Where There Is No Dentist by Murray Dickson

Where There Is No Dentist by Murray Dickson
Where There Is
No Dentist
by Murray Dickson
updated and expanded
with information about HIV and AIDS
by Richard Bebermeyer,
Martin Hobdell and Gene Stevenson
Introduction by David Werner,
author of Where There Is No Doctor
Berkeley, California, USA
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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
1919 Addison St., #304
Berkeley, California 94704
tel: 1-510-845-1447
fax: 1-510-845-9141
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 Jesús 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 Iñaki
Fernández 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 I owe my sincere thanks.
Much has happened since that day in Papua New Guinea when David
Werner’s letter arrived. His challenge was simple: “Since no one else
has written a dental manual like this, why don’t you?” With David’s
encouragement and constant support, I was able to take teaching notes and
produce a suitable draft that was the basis for this book. To you, David, for
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
Michael Blake deserves special mention. As editor of Where There Is No
Dentist, it was he who took the manuscript and nursed it along to completion.
Michael’s commitment to finishing the book was vital, and I sincerely
appreciate it.
My thanks go to Maggie Leung for typing the final draft, and to those
dedicated persons who helped get the book into final form: Annaloy Nickum
(page design); Hal Lockwood (typesetting and paste-up); Paul Chandler,
Serena Clayton, and Elaine Rossi (proofreading); Pat Bernier (typing); and
Howard Uno (photostats).
For their outstanding drawings, I am exceedingly grateful to: June Mehra,
Janet Elliott de Jacques, Michael Marzolla, Joan Thornpson, Mindy Mead,
Arlene Ustin-Cartagena, and Lynn Gordon. My own drawings in the manual
appear amateurish in comparison.
I want to thank the many persons who reviewed the manuscript and offered
valuable suggestions: Ken Cripwell, Bill Bower, Jeff Vore, Aaron Yaschine,
Rosalie Warpeha, Norma Francisco, Mike Muller, Marcia Anderson, Phil
Haskett, Bert Bali, Tom Coles, Sunil Mehra, and John Rogers. In particular,
thanks to Chris Lennox who, faced with stressful times in Papua New Guinea,
found time to read through two drafts; and to David Morley for his ideas for
improving the book and his assistance with its eventual publication.
For their financial help, I am grateful to the Ella Lyman Cabot Trust, Muttart
Foundation, the Canadian Organization for Development through Education,
and the James C. Penney Foundation.
I thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to
adapt several drawings from the Handbook of Clinical Pedodontics, and the
Medical Missionary Association (244 Camden Road, London NW1 9HE, U.K.)
for permission to use parts of David Halestrap’s book Simple Dental Care.
This book is based upon several years of practical experience, made possible
by the Canadian Organization CUSO. For this opportunity, and for CUSO’s
active interest and involvement in this book, I most gratefully say thanks.
Finally, I want to acknowledge my family’s contribution. For weeks on end,
my wife, Gerri, faithfully read and discussed with me each part of the book
as it changed and was rewritten. She did this cheerfully, at a time when she
was fully occupied in a graduate study program. For much longer than I had
anticipated, Gerri and our two boys, Michael and Brennan, had to tolerate my
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.
Introduction by David Werner
Part One: Learning and Teaching about Teeth and Gums
Chapter 1: Your Own Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Eat only good healthy foods. . . . . . . . . . . . . . . . . . . . 3
Sore bleeding gums. . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Clean your teeth every day. . . . . . . . . . . . . . . . . . . . . 4
More serious gum disease. . . . . . . . . . . . . . . . . . . . . 8
Cavities, toothaches and abscesses . . . . . . . . . . . . . 6
Chapter 2: Teaching Family and Friends in Your Community . . . . . . . . . . . . . . . 9
Chapter 3: Teaching Children at School. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chapter 4: School Activities for Learning about Teeth and Gums. . . . . . . . . . . 35
Why do we need teeth and gums?. . . . . . . . . . . . . . 37 How do germs make holes in the teeth?. . . . . . . . . 50
Why do some teeth look different?. . . . . . . . . . . . . 39 What makes the gums feel sore?. . . . . . . . . . . . . . . 52
What holds the teeth?. . . . . . . . . . . . . . . . . . . . . . . . 41 What does it mean if a tooth is loose?. . . . . . . . . . 54
How often do teeth grow in?. . . . . . . . . . . . . . . . . . 43 How can we prevent cavities and
What makes teeth hurt?. . . . . . . . . . . . . . . . . . . . . . 46 sore gums?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Chapter 5: Taking Care of Teeth and Gums. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Part Two: Treating Dental Problems
Chapter 6: Examination and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Where to examine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 A good diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
The instruments you need. . . . . . . . . . . . . . . . . . . . . . 75 Learn to tell similar problems apart. . . . . . . . . . . . . . 80
Chapter 7: Treating Some Common Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
The first rule of treatment: stay clean! . . . . . . . . 86
Dislocated jaw . . . . . . . . . . . . . . . . . . . . . . 113
Problems you will see most often . . . . . . . . . . . 92
Pain in the joint . . . . . . . . . . . . . . . . . . . . . 114
Cavities . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Swollen gums and epilepsy . . . . . . . . . . . . .115
Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Blood in the mouth . . . . . . . . . . . . . . . . . . .116
Infected sinus . . . . . . . . . . . . . . . . . . . . . . 95
After you take out a tooth . . . . . . . . . . . . . . . . 116
Tooth injuries . . . . . . . . . . . . . . . . . . . . . . . 96
Swelling of the face . . . . . . . . . . . . . . . . . . 116
Loose tooth . . . . . . . . . . . . . . . . . . . . . . . . 99
Pain from the socket . . . . . . . . . . . . . . . . . . 117
New tooth growing in . . . . . . . . . . . . . . . . .100
Bleeding from the socket . . . . . . . . . . . . . . .118
Gum disease . . . . . . . . . . . . . . . . . . . . . . .101
Tetanus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Fever blisters . . . . . . . . . . . . . . . . . . . . . . 104
Infection in the spit (saliva) gland . . . . . . . . . . . 119
Thrush . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Sores on the face . . . . . . . . . . . . . . . . . . . . . . 120
Canker sores . . . . . . . . . . . . . . . . . . . . . . .106
Noma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Some special problems . . . . . . . . . . . . . . . . . . 108
Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Broken bone . . . . . . . . . . . . . . . . . . . . . . . 108
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
Chapter 8: Scaling Teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Chapter 9: Injecting Inside the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Chapter 10: Cement Fillings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Chapter 11: Taking Out a Tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
The instruments you need. . . . . . . . . . . . . . . . . . . . 154
False teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Where you work is important. . . . . . . . . . . . . . . . . 156
Problems that can occur. . . . . . . . . . . . . . . . . . . . . 165
How to take out the tooth. . . . . . . . . . . . . . . . . . . . 157
Clean your instruments after you finish. . . . . . . . . 167
How to place a suture. . . . . . . . . . . . . . . . . . . . . . . 161
Chapter 12: HIV and Care of the Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . . 169
What is HIV?. . . . . . . . . . . . . . . . . . . . . . . . . . . 171
White or yellow patches in the mouth. . . . . . . 180
How is HIV spread?. . . . . . . . . . . . . . . . . . . . . . 172
Sores of the skin of the mouth. . . . . . . . . . . . . 182
Who gets HIV? . . . . . . . . . . . . . . . . . . . . . . . . . 173
Infection of the gums . . . . . . . . . . . . . . . . . . . . 183
How HIV affects the mouth. . . . . . . . . . . . . . . . 173
Cold sores or fever blisters. . . . . . . . . . . . . . . . 186
How to examine the mouth for
signs of HIV or AIDS. . . . . . . . . . . . . . . . . . . . . 174
Red or purple patches in the mouth. . . . . . . . . 188
Dental care for a person with HIV . . . . . . . . . . . 177
Helping people with HIV in
your community. . . . . . . . . . . . . . . . . . . . . . . . . 190
Common problems caused by HIV
and how to treat them . . . . . . . . . . . . . . . . . . . 178
Dry or painful mouth and throat. . . . . . . . . . . . 189
Working for change in your community. . . . . . 191
Get Rid of Wastes Safely. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
The Dental Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Records, Reports, and Surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Vocabulary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Other Books from Hesperian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
by David Werner
A healthy tooth is a living part of the body. It is connected by ‘life-lines’ of
blood and nerve to a person’s heart and brain. To separate the tooth from the
body, or even to interrupt those ‘life-lines’, means death to the tooth. It also
means pain and injury to the body, to the person.
Let us look at it another way. The health of the teeth and gums is related to
the health of the whole person, just as the well-being of a person relates to
the health of the entire community.
Because of this, the usual separation between dentistry and general health
care is neither reasonable nor healthy. Basic care of the teeth and gums—
both preventive and curative—should be part of the ‘know-how’ of all primary
health care workers. Ideally, perhaps, Where There Is No Dentist should be
a part of Where There Is No Doctor. Think of it as a companion volume, both
to Where There Is No Doctor and Helping Health Workers Learn.
Murray Dickson has taken care to write this book in a way that will help the
readers see dental care as part of community health and development. The
approach is what we call ‘people centered.’
Where There Is No Dentist is a book about what people can do for
themselves and each other to care for their gums and teeth. It is written for:
village and neighborhood health workers who want to learn more
about dental care as part of a complete community-based approach to
school teachers, mothers, fathers, and anyone concerned with
encouraging dental health in their children and their community; and
those dentists and dental technicians who are looking for ways to
share their skills, to help people become more self-reliant at lower cost.
Just as with the rest of health care, there is a strong need to
‘deprofessionalize’ dentistry—to provide ordinary people and community
workers with more skills to prevent and cure problems in the mouth. After
all, early care is what makes the dentist’s work unnecessary—and this is the
care that each person gives to his or her own teeth, or what a mother does
to protect her children’s teeth.
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 I and the Hesperian Foundation have
worked for many years), visiting dentists have also helped train village
‘dentics’. They, in turn, now teach basic dental skills to the part-time village
health workers. These village dentics, some of whom have had only 3
to 6 years of primary school, now practice—and teach—a wider range of
dental skills than the average dentist. Their activities include dental health
campaigns with school children, community puppet shows about low-cost
dental self-care, cleaning of teeth, extractions, drilling and filling, and the
making of dentures (false teeth). Several of the dental workers can now do
root canal work—a special treatment to remove the central nerve in order to
save an infected tooth. One of the village dentics, remembering what he had
seen a dentist do, taught himself how to do root canals when his girlfriend
had an infected front tooth that he did not want to pull. (He had also learned
to check the tooth from time to time afterward to make sure this treatment
had been successful.)
We still have much to learn about dental health. Dentists need to learn from
the knowledge of the local people, as well as the people from the dentists.
We have learned that villagers with little formal education often can learn
skills with their hands—such as tooth extractions, puppetry, or surgery—
much faster than university students (who have never learned to use their
hands for much more than pushing pencils). We also have observed that
the best way to learn dentistry is not through school but through practice,
helping someone with more experience who is willing to teach.
Where There is No Dentist has 2 parts. The first part (Chapters 1–5)
discusses teaching and learning about preventive care. It begins by
encouraging the health worker to examine herself and her family. To be a
good example is the best way to teach.
The second part (Chapters 6–11) talks about diagnosing and treating
common dental problems. It is especially for those who live where they
cannot reach or afford a dentist. A poor neighborhood in the city can be
as distant and neglected as a far-off village. This second part is intended
mainly for health workers who have helped organize people to meet their
own needs.
Murray Dickson—­a Canadian with primary care experience in Northern
Canada, Nigeria, Papua New Guinea, and Mozambique—has written this
book in clear, simple language. He takes care to use popular names instead
of unfamiliar scientific words. For example, instead of speaking of ‘dental
plaque’ the author speaks of the ‘coating of germs on the teeth.’ Such
simple language does not weaken the message. The message is stronger
because everyone understands.
The author has said:
I am sure some dentists will disagree with parts of this book.
Some points of disagreement may be small, like the failure to
use accepted dental terminology. Other ideas, particularly the
suggestion that non-dental people can be trained to provide
many kinds of treatments, may make some dentists angry.
The book is meant to be a source for argument and
discussion. This way, it may stimulate others to write the kind
of manual that is really needed in their countries.
The people must answer to the people’s needs. The health of teeth and
gums, along with general health, will improve only when people take the
lead in caring for themselves. The challenge for dentists and other health
professionals is to allow and encourage this to happen.
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?
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
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.
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
The best food is food that you grow or raise yourself. Mix different kinds of
food together and eat several times a day. This helps your body as well as
your teeth and gums to stay strong and healthy. Traditional food is usually
good food.
Sweet food, especially the kind you buy from the store, can mix with germs
and make cavities—holes in the teeth. Soft food sticks to the teeth easily
and it, too, can make a coating of germs and food on the teeth that starts an
infection in the gums—gum disease.
Soft and sweet food
and drinks with a lot
of sugar are bad for
both teeth and gums.
Breast feed to help a child’s teeth
grow and stay strong. An older child
can drink from a cup.
Do not give a baby anything to drink
from a bottle. Sweet tea, sugar water
or fruit juice can easily make holes in
the child’s 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
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.
Bits of food stay longer in
grooves and ‘hiding places’.
This is where both tooth and
gum problems start.
on top
the teeth
near the gums
Here are 3 places where problems start.
To prevent problems you
must take special care to
keep these protected places
It is better to clean your
teeth carefully once every
day than to clean poorly
many times a day.
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
bamboo, strong grass, or the skin
from sugar cane or betel nut.
2. Cut a piece that is
still green and soft.
3. Chew one end to make it
stringy like a brush.
4. Sharpen the other end so
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.
Where There Is No Dentist 2010
‘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
that hold it in the
jaw bone. Inside
each root is a nerve.
(p. 39 to 40 and 45)
When decay
touches the nerve
inside the tooth
aches, even when
you try to sleep.
When infection
reaches the
inside of a root,
it is called a
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:
hold warm water inside your mouth
near the bad tooth.
Wet a cloth with hot water and
hold it against your face. Do not
use water hot enough to burn
A tooth abscess can cause
swelling like this.
Where There Is No Dentist 2010
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).
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:
Eat more fresh fruits and green leafy vegetables, and fewer soft
sticky foods from the store.
Rinse your mouth with warm salt water. Do this every day, even
after your gums feel better.
(1) Mix some salt with a cup of warm water. (2) Take a mouthful
and rinse. (3) Spit it out. Repeat until all of the salt water is finished.
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Painful gums that bleed at the slightest touch need special treatment. If
you have this problem, ask for help. A dental worker can explain what is
happening and what needs to be done. A dental worker can also scrape the
teeth and remove the tartar that is poking the gums, making them sore.
At home, you can do some things to help.
• Clean your teeth near the gums with a soft brush. Gently push the
brush between the tooth and the gum. It may bleed at first, but as the
gums toughen, the bleeding will stop.
Make your food soft, so it is easier to chew. Pounded yam and soup
are good examples.
Eat plenty of fresh fruits and vegetables. If it is difficult for you to bite
into fruit, squeeze it and drink the juice.
Start rinsing your mouth with a mixture of hydrogen peroxide
and water. You can get hydrogen peroxide from your clinic or your
pharmacy (chemist).
The strength of hydrogen peroxide is important. Ask for a 3%
solution, and mix it evenly with water—that is, ½ cup of hydrogen
peroxide with ½ cup of water.
WARNING: Read the label to be sure the solution
is 3%. A mixture with more than 3%
hydrogen peroxide can burn the mouth.
Take some into your mouth and hold it there for
about 2 minutes. Then spit it out and repeat. Do
this every hour you are awake.
Use hydrogen peroxide for only 3 days. Then
change and start rinsing with salt water (page 7).
If you take care, you can keep your teeth for a lifetime.
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.
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Many people do not understand that tooth and gum problems are caused
by certain kinds of food, and poor cleaning of the teeth. In fact, some have a
completely different belief.
Do not attack a belief because it is traditional. Many traditions are more
healthy than ‘modern’ things. Often, instead of telling people that their belief
is wrong, you can remind them of a different tradition that is healthy.
Help your family and friends to recognize their
healthy traditions. Then help them find new ways
to use these same traditions for better health.
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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).
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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.
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
Deciding what to teach is important, but just as important is how to teach.
Learning cannot take place
when you use words that
people do not understand.
They will learn something
only when they see how it
is related to their lives.
Remember this when you teach about eating good food and keeping teeth
clean. Design your own health messages, but be ready to change them if
people are not understanding or accepting what you say.
Here are five suggestions for teaching well.
1.Learn First From the People
Get involved in your community’s activities. Learn about people’s
problems, and then offer to help solve them. People will listen to you
when they know that you care about them and want to help.
Sit and talk with people. Learn
about their customs, traditions
and beliefs. Respect them.
Learn about their health habits.
Improving health may require
changing some habits and
strengthening others.
Learn also about tooth
decay and gum disease in
your community.
Make people smile—then look into their mouths.
Find out how many children and adults are having
problems with their teeth and gums. Do a survey
such as the one on p. 214.
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2. Build New Ideas Onto Old Ones
People find their own ways to stay healthy. Many traditions are good,
helpful, and worth keeping. But some are not.
When you teach, start with what people already understand and are
doing themselves. Then add new ideas.
This method of teaching is called ‘association of ideas’. It helps people
to understand new ideas because they can compare them with what
they already are doing.
In this way people can more easily accept, remember, and do what you
Sweeping the compound
makes it a clean and
healthy place to live.
in the
Brushing the teeth and gums
keeps them clean and healthy.
A small child cannot find
his own lice. Mother
knows she must help him.
in the
A small child cannot see the
food on his teeth. He needs
help with that also.
Different vegetables
when planted together—
like maize and yams—
help each other to grow.
in the
Eating different kinds of food
helps people to grow. Eating
them several times a day makes
your teeth and gums, as well as
your whole body, grow stronger.
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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
One day Lucie, a dental worker from a nearby village, came to see her friend
Bertine. Lucie had a young baby, and Bertine asked her a lot of questions
about babies and about pregnancy. Then Bertine said, “Of course, l’m having
lots of problems with my teeth.” “Why do you say ‘of course’?” asked
Lucie. “Well,” Bertine replied, “For each child, a tooth.”
“But that’s not true!” Lucie cried. “You think you are having tooth and gum
problems because you are pregnant, but I bet you are having these problems
for all the usual reasons.”
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 I used to—I have two persons to feed!” “And do you
still eat sweet foods sometimes?” Lucie asked. “I guess I do,” said Bertine,
“and more sweets than before, because I eat more often.”
“How about teeth cleaning?” asked Lucie. “Do you clean as often as you did
before you were pregnant?” “No,” Bertine admitted, “I heard I was going to
have tooth problems anyway, and I have been so tired lately.... Oh! Do you
suppose that these are the only reasons I am having these problems? How
do you know so much about this, Lucie?”
“Because I had the same problems, Bertine. I learned the truth the hard
way. I had an infected tooth, and the infection passed to my kidneys. At the
health clinic, they told me it is not necessary to have tooth problems during
pregnancy—and it is even dangerous. I am lucky I did not lose my baby!
That can happen, you know, when a tooth problem is not treated. We must
fill your cavities right now.”
“You mean I can be treated now, before I have my baby?”
“Yes, and you should!” said Lucie. “And
you can take better care of your teeth.
