. Put topical anesthetic on the gums if you have
some (first dry the area with cotton so the topical anesthetic will stay
longer). Rinse away any loose bits of tartar with warm water.

3. Teach the person how to care for the gums at home:

e Rinse at home for 3 days with a weak solution of hydrogen peroxide,
(page 8), iodine, disinfectant mouth wash, or warm salt water. Try
to hold the solution in the mouth for several minutes. The longer the
solution touches the gums, the better it is for the gums. Rinse once
every hour. After 3 days, change to salt water, 4 cups a day.

e Clean the teeth with a soft brush. Parents can clean children’s teeth.
Show them how (page 18), and ask them to do it even if the gums
bleed.

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

Show parents how to do this. Give
them some cotton gauze and hydrogen
peroxide, iodine, or disinfectant mouth
wash to take home.

4. Cook food that is soft (like pounded yam) and not spicy (no pepper). Eat
fresh fruits and vegetables that give strength to the gums (page 102).
If you cannot eat well because of pain, take a multi-vitamin, or at least
Vitamin C and Zinc.

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.

104 Where There Is No Dentist 2010

FEVER BLISTERS

Herpes virus is a kind of germ that causes fever blisters. Fever blisters are
sores that can form inside the mouth on the gums or outside on the lips. Blisters
on the inside cheeks only are not from herpes (see canker sores, page 106).

Sores inside the mouth are a serious problem that usually affect children
between 1 and 5 years old. A child with fever blisters in his mouth can become
very sick. He will not be able to eat properly. If he does not drink enough fluids,
he can become dehydrated (lose his body water). This is dangerous! Fever
blisters are also a problem for people living with HIV. See pages 186 to 187.

SIGNS:
e Sore throat.

Inside the mouth

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 themselves in
about 10 days. The treatment is to help the person feel more comfortable and
to be sure he gets enough to eat and drink.

1. Give aspirin or acetaminophen for fever (page 94).

2. Wipe milk or yogurt over the sores to protect them before eating. Wash
your hands before touching the inside of someone’s mouth! (See
page 86.) Then give food that is soft and not spicy. If the person cannot
eat, prepare a special milk-oil drink, as on page 111.

3. Give lots of fluids to drink.

Sores on the lips usually occur after the age of 5. (æ a)
They often appear when the person is weak and {

sick (for example, with diarrhea or pneumonia.) .
Usually there is no fever. The blisters soon break
open and release water. When they dry, a crust
forms. The blisters often return. When sores leak
water they can pass infection. If you or anyone else
touches them, wash your hands immediately.

On the lips

To prevent the blisters from becoming infected, put an antibacterial cream

or petroleum jelly (Vaseline) on them. If you hold ice against the sores for
several minutes each day, it may help them heal faster. See page 187 for more
options.

Where There Is No Dentist 2010 105

THRUSH

Thrush is an infection caused by a yeast fungus called Candida. It often
appears when a person is weak and poorly nourished, or sick and taking
medicine like tetracycline or ampicillin. In a baby, thrush usually appears
on the tongue or top of the mouth. It can stop the baby from sucking. In
an adult, thrush often occurs under a denture. Thrush is a very common
problem for people living with HIV (see pages 180 to 181).

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,
diabetes, or anemia, change or stop the antibiotic medicine, or clean the
denture and leave it out of the mouth for a while. Then:

1. Cover the white patches with nystatin drops. Use a full dropper 4 or 5
times a day until the patches are gone. If you do not have nystatin you
can soak a piece of cotton in gentian violet and use it to paint the white
patches 2 times a day.

If the baby’s mother has sore, painful nipples, she may also have thrush
in her breasts. She should treat her nipples the same way she treats
the baby’s mouth.

Do not use penicillin or any other antibiotic unless you need to
treat something different. Thrush can get worse when a person uses
an antibiotic for a long time.

2. Continue breastfeeding. For older persons, make their food soft and
easy to chew.

IMPORTANT: Sometimes white lines appear on the inside of an adult's
cheek or on the roof of the mouth. If these lines become sore and do not
get better with treatment, they can change into a cancer (page 125). To
prevent this cancer, ask the person to stop smoking (especially pipes), stop
chewing betel nut, and get dentures adjusted if they do not fit properly.

106 Where There Is No Dentist 2010

CANKER SORES

The exact cause of canker sores is not known. Canker sores affect both
adults and children, and are very common among youth.

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

SIGNS:

e A sore can appear on the cheeks,
inside the lips, on the tongue, 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 or fixing a broken
tooth does help.) The treatment is simple. Tell the person how to feel more
comfortable while waiting for the 10 days to pass:

e Eat foods that are soft and not likely to hurt the sore.

e Do not eat spicy food.

e Drink lots of water.

e Chew food on the other side of the mouth, away from the sore.

A denture which does not fit
should be remade.

In the meantime, leave the
denture out of the mouth for
2 or 3 days.

Ask the person to rinse with
warm sait water, 4 cups each
day until the sore is better.

If the sore continues after 10 days, it may be infected. Give penicillin (page 93).

A sore that does not heal after antibiotic treatment may be cancer (see
page 125). See a doctor immediately.

Where There Is No Dentist 2010 107
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. v a _ ) p

He must close his jaw further to \ J
eat. That causes lines to form at
the corners of his mouth. a

Poor health can make lines at

the corners of the mouth crack
and become sore. These cracks are
often infected with thrush and can be treated with nystatin (see page 105).
If sores are not at the corners but around the mouth, they could be due to a
bacterial infection (see page 94).

A person with missing teeth needs dentures. Dentures will help him
chew more food and make him look younger. They support his lips and
open his mouth more. (See page 164).

A child who has had a fever or measles often has dry lips. The corners of her
mouth can crack and become sore.

Cracks and sores appearing at the
corners of a child’s mouth are signs of
dehydration and malnutrition.

The child needs to eat the kind of foods that give strength, energy, and
protection. Feed her beans, milk, eggs, fish, oils, fruits, and green leafy
vegetables (see page 67).

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.

108 Where There Is No Dentist 2010

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 Și

2. upper jaw bone

5

(lower jaw joins
the head here)

3. lower jaw bone moe

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 s
teeth do not meet lower teeth. 4} )
e The person cannot open or

close the mouth properly.
e There is bleeding from between 2 teeth.
e There is swelling or a bruise on the face or jaw.
e There is bleeding into the eye.

Where There Is No Dentist 2010 109

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

e When you move one tooth, y TOOTH ALSO MOVES
the tooth beside it also moves.

e When you move the loose

tooth, the bone moves with it. Siw @ BECAUSE THE

e Blood is coming from f BONE AROUND
under the gums. © PUSH GENTLY THEIR ROOTS
AGAINST ONE {S 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 put
wires around the teeth. An experienced dental worker should do this. There
are two things you can do. First, provide emergency care. Later, show the
person how to eat and how to keep his mouth clean.

Emergency care (pages 109-110):

1. Be sure the person can breathe.
2. Stop the bleeding.

3. Put a bandage on the person's head.
4. Give penicillin to stop infection.
5. Give aspirin or acetominophen for pain.

1. Be sure the person can breathe.

Lie him on his side so
that his tongue and
jaw fall forward.

Later, carry him to the hospital in that position. If he goes in a car, be sure
he sits with his head forward. His jaw and tongue will be forward and he
will breathe more easily.

Look inside the mouth to see if any tooth is broken and very loose. A
broken piece of tooth can fall out and block the person's airway, so take
out the broken part now. You can leave in the root, but if you do, tell the
dental workers at the hospital (p. 213). 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.

110 Where There Is No Dentist 2010

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 be

Place a piece of wire around 2 teeth,
one on each side of the break. Choose
the strongest tooth on each side—the
ones with the longest or the most roots.

Tighten the wire around the two strong
teeth with pliers or a hemostat.

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 204) for 5 days to stop infection inside
the bone.

5. Give something for pain. Aspirin (page 94) may be enough. Give
600 mg by mouth, 4 to 6 times a day, as needed. For children, see doses
on page 165. If there is a lot of pain and the person cannot sleep, give
codeine. The dose for an adult is 30 mg, 4 to 6 times a day as needed.

Where There Is No Dentist 2010 111

Send the person to the hospital as soon as possible. The person must have
wires placed on his teeth within a week of the accident. The wires must
remain there for 4 to 6 weeks. Every week, the person must return to the
hospital to have the wires tightened. During this time he cannot open his
mouth to chew food or brush his teeth.