It is true that because of the pregnancy,
your gums are weaker, and they can get
infected. But this means you should take
even more care than usual to: (1) clean
regularly and (2) eat the right foods. You
need to have strength when you are
pregnant. An infection in your mouth does
not help that. Because your gums are
weak, it is also good to (3) rinse your mouth
every day with warm salt water (see page
7), and if you cannot get fresh fruits and
vegetables, then (4) take a tablet of Vitamin
C every day.”
Lucie then offered to clean Bertine’s teeth and to fill her cavities. When she
touched Bertine’s gums, they bled, and Lucie said, “They will bleed at first,
but after you clean them regularly for a while, they will be stronger. Bleeding
gums are dangerous to a pregnant woman. The bleeding can increase
anemia, which is a serious problem.”
“If a pregnant woman’s tooth has an abscess, is it safe to pull it before she
has the baby?” asked Bertine. “Yes,” said Lucie, “you just must be gentle.
A woman gets tired sitting in a dental chair for a long time, and sometimes
you must give some extra anesthetic so she does not feel any pain.”
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:
Use simple words (see page 13). If you must use a big word, take
the time to explain it.
Teach people when they are ready to learn. A sick person, for
example, usually wants to know how to prevent his sickness from
returning. He will remember what you tell him.
Repeat the most important message many times. Whenever you
teach about staying healthy, remember to emphasize eating good
food and keeping teeth clean. Repetition helps people remember.
Let people see what you mean. See pages 26 to 34 for ways to use
pictures, puppets, and plays.
4. Teach Wherever People Get Together
Knowing where to teach is sometimes as important as how you teach.
Instead of asking people to come to a class you have organized, go to
them. Look for ways to fit into their way of living. You both will gain
from the experience. They will ask more questions, and you will learn
how to work with people to solve problems.
Talk with people where they gather near their homes.
Talk to men
and women
at church
in parents’
groups at their
school, and
at community
Talk to
women at
health clinics
and in the
market. Talk
to men at
and farming
Teach men and women at reading groups.
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
own child’s teeth. Teach her to
clean on top and on both sides
of every tooth.
Ask her to do the same at home
each day. At the next clinic, look
at the children’s teeth and see
how well the mothers are doing.
Give further help when needed.
Always praise and encourage
those who are doing well.
Teaching Children
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.
Where There Is No Dentist 2010
More children than ever before are having
problems with their teeth and their gums.
A tooth that hurts or gums that are
sore can affect a student’s ability to pay
attention in school and learn.
Treating the problem makes the child feel
better, and that is important. It is equally
important to prevent the same problem
from returning later.
Working together, teachers and school children can do much
to prevent both tooth decay and gum disease.
Keeping the mouth healthy involves learning about eating good food and
keeping teeth clean. Just giving information is not enough, though. To truly
learn, children need a chance to find out things for themselves.
Forcing a person simply to accept what
you say does not work very well.
A student learns not to question. What
you teach may have no relation to his
own experiences and needs.
As a result, he may end up not doing
what you teach—not eating good foods,
and not cleaning his teeth.
Learning happens when a student with a
question or an idea is able to discover more
about it himself.
It also happens when he has a chance to do
whatever is necessary to take better care of
himself and his family.
He can learn by doing. Give him a chance to
eat good food and clean his teeth at school.
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
1.Teach and learn together with your school children.
2.Start with what the students already know.
3.Let students see and then do.
4.Let children help each other.
5.Teach about teeth and gums together with other subjects.
6.Be a good example.
7.Make the community part of your classroom.
1.Teach and Learn Together with School Children
Share ideas
instead of always
giving information.
Children learn
more when they
are involved.
A discussion draws out
information and opinions.
It helps you
to learn more
about the
school children,
what they
already know
and believe to
be true.
But it also allows
you to introduce
information that
is related to the
A lecture transfers
your own notes
to the children’s
notebooks without
ever passing
through their minds.
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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
This way
makes students
feel stupid.
This way lets the
students feel good,
because it makes
sense and they know
something about it.
When you can understand new information, you gain confidence and
you look forward to learning more.
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3. Let Students See and Do
Students learn best when they can take part and find out for themselves
about something new.
A lecture about brushing teeth is usually not interesting at all.
Learning is more interesting when students can see how to make a
brush and how to clean teeth properly.
If students can actually make their own brushes and clean their own
teeth, it is not only interesting but fun.
A student who takes part will not forget. What he learns by doing
becomes part of himself.
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:
When they feed their younger
brothers and sisters they can
encourage them to eat good food,
like fruit instead of candy.
They can do a play or puppet show
about care of teeth and gums.
They can check the teeth and
gums of the younger children and
‘score’ them on how healthy they
are (see p. 60).
Best of all, they can actually clean
the teeth of the younger ones,
and show them how to clean their
own teeth when they are able.
Here a group of school children
in Ajoya, Mexico is putting a
high-fluoride paste (see p. 205)
on the teeth of the younger
5. Teach About Teeth and Gums
Together with Other Subjects
Teeth and gums are part of a bigger health picture. Teach about them in
class at the came time.
Eating good food can be part of a discussion on nutrition, teeth,
farming methods, and the politics of who owns the lands.
Cleaning the teeth can be part of a
discussion on hygiene, clean water, and
traditions and customs.
A good way for school children to learn
about using numbers is to do a survey in
the community.
The results will tell the children
something about health problems in
their community. For an example of a
survey of health problems, see page
3‑14 of Helping Health Workers Learn.
*For more ideas on how school children can help each other, write to CHILD-to-child Trust,
Institute of Education, 20 Bedford Way, London, WC1H 0AL, UK. Tel: 44-207-612-6649.
Fax: 44-207-612-6645. E-mail: ccenquiries@ioe.ac.uk. Website: www.child-to-child.org
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
Your family can be
a good example for
Clean your teeth carefully every day. Also, help your children keep
their teeth clean.
Make a garden near your house and plant a variety of vegetables and
fruits in it.
Buy only good, healthy food from the store. Do not buy sweet foods
and drinks for yourself or your children.
7. Make the Community Part of Your Classroom
A child’s home and his community are really more important to him
than his school. Learning will be more interesting for a student if the
day-to-day needs of his home and his community are part of school
Let students find out more about problems
at home and in their community.
For example:
How many small children have
cavities or red, bleeding gums?
How many stores have mostly
sweet snack foods on their
Why do the people not grow
and eat more local food?
Back in the classroom, students can record what they find. Ask the
children to think of ways to solve the problems they found. If they can
think of a program to help solve a health problem, let them go back into
their community and try it.
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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
Puzzles can help school children discover answers for themselves. You can
make your own. The best puzzles are with words that the students know
and can use easily.
EXAMPLE (for younger children just
learning to read) Try to find these words:
As you find each word, put a
beside it.
An older child can try to find important words that are more difficult.
Spell some of the words diagonally (slanted). It will make the puzzle harder.
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.
Hang up other posters in
the store, church, or other
places where people will
see them.
Pictures can be made to
stick to cloth and then used
to tell a story. Cover a board
with a piece of flannel cloth
or a soft blanket, to make a
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
Where There Is No Dentist 2010
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
mothers’ and children’s health. Notice
the rings at the top that hold the flip
chart together. They are made from old
electrical cords.
There is also a
small copy of the
big picture on the
back of the page
Find a way to attach the sheets of heavy paper. Here are two ways:
with 2 thin pieces of wood
with metal or wire rings
Where There Is No Dentist 2010
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
Both cavities and gum disease can be treated.
3)What happens if tooth and gum
problems are not treated?
a)The black hole grows bigger on
the tooth and a sore forms on the
gums near the root. The tooth hurts
whenever you touch it.
b)The red, loose gums pull away from
the tooth. Infection gets to the bone
and eats it. The tooth loses the bone
and the gum around it.
The first problem is a tooth abscess. The second is advanced gum
disease. If either of these things happens, the tooth must be taken out.
4)Why does the boy have cavities and gum disease?
There are 2 reasons.
a)He eats too many sweet foods.
What foods do you see here?
What other foods hurt the teeth?
b)He does not clean his teeth regularly.
The germs in his mouth eat sugar from
his food and make acid. Acid causes
both cavities and gum disease.
Where There Is No Dentist 2010
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
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.
Where There Is No Dentist 2010
Use puppet shows to act out the
messages of eating good food and
keeping teeth clean.
Students can make their own
puppets to look like people or
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
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
Above, school children in Ajoya, Mexico are holding puppets they made
themselves. On the left, you see them in front of the stage and at right, the
children show how they hold the puppets behind the stage.
1) They called their puppet show “Rotten
Teeth—And A Friend’s Advice.”
2) Pedro, a schoolboy, is sad. His friends
looked into his mouth and saw two
teeth with big holes in them. He tells
his brother he wants to walk home
3) On the way, Pedro meets Maria, a
friend who is a dental worker. “l’m not
sad because the others are laughing,”
says Pedro.“ I know the real problem.
The holes in my teeth will get bigger.
My teeth will rot and fall out, and
maybe my permanent teeth coming in
will rot, too.”
Maria thinks she knows what to do. “We
will talk to your father,” she says.
* For another example of a puppet show, and more suggestions for making puppets, see pages
27-35 to 27-39 of Helping Health Workers Learn.
Where There Is No Dentist 2010
4) One day later.
(Note how the scene behind the
puppets changes. lt is a flipchart with
pictures to show the different places
the puppets ‘go’.)
5) “I am a poor farmer,” Pedro’s father
tells Maria. “I only go to the city two
times a year to sell my crops. I cannot
take the boy to the city and pay for
fillings in his teeth.”
Maria answers, “But we can save his
teeth with a temporary cement filling.”*
6) “Then, when you have time and
money, you can go to the city. I know
a dental worker who will put in a
permanent filling. I trust him. I will
send a note with you, and it will not
cost much.
”Good!” says the father. “Come on,
Pedro,” says Maria, “l’II put some
cement in those holes!”
7) Four months later, Pedro visits the
dental worker in the city. “Maria’s
good fillings saved your teeth,” he says.
“These permanent fillings will last for
“Terrific!” says Pedro.
8) After the show, the puppets played
a game. Throwing a ball into the
audience, they asked questions like
“How do you keep cavities from
happening?” Each child who caught
the ball answered the question and
threw it back. Then the children in
the audience began asking questions
for the puppets to answer. “Why did
you get rotten teeth?” one child asked
Pedro. The puppet looked down and
said, “Too much candy!”
* To learn how to make a temporary filling, see Chapter 10.
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
Teacher, each day at school:
Suggest ways
for your
students to eat
good healthy
kinds of food.
Give your
students time
to clean their
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
To begin, talk with your students to find out what they think and what they
already know. What are their traditional beliefs? Some may be helpful, and
others may need changing. At first it is best simply to discuss.
Ask the kind of questions that get students talking. Later they will take part
in discussions more easily.
Add new information as you go along, changing some ideas but usually
building upon what the students already know.
This chapter asks nine questions:
Why do we need teeth and gums?
Why do some teeth look different?
What holds the teeth?
How often do teeth grow in?
What makes teeth hurt?
How do germs make holes in the
What makes the gums feel sore?
What does it mean if a tooth is
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
Where There Is No Dentist 2010
Why Do We Need Teeth and Gums?
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.
1. Draw or cut pictures of people from magazines. Make posters to
show that healthy teeth make a person happy, while bad teeth make a
person sad. Use the posters for discussion.
Hang up a picture of a person the
students know and like. Put black on
one of her front teeth. Talk about it.
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.
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.
“th” — the, teeth — the tongue touches
the top teeth.
“s” — sun — air goes between the teeth.
Now, try saying the same words again,
but do not let the tongue or lips touch the
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
many more!
No Teeth Needed
but not
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
Why Do Some Teeth Look Different?
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
Small bits of food
often get caught
inside deep lines, or
grooves, in a tooth.
Food that is not
cleaned away
from the grooves
can make a cavity
(hole) in them.
Look for them on
the top and the sides
of back teeth.
A tooth with a
cavity is weak and
often hurts.
Where There Is No Dentist 2010
1. Ask the students to bring different kinds of food to class. Bring
some yourself.
Eat the food using first the front and
then the back teeth.
Bite a guava using only the back teeth.
Chew completely a mango or piece of
maize, using only the front teeth.
2. Collect teeth from different animals. Let the students discover from
the shape of an animal’s teeth the kind of food it usually eats. For
instance, a wild cat needs sharp pointed teeth to tear meat, but a goat
needs flat teeth to chew grass.
Make a poster to show the animal, its teeth, and the kind of food it
likes to eat.
3. Have each student take a partner. Let each look at the shape of the
front and back teeth in the other’s mouth.
Talk about the many different kinds of food we need to stay healthy.
Discuss which teeth we use to chew meat, fish, mango, and other
good foods in your area. (For most foods, the answer is both front and
back teeth!)
Where There Is No Dentist 2010
What Holds the Teeth?
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.
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.
1. Have the students look for
an old jaw bone from a dog
or other animal. Notice that
bone goes around every root
of every tooth and holds it
tightly. Break away some
of the bone and look at the
roots of the teeth.
Front teeth need only one root
because they are used for biting.
Back teeth have 2, 3, or even 4
roots. That makes them strong
enough to chew tough meat and
even break hard bone.
Where There Is No Dentist 2010
2. Show your students how infected gums can cause teeth to fall out.
top of
A. When gum disease is beginning, a small red `pocket’ forms where the
tooth meets the gum. Germs and food collect in the gum and make acid.
This makes the gums sore.
B. As a result, the gum pulls away and the pocket becomes deeper.
C. The bone moves away from the infection and no longer holds the tooth.
Try to think of other ways to teach how gum disease pushes the
bone away from the tooth. In Jamaica, dental workers ask, “What do
you do if someone attacks you with a machete (long knife)?” “I run
away!” most people answer. “Exactly,” say the dental workers, “and
when you have a lot of germs attacking the root of your tooth, the
bone ‘runs away’ and leaves the tooth with nothing to hold it.”
Tell a story to show how, when the gum moves away from the top of
the tooth, the root and bone are open to attack. For example:
One day, a hen was sitting on the eggs in her nest. The hen was
hungry, and when she saw a worm, she left the nest to catch the
worm. Just then, a possum came along, saw the fresh, warm eggs,
and ate them all up.
Explain to the students that the gums protect the teeth the way a
hen protects her eggs. When she leaves the eggs unprotected and
exposed, an animal can attack and destroy them. When gums around
a tooth are red and sore, the tooth is exposed to germs that can attack
not only the top of the tooth, but also the bone and root.
Where There Is No Dentist 2010
How Often Do Teeth Grow In?
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.)
Where There Is No Dentist 2010
Have the students examine each other.* Help them learn which are baby
teeth and which are permanent teeth. Look for the important 1st permanent
molars at the back.
Show the students
how to count the
teeth and the spaces
that are ready for new
teeth to grow in.
Then have them count
their friends’ teeth, to find
out how many teeth should
be growing in different age
groups. Later, they can do this with their brothers and sisters at home.
Wash your hands.
Count the teeth.
Count the spaces where new teeth have not yet grown in.
TOTAL = teeth + spaces
Find out the person’s age.
Have the students first write their totals on the blackboard. Then make a
chart for the children to remember and discuss the results.
* Here the children are only counting the teeth. They can also learn to check for cavities and
gum disease (see p. 49).
Where There Is No Dentist 2010
Discuss the number of teeth children have at different ages. Young children
6 to 12 years old, for example, have 24 teeth; older students, 28 teeth; and
most adults, 32 teeth.
At home, students can count brothers’ and sisters’ teeth to learn how many
teeth small children have. Count only the teeth and not the spaces.
Ask the students what other things they saw inside someone else’s mouth.
This is a good time for students to discover important things about good
health practices. Encourage them to learn as much as they can from what
they see, and then show them how to use a book like this to answer their
own questions, For example, if students see cavities and red bleeding gums,
you can start a discussion on tooth decay and gum disease. Use some of the
activities on pages 55 to 60.
For another example, if the students see a baby who has only a few teeth,
they may have some interesting questions. Show them this book and invite
them to read pages 63 to 65 to find answers to questions like these.
Can Chenia, who is 6 months old and has no teeth, eat soft foods?
Should she have more than just breast milk?
When Chenia’s teeth grow in, will they give her diarrhea and fever?
Will a 2-year-old girl get more baby teeth?
Why do we care for baby teeth, when we only need them for a few
Where There Is No Dentist 2010
What Makes Teeth Hurt?
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.
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
A cavity may look small on the outside, but it is much bigger inside. Decay
spreads more easily in the soft part under the hard cover of the tooth.
A tooth with a cavity may hurt, but it usually does not hurt all the time. This
is because the bottom of the cavity is close, but not yet on the nerve inside
the tooth.
Fill a small cavity and save a tooth.
A small cavity that is not treated grows bigger and gets deeper. When the
cavity finally touches the nerve, it causes a tooth abscess. Infection from
the tooth decay going inside the tooth causes the tooth to ache all the time,
even when you try to sleep.
Infection can pass from the tooth to the bone. As it spreads under the skin,
there will be swelling of your face.
A tooth with an abscess must either be taken out
or have its nerve treated.
An abscessed tooth is dying. When it dies the tooth changes color from
white to dark yellow, grey, or even black. Pus from the end of its root can
pass to the gum, making a sore called a gum bubble.
A tooth is like a light bulb.
When the bulb is alive from power inside, it is
bright and useful.
The little wires inside the bulb are like the nerves
inside the tooth. When the bulb burns out, it is dark
and not useful any more.
Where There Is No Dentist 2010
1. Have each student look inside a partner’s mouth. Look for black
spots that may be cavities, for dark teeth that are dead, and for sores
on the gums, especially near a bad tooth.
2. Discover how sweet food sticks to teeth.
Cut several different kinds of food with a knife.
Vegetables and meat do not stick to
the knife.
Sweet foods, like chocolate and
jam buns, do stick to the knife.
They stick to your teeth the
same way.
Pour some cola or juice in a dish, and leave it outside overnight.
As water is lost, the juice left in the dish
becomes sticky. It attracts flies.
The air you breathe dries the cola and
causes a sticky, very sweet coating to
form on your teeth. It attracts germs.
Try to find some old teeth. Ask the
students to keep their own baby teeth
when they fall out. (Note: in some
countries this is not acceptable.) Your
dental worker can save you some
teeth that were taken out at the clinic.
Scrape the outer cover of the root with a knife. Feel how hard and
smooth it is.
Then find out what happens
when the students leave a tooth
in cola, milk, or plain water.
After 3 days scrape each tooth
again with a knife. Students will
discover that sweet cola drinks
make teeth softer and darker
in color.
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.
• Take a hammer.
• Gently break open a tooth.
• Look inside.
See how much bigger the cavity is on the
inside. lt spreads under the hard cover.
Cut through a rotten yam. See how the
rotten part spreads under its skin in the
same way.
4. Do a project in class.
Count the number of students with cavities.
Count the number of teeth having cavities. Show the students how
to look for them on the tops, sides and between the teeth.
Find out the person’s age.
Have the students write on the blackboard what they counted. Then
make a chart or graph.
Decide if tooth decay is a serious problem in your school. Ask your
dental worker to look at your results and to come and treat the
students, and help you prevent the problem from returning.
Do the same with brothers and sisters at home. Find out if tooth
decay is a problem with these young children. Tell your dental
worker what you find.
Where There Is No Dentist 2010
How Do Germs Make Holes in the Teeth?