CARING FOR A PERSON WHO CANNOT EAT PROPERLY
1. Give liquid foods for strength and energy.

Prepare food in two ways: (a) First, a milk-oil drink to build strength and
then (b) a special soup to keep him strong and give him energy.

To build strength: Milk-oil drink

Mix for him each day at your clinic:

e 9 cups of water e 150 ml of peanut oil or coconut milk
e 3 cups of milk powder e %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 tin of fish or a handful of dried fish

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

e 1 large handful of green leaves
e 1 small spoonful of salt

Pour the soup into an empty tin with small holes made in the bottom.
Use the back of a spoon to press as much of the cooked food as you can
through the holes. The person can suck the soup between the teeth to
the throat and then swallow it. Clean the tin and set it in boiling water, so
you can use it again the next day.

2. Keep the teeth clean and the gums tough.

The person must learn to clean teeth and gums or the gums can quickly
become infected and the mouth will feel sore. So:

e Scrub both the wires and the teeth with a soft brush after drinking
soup.

e Rinse with warm salt water (page 7), 2 cups every day.

112 Where There Is No Dentist 2010

LOOSE TEETH

If the bone around the roots of the teeth is cracked, those teeth will be
loose. Do not take the teeth out until the bone is healed. Otherwise,
bone will come out with the teeth and there will be a big hole in the jaw.
Instead, support the teeth, in order to hold both sides of the bone steady.

1. With your thumb and finger, gently
move the loose teeth and bone back
into normal position.

2. Cut a hypodermic needle and use it
as a splint. Make it long enough to fit

around two strong teeth on each side of BEND THE NEEDLE

AROUND THE TOOTH

the loose teeth. Curve the needle so it SO IT DOES NOT
fits the curve of the teeth. To make the STICK OUT
sharp ends smooth, use a file or rub the A

ends against a stone. TT
3. Tie each tooth to the needle. Use short
pieces of 0.20 gauge ligature wire (page 110).

Put one end of the wire under the needle.
Bring it around the back of one tooth and
out to the front again over the needle.

Use the end of a small instrument to aN
hold down the wire at the back of the USE A STRONG
teeth. Then twist the ends together. HEMOSTAT OR
Tighten the wire around each one of NEEDLE HOLDER
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 % 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:

e give these teeth a rest. Use other teeth for chewing.
e clean both the teeth and the wires with a soft brush.
e rinse with warm salt water, 2 cups every day (page 8).
e 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.

Where There Is No Dentist 2010 113

DISLOCATED JAW

If a person opens her mouth wide and then is unable to close it, we say her
jaw is dislocated. It is stuck in the open position. This problem often happens
to a person who does not have several of her back teeth. When she opens
wide to yawn or shout, the part of her jaw that joins her head moves too far
forward inside the joint. It is then unable to return to its normal position. You
can also dislocate the lower jaw by accident while extracting a tooth.

SIGNS:

e She is unable to close her
teeth together.

e She cannot close her lips
easily.

e Her lower jaw looks long
and pointed.

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

e She cannot speak clearly.

NORMAL DISLOCATED

TREATMENT:

The treatment is to try to move the lower jaw back where it belongs. Then
hold it in that position until the muscles can relax.

1. Find a way to support the person's head. For example, have the person
sit on the floor with her head against a wall.

2. Kneel in front of her. Put your fingers under her jaw, outside the
mouth. Put your thumbs beside her last molar tooth on each side. Do
not put your thumbs on the molars. The person may bite them!

Press down hard with the ends of your
thumbs. Force the jaw to move quickly
down and back into position. Be sure
to press down before you press back.

If the jaw will not move, perhaps the
muscles are too tight. A doctor or
dentist can put the person to sleep,
which will relax the muscles.

3. Support the jaw with a head—and-chin
bandage for 3 to 4 days (page 110).

4. Give aspirin or acetominophen for pain (page 94).

5. Explain the problem to the person and tell her how to care for her
jaw: (a) eat mostly soft foods for 2 weeks; (b) hold a warm wet cloth
against the jaw; (c) remember not to open the mouth wide anymore. If
possible, replace the missing back teeth with dentures (page 107).

114 Where There Is No Dentist 2010
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. (Also check the lower
jaw on the other side since a fracture
near the joint is often caused by a
blow to the other side of the face.)

(3) The teeth do not fit together properly.

TREATMENT:

Before you treat, decide what is causing the pain. We will discuss the three
causes mentioned above.

1. Tension.

Talk with the person and help, if you can, to find a solution to her
personal problems. This can do much to help her and her muscles relax.
In addition, explain how to care for the sore joint:
(a) Eat only soft foods until it no longer hurts to chew.
(b) Hold a hot, wet cloth against the jaw, to help relax the muscle.

Do this as often as possible, but be careful not to burn the skin.
(c) Take aspirin or acetominophen (page 94) to reduce the pain.

2. Fracture.

If an X-ray shows a fracture, the person needs expert help. A dentist
can wire the teeth in a way that will allow the bone to heal.

3. Teeth do not fit together properly.

Imagine a line that passes between the 2 middle upper teeth and the

2 middle lower teeth in the person's closed mouth (see the next page).
When the person opens the mouth, this line becomes longer, but it is
still a straight line. If it is not, this condition can, after a long time, cause
pain in the joint.

Where There Is No Dentist 2010 115

These teeth are normal. The line formed between the
two middle teeth does not shift when the mouth opens.

When you see teeth that do not fit
properly:

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

e Tell the person what can be done
to help. Often a dentist can grind
the teeth in a special way and this
can end the pain.

These teeth do not fit properly. Because the
line shifts, this means the jaw is also shifting.
This shift can cause pain in the joint.

SWOLLEN GUMS AND EPILEPSY

Many persons who suffer from epilepsy
(see Where There Is No Doctor, page
178) 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 69 to 72. Persons who take this drug
may be able to prevent the swelling by brushing the teeth carefully after
each meal, and taking special care to clean between the teeth (page 71).

116 Where There Is No Dentist 2010

BLOOD IN THE MOUTH

Use wet cotton gauze to wipe away the old blood from inside the mouth.
Then you can see where it is coming from. Treat the cause of the bleeding.

IF YOU SEE: TO STOP THE BLEEDING: SEE =
a large red clot growing 1. Remove the clot with
out of a socket where you cotton tweezers.
have taken out a tooth 2. Ask the person to bite

on a piece of cotton.

sore and bleeding gums 1. Rinse with a mixture of
and the mouth smells hydrogen peroxide and water.
bad (Vincent's infection) 2. Remove as much tartar as you can.

a red, bleeding growth Take out the tooth;
inside the cavity in a tooth it has an abscess.

a loose tooth with Hold the tooth with wires, or if the
bleeding gums around it root is broken, take out the tooth.

torn gums with broken 1. With wire, hold the broken

bone and bleeding parts of the bone together.
2. Send the person to an

experienced dental worker.

PROBLEMS AFTER YOU TAKE OUT A TOOTH

Problems such as swelling, severe pain, and bleeding can occur after you
take out a tooth. Tetanus (page 118), a more serious problem, can also
occur, especially if your instruments were not clean.

Swelling of the Face

You can expect some swelling after
you take out a tooth. But if the
swelling continues to grow, and it is
painful, this is not normal. Probably an
infection has started. The treatment
is the same as for a tooth abscess:
penicillin for 5 days to fight infection,
heat to reduce the swelling, and
aspirin or acetominophen for pain.
See page 94 for the proper doses.

Where There Is No Dentist 2010 117

Pain from the Socket

There is always some pain after a tooth is taken out. Aspirin is usually
enough to help.

However, sometimes a severe kind of pain starts inside the tooth’s ‘socket’
(the wound) 2 to 3 days after you take out the tooth. This problem is called
dry socket and it needs special care.

TREATMENT:
1. Place a dressing inside the socket. Change it each day until the pain stops.

First, clean out the socket.

Squirt warm water inside the socket with
a clean syringe. After the person spits out
the water, squirt water inside once more.
Use a blunt needle so that it does not

hurt the gums or bone if it touches them.

Third, place the dressing
gently inside the socket.

Place one piece of dressing
into each root space. Push

Soak 1 to 2 small pieces it down into the root space
of cotton in eugenol (oil of gently.

cloves.)

Squeeze each piece so that it
is damp but not wet.

Second, prepare the dressing.

Cover the socket with plain
cotton gauze, and send
the person home bitting

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

against it. He can remove
the plain cotton in an hour.
The dressing should remain
inside the socket.