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
Here is a game called “Scatter!” that students can play outside. You need:
Five ‘bases’ (a tree, rock, or
the corner of a house can
be a base) in a half circle,
12 meters apart. Each base
must have a ‘monitor’ who
stays at the base.
Note: children who cannot
run can be good monitors.
One person with a broom.
This person is the
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
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.
The ‘decolonizer’ (with broom) has lost
the game. The children behind him have
formed a ‘colony’.
Here the decolonizer stops a boy from
completing a chain.
Play two games: one with
children trying to form the first
kind of colony, one with the
second kind. These photos are
from the second game.
The decolonizer tries to stop the
others by touching them with the
broom. When the decolonizer
touches a colonizer with the
broom, the colonizer must leave
the area for one minute. (Give
that child a task to do—run
around the school-house or lie
down and sit up 30 times.)
The decolonizer wins if no
colonies form in 5 minutes.
After The Game:
Talk to the students about germs
in their mouths and how small
they are. Can anyone see germs?
No, but they can feel them and
taste them. Ask the group what
their mouths feel like in the
morning when they wake up. You
may get these answers:
My teeth feel mossy.
My breath is bad.
I feel a coating on my teeth,
but it goes away when I
brush them.
To teach about things too small to see, look
at the suggestion on page 11-29 of Helping
Health Workers Learn.
Tell the students that this coating on the teeth is a ‘colony’ of germs. They
are always trying to group together on the teeth or in spaces between the
teeth—just as the ‘colonizers’ did in the game!
Where There Is No Dentist 2010
What Makes the Gums Feel Sore?
Healthy gums fit tightly around the teeth and help to hold them strongly.
Healthy gums also cover and protect the bone under them.
Healthy gums are pink in color, or
even blue or dark yellow in some people.
But healthy gums are never red.
Healthy gums are pointed between
the teeth. This lets food slide away and
be swallowed.
Healthy gums fold under, making a
little pocket around the tooth.
As we saw with the last activity (p. 50), when you have ‘colonies’ of germs
on your teeth, they can make acid that makes holes on your teeth. The same
coating of germs can make a different acid that makes the gums sore. This
also happens when food mixes with the coating on your teeth. Soft food
is the worst kind, because when it mixes with spit it sticks more and stays
longer on your teeth. Juice from tea, betel nut, and meat color this food,
making the tooth look dark.
Healthy gums become sore because of acid. When the coating on the
teeth (p. 50) becomes hard, it is called tartar. Tartar can hurt the gums.
Also, the ‘colonies’ of germs can make a coating on top of tartar more
easily than on a clean tooth. When the colonies are new, they make more
acid which causes tooth and gum problems. After 24 hours, it hardens
and makes a new layer of tartar. The tartar gets bigger and bigger.
Sore gums are infected.
Infected gums are red
and bleed easily.
Here is a larger picture of the
teeth in the box above:
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
Infection in the gums is called gum disease. It is important to treat gum
disease early, before it can spread to the root fibers and the bone.
If you have sore, bleeding
gums, you can do much to
treat the infection yourself.
1.Clean your teeth with a soft
brush gently and more often
(see page 71).
2.Eat more fresh fruits and
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.
1. Have the students look in each other’s mouths.
Can they see the coating on the teeth? Usually
they cannot. They may see food or ‘white stuff’,
but this is not the coating that makes acid.
However, if someone has been chewing betel nut
or eating berries, you will see stains on her teeth
and the stains will be darkest where she has
these colonies of germs on her teeth.
2. Put something on the teeth to stain the colonies of germs. Try using
food dye, betel nut or berry juices. Remember: first wash your hands!
Older students can rub berries on the teeth of the younger ones. Have
them rinse with a little water and spit it out. After this, the colored areas
on the teeth will show where the colonies of germs are forming. Where
are they? Usually you will see the dark colors:
between the teeth
in the pits or holes in the teeth
on the tops (biting surfaces) of the teeth.
The older students can show the younger ones the best way to clean
teeth (see pages 69–72). Have them use a mirror to see if they are getting
the colored juice from their teeth. They will learn that it is most difficult
to get rid of the color between their teeth. Give them some string, dental
floss, or the soft stem from a young palm leaf and show them how to use
it between their teeth (p. 72). Remind them to be gentle, or they will hurt
their gums. Clean between your teeth every day.
Where There Is No Dentist 2010
What Does It Mean if a Tooth is Loose?
Baby teeth become loose when children are between 6 and 12 years old.
This is normal. If a loose baby tooth does not have a cavity, and if the gums
around it are healthy, there is probably a permanent tooth growing under it.
But a tooth might be loose because it is broken or because it is sick from an
abscess or gum disease. Either can destroy the bone around the tooth’s roots.
When bone is lost, the tooth
becomes loose. A loose tooth hurts
and usually must be taken out.
There is no medicine to make bone
grow back around the roots of
loose teeth. All you can do is stop
the infection from getting worse.
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
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.
Vegetables, especially
those with dark green
Fruits, like banana,
guava, oranges,
and papaya.
Peas and beans, like green
beans, soybeans, winged
beans, and mung beans.
Oil, from palm nut
kernels, ground nuts,
and coconut.
Fish, meat and eggs.
Clean water, coconut
water, and milk are best
to drink.
Soft foods and sweet foods from the store
are not good for you. Soft foods stick to your
teeth easily. They can work longer to cause
cavities and infected gums. Sweet foods have
mostly sugar in them, and it is ‘factory sugar’,
not the ‘natural sugar’ that is in the foods in
the pictures above.
This kind of sugar is quick to mix with germs
and make acid. Remember: natural sugar
makes acid slowly; factory sugar makes acid
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
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.
Buy a brush from the store, or make one yourself (see p. 4). But be sure the
cleaning end of the brush is soft so that it won’t hurt the gums.
Use your brush to clean all the teeth, especially the back ones with the
grooves. Back teeth are harder to reach and so it is easy not to clean them
well enough. Cavities start from sweet food and germs left together inside
the grooves.
1.Scrub the inside,
outside, and top of
each tooth.
2.Push the hairs of
your brush between
two teeth. Sweep
the food away.
3.Wash your mouth
with water, to
remove any loose
bits of food.
Small children are not able to clean their teeth carefully enough by
themselves. They need help. Look at the pictures on the cover and p.18 to
see how you can do this. Older children can care for younger brothers
and sisters at home.
Where There Is No Dentist 2010
One of the best ways to teach is by example.
Students will believe what their teacher says if they know he eats good food
and cleans his teeth.
The reverse is also true. Learning is harder when students know that their
teacher does not do those things himself.
Students can be a good example for their community, too. They can:
draw pictures of foods that are both good and bad for teeth. Use them
to make posters and flannel-board stories.
make puppets and plays to discuss ways people can become healthier.
There are some other ways to make learning meaningful and fun.
1. Make a garden at school. Divide the ground so that each class has its
own space to plant a garden.
Use some of the garden’s food to prepare a meal for the students,
perhaps once a week. Students can bring food from home if there is
not enough ready in the garden.
2. Organize a school lunch program. Each day the students can bring
some good food from home. Cooked yams, or maize, nuts, fruit and
fresh vegetables are all good. Often the students will exchange food
and talk about the many different foods that can be grown locally.
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
sticky food
and rinse
...eat a
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.
Where There Is No Dentist 2010
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.
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 holder.
... or on a
rack at the
back of the
Let each student look after
her own soap and brush.
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.
Pick 4 teeth, a back tooth and
a front tooth—two on top and
two on the bottom.
Use the same 4 teeth for each
person. Look for food on each
tooth near the gums.
A clean tooth = 2 points.
A dirty tooth = 0 points.
Total possible points each day
is 4 teeth x 2 = 8 points.
In this example the score is:
Tooth 1 = 2 points
Tooth 2 = 0 points
Tooth 3 = 0 points
Tooth 4 = 2 points
= 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.
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
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
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.
Where There Is No Dentist 2010
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
are white and their
front surface is smooth.
Weak teeth
have yellow marks that
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:
Eat enough good kinds of foods, both for herself and her baby growing
inside (page 68; also see Where There Is No Doctor, Chapter 11, and
Helping Health Workers Learn, pages 25-39 to 25-44.)
Attend health clinic each month, so the health workers can examine her
regularly and she can receive important medicines (see Where There
Is No Doctor, page 250).
Not use the medicine tetracycline, because it can cause the teeth
to turn dark. You, the health worker, must remember—do not give
tetracycline to a pregnant woman or to a young child. If she needs
an antibiotic, use a different one.
For baby teeth to stay strong, and to prevent marks from turning into
cavities, mother should:
Continue to 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.
Wipe her baby’s teeth with a clean cloth after
the baby eats. This cleans the baby’s teeth,
and helps the baby get used to teeth cleaning.
Later he will be happy with a brush.
Around 1 year of age, there will be several baby teeth. At that time, mother
should start using water—not toothpaste—on a soft brush or brushstick.
(With toothpaste, you cannot see the child’s teeth clearly because of the
bubbles it makes.) She should scrub the sides and tops of each baby tooth
as well as she can (page 69).
The child can also try to clean his own teeth. That should be encouraged.
However, since he is too young to clean properly, mother (or father, or older
brother, sister) must clean his teeth once a day for him. Continue helping in
this way until the child is old enough to go to school.
You can make a large brush smaller,
to fit more easily into a young
child’s mouth.
Pull out some of the back hairs, or
cut them out with scissors. Do not
cut the hairs in half, because the
tops are often rounded or softer, and
that is better for the gums.
*See the story about pregnancy and dental care on pages 15–16.
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.
(PM) come
in behind
the baby
Under each baby tooth a new
permanent tooth is growing.
At the same time, extra
permanent molars are forming
at the back of the mouth,
inside the bone (page 43).
Front baby teeth become
loose and fall out (usually
6–7 years, but sometimes as
young as 5 years) ahead of
back baby teeth (10–12 years).
This is because the front
permanent teeth are formed
and ready to grow in first.
The permanent molar (1 PM) is often the first of the permanent teeth to grow
into the mouth. That happens at 6 years of age.
The first permanent molar grows into
the mouth by sliding against the back
of the second baby molar (2BM).
Slowly but steadily the upper and
lower permanent molars grow until
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.
to make
10 years
10 years
to make
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).
Where There Is No Dentist 2010
We often notice front teeth growing in, but not the back ones. Back teeth
molars are not so obvious. Swelling on the face can be either a new molar
growing in or an abscess. So, to help you to decide, look at the tooth for a
cavity and at the gums beside it for a gum bubble.
When you see a swollen face, look for the two signs of an abscess.
But if the person is young (16–22 years), it often is not an abscess. The third
permanent molar tooth may be growing in at the back of her mouth. As the
tooth grows, it cuts through the skin. Just as a dirty cut on a person’s hand
can get infected, the cut gum around her new tooth also can get infected,
causing a swollen face.
Look behind her back teeth.
See the red swollen skin on
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
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
This book often repeats an important message: eat good food and clean
your teeth. It is repeated because this is the most important thing you
can Iearn from this book. Later chapters will discuss what to do when
problems occur, but if you follow these two suggestions, you will almost
never have problems with your teeth and gums. This is true because good
food keeps your whole body healthy, including your teeth. Also, with no
‘colonies’ of germs (page 50) or harmful factory sugar (page 55) on your
teeth, your mouth cannot make the acids that cause both tooth and gum
problems. So, remember:
1. Eat Good Food
An easy-to-remember rule is the same foods that are good for the
body are good for the teeth. A healthy body is the best protection
against infection.
Good nutrition (eating well) means 2 things:
1) Eat a mixture of different kinds of foods
every time you eat. Look at the pictures
on page 55. There are several groups of
foods. Every time you eat, try to eat one or
two foods from each of the groups. This
way, you will get 3 important kinds of food:
grow food (body-building food) to give you
the protein you need; glow food (protective
food) to give you vitamins and minerals; and
The MAIN FOOD is at
go food (concentrated energy food) to give
the center of every meal.
you calories to be active all day.
2) Be sure you eat enough
food to give your body the
energy it needs. This is even
more important than the first
suggestion. We get half or
more of our energy from our
main food. In most parts of the
world, people eat one low-cost
energy food with almost every
meal. Depending on the area,
this main food may be rice,
maize, millet, wheat, cassava,
potato, breadfruit, or banana.
The main food is the central or
‘super’ food in the local diet.
A spoonful of cooking oil
added to a child’s food
means he only has to eat
about ¾ as much of the
local main food in order to
meet his energy needs. The
added oil helps make sure
he gets enough calories by
the time his belly is full.
Where There Is No Dentist 2010
Be sure always
to eat grow
foods and
glow foods
to get the
vitamins and
protein you
Your energy
foods give
you the most
part of your
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.
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.
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
Here are three ways to clean between the teeth:
1. Push the hairs of a toothbrush between the teeth, and sweep the bits
of food away.
2. Remove the stem from a palm leaf. Use the thinner end and move it
gently in and out between the teeth.
Rub the stem against
one tooth and then
the other. This way,
you clean the sides
of both teeth.
3. Use some thin but strong thread or string. String can be the best
method of all—but you must be careful with it.
Get some thin cotton rope
used for fishing nets. Unwind
and use one strand of it.
Buy and use dental floss.This
is a special kind of string for
cleaning between the teeth.
Be careful! The string can hurt your gums if you do not use it correctly.
The next page shows how to use the string, but the best way to Iearn
how to ‘floss’ your teeth is to have someone show you. Ask a
dental worker who has experience.
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.
and Diagnosis
Whenever you do an
examination, remember
to examine the mouth.
You can prevent much suffering
and serious sickness when
you notice and treat problems early.
Whenever you hold a health clinic, try
to find out how healthy each person’s
mouth is.
Ask if she is having a problem now, or
has had a problem recently.
Always write down what you find out,
so you remember what treatment that
person needs.
1.Are the teeth healthy? Look for:
3.A Loose
4.A Dark
When you look inside someone’s
mouth, ask yourself these questions.
1. A New
Tell the person what is
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).
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
both the tooth and the gum around it.
A bubble beside a healthy tooth is a sign
of infected gums. Scale the tooth carefully.
See Chapter 8.
A bubble beside a decayed tooth is a sign
of a tooth abscess. (See page 93.)
A sore on the gums from a badly decayed
tooth appears when a gum bubble breaks
open and lets out the pus from inside.
3.Are there any sores?
Look for sores under the smooth skin on the inside of the lips and
cheeks. Look also under the tongue and along its sides.
1.A sore on the
gums may be
from an infected
tooth (p. 93).
2.Sores on the inside
of the lip or cheek
may be from a
virus (p. 104).
3.Sores on the
lips or tongue
may may be
cancer (p. 125).
After your examination, tell the person what you have found. If you notice
a problem starting, explain what to do to prevent it from getting worse. If
there are no problems and the mouth is healthy, congratulate the person.
Share your knowledge—explain things to people.
Help them Iearn how they can prevent and even
manage their own problems with their teeth.
Where There Is No Dentist 2010
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.
Three instruments are really enough:
1. A wooden tongue blade to hold back
the cheek, lips, and tongue.
2. A small mirror to let you look more
closely at a tooth and the gums
around it.
3. A sharp probe to feel for cavities
and to check for tartar under the
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.
Where There Is No Dentist 2010
You are making a diagnosis when you decide what a person’s problem is
and what is causing it. To do this, you need information. You need to make
a careful examination to make a good diagnosis.
Learn all you can about the person’s problem:
1.Ask questions about the problem.
2.Look at the person’s face. Think about the person’s age.
3.Examine the mouth more carefully than before.
4.Touch the place that is sore.
1.Ask the person about the problem.
Give a sick person a chance to
describe how he is feeling.
Listen. Think about what possibly is
happening in his mouth.
You may have an idea about what
the person has. Now try to find out
more by asking questions:
What is the problem? Ask him
to talk about the pain, swelling,
bleeding, or whatever he is feeling.
Where does it feel that way? See if he can put his finger on the tooth
or place that is bothering him.
When do you have the most pain? Find out if it happens all the time
or only some of the time (for example, when he drinks something very
When did it start? Find out if he has already had this problem before.
Ask how he took care of it.
Have you had an accident or injury lately? Infection still inside the
bone from an old injury in the mouth can make a sore on his face, or
start swelling.
Are you having other problems? A head cold or fever can make the
teeth hurt.
How old are you? Think about a new tooth coming into the mouth.
After you hear the answers to your questions, decide if your original idea
is the correct diagnosis. If not, try to think of another possibility and ask
more questions. This is the scientific method of making a diagnosis.
For a good explanation of scientific method, see Chapter 17 of Helping
Health Workers Learn.
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
protecting her baby as well (see pages
15 to 16).
Train midwives to examine
women’s mouths. When
they send women to you for
dental care, they can give
you helpful information
about the women’s health.
Caring for a pregnant woman—a guide for dental workers
1. Ask her how many months she has been
pregnant and find out if she has high blood
pressure. Any person with blood pressure over
150/100 may bleed excessively after extraction.
To get this information, encourage all women
to have regular check-ups with a midwife or a
trained health worker who has equipment for
measuring blood pressure.
2. Do not take X-rays of teeth unless absolutely
necessary. X-rays are dangerous to the unborn
baby inside. Before an X-ray, always cover the
mother’s chest, belly, and thighs with an apron
lined with lead.
3. Do not give her tetracycline or doxycycline while she is pregnant
or breastfeeding.
4. Always give a careful and complete mouth examination. Tell her
what treatment she needs and how to prevent tooth problems.
5. Be gentle. Show the woman that you care, that you want her to
be comfortable, and that you can treat her without hurting her.
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.
Swelling can come from:
Swelling can come from:
• mumps
• an infection
• a
in the spit
gland (p. 119)
• a tooth abscess (p. 93)
new tooth growing
in (p. 100)
• a tooth abscess (p. 93)
Swelling can come from:
• a
• a
• a
tooth abscess (p. 93)
broken jaw (p. 113)
tumor (p. 125)
A sore can come from:
A sore can come from:
• impetigo
• Vincent’s
• fever blisters (p. 104)
• a tooth abscess (p. 93)
(p. 102)
A sore can come from:
• a
• a
tooth abscess (p. 93)
bone infection
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:
• Is a new one growing in?
• Is a tooth loose?
• Is there a dark (dead) tooth?
Look at the gums:
Are they red?
Is there any swelling?
Do they bleed?
Are the gums eaten away
between the teeth?
Look also for sores on the inside of the cheek or lips, and on the tongue.
4.Touch the sore place.
Touching is a good way to find out how serious the problem is. This will
help you decide which treatment to give.
Push gently against each tooth in the area of pain to see if a tooth is
loose. Rock the loose tooth backward and forward between your fingers,
to see if it hurts when you move it.
Using the end of your mirror, tap against
several teeth, including the one you suspect.
There is probably
an abscess on a
tooth that hurts
when you tap it.
Press against the gums with cotton gauze. Wait a moment, and then look
closely to see if they start bleeding. Then use your probe gently to feel
under the gum for tartar. Carefully scrape some away. Wait and look again
to see if the gums bleed. When gums bleed, it is a sign of gum disease.
Where There Is No Dentist 2010
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.
It hurts only after eating or
drinking. There is a cavity, but the
tooth does not hurt when you tap it.
a cavity
Part of the filling has fallen out, or is
cracked and ready to fall out. Eating
and drinking make the tooth hurt.
a cavity
under an
old filling
The tooth hurts when chewing food.