2. Give aspirin or acetominophen for pain (page 94).

118 Where There Is No Dentist 2010

Bleeding from the Socket

When you take out a tooth it leaves a wound, so you can expect some
blood. However, if the person bites firmly against a piece of cotton, it usually
controls the bleeding. To help the wound heal (from a clot), tell the person
not to smoke, rinse with salt water, or spit for 1 or 2 days after you take out
the tooth.

When the first bleeding occurs, put a new piece of cotton on top of the
wound and ask the person to close her teeth against it for an hour. Keep
her there with you, to be sure she continues to bite on the cotton. (If it is
too painful, you may want to inject anesthetic. See Chapter 9.) Change the
cotton if it becomes soaked with blood.

TREATMENT (if the bleeding continues):

1. Take her blood pressure (see Where
There Is No Doctor, pages 410-411). If it
is high, you may need medicine to bring
it down. That can help slow the bleeding.

2. Look carefully at the wound.
If the gum is torn or loose,
put in a suture (pages 161-163).

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 161).

TETANUS

This is a very serious infection. Tetanus germs enter the body when a
wound, like a wound on the bottom of the foot, gets dirty. Germs can also
be carried to the socket when you use a dirty instrument to take out a tooth.
To avoid this, carefully read pages 86 to 89.

SIGNS: OLD, DRY BLOOD

e the jaw becomes stiff and tight
not
cleaning

e the whole body becomes tight, properly
with sudden spasms

e itis hard to swallow

(e)

TREATMENT:

A person with signs of tetanus requires immediate medical help. See
Where There is No Doctor, pages 182 to 184, if you cannot get help
immediately.

Where There Is No Dentist 2010 119

INFECTION INSIDE THE SPIT (SALIVA) GLAND

Spit glands are places where the spit or saliva is made. They are located in front
of the ear and under the jaw, on each side of the head. If there is an infection
inside a spit gland, the face will become swollen and the area will hurt.

Spit is sent from the gland to the mouth through a thin pipe called a duct.
Ducts open into the mouth in two places: on the inside of each cheek and
under the tongue.

A small stone can often block a duct and cause an infection in the spit gland
and swelling of the face. You may be able to feel the stone near where the
duct enters the mouth.

SIGNS:

TONGUE

swelling in the area of the spit gland.

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

the opening of the duct is red, swollen, and hurts when you touch it.

spit from
this gland
enters on
the inside of
the cheek

spit from
this gland
enters under
the tongue

TREATMENT:
Reduce the infection and swelling first. Later try to remove the stone.

1.

Give penicillin for 5 days (page 94). If the swelling is large and the
infection serious, start with short-acting crystalline penicillin (see
page 204).

2. Give aspirin or acetominophen for pain (see page 94).

3. Apply a wet hot cloth to the swelling as often as possible.

4. Give enough soft food to prevent the person from feeling hungry.

The pain will be less then.

. When the person feels better, a dentist or doctor can remove the

stone that is blocking the duct.

120 Where There Is No Dentist 2010

SORES ON THE FACE

Whenever you see a sore on a person's cheek or under his chin, remember
there may be a tooth or gum problem. If it is a gum problem, it may be
Noma. See the following pages.

A bad tooth:

Ask him to open his mouth.
Look for an infected tooth in
the area of the sore. There
may be a large cavity and the
tooth may be loose.

Or the tooth may be darker
in color than the others.
This is because it is dead.

The pus is draining onto
the skin, so the pressure
is reduced and the person
does not complain of pain.

TREATMENT:

1. Take out the tooth (see Chapter 11).
2. Give penicillin for 7 days (see page 94).

3. After the penicillin treatment, check the sore. If it has healed, there is
no longer infection inside. The treatment is finished.

But if the sore is still open and you can squeeze out pus, you will need the
help of experienced health workers who can:

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.

If infected gums (and not a bad tooth) are the cause of a sore on the cheek
or chin, the problem is more serious. See the next 4 pages.

Where There Is No Dentist 2010 121

NOMA

When a child is sick, a simple gum infection can get out of control and
spread through the cheek to the face. When that happens the condition
is called Noma or Cancrum Oris. Noma is a complication of Vincent's
Infection of the gums (page 102).