It may hurt when tapped, but there is
no cavity and the tooth looks healthy.
the teeth
It hurts all the time—even when
person tries to sleep. The tooth
hurts when you tap it and it feels a
bit loose.
an abscess
It hurts when person breathes in cold
air. The tooth was hit recently.
a cracked
or broken
He cannot open his mouth properly.
Steady pain and a bad taste are
coming, from the back of the mouth.
a new tooth
growing in
Several top teeth hurt, even when
you tap them. She had a head cold
and can only breathe through her
an infected
Where There Is No Dentist 2010
a tooth
She is young, about 18 years
old, and has trouble opening
her mouth.
a new tooth
growing in
He was hit on the face or jaw.
The bone hurts when you
touch it. The teeth do not fit
together properly.
a broken bone
The swelling is under or
behind the jaw. It gets worse
when he is hungry and smells
an infection
inside the spit
The swelling has been there for
a long time. It does not seem to
get better.
a tumor
He had a toothache recently.
The bad tooth hurts when
you tap it.
Food and tartar are attached
to the tooth. The gums
around it are loose and
inside the root
gum disease
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.
infection in the
an old tooth
The tooth was hit
some time ago.
a root broken
under the gum
When the loose tooth
moves, the bone around it
and the tooth beside it also
a broken bone
around the
tooth’s roots
infection inside
the bone from
When you ask the person to
slowly close his teeth, one
tooth hits another, before the
other teeth come together.
a tooth is out
of position and
biting too hard
aganist another
Where There Is No Dentist 2010
from a
in another
The gums are red and
swollen. They bleed when the
teeth are cleaned.
gum disease
Between two teeth the gums
are sore and swollen, like a
small tumor.
caught under
the gum
The gums between the teeth
have died and are no longer
pointed. Pus and blood around
the teeth make the mouth
smell bad.
Infection (a
more serous
gum infection)
The gums are bright red and
sore, but between the teeth
they are still pointed.
fever blisters
on the gums—
from Herpes
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 canker sore
A sore spot around or under
a denture hurts when you
touch it.
a sharp place
on a denture,
or an old
denture that
needs to be
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.
gum bubble
The corners of the mouth
are dry. The lips crack and
are sore.
Small painful blisters on the
lips soon break and form dry
fever blisters—
from Herpes
Where There Is No Dentist 2010
Inside his mouth, he has a
tooth abscess or a broken
tooth near the sore.
abscessed tooth
draining pus to
the outside of
the face
A dark sore is eating through
the cheek. Her gums are
badly infected. A bad smell is
coming from the dying skin on
the face, and from inside the
a condition
called Noma—
starting from
Infection of the
A 1-month-old sore on the lips
is not healing with medicine.
He is young, between
16–24 years, with some
swelling behind his jaw.
a new tooth
growing in
He recently had an accident.
a broken jaw—
probably in
front of the ear
He had a toothache before
in a back tooth with some
an abscess in a
back tooth
When she tries to open
her mouth, there is clicking
sound from in front of her
ear. It also hurts in that place
whenever she tries to open
her mouth or chew food.
pain in the
the jawbone
joins the head
Swallowing is difficult and
the jaw grows stiff. Germs
have gone into the body
from dirty instruments or an
infected wound.
After opening wide to eat
or yawn, his mouth became
stuck there. He was many
missing back teeth.
a dislocated
He had an accident and now
something is stopping the
teeth from coming together.
a broken jaw
Where There Is No Dentist 2010
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
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.
Where There Is No Dentist 2010
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.
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
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:
Add 5 spoonfuls (20 ml) of oil to every liter of water you boil.
Then lay the hot instruments on a dry, clean (sterile, if possible) cloth,
so the water can evaporate.
Never put an instrument away while it is wet.
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 Iid so steam can escape
when the pressure becomes too great.
A special pot called a pressure cooker is perfect for this. It even has a safety
hole on it to release extra steam.
1. Put 2 cups of water and
2 spoonfuls of cooking
oil into the pot.
2. Place the handles together.
Put on high heat until a loud
hissing noise begins.
3. Put on lower heat. Begin
timing now. Leave the hissing
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.
The next time you use the pot,
you can use the same water that
was Ieft inside it.
Where There Is No Dentist 2010
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
1. Mix in a large container each week:
7 parts alcohol (95%) with 3 parts
clean water. Keep the container
tightly covered to prevent
tight fitting
2. Keep a covered pan half filled with
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
pan, completely covered with the
liquid, for 30 minutes.
Bleach solution (sodium hypocholorite)
Find the cheapest brand name in your area for bleach.
Examples are Javex, Clorox, Purex, and Cidex. Make
1 liter of solution with a mixture of ½ cup
(125 ml) of bleach and 3½ cups (875 ml)
of clean water.
3 + ½ CUPS
Unfortunately, bleach rusts metal
instruments. To reduce rust,
add 1 large spoonful of baking
soda (sodium bicarbonate) to
the solution, and leave your
instruments in the solution for only
30 minutes.
Wipe each instrument with alcohol
to remove the film of bleach. Then
store it dry inside a clean cloth or in
another covered pan.
Change the solution each week.
Where There Is No Dentist 2010
Keep your sterile instruments together in a clean place.
Wrap them in a clean cloth
Mark with tape the names
of the instruments inside.
Leave them in disinfectant
(p. 89)
Before you use any instrument
again, wash it with clean water—to
remove the taste of the disinfectant.
Germs living in dirty cotton can easily go inside the socket and start an
infection. It is important, therefore, to keep the cut pieces in a container that
is clean and has a cover. Use clean tweezers to remove the cotton gauze
when you need some.
Also, keep your room and work area clean. Sweep or mop the floor one or
two times a day, and wipe down the chair and tables after every patient.
Staying clean is a part of staying healthy.
Where There Is No Dentist 2010
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
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.
Where There Is No Dentist 2010
problems you will see most often
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.
Pain when drinking water or eating
something sweet.
A hole (or black spot) on the tooth, or
between two teeth.
Pain if food gets caught inside the hole.
No pain when you tap the tooth.
TREATMENT (when there is no abscess):
Try to remove any loose piece of filling with a probe. Then, following the
steps in Chapter 10, put in a temporary filling.
1. Fill the hole with cement. If you have no cement, put some cotton into
the hole to keep food out.
2. Look for cavities or broken fillings in the other teeth. Fill each one with
cement before it gets worse and starts to hurt.
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
properly, you need to shape the groove with
a drill. To help temporarily, you can put a little
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
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.
Pain all the time, even when trying
to sleep.
Tooth often feels longer, and even
a bit loose.
Tooth hurts when it is tapped.
A sore on the gums near where
the root ends (gum bubble).
Swelling of the gums around the
tooth, or swelling of the face on
the same side as the bad tooth.
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 ½ as much. For
most infections, penicillin by mouth is taken 4 times a day for 5 to 7 days.
The first dose is double and then the regular dose is taken every 6 hours. The
person should take all of the penicillin, even if the pain or swelling goes
down. For the correct doses, see the next page.
Where There Is No Dentist 2010
(for those allergic to penicillin)
Penicillin: 1 tablet = 250 mg
Give enough tablets for 5 to 7 days
First Dose (take all at once)
and children over 25 kg
Children under 25 kg
and children over 25 kg
Children under 25 kg
Erythromycin: 1 tablet (or capsule) = 250 mg
Give enough tablets for 5 days
4 tablets
(1000 mg)
2 tablets
(500 mg)
and children over 25 kg
Children under 25 kg
and children over 25 kg
Children under 25 kg
Then every 6 hours for 5 to 7 days
2 tablets
(500 mg)
1 tablet
(250 mg)
IMPORTANT: to allow it to best fight infection,
take penicillin before eating.
First Dose (take all at once)
4 tablets
(1000 mg)
2 tablets
(500 mg)
Then every 6 hours for 5 days
2 tablets
(500 mg)
1 tablet
(250 mg)
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
For many infections, taking penicillin for 5 days should be enough. For
serious infections, it may be necessary to take the antibiotics for 7 days.
For however long you take them, always take the double dose the first time,
and then the regular dose 4 times a day (every 6 hours). If the infection does
not heal, you may need a different medicine. Usually you can take out the
tooth 1 or 2 days before the end of the antibiotic treatment, but the person
must continue to take all of the tablets, even after you have taken out
the tooth. If not, the infection might come back even stronger than before.
If the swelling is ‘pointing’, open it with a sharp sterile knife to release the
pus. Cover the wound with a sterile dressing to keep it clean. If you are not
able to do that, explain how to reduce the swelling with heat. As often as
possible until the swelling goes away:
soak a cloth in warm water and hold it against the face.
hold warm water inside the mouth near the swelling. It is not
necessary to add salt to the water.
Finally, give the person medicine for pain. A 2-day supply will be enough,
because the penicillin and the heat will reduce the pressure and that will
reduce the pain. The best medicines for pain are aspirin, which 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
EVERY 6 HOURS (4 times a day):
8 to 12 years
3 to 7 years
1 to 2 years
600 mg
1000 mg
300 mg
150 mg
do not use
500 mg
250 mg
125 mg
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.
Toothache in several top teeth. The
teeth look healthy, but hurt when you tap
A head cold, and plugged nose. She can
only breathe through her mouth.
Hurts when you press against the bone
under her eyes.
Tooth feels different when patient bends over forward.
Do not take out any teeth. They will feel better after you treat the sinus
1.Give penicillin for 5 days (page 94).
2.Explain to the person that she should:
drink lots of water.
breathe steam from boiling water to clear
her nose.
hold a warm wet cloth against her face, as
often as possible.
not try to blow her nose, or else her ears will
hurt. Wiping the nose is better.
3.See the person again after 3 days, and
examine her teeth closely, tapping them to be sure they are strong
and healthy.
if she is not better, get help from a more experienced health worker.
Where There Is No Dentist 2010
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.
Pain when breathing air or drinking
Blood from the gums around the tooth.
Tooth moves when you touch it.
Take out the broken tooth if:
its nerve is not covered. If no one can give special root canal
treatment, the tooth must come out. Germs from the saliva have
already gone inside the tooth and started a small infection.
its root is broken. To see if it is broken, push gently against the
tooth as you feel the bone around its roots. The tooth’s root
probably is broken if the tooth moves but the bone does not. The
root probably is not broken if both the tooth and bone move.
However, the bone around the roots may be broken (page 109).
You can save a broken tooth if the nerve is still covered and the
root is not broken. To do this, use a file on the sharp edges around the
break. This makes them smooth so they do not cut the tongue. Later, an
experienced dental worker who has the equipment can cover the broken
part with a cap or a filling. Until this is possible, tell the person how to
protect the tooth:
Give the tooth a rest. Use other teeth to eat.
Do not drink things that are very hot or cold, and do not eat spicy
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
any bits of dirt on the
root of the tooth.
Keep the tooth
damp with wet
cotton gauze.
Do not scrape away any skin from the
root or from the inside of the socket.
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.
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
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
A tooth may be loose for one of several reasons. Decide the reason before
giving the treatment.
a new permanent tooth is
growing under it.
1. tell the mother and child what is happening.
2. pull out the loose baby tooth, if it is hurting the
gum disease or an old abscess has
eaten the bone around its roots.
1. take out the tooth, especially if it also hurts.
2. explain to the person what to do to prevent this
problem in other teeth. (See Chapter 5.)
its root has been broken.
take out both parts of the tooth. If you have trouble
taking out the broken root, leave it and try again a
week later.
the bone around its root is cracked.
(The bone moves when you push
against the tooth.)
Do not take out the tooth. If you do, the bone will
come out with it. Instead, hold the tooth with wires
(page 110).
A tooth may also be loose because another
tooth is biting too hard against it.
• You can feel the tooth move when
the upper and lower teeth meet.
That tooth hurts.
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.
100 Where There Is No Dentist 2010
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.
Toothache at the back of the jaw.
Mouth cannot open properly.
A bad taste coming from the back
of the mouth.
Sore throat.
Skin over the new tooth is sore
and hurts when you touch it.
The age of the person is the right
age for growing a new molar
tooth (page 66).
Infection in the gums and pressure from
the new tooth are painful. Notice the
‘flap’ of skin over the new tooth.
Do not take out a new tooth while there is still infection and pain. Wait
for the infection to finish. Then decide if there is room for the tooth to grow
in. A dental X-ray can help you make that decision. New molar teeth are
often difficult to take out. Ask an experienced dental worker to take out the
tooth, if it must be done.
What you can do
First, treat the infection. Then wait for the new tooth to grow more into the
mouth. Tell the person what is happening. Tell him what he can do to keep
the gums healthy while the tooth grows in:
Rinse the area with warm salt water (page 7). Make 4 cups each day
until the mouth opens normally again. Then make 1 cup each day to
prevent the problem from returning. Keep rinsing this way until the
tooth grows all the way in.
Hold a warm wet cloth against the jaw as often as possible each day.
Take aspirin for pain (page 94).
Give penicillin (pages 93–94) if there is fever, a swelling, or if he is only able
to open his mouth a little.
Where There Is No Dentist 2010 101
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.
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
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).
Gums are red instead of pink.
Gums are loose instead of
tight against the tooth.
Between the teeth, gums are
round instead of pointed.
Gums bleed when the person
brushes or flosses.
Gums bleed when you press
against them, or when you scrape away food from under them.
The person has bad breath and a bad taste inside the mouth.
Feel for tartar under the gum—or
even a piece of fishbone.
102 Where There Is No Dentist 2010
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.
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.
• Gums between the teeth are dying
and turning gray.
Pus and old blood collect around
the teeth.
Burning pain from the gums.
Bleeding from the gums.
The mouth smells bad.
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:
Tell the person to rinse his mouth with warm water.
Wipe his gums with cotton soaked in a 3% solution of hydrogen
peroxide, iodine, disinfectant mouth wash, or warm salt water. Rinse
with warm water. For a child, use a weaker solution, such as 1 part
hydrogen peroxide mixed with 5 parts water.
Scrape away the bigger pieces of tartar. Do not try to remove all of it.
You can do that later. Put topical anesthetic on the gums if you have
some (first dry the area with cotton so the topical anesthetic will stay
longer). Rinse away any loose bits of tartar with warm water.
3.Teach the person how to care for the gums at home:
Rinse at home for 3 days with a weak solution of hydrogen peroxide,
(page 8), iodine, disinfectant mouth wash, or warm salt water. Try
to hold the solution in the mouth for several minutes. The longer the
solution touches the gums, the better it is for the gums. Rinse once
every hour. After 3 days, change to salt water, 4 cups a day.
Clean the teeth with a soft brush. Parents can clean children’s teeth.
Show them how (page 18), and ask them to do it even if the gums
For a young child who is not able to
rinse, Mother or Father can wipe his
gums with the weak solution 4 times
a day.
Show parents how to do this. Give
them some cotton gauze and hydrogen
peroxide, iodine, or disinfectant mouth
wash to take home.
4.Cook food that is soft (like pounded yam) and not spicy (no pepper). Eat
fresh fruits and vegetables that give strength to the gums (page 102).
If you cannot eat well because of pain, take a multi-vitamin, or at least
Vitamin C and Zinc.
Stop smoking and stop chewing betel nut.
One week Iater, scrape away the rest of the tartar from the teeth. Then
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
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.
Inside the mouth
Sore throat.
Crying, stops sucking 2-3 days before sores appear.
Spit spills from the mouth because it hurts to swallow.
Painful swelling under the jaw.
Bright red blisters on the gums, but not between the teeth. Blisters also
may be on the roof of the mouth.
Medicine cannot kill the herpes virus. The sores will go away by themselves in
about 10 days. The treatment is to help the person feel more comfortable and
to be sure he gets enough to eat and drink.
1. Give aspirin or acetaminophen for fever (page 94).
2. Wipe milk or yogurt over the sores to protect them before eating. Wash
your hands before touching the inside of someone’s mouth! (See
page 86.) Then give food that is soft and not spicy. If the person cannot
eat, prepare a special milk-oil drink, as on page 111.
3. Give lots of fluids to drink.
Sores on the lips usually occur after the age of 5.
They often appear when the person is weak and
sick (for example, with diarrhea or pneumonia.)
Usually there is no fever. The blisters soon break
open and release water. When they dry, a crust
forms. The blisters often return. When sores leak
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
Where There Is No Dentist 2010 105
Thrush is an infection caused by a yeast fungus called Candida. It often
appears when a person is weak and poorly nourished, or sick and taking
medicine like tetracycline or ampicillin. In a baby, thrush usually appears
on the tongue or top of the mouth. It can stop the baby from sucking. ln
an adult, thrush often occurs under a denture. Thrush is a very common
problem for people living with HIV (see pages 180 to 181).
• White patches on the tongue, cheek, or
top of the mouth. Wipe the white area: If
there is no bleeding it is old milk. If there
is bleeding, it is thrush.
• The child may not want to suck or eat.
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
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.
• A sore can appear on the cheeks,
inside the lips, on the tongue, or below
the gums on the smooth skin.
• The sore is white or yellow with the
skin around it bright red.
• The person may have had a similar kind
of sore before. It tends to come back.
Note: a sharp edge of a denture rubbing against the gums can
make a similar kind of sore.
A canker sore goes away by itself in about 10 days. Medicine does not make
that happen any faster. (However, smoothing a denture or fixing a broken
tooth does help.) The treatment is simple. Tell the person how to feel more
comfortable while waiting for the 10 days to pass:
Eat foods that are soft and not likely to hurt the sore.
Do not eat spicy food.
Drink lots of water.
Chew food on the other side of the mouth, away from the sore.
A denture which does not fit
should be remade.
In the meantime, leave the
denture out of the mouth for
2 or 3 days.
Ask the person to rinse with
warm 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
Teeth support the lips. When they come together for chewing, the teeth
stop the person’s chin from moving any closer to the nose.
A person without many teeth looks old. A person with a poor fitting denture
also looks old.
The distance from his chin to his
nose is shorter than normal.
He must close his jaw further to
eat. That causes lines to form at
the corners of his mouth.
Poor health can make lines at
the corners of the mouth crack
and become sore. These cracks are
often infected with thrush and can be treated with nystatin (see page 105).
If sores are not at the corners but around the mouth, they could be due to a
bacterial infection (see page 94).
A person with missing teeth needs dentures. Dentures will help him
chew more food and make him look younger. They support his Iips and
open his mouth more. (See page 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
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.
Three main bones form the face and lower jaw.
1. cheek bone
2. upper jaw bone
(lower jaw joins
the head here)
3. lower jaw bone
A bone can break completely, or part of it can crack. In either case, the teeth
are usually pushed out of position. Look for this as a sign of a broken bone.
SIGNS of a broken bone:
The person has had an injury.
When teeth are closed, some upper
teeth do not meet lower teeth.
The person cannot open or
close the mouth properly.
There is bleeding from between 2 teeth.
There is swelling or a bruise on the face or jaw.
There is bleeding into the eye.
Where There Is No Dentist 2010 109
SIGNS of a cracked bone
around the tooth’s roots:
When you move one tooth,
the tooth beside it also moves.
When you move the loose
tooth, the bone moves with it.
Blood is coming from
under the gums.
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 best.
Place a piece of wire around 2 teeth,
one on each side of the break. Choose
the strongest tooth on each side—the
ones with the longest or the most roots.
Tighten the wire around the two strong
teeth with pliers or a hemostat.