You will usully see Noma in children. It will only
develop if these 3 things are true:

(1) The child's general resistance is low.
Usually, he is undernourished and anemic
(lacks iron). He may have tuberculosis.

(2) The child has Vincent's Infection.

(3) The child has recently had a serious
illness such as measles or malaria.

Noma can also be a problem for adults living with HIV. See page 185.

SIGNS: Pa
The infection starts in the mouth.

Then it passes to the gums.
1. Sore mouth with itching gums. E
2. Swollen, sore gums. Y us
3. Gums bleed when eating or ax D B
when teeth are cleaned. S )

4. Bad breath, spits a lot.

Then it reaches the jaw.
5. Loose teeth.
6. Loose pieces of bone
around the teeth. ien

Finally, it affects the cheek.
7. Skin is tight with dark red
swelling.
8. Black spot on the cheek

= oon
breaks open, leaving a hole A wD B

into the mouth.
9. A line separates dead
tissue from healthy tissue.

122 Where There Is No Dentist 2010

TREATMENT:

You must start treatment for Noma immediately in order to prevent the hole
from getting bigger. The bigger the hole, the tighter the scar that forms after
you close the hole. A tight scar will prevent the child from opening his mouth
and chewing the food he needs to grow stronger.

1. Give fluids.

The child needs to overcome both
the lack of body water (dehydration)
and his lack of resistance to disease.

Start giving the milk-oil drink
described on p. 111.

If he cannot drink by himself, help
him. Use a spoon or syringe.

Place the fluid on the inside of the
healthy cheek and ask the child to
swallow.

2. Treat the anemia.

Start giving iron (ferrous sulfate) now. The child should continue taking
the tablets or mixture for 3 months, with food.

Ferrous Sulfate Tablets

over 6 years 200 mg (1 tab) 3 times a day

3-6 years 100 mg (% tab) 3 times a day

under 3 years 50 mg (4 tab) 3 times a day

You can also use ferrous fumarate. Advise the mother that the iron
will make the child’s stool black.

Also give food rich in iron: meat, fish, eggs, dark green leafy
vegetables, peas and beans.

Note: A child may have anemia because he has worms. It is a good
idea to do a stool analysis to find out. If he has worms, give him
medicine right away. Mebendazole, albendazole, and thiabendazole
treat many different worm infections. Piperazine treats roundworm and
pinworm infections, and there are other medicines for tapeworm and
blood flukes. Also give folic acid. For doses, see Where There Is No
Doctor, pages 373 to 376, and page 392.

Where There Is No Dentist 2010 123

3. Start antibiotics.

Metronidazole is the best medicine to use. Give 200 mg by mouth 3 times
a day for 10 days. You can also use clindamycin. To decide how much to
give, weigh the child. For adults, see the medicines and doses on page
185.

Weight Dose for clindamycin (give 3 times a day for 5 days)

5 to 10 kg 50 mg by mouth or 60 mg by injection

10 to 17 kg 100 mg by mouth or 130 mg by injection
17 to 25 kg 150 mg by mouth or 225 mg by injection
over 25 kg 250 mg by mouth or 333 mg by injection

4. Treat the other illness that helped Noma to develop.
It is wise to assume that the child has malaria and to begin treating

with antimalarial drugs (see Where There Is No Doctor, pages 364
to 367).

Look for any other illnesses and treat them, too, especially measles and
tuberculosis.

5. Clean the sore.

Gently pull away any dead skin with tweezers. Wash the inside of the
sore with hydrogen peroxide. (Be sure you measure the hydrogen
peroxide carefully. See page 8.) Then put in a wet dressing. (You can also
clean the sore with an iodine solution.)

The dressing:

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 161 to
163).

124 Where There Is No Dentist 2010

7. Keep the mouth clean.

e Use a soft brush
…[truncated]

Summary: Where There Is  No Dentist    by Murray Dickson    updated and expanded  with information about HIV and AIDS  by Richard Bebermeyer,  Martin Hobdell and Gene Stevenson    Introduction by David Werner,  author of Where There lIs No Doctor    EULIEN GA  hesperian    Berkeley, California, USA  www.hesperian.org    Hesperian encourages others to copy, reproduce, or adapt to meet local needs any  or all parts of this book, including the illustrations, provided that the parts reproduced  are…