Ask the person to close his teeth. Lift up the broken part of the jaw and
hold it so the lower teeth meet the upper teeth properly. This is the
normal way the jawbone holds the teeth.
Now join the wires. Twist and tighten
them together. This may be painful.
You can inject local anesthetic—see
Chapter 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 Iiquid foods for strength and energy.
Prepare food in two ways: (a) First, a milk-oil drink to build strength and
then (b) a special soup to keep him strong and give him energy.
To build strength: Milk-oil drink
Mix for him each day at your clinic:
9 cups of water
150 ml of peanut oil or coconut milk
3 cups of milk powder
½ cup of honey or 1 cup of sugar
Leave some near his bed, and keep the rest in a cool place.
To keep strength and give energy: Special vegetable soup
Cut into small pieces and cook together in a pot of water:
½ tin of fish or a handful of dried fish
4 small spoonfuls of peanut oil or palm oil
6 sweet potatoes or small yams
1 large handful of green leaves
1 small spoonful of salt
Pour the soup into an empty tin with small holes made in the bottom.
Use the back of a spoon to press as much of the cooked food as you can
through the holes. The person can suck the soup between the teeth to
the throat and then swallow it. Clean the tin and set it in boiling water, so
you can use it again the next day.
2.Keep the teeth clean and the gums tough.
The person must learn to clean teeth and gums or the gums can quickly
become infected and the mouth will feel sore. So:
• Scrub both the wires and the teeth with a soft brush after drinking
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
the loose teeth. Curve the needle so it
fits the curve of the teeth. To make the
sharp ends smooth, use a file or rub the
ends against a stone.
3. Tie each tooth to the needle. Use short
pieces of 0.20 gauge ligature wire (page 110).
Put one end of the wire under the needle.
Bring it around the back of one tooth and
out to the front again over the needle.
Use the end of a small instrument to
hold down the wire at the back of the
teeth. Then twist the ends together.
Tighten the wire around each one of
the 6 teeth.
4. Cut the ends of the ligature wire. Turn
them toward the teeth, so they will not
cut the lip.
5. Tighten the wires the next day, and then once each week. But be
careful. Only ½ a turn usually is needed. More, and the wire will break.
Always twist in the direction a clock moves. With this habit, you will
remember which way tightens the wire and which way loosens it.
6. Explain to the person that it takes 4 weeks for the bone to heal. The
wires must remain on the teeth for this time. To help the teeth to heal,
ask the person to:
• give these teeth a rest. Use other teeth for chewing.
• clean both the teeth and the wires with a soft brush.
• rinse with warm salt water, 2 cups every day (page 8).
• return to have the wires tightened every week.
7. After 4 weeks, cut and remove the wires. Ask the person to watch
those teeth. A dark tooth and gum bubble are signs that the tooth is
dying. Take it out, unless you can give special nerve treatment.
Where There Is No Dentist 2010 113
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.
She is unable to close her
teeth together.
She cannot close her lips
Her lower jaw looks long
and pointed.
It hurts when you press on
the joint in front of her ear.
She cannot speak clearly.
The treatment is to try to move the lower jaw back where it belongs. Then
hold it in that position until the muscles can relax.
1. Find a way to support the person’s head. For example, have the person
sit on the floor with her head against a wall.
2. Kneel in front of her. Put your fingers under her jaw, outside the
mouth. Put your thumbs beside her last molar tooth on each side. Do
not put your thumbs on the molars. The person may bite them!
Press down hard with the ends of your
thumbs. Force the jaw to move quickly
down and back into position. Be sure
to press down before you press back.
If the jaw will not move, perhaps the
muscles are too tight. A doctor or
dentist can put the person to sleep,
which will relax the muscles.
3. Support the jaw with a head–and–chin
bandage for 3 to 4 days (page 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
A joint is the place where one bone joins another. The jawbone has two
joints, for it joins the head in front of each ear.
The mouth opens and closes because:
• muscles pull the jawbone; and
the jawbone slides against the head
bone, inside the joints.
Pain in these joints may be because:
(1) The muscles are tight because the
the person is tense or nervous.
(2) The jawbone is fractured in the area
of the joint. (Also check the lower
jaw on the other side since a fracture
near the joint is often caused by a
blow to the other side of the face.)
(3) The teeth do not fit together properly.
Before you treat, decide what is causing the pain. We will discuss the three
causes mentioned above.
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.
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
Warn the person not to open his
mouth wide. Suggest, for example,
that he take his food in small bites.
Tell the person what can be done
to help. Often a dentist can grind
the teeth in a special way and this
can end the pain.
These teeth do not fit properly. Because the
line shifts, this means the jaw is also shifting.
This shift can cause pain in the joint.
Many persons who suffer from epilepsy
(see Where There ls No Doctor, page
178) have a problem with swollen
gums. In severe cases, the gums are so
swollen 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
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.
a large red clot growing
out of a socket where you
have taken out a tooth
1. Remove the clot with
cotton tweezers.
2. Ask the person to bite
on a piece of cotton.
sore and bleeding gums
and the mouth smells
bad (Vincent’s infection)
1. Rinse with a mixture of
hydrogen peroxide and water.
2. Remove as much tartar as you can.
a red, bleeding growth
inside the cavity in a tooth
Take out the tooth;
it has an abscess.
a loose tooth with
bleeding gums around it
Hold the tooth with wires, or if the
root is broken, take out the tooth.
torn gums with broken
bone and bleeding
1. With wire, hold the broken
parts of the bone together.
2. Send the person to an
experienced dental worker.
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.
1. Place a dressing inside the socket. Change it each day until the pain stops.
First, clean out the socket.
Squirt warm water inside the socket with
a clean syringe. After the person spits out
the water, squirt water inside once more.
Use a blunt needle so that it does not
hurt the gums or bone if it touches them.
Third, place the dressing
gently inside the socket.
Second, prepare the dressing.
Soak 1 to 2 small pieces
of cotton in eugenol (oil of
Squeeze each piece so that it
is damp but not wet.
Note: There may be local
medicine in your area that
relieves pain. Use it instead of
Place one piece of dressing
into each root space. Push
it down into the root space
Cover the socket with plain
cotton gauze, and send
the person home bitting
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).
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.
• the jaw becomes stiff and tight
it is hard to swallow
the whole body becomes tight,
with sudden spasms
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
Where There Is No Dentist 2010 119
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.
• 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
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.
5.When the person feels better, a dentist or doctor can remove the
stone that is blocking the duct.
120 Where There Is No Dentist 2010
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.
1. Take out the tooth (see Chapter 11).
2. Give penicillin for 7 days (see page 94).
3. After the penicillin treatment, check the sore. If it has healed, there is
no longer infection inside. The treatment is finished.
But if the sore is still open and you can squeeze out pus, you will need the
help of experienced health workers who can:
test the pus to see if it is resistant to penicillin. The person may
need to take a different antibiotic.
take an X-ray to see if there are dead pieces of bone which are
keeping the infection alive. If there are, they must be removed.
If infected gums (and not a bad tooth) are the cause of a sore on the cheek
or chin, the problem is more serious. See the next 4 pages.
Where There Is No Dentist 2010 121
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.
The infection starts in the mouth.
Then it passes to the gums.
1.Sore mouth with itching gums.
2.Swollen, sore gums.
3.Gums bleed when eating or
when teeth are cleaned.
4.Bad breath, spits a lot.
Then it reaches the jaw.
5. Loose teeth.
6. Loose pieces of bone
around the teeth.
Finally, it affects the cheek.
7. Skin is tight with dark red
8. Black spot on the cheek
breaks open, leaving a hole
into the mouth.
9. A line separates dead
tissue from healthy tissue.
122 Where There Is No Dentist 2010
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
2.Treat the anemia.
Start giving iron (ferrous sulfate) now. The child should continue taking
the tablets or mixture for 3 months, with food.
Ferrous Sulfate Tablets
over 6 years
200 mg (1 tab) 3 times a day
3–6 years
100 mg (½ tab) 3 times a day
under 3 years
50 mg (¼ tab) 3 times a day
You can also use ferrous fumarate. Advise the mother that the iron
will make the child’s stool black.
Also give food rich in iron: meat, fish, eggs, dark green leafy
vegetables, peas and beans.
Note: A child may have anemia because he has worms. It is a good
idea to do a stool analysis to find out. If he has worms, give him
medicine right away. Mebendazole, albendazole, and thiabendazole
treat many different worm infections. Piperazine treats roundworm and
pinworm infections, and there are other medicines for tapeworm and
blood flukes. Also give folic acid. For doses, see Where There Is No
Doctor, pages 373 to 376, and page 392.
Where There Is No Dentist 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
Dose for clindamycin (give 3 times a day for 5 days)
5 to 10 kg
10 to 17 kg
17 to 25 kg
over 25 kg
50 mg by mouth or 60 mg by injection
100 mg by mouth or 130 mg by injection
150 mg by mouth or 225 mg by injection
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
5. Clean the sore.
Gently pull away any dead skin with tweezers. Wash the inside of the
sore with hydrogen peroxide. (Be sure you measure the hydrogen
peroxide carefully. See page 8.) Then put in a wet dressing. (You can also
clean the sore with an iodine solution.)
The dressing:
Soak cotton gauze in salt water. Squeeze out the extra water so that
it is damp but not wet.
Put it in the hole and cover it with a dry bandage.
Every day, remove the bandage, wash the hole with hydrogen
peroxide, and put in a new dressing. Do this until the hole does not
smell anymore and there is no more dark dead skin.
6. Remove the loose teeth and dead bone.
You can use a local anesthetic (Chapter 9). Usually there is not much
bleeding. If gums are loose, join them with a suture (see pages 161 to
124 Where There Is No Dentist 2010
7. Keep the mouth clean.
• Use a soft brush gently to clean the remaining teeth. Do this 3 times a
day for the child.
Wipe the gums with a weak solution of hydrogen peroxide. Use cotton
gauze that is damp with the solution. Do this every 2 hours for 5 days.
Then after 5 days, start rinsing with warm salt water 3 cups a day.
8. Get advice on whether surgery is needed.
Unfortunately, the child will probably need surgery, to release the
scar. Without this surgery, the child will not be able to open his mouth
Send the child for medical help when the
infection is finished and the wound starts
to close.
You may also need a dentist’s help at this
time. The child’s jaws may need to be
wired. The wires are put on the healthy
teeth in a way that holds the mouth open
while the tight scar is forming. When the
wires are removed, the child will be able to
open and close his mouth to chew food.
Noma need not occur. We can prevent it. Always give special attention
to the mouth of a sick child, to be sure to keep his teeth clean.
Whenever someone is nursing or caring for a sick child, that person
should clean the child’s teeth as a normal activity. This is especially
true for a child who is weak, undernourished, and with little body water
Such a child should always:
have his teeth carefully cleaned
each day with a soft brush.
rinse his mouth with a warm salt
water solution (page 7), 2 times
a day.
eat fresh fruits and vegetables,
especially the kind that have
Vitamin C: guavas, oranges,
pineapples, papayas, tomatoes,
peas, and dark green leaves.
Where There Is No Dentist 2010 125
A tumor is a lump that grows under the skin or inside the bone. It grows
slowly but steadily, usually without any pain.
If the swelling does not get better after 5 days of antibiotics and heat
treatment (page 94), it may be a tumor.
Do not waste any more medicine or any more time. A tumor may be
cancer. Send for medical help. Surgery is needed to remove a tumor.
Any sore or bump that does not
heal within 2 weeks may be cancer.
The lips and tongue are the 2
places in the mouth where cancer
starts most often. Also check
the floor of the mouth under the
tongue, the soft part of the roof of
the mouth, and the gums.
Cancer is deadly.
Cancer can spread quickly to the inside of the person’s body where you
cannot see it. This can lead to the person’s death. But cancer can be treated
if you notice it early.
Whenever you treat a sore and it does not get better, send the person for
medical help immediately. A doctor can cut out a piece from the sore, look at
it under a microscope, and decide if it is cancer. If it is cancer, you will need
specialized treatment.
Where There Is No Dentist 2010
Scaling Teeth
Scaling means ‘scraping away.’ You can scale old food, tartar, or even a fish
bone caught under the gum. You usually scale teeth to remove tartar.
We get tartar when the coating
of germs on our teeth (page 50)
becomes hard.
Gums that press against tartar
become sore and infected.
Clean teeth keep our gums healthy. Scaling a person’s teeth gives infected
gums a chance to become normal again.
However, gums remain healthy only when we keep the teeth beside
them clean. If we are not careful about cleaning our teeth after they are
scaled, tartar will soon return. Instead of being healthy, the gums will
become sore and infected again.
Scale a person’s teeth, but also teach how to keep teeth clean.
You must remove something caught under the gums (page 133) before it
causes more pain and swelling. Remove a piece of fish bone or piece of
mango string now.
If the person has a mild gum problem (gums that bleed), wait a week or so
before scaling. If the person uses this time to clean his teeth better and to
rinse with warm salt water (page 7), the gums will improve. The person’s
teeth will be easier for you to scale, and he will learn that he can do much by
himself to care for the gums.
Use a mirror to show the person gum infection inside his own mouth.
Later he can see the improvement he has made. He can learn about how to
keep gums healthy as he follows his own progress.
Scale a person’s teeth only when he really wants to try to keep them
clean. If he does not want to clean his teeth, the tartar will soon return. Do not
waste your time scaling the teeth of a person who does not want to learn.
128 Where There Is No Dentist 2010
We scale teeth with special instruments called scalers. There are many
different kinds of scalers for different teeth, to make scaling easier. It can be
a problem to know which ones to buy.
Scalers are expensive instruments. For that reason, it is better to order only
a few instruments that you can use to clean most teeth.
You need only 2 double-ended scalers, or 4 single-ended scalers.
For instance:
1. One with two pointed tips—to remove tartar from the part of the
tooth near the gum.
Its proper name is
lvory C -1 scaler.
2. Another with two blunt, rounded ends—to remove tartar from the
part of the tooth under the gum.
Its proper name is
G-11 and 12 curette.
The ends of the scaler are the important parts. One end is bent to the left
and the other end is bent to the right, so you can reach more easily around
all sides of the tooth.
The blade at each end of the scaler is sharp. You must keep the blade sharp.
A sharp blade can break more of the tartar away than a blunt blade.
You also need these:
Sharpening stone
(Arkansas stone)
(cotton pliers)
NOTE:When you order an instrument, use both its common and proper
name. Then you have a better chance of receiving the instrument you
want. You can also make some of your own instruments. See pages
Keep everything in a Scaling Kit.
Where There Is No Dentist 2010 129
Tartar starts to form inside the gum pocket. There it builds up, because the
gums protect it. So you often must feel rather than see the tartar when you
scale a tooth.
You must remove all of the tartar so the gums can heal. New tartar grows
faster when there is old tartar Ieft behind for it to build upon.
Lay out what you need ahead of time:
your instruments: scalers, mirror, probe, tweezers
sharpening stone
cotton gauze
Your light must be good enough to see the tooth and gums around it clearly.
Scaling teeth requires time and practice. Make yourself and the person
comfortable. You can sit next to a special chair that lets the person lean back
(see page 75).
The steps in scaling teeth are these (pages 135–139):
1.Explain to the person what you are going to do.
2.Feel under the gum for rough spots (tartar).
3.Place the scaler under the tartar.
4.Pull the scaler against the side of the tooth.
5.Check to be sure the tooth is smooth.
6.Explain what you have done and what the person should now do.
1. Explain what you are going to do. Tell the person what to expect.
There will be some bleeding and possibly some pain. However, you can
stop and rest, or inject local anesthetic, if it is painful. Remember: first
wash your hands and your instruments! (See pages 86–89.)
2. Feel under the gum for tartar. Tartar feels like a rough spot on the root
of the tooth. Since tartar can form anywhere inside the gum pocket, feel
for it on all sides of the tooth.
You can check for tartar two ways:
a. Use your probe. Slide the point up and
down along the root surface under the
gum. Feel for places that are rough.
Teeth without tartar are smooth.
b. Use cotton gauze. Twist a corner and
press it between the teeth. The gauze
lowers the gum and soaks up the spit.
You can then see more tartar.
130 Where There Is No Dentist 2010
3. Place the scaler under the tartar. You must learn two important things:
how to hold the scaler and how to slide the scaler into the gum pocket.
Hold the scaler almost as you
would hold a pen. You can
then pull it against the tartar
with both power and control.
Control is very important. The ends
of the scalers are sharp. If you are not
careful, the blades can cut the gums.
Be gentle and do not hurry. Always hold
the tip of the scaler on the tooth to avoid
poking the gums.
Rest your 3rd finger against a tooth. This
will steady your hand and let you slide the
sharp scaler under the gum with care.
Where There Is No Dentist 2010 131
The edge of the gum, near the tooth, folds under to form a pocket. This gum
pocket goes completely around each tooth. The gum pocket can be shallow
or deep. A deep pocket means there has been an infection for a while.
Tartar starts forming deep
inside the gum pocket. If
you remove tartar that you
can see above the gum,
it is helpful, but not good
enough. You must remove
the rest of the tartar, or the
infection will continue. If
part of the tartar stays on
the tooth, the infection
will continue.
First, use the
pointed-tip scaler
to remove the tartar
that you can see.
Then, go back with your
rounded-tip scaler and
scrape away the
remaining tartar.
Be careful when you place the rounded end of
the scaler inside the gum pocket.
a) Put the sharp face of the blade
against the tooth. Slide it along the
tooth down into the gum pocket.
b)You can feel the edge as it goes over
the rough tartar. Stop when you feel
the bottom of the gum pocket.
132 Where There Is No Dentist 2010
4. Hold the end tight against the side of the tooth and pull the scaler.
Try to break free as much tartar as possible at once. It is a bad idea to
remove the tartar a bit at a time, because the remaining tartar becomes
smooth and harder to scrape away.
1. Tighten your fingers
on the scaler.
2. Pull the scaler with a
firm short stroke.
3. Wipe the end of the
scaler with cotton gauze.
4. Press against the gums
to stop the bleeding.
5. Check to be sure the tooth is smooth.
With your probe, feel under the gum
for any place that is still rough.
When all the sides of the tooth feel
smooth, move to the next tooth.
Do not hurry. It is more important to take your time and carefully
remove all the tartar. If the person has a lot of tartar, scale only half
the mouth now. Do the other half on another day, as soon as the
person can return.
Finally, make the tooth look clean. Use the sharp edge of either scaler.
Scrape away the dark material on the front and back sides of the tooth.
The tooth itself has not turned dark. It is just a
stain. People most often get these stains when
they eat meat, drink tea or smoke tobacco.
You can scrape away this old food and uncover
the white tooth. But remember: the teeth will
turn dark again if not cleaned carefully every day.
Where There Is No Dentist 2010 133
6. Talk to the person about what you have done and what to
expect. The gums will be sore for the next few days. That is normal.
Then explain to the person what to do to make the gums strong and
tough again.
Clean your teeth better with a soft brush. Reach with the brush
into the gum pocket, and behind your front teeth. That is where
tartar collects most often (page 69).
Clean between your teeth. Use your brush, the stem from a palm
leaf, or a piece of strong, thin thread (page 71).
Rinse your mouth with warm salt water. Start with 4 cups a
day, to make the gums strong. Then use 1 cup a day to keep them
strong (page 7).
Eat local foods that give strength to gums. Fresh fruits like
guava and oranges, and fresh vegetables with dark green leaves
are good for the gums.
If the gum between two teeth is red and swollen, something may be caught
inside the gum pocket. Ask what the person has been eating. The object
may be a fish bone, mango string, or a sharp piece of tartar.
First try to feel the object with your probe. Then remove it using a scaler or a
piece of strong thread.
Use the rounded-tip scaler in the same
way as you would to remove tartar.
Feel the object, go under it gently,
and then lift it out.
Tie a knot in a piece of thread. Then slide
the thread between 2 teeth (page 71).
However, do not move the thread up and
down. Instead, pull it and the knot out
the side. The knot can pull the object out
with it.*
*If the gum has grown into a kind of tumor (epulis), an experienced dental worker should cut it away.
134 Where There Is No Dentist 2010
A sharp scaler bites into tartar better than a blunt one. Sharpen the edge
whenever you feel it sliding over the tartar.
From time to time, feel the cutting edge to be
sure it is sharp.
Scrape it against your fingernail. If the cutting
edge is not able to cut your nail, it will not
be sharp enough to break the tartar free.
Sharpen the cutting edge of the scaler on a fine-grain stone (Arkansas
stone). Put a few drops of oil or water on the stone first, so the scaler
can slide against it more easily.
Rest your 2nd or 3rd finger against the side
of the stone. This is for control.
Rub the cutting edge against the stone.
Move it back and forth.
Turn the round scaler as you sharpen it.
This helps to keep the scaler’s round shape.
Scalers must be more than clean—they must be sterile. This is because
there may be spots of blood on them. Hepatitis (Where There Is No Doctor,
page 172) and other diseases can pass from the blood of one person to the
blood of another person. To learn how to sterilize, see pages 87 and 88.
Your mirror, probe, and canon tweezers do not need sterilization. A
disinfectant (see page 89) will clean them. Dry all the instruments with a
towel. Then wrap them inside a clean cloth and put them in your scaling kit.
They are now ready for use whenever you need them again.
Remind each person: scaling is
not a cure. Rather it is a way of
giving her a new start. Only she
can give herself the care she needs
to keep her gums healthy. You
have removed the hard material
from her teeth, and if she brushes
carefully, the tartar will not return!
Injecting Inside
the Mouth
It is possible to treat a tooth without pain. You do this with an injection of
local anesthetic. You must inject near the nerve, so to give good injections,
you must know where the nerves are.
Injecting is a skill that develops with experience. The best way to learn is not
from a book, but from a person who has experience giving injections.
Watch an experienced dental worker give injections. That person
can then watch you and show you how to inject carefully and safely.
Local anesthetic is an injectable medicine. When it touches a nerve, the
tooth joined to that nerve feels numb or dead for about an hour. This usually
gives you enough time to take out a strong tooth or to put a cement filling
into a deep cavity.
There are two kinds of syringes for injecting local anesthetic inside the
mouth. One is made of metal and the other is made of glass. The metal
syringe uses local anesthetic in a cartridge. The glass syringe uses local
anesthetic from a bottle.
This is a dental syringe. It uses special
needles, and the local anesthetic is sealed
inside a glass cartridge. After injecting,
safely dispose of the needle and the
cartridge. See pages 199 to 200.
This kind of syringe is for injections of
medicine like penicillin, but you can use
it in the mouth. Sterilize the syringe and
needles (pages 88 and 138) before and
after each use. When sterile, the needles
are ready for another person.
Before you inject, be sure
the local anesthetic is able
to come out of the needle.
Use a new needle and a new cartridge of local
anesthetic for each person.
Be careful! Do not touch the needle.
136 Where There Is No Dentist 2010
It is safer to use the metal dental syringe but it depends on the local
anesthetic you can get. Order needles to fit your particular kind of syringe.
plastic or GLASS SYRINGE
1. syringe: aspirating dental cartridge
syringe, 1.8 ml (1ml=1cc)
2. needles: disposable needles for dental
cartridge syringe (27 gauge, long)
1. syringe: standard syringe that
holds around 3 ml (1ml=1 cc)
2. needles: 24 gauge, long (40 mm
x.56 mm or similar)
3. local anesthetic: 20 ml bottle of
lidocaine (lignocaine) 2%
one box contains 100 needles, each
one inside a plastic cover.
3. local anesthetic: local anesthetic
cartridges for a dental syringe
one sealed tin contains 50 cartridges
of lidocaine (lignocaine) 2%.
or, if not available: order
2 ml ampules of procaine
hydrochloride 1%.
NOTE: Lidocaine will keep the teeth numb longer if there is epinephrine in
it. But this is more expensive, and you should not use it on persons
with heart problems (see the bottom of the next page).
You can deaden a nerve with an
injection of local anesthetic:
1. near the small nerve branch
going inside the root of a tooth.
2. near the main nerve trunk before
it divides into small branches.
Smaller nerves ‘branch’ off from the main nerve—much like branches of a
tree leave its main trunk.
One small nerve then goes to each root of every tooth.
Inject an upper tooth near its roots.
Bone in the upper jaw is soft and spongy.
Local anesthetic placed near the root of
an upper tooth can go inside the bone
and reach its nerve easily.
The same injection also makes the gums
around that side of the tooth numb.
Where There Is No Dentist 2010 137
It is more difficult to inject the lower teeth.
The lower jaw bone is thicker. When you inject near the roots of a lower
tooth, the anesthetic is not able to reach its nerve as easily.
Note: You can inject lower front teeth
in young children, or very loose lower
front teeth in adults, near their roots.
To make a lower tooth
completely numb, you must
block the main nerve (a) before
it goes inside the jaw bone.
If you are treating a back
tooth, you must give a
second injection for nerve (b).
See page 140.
nerve (a)
jawbone here
nerve (a)
nerve (b)
goes to 3
back teeth
These 2 injections also make the
gums around the teeth numb.
Inject local anesthetic whenever the treatment you give may hurt the
person. If, after you inject, the person says the tooth still hurts, be kind. Stop
and inject again.
Inject local anesthetic slowly and carefully.
You can then treat a bad tooth and not hurt the person.
For a good, safe injection, remember these 5
1. Do not inject local anesthetic
into an area that is swollen.
This can spread the infection.
Also, pus inside the swelling
stops the local anesthetic from
working properly.
Instead, treat the swelling first (page 94) and take out the tooth later.
2. If the person has a heart problem, do not inject more than
2 times in one visit. Also, it is best not to use an anesthetic with
epinephrine on persons with heart problems. Use lidocaine only, or
mepivacaine 3% only.
*Local anesthetics are the only injections given in the mouth. To learn about injecting antibiotics,
see page 204.
138 Where There Is No Dentist 2010
3. Before you push the needle under the skin, be sure its pointed end is
facing in the correct direction.
The local
anesthetic must
come out against
the bone, where
the nerve is.
4. Before you inject the local anesthetic, wait a moment to see if any
blood enters the syringe. (Note: only an aspirating syringe will do this.)
Pull back on the plunger. If
blood comes inside, it means
you have poked a blood vessel.
Pull the needle part way out
and gently move it over to a
different place.
If you inject local anesthetic into the blood vessel, there will be more
swelling afterward, and the person may faint. If the person faints:
• Lie him on his back.
Loosen his shirt collar.
Lift his legs so they are higher than his head.
5. Be sure your syringe and needles are clean and sterile (see pages 86
to 89). Do not pass an infection from one person to another by using dirty
Boil the syringe and needle in water (page 88)
for at least 30 minutes in a covered pot. It is
also a good practice to boil your metal syringe.
Use a new cartridge for each person who
needs an injection. Do not use local anesthetic
from a cartridge that you have used on another person.
Use each disposable needle only 1 time and then throw it away in
a box like the one on pages 199 to 200. If you must reuse a needle,
replace the cap very carefully and put the needle in a safe place (such
as a pan of bleach solution) until you are ready to clean and sterilize it
(see pages 87–88).
Where There Is No Dentist 2010 139
Injecting the Upper Teeth
Inject local anesthetic near the root of
the tooth you want to treat.
Front teeth have one root. Back teeth
have more than one.
For a tooth to become completely numb,
the local anesthetic must touch the small
nerve going to each one of its roots.
1. First decide where to inject.
Lift the lip or cheek. See the
line that forms when it joins
the gum.
The needle enters at the
line where the lip or cheek
meets the gum.
2. Push the needle in, aiming
at the root of the tooth. Stop
when the needle hits bone.
Inject about 1 ml of local
anesthetic (½ of a cartridge).
Pull the needle part way out
and move it over to the next
root. Inject again.
If the tooth is to be taken out, leave .25 ml for the next step.
3.If you are taking out a tooth, also inject the gums on the inside.
Ask the person to open wide. Inject the remaining
anesthetic (.25 ml) directly behind the back tooth
that must come out.
One injection can numb
the gum behind the
6 front teeth. Inject into
the lump of gum behind
the middle front teeth.
(Note: This injection hurts! It may help to use
‘pressure anesthesia.’ See page 141.)
4. Wait 5 minutes for the tooth to become numb.
140 Where There Is No Dentist 2010
Injecting the Lower Teeth
When you block the nerve, it affects all of the teeth as well as gums on that
side. However, it takes practice to do this successfully. Ask an experienced
dental worker to help you learn how to give this injection properly.
Stand in such a way that you can see clearly where you need to inject. Ask
the person to open wide.
1. First feel for the place to be injected.
Put your thumb beside the last molar tooth. (Wash your hands first!
See page 86.) Feel the jawbone as it turns up towards the head. Rest
your thumb in the depression there.
2. Press against the skin with the end of your thumb.
The skin forms a ‘v’ shape. Your needle must go into the ‘v’.
Hold the syringe on top of tooth
number 4 and aim the needle at the ‘v’.
Push the needle in until it hits the
jawbone, (about ¾ of the length of a
long needle). Pull back on the plunger
of the aspirating syringe to check for
blood (page 138).
Inject 1.5 ml of local anesthetic (¾ of a cartridge).
Try to feel your way: If you hit bone too early, pull the needle part
way out and move it over so that it points more toward the back of the
mouth. Try again.
If you do not hit bone, the needle is too far back. Pull it part way out,
and point it more toward the front. Push it in again.
Where There Is No Dentist 2010 141
3. Give a second injection BESIDE the back teeth.
If you are going to fill or remove a
back tooth, inject beside that tooth,
where the cheek joins the gum.
Inject .5 ml of local anesthetic
(¼ of a cartridge).
This injection is not needed for front
teeth. It is enough to block the main nerve.
4. Wait 5 minutes for the tooth to become numb.
Take time with children
1. Put some topical anesthetic on the
gum before you inject. But be sure
the gums are dry in that place. If you
wipe the gum with cotton, the topical
anesthetic will stay on longer. Give
the anesthetic time to work: wait a
minute before injecting.
If you do not have topical
anesthetic, try using pressure.
You can use ‘pressure anesthetia’
whenever you have to give an
injection in a sensitive place, like the
roof of the mouth.
Wind some cotton around the end
of a match-stick. Press firmly for
a minute behind the bad, tooth. Then inject quickly into the
depression that formed where you pressed.
2. Be sure the anesthetic is warm when you inject it. Hold the
cartridge or bottle in your hands for a few minutes before you use it.
3. Use a new, sharp needle.
4. Have someone pass you the syringe out of sight of the child. Then
the child will not have to look at it and be frightened.
5. Be ready to stop the child from grabbing the syringe.
6. Inject the anesthetic slowly. Do not hurry. A too-quick injection can
cause sudden pressure, which hurts and frightens the child.
142 Where There Is No Dentist 2010
Before you begin treatment, test the tooth and gums to be sure that they
are numb. Wait 5 minutes for the anesthetic to start working. Ask the person
how his lips feel—they should feel ‘heavy’ or numb. Then test the area.
Poke the gums between the teeth
with a clean probe.
Watch the person’s eyes—you will
see if you are hurting. If the person
still feels pain, stop. Think about your
injection technique, and inject again.
After you finish treatment, always talk to the person about what you have
done. Tell the person what to expect, and how to be careful with the numb
area of the mouth:
The area will feel normal again in about 1 hour.
Do not bite or scratch the area while there is no feeling.
Do not drink anything hot. It can burn the skin inside the mouth.
With a child, always place a ball of cotton between the teeth on the side
where you injected. The child should leave it there for 2 hours, until the area
feels normal again. Explain this to the mother, and give her a bit of extra
cotton to take home. It is much better for the child to chew cotton instead of
the numb lip or cheek!
Try not to hurt anyone. You can treat a bad tooth
easier, faster, and without pain if you inject local
anesthetic slowly and carefully into the right place.
Cement Fillings
When someone’s tooth hurts, you do not always need to take it out. There
may be a way to treat it and keep it. Always ask yourself whether a bad
tooth really needs to come out.
This chapter is about filling cavities.
Cavities are the holes that tooth
decay makes in the teeth.
From this chapter, you can learn:
When to fill the cavity, or when
to take out the tooth.
How to place a temporary filling.
Do not fill a cavity if you think there is an abscess
in the tooth. Look for these signs of an abscess:
The face is swollen.
There is a gum bubble (page 74)
near the root of the tooth.
The tooth hurts constantly, even
when the person tries to sleep.
The tooth hurts sharply when you tap it.
An abscess occurs when germs from tooth decay start an infection on the
inside of the tooth. If you cover up an abscess with filling material, it will
make the problem worse. Pressure builds up inside the filled tooth, causing
even more pain and swelling.
If a tooth has an abscess, take it out (see the next chapter), unless you can
give special nerve treatment (root canal treatment).
144 Where There Is No Dentist 2010
You can fill a cavity if the tooth does not have an abscess. There is
probably not yet an abscess if:
there is no swelling of the face or gums
near the bad tooth.
the tooth hurts only once in a while —
for example, if it hurts only after food or
drink, or when breathing cold air.
the tooth feels the same as the others
when you tap against it.
These signs mean that the decay is deep
enough for the nerve to feel temperature
changes, but not near enough to the nerve to
be infected. So there is not an abscess. You can save the tooth by filling
the cavity as soon as possible.
What a Filling Can Do
A filling can help a person in three ways:
It stops food, air, and water from entering the cavity. This will stop
much discomfort and pain.
It stops the decay from growing deeper. This can prevent a tooth
It can save the tooth, so the person can use it for many more years.
A permanent filling is made to last for many years. To place one requires
special equipment and skills. An experienced dental worker can shape the
cavity with a dental drill so it can hold the filling material better (see pages
151–152). Or, a dental worker trained in Atraumatic Restorative Treatment
(ART) can fill the cavity with a sticky material called glass-ionomer.
A cement filling is a temporary filling. It is meant to last only for a few
months. It helps the person feel more comfortable until it is possible to get a
permanent filling.
Replace a temporary filling with
a permanent filling as soon as possible.
This chapter shows how to place cement fillings only, for most readers
do not have the expensive equipment needed to make permanent fillings.
But remember that many people can benefit from the extra time that a
temporary filling gives them before they get a permanent filling.
A cement filling is often the first step to saving a tooth.
Where There Is No Dentist 2010 145
In many places, government medical stores can provide most of the
instruments as well as cement filling material. If this is not possible, a dentist
may be able to help you to order what you need.
Most dental instruments look alike, but the small end of each instrument is
shaped to do a special task. Try to get instruments similar to these and keep
them in a kit.
(cotton pliers)
(spoon excavator)
filling tool
(filling instrument)
mixing tool
(cement spatula)
Some instruments have more than one name. The second one, in ( ), is the
proper name. Use the proper name when you order.
Cement Filling Material
Many companies make temporary filling material. The names on the
packages are different. This makes it hard to know which one to order.
However, the basic material of each product is the same—zinc oxide and
oil of cloves (eugenol). To save money, order these two main ingredients in
bulk, instead of an expensive kind of cement filling material.
Oil of cloves is a liquid.
Zinc oxide is a powder.
You may be able to buy a special kind of zinc oxide powder called I.R.M.
(Intermediate Restorative Material). Fillings with I.R.M. are stronger and
harder, so they last longer. But it is more expensive than zinc oxide.
146 Where There Is No Dentist 2010
Lay out on a clean cloth:
your syringe, needle,
and local anesthetic
(in case a tooth hurts)
oil of cloves
(eugenol) and
zinc oxide
Your instruments:
mirror, probe,
tweezers, spoon,
filling tool,
mixing tool
lots of cotton:
cotton rolls,
gauze, or
cotton wool
smooth glass to
mix cement
To place a cement filling, follow these 6 steps (pages 146–150):
1.Keep the cavity dry.
2.Lift out some, but not all, of the soft decay. (If the tooth hurts,
inject local anesthetic.)
3.Mix the cement.
4.Press the cement into the cavity.
5.Remove the extra cement from around the cavity and the tooth.
6.Explain what you are doing to the person.
1.Keep the cavity dry. The cavity and the area around it must be dry so
you can see what you are doing. Just as important, cement stays longer
inside a dry cavity.
Place cotton between the cheek and
gums to keep the area dry. Put some
cotton under the tongue when you
work on a lower tooth.
Use whatever kind of cotton you
have: gauze, wool, or even rolls.
Change the cotton whenever it
becomes wet.
Keep the cavity dry while you work.
Wipe the inside of it every now and
then with a bit of cotton.
Then leave a piece of cotton inside
the cavity while you mix the cement.
Where There Is No Dentist 2010 147
2. Lift out some of the decay. You do not need to remove all of the decay
on the bottom of the cavity. You can leave some, as long as you cover
it with cement. If you try to dig out all of the decay, you might touch the
nerve. Try to cover the decay so it stops growing.
However, you must remove all of the decay from the edge of the
cavity. Otherwise, germs and food can go between the cement and the
cavity and keep the decay growing inside.
Scrape clean the walls and the edge of the cavity. If you find that
the edge is thin and weak, break it deliberately with the end of your
instrument. That makes for stronger sides to hold onto the cement.
Use the spoon tool and lift out soft decay from inside the cavity. Do not
go too deep. Make the cavity just deep enough to give thickness and
strength to the cement. If the tooth hurts when you do this, stop and
inject some local anesthetic. Use cotton gauze to collect the bits of
decay so that the person does not swallow them.
Use your mirror and look closely around the edges of the cavity for decay
that you may have missed. Put some cotton inside the cavity and leave it
there while you mix the cement.
3. Mix the cement on a piece of smooth glass. Place separately onto the
glass a pile of zinc oxide powder and a few drops of eugenol liquid.
Pull a small amount of the powder to the liquid with the mixing tool
and mix them together. Add more powder in this way, until the cement
mixture becomes thick.
Suggestion: Practice with the cement ahead of time.
You can then find out the time it takes to become hard.
148 Where There Is No Dentist 2010
Cement is much easier to use when it is
thick and not too sticky. Roll a bit between
your fingers. If the cement sticks, it is not yet
ready. Add more powder and then test again.
Now take the cotton out of the cavity. Check to be sure the
cavity is dry. If the cotton around the tooth is wet, change it.
4. Press some cement into the cavity. Put a small ball of cement on the
end of your filling tool. Carry it to the cavity. Spread it over the floor of the
cavity and into the corners.
Then add another ball of cement, pressing it against the other cement
and against the sides of the cavity.
REMEMBER:Decay stops growing only when the
cement covers it completely and tightly.
Keep adding cement until the cavity is over-filled. Smooth the extra
cement against the edge of the cavity.
If a cavity goes down between two teeth, one other step is necessary.
You need to take care that the cement does not squeeze and hurt the
Before you spread
the cement, place
something thin
between the teeth.
You can use the soft stem from
a palm leaf, a toothpick, or a
tooth from a comb. Be sure it
has a rounded end to prevent
damage to the gums.
Where There Is No Dentist 2010 149
5. Remove the extra cement before it gets too hard. Press the flat side
of the filling tool against the cement and smooth it towards the edge of
the cavity.
As you smooth the cement, shape it to look like the top of a normal tooth.
This way, the tooth above or below it can fit
against the filling without breaking it.
After you take out the stem or toothpick (p.148),
smooth the cement. Gums stay healthier when
the cement beside them is smooth.
Cement that sticks out and is not smooth can
hurt the gums. It can also later break off. When
that happens, spit and germs are able to go
inside and start the decay growing again.
It is also important to look closely around the tooth for loose pieces
of cement and to remove them before they make the gums sore.
Use the end of your probe. Gently
reach into the gum pocket and lift out
any pieces of cement caught there.
Wipe off your probe with cotton
gauze each time.
Now remove all the cotton and ask the person to gently close the teeth.
The teeth should come together normally and not hit first against the
cement filling. Too much pressure against the cement filling will
crack and break it.
Always check to see if part of the filling is high:
(1) lf the cement is still wet, you can see
the smooth place where the opposite
tooth bit into it. Scrape the cement
away from this place.
(2) If the cement is dry, have the person
bite on a piece of carbon paper. If there
is too much cement, the carbon paper
will darken the cement. Scrape away
that extra cement.
If you have no carbon
paper, darken some
paper with a pencil.
The person must not leave your clinic until the
filled tooth fits properly against the other teeth.
150 Where There Is No Dentist 2010
6. Explain things to the person. Explain how to look after the filling so it
will not break:
Do not eat anything for 1 hour—let the cement get hard and strong.
Try not to use that tooth for biting or chewing. Until there is a
permanent filling, the cement and sides of the cavity are weak. They
cannot take much pressure.
If the tooth hurts more after you place the cement filling, there is
probably an abscess. Take out the tooth. If you cannot take out the tooth
immediately because of swelling, take out the filling to relieve the pressure,
and take out the tooth after you treat the swelling (page 93).
You do not need to boil your cement filling instruments. In fact, boiling can
weaken the small pointed ends.
First scrape the dried cement from the filling and mixing tools. Then,
after you scrub them with soap and water, leave them for 20 minutes in
disinfectant (see page 89). Finally wrap the instruments together in a clean
cloth so they are ready for use when you need them again.
REMEMBER: A cement filling is only a temporary measure.
A good one can last up to 6 months. During this
time, the person must see a dental worker who
has the equipment to put in a permanent filling.
For this, the person may have to travel to the city,
or wait for the dental worker to visit your area.
Where There Is No Dentist 2010 151
This chapter has shown how to place a temporary filling. Remember
that within a few months, the person needs to replace this filling with
a permanent one. This book does not give full instructions for placing
permanent fillings, but if you have been trained to place permanent fillings
with a dental drill or using Atraumatic Restorative Treatment (ART), see
pages 211 and 215-216 for ideas about getting equipment and resources.
Some Simple Dental Drills
We use a dental drill to remove all
decay from a cavity and to change
the shape of the hole in the tooth
so it can firmly hold the permanent
filling material. The most expensive
drills use electricity, but some drills
are powered by people instead of
Village dental workers in the
mountains of western Mexico use
bicycle power to make compressed air,
which runs a high speed drill.
Local young people or family members
volunteer to pump the air while they
wait to have their own teeth fixed.
In India and Guatemala, health
workers use a foot treadle to power
a drill, the same way they operate a
sewing machine. This kind of drill is
slower than a compressed-air drill,
and the grinding produces a lot of
heat, so one must take care not to
let the tooth ge so hot that it kills
the nerves (see page 152). Still, this
is one of the simplest and cheapest
ways to place a permanent filling.
There are many other excellent ideas for simple, low-cost dental drills. Some
are lightweight, so you can carry them to remote areas.*
* Some simple but strong portable equipment has been made for use in remote areas by the
National School of Dental Therapy, 710 15th Ave. E., Prince Albert, Saskatchewan S6V 7A4,
Canada. E-mail: sahenakew@firstnationsuniversity.ca. Website: www.firstnationsuniversity.ca.
152 Where There Is No Dentist 2010
How a Dental Drill Works
Even if you have the equipment, it is essential that you learn how to make
permanent fillings from a person who has experience using a dental drill.
The tip of the drill (drill bit) is sharp.
The ones powered by compressed
air move at high speed, which
makes it easier to dig out all of the
decay and shape the hole. Some
drills spray water on the tooth to
keep it cool. Cooling is especially
important with a slower treadlepowered drill. An assistant can
spray water on the tooth if the drill
does not have a sprayer.
As the drill bit moves slowly back and
forth, it opens the cavity further. This
makes it easier to see all of the decay.
The decay is later removed with a spoon
instrument (page145).
The drill bit also changes the shape of the
cavity. The hole in the tooth is shaped
so that it will keep the permanent filling
material in place.
When all of the decay is removed,
the dental worker will place a paste
containing calcium hydroxide into the
deepest part of the cavity. This paste helps to separate the final filling from
the nerve, so the filling will not cause pain.
The filling material, which
is made of metal or plastic,
must be very strong. It
must not break apart when
the person chews food or
when saliva washes over it.
Unfortunately, the best
kinds of filling material
often require special
instruments to prepare and
place them in the cavity.
Taking Out a Tooth
Not every painful tooth needs to come out. You must decide how serious
the problem is, and then decide if you can treat and save the tooth. Some
problems—such as root canal treatment for a tooth with an abscess, or
wiring for a loose tooth—require the skills of an experienced dental worker.
Even if you cannot treat every person, a more experienced worker can help
you by taking care of the more difficult tooth problems.
Remove a tooth only when it is necessary. Here are three reasons to take
out a tooth:
It hurts all the time or hurts enough to wake the person at night.
It is loose and hurts when you move it.
It has a broken root (p. 96) or a broken top with an exposed nerve.
It is important to learn from another person, not just from a book. Find an
experienced dental worker who can show you how to take out a tooth
and who can then watch you as you try it yourself.
Before You Begin: Ask Questions!
Before you take out a tooth, you need to learn about the person’s health.
Tell the person what to expect, and then ask:
Do you bleed a lot when your skin is cut? (If so, you may bleed a
lot when your tooth comes out.)
Do you have swollen feet and difficulty breathing? (You may have
heart disease.)
Do you have any allergies? (You may be allergic to some
medicines we give when we take out a tooth.)
Are you a diabetic? (If you have diabetes, your wound will take a
long time to heal.)
Are you pregnant? (Some problems can be treated during
pregnancy, but sometimes it is better to wait. See pages 15–16,
77, 102, and 154.)
If the person answers “yes” to any of these questions, you must take
special precautions. See the next page.
154 Where There Is No Dentist 2010
A person who bleeds a lot must know how to prevent bleeding afterward.
Explain very carefully the steps given on page 161. You may also want to
place a suture (page 161) to hold the gums tightly together.
Persons with heart disease often take aspirin or medicines called
anticoagulants that do not allow the blood to clot normally. Ask what
medicine the person takes. Heparin, Coumadin, and Warfarin are examples
of anticoagulants. Another heart medicine, digitalis, is not an anticoagulant. If
the medicine is not an anticoagulant, you can take out the tooth. But do not
use more than 2 cartridges of local anesthetic. The epinephrine inside the
anesthetic can harm a weak heart. (See page 137, #2).
A person with allergies may be allergic to aspirin, penicillin, erythromycin, or
other medicines you often use. Find out which medicine has caused problems
and give a different medicine, one that will not cause a reaction.
A diabetic’s wound may become infected. Watch carefully the place where
you took out the tooth and give antibiotics (page 94) if an infection begins.
During the last month of pregnancy, a woman may be too uncomfortable to
have a tooth taken out. Control the infection with a 5-day course of penicillin
(page 94), and take out the tooth after the baby is born. It is also better to
wait if the woman has high blood pressure, because she may bleed too much
when you take out the tooth. For more information about treating pregnant
women, see page 77, and the story on pages 15 to 16.
Be Patient, Careful, and Considerate
Inject local anesthetic slowly in the right place, so the tooth becomes
numb and you do not hurt the person when you remove it. If the person
says the tooth still hurts, it is probably true! Inject again.
Use the correct instrument in the correct way. If you are careful you
can avoid breaking the tooth. When you take out a baby tooth, be extra
careful not to hurt the new tooth growing under it.
Explain everything to the person. Tell the person if something is going
to hurt, even a little. When you take out the tooth, you can explain, for
example, that there will be a feeling of pressure. Press on the person’s
arm to demonstrate what it will be like. When you finish taking out the
tooth, explain what you have done and what the person can do at home
to help the mouth heal.
Buying instruments can be confusing, because there are so many. Only a few
of them are really necessary. You can take out most teeth with the 4 basic
instruments on page 155.
Where There Is No Dentist 2010 155
When you order, use the proper name. Many companies use numbers
to describe the instruments, but a different company may use a different
number. If you use the proper name along with the number given here, most
companies will understand what you want. (See page 207.)
The Four Basic Instruments
You can take out most teeth with these 4 instruments:
A spoon or probe…
… an elevator…
… and two forceps
upper universal forcep
lower universal forcep
Use this to
separate the gum
from the tooth.
An elevator will
loosen a tooth, or lift
out a broken root.
Use forceps to pull out the
tooth. There is one for upper
teeth and one for lower teeth.
Other forceps can be useful, especially for taking out a strong back tooth.
They have pointed beaks that are made to fit between the roots of a back
molar. As a result, you can hold onto the larger tooth better.
lower molar
‘hawk’s bill’
156 Where There Is No Dentist 2010
Curved elevators are good for taking out broken roots. You can force their
pointed ends more easily between the root and the bone that is holding it.
Cryers elevators
Unfortunately, forceps and elevators are expensive. If you want to order
more than the 4 basic instruments (page 155), remember the cost.
Work wherever it is light and bright. You must be able to see what needs to
be done. Sunlight or light from a lamp is usually enough. Use a dental mirror
(page 145) to direct more light into the mouth.
Use a chair that has a back high enough to support the person’s head.
Think about how you can stand and work the most easily.
To take out a lower tooth, you need
to push down and then pull up.
To take out an upper tooth, you need
to push up and then pull down.
So the person should be
sitting down low.
So the person should be
sitting up high.
If you stand on a box, he will be lower.
If he sits on cushions, he will be higher.
Where There Is No Dentist 2010 157
Once you are certain which tooth must come out, decide which instruments
you will need. Lay them out ahead of time on a clean cloth:
a syringe,
needle, and
local anesthetic
an elevator
cotton gauze
spoon instrument
Before you touch your instruments, be sure your hands are clean. Wash with
soap and water, and put on clean plastic or rubber gloves. See pages 85 and 86.
Be sure, also, that your instruments are clean. See pages 87 to 90. Prevent
infection—keep clean!
To take out a tooth, follow these
8 steps (pages 157–164):
1.Explain what you are going to do.
2.Inject local anesthetic.
3.Separate the gum from the tooth.
4.Loosen the tooth.
5.Take out the tooth.
6.Stop the bleeding.
7.Explain to the person what to do at
home to look after the wound.
8.Help the person to replace the tooth
with a false tooth.
1. Always begin by talking to the person. Explain why you must take
out a tooth (or teeth) and tell how many teeth you will take out. Begin
working only when the person understands and agrees.
2. Inject some local anesthetic slowly, in the right place. Remember
from Chapter 9 that the injection for a lower tooth is different from the
injection for an upper tooth.
Wait 5 minutes for the anesthetic to work, and then test to be sure the
tooth is numb. Be kind—always test before you start. If the person still
feels pain, give another injection.
158 Where There Is No Dentist 2010
3.Separate the gum from the tooth.
The gum is attached to the tooth inside
the gum pocket. Separate the gum and
tooth before you take out the tooth. If
you do not, the gum may tear when
the tooth comes out. Torn gums bleed
more and take longer to heal.
Use this
Slide the end of the instrument along the
side of the tooth into the gum pocket. At the
deepest part of the pocket, you can feel the
place where the gum attaches to the tooth.
or this
Front Side
Push the instrument between this
attached part and the tooth. Then
separate the tooth from the gum by
moving the instrument back and forth.
Do this on both the cheek side (outside)
and the tongue side (inside) of the
Back Side
The attached gum is strong, but it is also thin. Control your
instrument carefully so that it only cuts through the part that is
attached to the tooth. Do not go any deeper.
4.Loosen the tooth. A loose tooth is less likely to break when you take
it out. Before you take out a strong tooth, always loosen it first with a
straight elevator.
Caution: if you do not use it properly, a straight
elevator can cause more harm than good.
It is important to hold a straight elevator properly.
Place your first finger against the next tooth while you
turn the handle. This will control it.
Remember that the sharp blade can slip and hurt the
gums or tongue.
The blade goes between the bad tooth and
the good one in front of it. Put the
curved face of the blade against
the tooth you are removing.
Slide the blade down the side
of the tooth, as far as possible
under the gum.
Turn the handle so that the
blade moves the top of the
Put pressure on the bone, not the tooth
bad tooth backward.
beside it. Do not loosen the good tooth!
Where There Is No Dentist 2010 159
5. Now, take out the tooth. Push your forceps as far up the tooth as
possible. The beaks of the forceps must hold onto the root under the gum.
Use your other hand to support the bone around the tooth. Your fingers
will feel the bone expanding a little at a
time as the tooth comes free.
With practice, you will be
able to decide how much
movement the tooth can
take without breaking.
To decide which way
to move a tooth,
think about how
many roots it has.
If a tooth has 1 root, you can turn it.
If a tooth has 2 or 3 roots,
you need to tip it back and forth.
Take your time. If you hurry and squeeze your
forceps too tightly, you can break a tooth.
Removing a tooth is like pulling a post out of the
ground. When you move it back and forth a little more
each time, it soon becomes loose enough to come out.
160 Where There Is No Dentist 2010
Front teeth come
straight out
Back teeth usually come
out toward the cheek
When you remove lower molars with the lower molar ‘cow-horn’ forcep,
you use it in a different way:
Fit the points under the gum,
between the tooth’s roots.
Squeeze the handles gently
and move them up and down,
then side to side. This will force
the points of the forcep further
between the roots and lift the
tooth up and out.
Note: some lower molars come out
toward the tongue.
Warning: Do not use the
‘cowhorn’ forcep to take out a baby
molar. Its points can damage the
permanent tooth growing under it.
When the tooth comes out, look carefully at its roots to see if you have
broken any part off and left it behind. Whenever possible, take out
broken roots so that they do not cause infection Iater inside the bone.
Where There Is No Dentist 2010 161
6.Stop the bleeding. Squeeze the sides of the socket (the hole that is left
after you take out the tooth) back into place. Then cover the socket with
cotton gauze and ask the person to bite firmly against it for 30 minutes. A
child should bite firmly on the gauze for 2 hours. See page 142.
Whenever the gums are loose, join them together. To stop the bleeding
and heal the wound, you must hold the gums tightly against the bone
under them.
When you remove 2 or more teeth in a row, it is a good idea to join
the gums with a suture (needle and thread). If you need more than
one suture, place the first one nearest the front of the mouth and
work toward the back.
The needle and thread you use must be sterile.
Boil both for 30 minutes. See page 88.
You will need an instrument to hold the needle firmly (hemostat) and
scissors to cut the thread.
a) Pass the needle through the loose gum—the one you can move
most easily. Then pass it through the more firmly attached gum.
If the looser gum is on the outside,
you will bring the needle toward the
tongue. Protect the tongue with a
tongue blade or your dental mirror.
You must suture both the upper and
the lower gums in this way.
After this you must tie 2 knots and
cut the thread. See the next page.
162 Where There Is No Dentist 2010
b) Pull the thread until about 4 cm of thread
is left loose on the starting side.
Wrap the longer end of thread 2 times
around the beaks of the needle holder.
Then grab the shorter free end of
the thread with the tip of the needle
holder. With the needle in your fingers,
pull the needle holder in the opposite
direction. The thread will slide off the
beaks and form the first knot.
Tighten the knot onto the side of the wound, not on top of it.
c) Tie a second knot, to keep the first one tight.
Wrap the thread once around the beaks
of the needle holder.
Grab the free end with the tip of the
needle holder as you did before. Pull the
2 ends in opposite directions. The second
knot will form over the first knot.
d) C
ut the threads so that about .5 cm is left free. If the ends are too
long, they will bother the person’s tongue. If they are too short, the
knot may come open.
Then cover the area with cotton gauze.
Tell the person to:
bite against the cotton for 1 hour
to stop the bleeding, and
return in 1 week for you to
remove the thread.
There is a special kind of suture material that disappears by itself,
which is good to use because the person does not have to return for
you to remove sutures. Unfortunately, it is expensive. If you cannot
afford it, use sewing thread and remove it 1 week later.
Where There Is No Dentist 2010 163
7.Explain to the person what you have done, and what to do at
home to look after the wound. Remember that her mouth is numb,
so she cannot feel what is happening.
Taking out a tooth is like a small operation. There will be bleeding and
later some pain and swelling. This is normal and should be expected.
Tell the person this. Then give the following advice:
• Bite firmly on cotton gauze for an hour, and again later if blood
comes from the socket.
Always give the person some extra cotton gauze
to carry home, in case bleeding starts again later.
Show her how to use the cotton gauze.
Take aspirin or acetominophen for pain as soon as you need it,
and then every 3 or 4 hours. See page 94.
Keep your head up when you rest. This
reduces bleeding because it is harder for
blood to flow uphill. It also hurts less.
Do not rinse your mouth. In some places
people believe they should immediately
rinse with salt water and spit a lot after a tooth comes out, but
this is harmful! It is important for the blood clot to stay inside the
socket and not wash away.
Do not drink hot Iiquids like tea or coffee, because they
encourage bleeding. However, cool Iiquids are good for you.
Drink a lot of water.
Continue to eat, but be sure the food is soft and easy to chew.
Try to chew food on the side opposite the wound.
Keep your mouth clean. Start on the second day and continue
until the socket is well. To do this, rinse your mouth with warm
salt water (page 7) and keep your teeth clean (pages 69–72),
especially the teeth near the socket.
False Teeth
After a tooth comes out, it is a good idea to
replace it with a false tooth. If you do not,
the other teeth soon starts to shift into the
open space.
This weakens the bone around their roots.
After some years, they too become loose
and sore, and they have to be taken out.
164 Where There Is No Dentist 2010
When you take out a tooth, it is like removing a brick from the center of a
wall. The area around the space becomes weaker and begins to crumble.
To prevent this, a plastic tooth can fit into the space. This tooth is not
for chewing food but to hold the remaining teeth in their normal, healthy
A full set of teeth allows a person to chew the foods needed to stay healthy
and feel good. Moreover, teeth help you look good!
A person
without many
teeth looks old.
With a new set of
plastic ‘false teeth’,
the same person
looks and feels
much younger.
If possible, after you take out a tooth, encourage the person to replace
the tooth with a plastic tooth. Find out where they are made and how
much they cost. Then explain:
how to clean the remaining teeth to prevent them from going bad
(pages 69–72), and
how it is possible to get a replacement plastic tooth.
Where There Is No Dentist 2010 165
Sometimes a problem develops even though you have tried to be careful.
Give help whenever you can. If you are not able to help, refer the person
to a doctor or dentist as soon as possible.
Broken Roots
If you can see the root, try to remove it. If you leave a broken root inside the
bone, it can start an infection.
Removing a broken UPPER root. Use your straight elevator. Slide the
blade along the wall of the socket until it meets the broken root.
1. Force the blade between
the root and the socket.
2. Move the root away
from the socket wall.
3. Move the root further
until it is loose.
4. Grab the loose root and
pull it out.
Removing a broken LOWER root. Use a straight elevator (or a curved
elevator if you have one). If the broken root is from a molar tooth, slide the
blade into the socket beside the broken root.
1. Break away the bone between
the root and the blade.
2. Force the blade between
the root and the socket.
3. Move the root away
from the socket wall.
4. Grab the loose root and
pull it out.
Warning:It is better to leave a small broken root inside the socket.
In a week or so, it will loosen itself and be easier to remove.
166 Where There Is No Dentist 2010
Root Pushed Into the Sinus
An upper root that seems to disappear may have gone into the sinus (page
95). Do not try to find it. Instead, cover the socket with cotton gauze and
send the person to the hospital. A special operation is needed to open the
sinus, find the root, and take it out.
Ask the person not to blow his nose. That forces air through the opening and
prevents it from healing.
Bone Chips and Tags of Flesh
Small pieces of bone that lie loose inside the socket can cause bleeding and
delay healing.
Gently reach into the socket with the end
of an elevator or spoon instrument. Feel for
the piece of bone and carefully lift it out.
Give local anesthetic if needed.
When you are finished, ask the person to bite on cotton gauze until the
bleeding stops.
Small tags of flesh are not serious, but they bother the person. Hold the tag
steady with cotton tweezers and use sterile scissors carefully to cut the bit
of flesh free.
Rinsing with warm water makes gums tough and helps them heal. But do
not rinse for the first 24 hours. See page 163.
If the first cotton gauze (page 161) does not stop the bleeding in the
socket, place more cotton gauze. Wait 5 minutes to see if the bleeding
stops. If this does not work, follow the steps on pages 161–162 for
placing a suture.
Hold a cloth wet with cold water against the face. This helps to prevent
swelling. This is a good thing to do if the tooth was hard to take out, or if it
took a long time.
If there already is swelling, heat against the face will help to reduce
swelling. Hold a cloth wet with hot water against the swollen area, 30
minutes on and 30 minutes off. Be careful not to burn the skin!
A large swelling usually means there is an infection. The person needs
additional treatment. See page 116.
Where There Is No Dentist 2010 167
Painful Socket
The socket area often hurts for a day or so after the tooth has been
removed. Aspirin or acetominophen (page 94) is usually enough to relieve
the pain.
A strong, steady pain that lasts for several days is a sign that the person is
having a problem called dry socket. The treatment for this special kind of
problem is given on page 117.
Dislocated Jaw
When you press against a person’s jaw while taking out a tooth you can
sometimes dislocate it. The jaw has been pushed out of position and it is not
able to go back again.
We describe the care for a dislocated jaw on page 113.
Most important: Be sure to tell each person you treat, “If your
problem gets worse, you can come back to see me immediately!”
If your instruments are dirty, they can pass on germs that cause tetanus
(page 118) or hepatitis (see page 172 in Where There is No Doctor).
Germs on dirty instruments can also go into the socket and start an
Dental instruments must be not only clean, but also sterile. This means they
need to be both scrubbed and then boiled before they can be used again.
See pages 86 to 89.
Use a brush and clean each
instrument with soap and water.
Be careful to scrub away all bits
of old dried blood.
Then kill the germs by
placing the instruments into
a covered pot of boiling
water for 30 minutes.
Where There Is No Dentist 2010
HIV and Care
of the Teeth and Gums
Many things in the world have changed since Where There Is No Dentist
was first published in 1983. One of the most profound changes has been
the spread of HIV and AIDS worldwide. Although millions of people are now
infected with HIV, the illness is still surrounded by fear and disinformation.
This chapter explains HIV and AIDS, what they mean for people who are
infected and for oral health workers, and how we can all work together to
prevent the spread of HIV.
For people with HIV, good
dental care can mean the
difference between living
and dying.
If a person with HIV has a
clean and healthy mouth,
he or she will be able to
eat well, be stronger, feel
better, and live longer.
Mary and David
Mary was 17 years old. She and her boyfriend David were expecting a baby.
David was Mary’s first boyfriend and he was very attentive and kind to
her. But David had not been well lately. His mouth had been very sore and
smelled bad all the time. Although he did not seem to have problems with
his teeth, it was hard to chew or swallow, and white spots appeared on
the roof of his mouth. Mary thought he should go to see the dental worker
at the health center. At first David refused. He said he did not want to talk
about it in a nervous voice. Finally David agreed to go if Mary would go too.
David said he wanted to see the dental worker by himself. So Mary sat in
the waiting room while David saw the dental worker.
170 Where There Is No Dentist 2010
After a while the dental worker came out and asked Mary to come into the
room. David was sitting on a chair looking worried. He tried to give Mary a
smile, but she could see his heart was not in it. The dental worker asked
David if she could tell Mary what she had found in David’s mouth. David
agreed, so the dental worker explained to Mary that David did not have any
problems with his teeth. He had infections in his mouth, gums, and throat.
This was why his mouth was sore and smelled bad all the time.
The dental worker said she would give David the dental care he needed.
But she also said she thought David’s problem might be caused by a much
more serious infection called HIV. That would explain why his body is weak
and he is unable to fight off the infection in his mouth. But to be sure, David
should get a blood test for HIV. And because HIV can be passed from one
person to another she encouraged Mary to get tested too. She explained
that the sooner you find out if you have HIV, the sooner you can start taking
medicines that help you and your baby live long and healthy lives.
I can treat the
problem in David’s
mouth, but I think he
has a serious infection.
It would be good for you
both to get tested so that
if you have HIV you can
protect youselves and
your baby.
The right information will help dental workers give good dental care to everyone.
This story shows why it is important for dental workers to know about
infections in the mouth that may be caused or made worse by HIV. With
correct and up-to-date information, dental workers can give the good dental
care everyone deserves, and can help prevent HIV from spreading to other
people or to themselves.
Health and dental workers must give people with HIV
the care they need. Make sure your health system provides the
resources (equipment, medicines) you need to give good care.
Where There Is No Dentist 2010 171
What ARe HIV And AIDS?
HIV (Human Immunodeficiency Virus) is a germ that causes AIDS (Acquired
Immune Deficiency Syndrome) by weakening the immune system, the part
of the body that fights off infection and disease.
A person is said to have AIDS when he or she starts to get many common
health problems more often than usual and stays sick longer. Some of these
problems are losing weight, sores that will not heal, a bad cough, sweating
at night, diarrhea, skin rashes, a fever, or feeling very tired all the time.
Without treatment the immune system of a person with AIDS gets weaker
and weaker and the person is less able to fight these health problems.
Most people with AIDS die from diseases their bodies are no longer strong
enough to fight.
Many people who are infected with HIV do not get sick for several years.
This means that a person can be infected with HIV and not know they have
it because they feel healthy. But HIV can be passed from one person to
another as soon as a person is infected. So, the only way to know if you are
infected is to take a blood test called an HIV test. This test can be done at
many clinics, hospitals, and other locations.
Medicines called anti-retrovirals, or ARVs,
can help people with HIV regain their
health or stay healthy for many years.
ARVs can also help prevent the spread
of HIV to a baby or to people who are
exposed accidentally. ARVs cannot cure
HIV, however. So these medicines must be
taken every day, for life.
Medicines for HIV are expensive, though
people affected by HIV have organized to
make them available in more countries and
at lower prices. Many governments and organizations provide ARVs for free
either through their own funding or with the support of international donors.
Talk to a health worker who has experience working with HIV to find out
where to go for treatment for HIV.
172 Where There Is No Dentist 2010
How is HIV Spread?
HIV lives in certain body fluids, such as blood, semen (sperm), and the fluids
in the vagina. The virus is spread when these fluids get into the body of
another person. This means that HIV can be spread by:
having unsafe or risky sex with someone who has the virus
(see page 192).
using injection needles or syringes that have not been sterilized
(see page 87).
using dirty instruments that cut the skin for injecting drugs, scarring,
piercing, circumcision, or dental care. Even if instruments have been
washed and look very clean, they can still have germs on them and can
spread HIV if they have not been sterilized (see page 87).
touching or receiving the blood of an infected person.
mother to child during pregnancy, birth, or breastfeeding.
splashing of blood into the eyes or mouth.
HIV does not live outside the
human body for more than a
few minutes. It cannot live on
its own in the air or in water.
This means you cannot give
or get HIV from everyday
contact, such as play, working
with someone, shaking hands,
sharing meals, or from spitting,
sneezing, coughing, sweating,
from tears, or from insect bites.
HIV is not spread by casual contact.
Where There Is No Dentist 2010 173
Who Gets HIV?
Millions of people all over the world are
infected with HIV. If the body is strong,
the HIV virus can grow quietly for several
years, slowly weakening the immune
system before it turns into AIDS. If the
body is weak, the diseases of AIDS may
develop more quickly.
Both rich and poor people can be infected with HIV, but the sickness is
worse for the poor. This is because poor people get more infections, which
weaken the body, because they do not have access to:
low-cost health care.
clean, safe drinking water.
enough nutritious food.
good sanitation.
safe, uncrowded living conditions.
Working to change these
conditions is an important
part of preventing the
spread of HIV and
improving the lives of
people who have HIV.
Most mouth infections
are not caused by
HIV, but all mouth
infections are serious
when a person is
infected with HIV.
How HIV Affects the Mouth
People with HIV are likely to have more problems inside the mouth than
people who do not have HIV. Because their bodies are weaker, any sores
and infections may spread more quickly than they do for healthier people.
So people with HIV may need more regular and careful help from dental
workers than other people in the community.
Most people with HIV will get at least one kind of infection or problem in
the mouth at some time during their illness. If this is not treated, it can be
painful, can affect how much food the person eats, and can cause more
serious health problems.
Infections in the mouth related to HIV affect the soft skin (tissue)—the
lips, the cheeks, the tongue, the lining of the roof of the mouth, under the
tongue, and the skin around the teeth (the gums). HIV does not directly
affect the teeth themselves. In the final stages of AIDS, the gums and the
jaw bone, which hold the teeth in place, may be destroyed. Also, HIV can
cause “dry mouth,” especially for people using ARVs (anti-retroviral drugs),
which makes it easier to get cavities (tooth decay).
174 Where There Is No Dentist 2010
How to Examine the Mouth
for Signs of HIV or AIDS
ou cannot tell from looking at a person
if he or she has HIV.
Dental workers must always be careful to make sure they do not pass the
virus from one person to another during dental care.
Also, dental workers must protect themselves to make sure the virus
does not pass to them from someone they are treating. So always use
precautions against HIV infection with every person you see.
The best precautions are to always wear clean latex gloves or plastic bags
on the hands, a face mask, eye protection, and to use only clean, sterile
instruments. For information on how to clean and sterilize instruments, see
pages 86 to 91.
When you examine someone, always try to:
Wear glasses or goggles. Make sure
you can see through them clearly.
Wear a clean cloth or mask over
your nose and mouth. Try to
change the cloth several times a
day. Before wearing a cloth again,
wash it in clean soapy water,
rinse, and hang it in the sun to dry.
Wear clean gloves or plastic
bags on your hands.
If possible, dental workers should always be protected so they can prevent
HIV from passing to themselves, the people they are treating, their families,
and their sexual partners.
Where There Is No Dentist 2010 175
Always examine the lips, face,
and inside the mouth of someone
who wants advice about a dental
problem. Look for any swelling,
broken skin, sores, redness,
infection, or unusual color
changes. For information about
the most common problems
caused by HIV, see page 178.
Before you examine
someone, always
explain carefully
what you are going
to do.
Look carefully inside the cheeks and lips. Ask
the person to lift up her tongue so you can look
underneath it. Also, ask her to stick her tongue out.
Wrap a small piece of clean cloth around the tip of the
tongue and gently pull it forward so that you can see
the sides of the tongue, the back part of the mouth
and tongue, and as far down the throat as possible.
For more information on how to examine the mouth
and teeth, see Chapter 6, pages 74 to 83.
It is important to ask about the person’s general
health too. There may be other signs of HIV such as
fevers, night sweats, feeling very tired all the time,
weight loss, or diarrhea. Many people with HIV also
become ill with tuberculosis or cancers. If the person has
any of these problems, make sure he or she goes to see a
health worker or doctor who is experienced with HIV.
Feel along the jaw, underneath the jaw bone, and on
the upper neck to see if there are any lumps or pain.
176 Where There Is No Dentist 2010
Always tell the person what treatment you would like to give. After your
examination, explain what you found and what can be done to help or
prevent it from getting worse. Always ask the person for permission before
you do any treatment, just as you should for any person you see.
No one else should know if
someone has HIV, except
for those the person wants
to know. If you think it is
important to tell others,
always ask for permission first.
If you know or think
someone is infected with
HIV, do not tell anyone
else—even the person’s
Respect the privacy of a person with HIV as you
would anyone who comes to you for dental care.
(See page 192, “Treat everyone with respect.”)
Where There Is No Dentist 2010 177
Dental care For a Person with HIV
In general, there is no need to change dental treatment because a person
is infected with HIV. This is especially true if the person has no signs of
HIV. If there is already an infection in the mouth, use a mouth wash before
treatment (see the “General Treatment” box on pages 178 and 179). This
will help prevent the infection from getting worse.
Anyone with HIV has the
right to get good dental
care and to be treated
with respect.
There are no special problems in doing simple fillings, or fitting false teeth
(dentures) for a person infected with HIV. But as the HIV infection advances
to AIDS, you will be able to give better dental care if you know about any
health problems the person may have. For example, if you need to take
out a tooth, you must be extra careful not to cause an infection (see page
pages 85 to 90). Remember, always use clean, sterilized instruments, and
when you give injections use only clean, sterilized needles and syringes, or
disposables, so you do not cause infections. If you have any concerns about
someone’s health, it may help to speak with a health worker.
Taking out a Tooth
To take out a tooth, follow all the guidelines in Chapter 11, page 157. In
addition, to prevent infection for someone with HIV, before you remove the
tooth, make sure the person’s mouth is as clean as possible. A mouth rinse
can help (see the “General Treatment” box on pages 178 and 179).
To prevent infection and to help with healing, gently scale or scrape away
the tartar (see page 127) from all the teeth. Be careful to do as little damage
as possible to the gum and bone around the tooth you are taking out. An
infected tooth socket (the hole that is left after you take out the tooth) in a
person with HIV can be a serious problem. For problems after you take out a
tooth, see pages 165 to 167.
In the later stages of HIV infection when the person has AIDS, the blood
may not clot as quickly as normal. Be very gentle when you take out the
teeth. Take only one tooth out at a time, and wait until bleeding is controlled
before taking another one out.
178 Where There Is No Dentist 2010
Common Problems Caused by HIV
and How to Treat Them
There are many infections that occur in the mouth, such as a cold sore
or gum infection. Most of these infections are not caused by HIV and do
not usually cause serious problems. But all infections are serious when a
person has been infected with HIV because the virus makes the person’s
body weak and unable to fight off infection. Smoking or chewing tobacco
can also make problems in the mouth worse. Many infections for people
with HIV, including mouth infections, can be prevented by taking 480 mg of
cotrimoxazole 2 times a day with lots of water.
The main problems in the mouth
for persons with HIV are:
1. white or yellow patches
4. cold sores or blisters
2. open sores
5. dark-colored skin patches
3. gum infections
6. dry or painful mouth and throat
General treatment
Always remove false or plastic teeth (dentures) before using any of
these treatments.
Most of the problems in this chapter can be helped:
if the teeth are kept clean by brushing or
using a chewing stick every day, including
false or plastic teeth.
by rinsing the mouth several times a day
with a simple mouth wash made with salt
and clean water (see page 7).
Where There Is No Dentist 2010 179
by gently cleaning any infection or sores with a clean cloth that
has been moistened with salt water.
by gently wiping inside the mouth (teeth, gums, all the soft inside
skin) with a clean cloth.
Be careful if you use a chewing stick. Some wood is very hard and can
hurt and damage the gums. The soft wood from the neem tree (which
grows in many tropical countries) works well. You can also wrap clean
cloth around the pointed end of a small stick or tooth pick and use it to
carefully clean the teeth one at a time.
Other treatments that can help are:
chlorhexidine gluconate, 0.2%—a mouth wash that has no
alcohol in it. Hold some in the mouth for 1 minute, 2 times a
day. Make sure it covers the whole mouth inside, and then
spit it out. This mouth wash reacts badly with some kinds of
toothpaste. So wait 30 minutes between using this mouth wash
and brushing your teeth.
gentian violet, 0.5%—a purple-colored liquid that kills
germs. Paint it onto the parts of the mouth that are infected.
Sometimes it may be necessary to paint the whole inside of the
mouth. Try not to swallow any.
povidone iodine, 1%—a brown-colored liquid that kills germs.
Hold some in the mouth for 1 minute, 2 times a day. Make sure
it covers the whole mouth inside, and then spit it out (do not
swallow any). Do not use for more than 14 days. Do not use if
you are pregnant or breast feeding.
hydrogen peroxide, 3% and clean water—(see page 8).
Mix hydrogen peroxide
evenly with water—that is
½ cup of hydrogen peroxide
with ½ cup of water.
Hold some
in the mouth
for about
2 minutes.
Spit it out and
repeat. Do this
every hour when
awake for 3 days.
180 Where There Is No Dentist 2010
1. White or yellow patches in the mouth
(thrush, oral candidiasis)
White, yellow,
or (sometimes)
red patches. The
patches in this
picture are behind
the bottom, front
teeth, but they
most often appear
on the roof of the
mouth and the top
of the tongue.
Thrush is the most common infection in the mouth seen in people with
HIV infection. Thrush can also be a problem for people who do not have
HIV. For more information about this, see page 105.
A burning or swelling feeling in the mouth, especially when eating
spicy foods. Because of pain, eating and swallowing become more
and more difficult.
The skin inside the mouth is usually covered with white, yellow, or
red patches. If you try to remove the white patches with a clean
cloth, they will come off, but sometimes leave a bleeding red
surface underneath. In some people they may not come off easily.
In a few people, there are no white patches. Instead, the skin of the
mouth is red and blotchy. It may look very rough.
Sometimes there are painful cracks
at the corners of the mouth that
will not heal and sometimes bleed.
Where There Is No Dentist 2010 181
Gently scrub the tongue and gums with a clean
cloth or soft toothbrush 3 or 4 times a day.
Then rinse the mouth with salt water and
spit it out (do not swallow). In addition, if
possible, use any ONE of these remedies:
Put 2.5 ml (½ teaspoon) of
nystatin solution in the mouth and
hold it there 2 minutes and then swallow
it. Do this 5 times a day for 14 days. OR,
Use either gentian violet or chlorhexidine gluconate mouthwash, as
described in the “General Treatment” box on page 178 and 179. OR,
Cut or break a 100 mg clotrimazole vaginal insert into 2 pieces. In the
morning, put 1 piece in the mouth and let it slowly melt there. Use the
second piece at night. The package may say: “Do not take by mouth.”
This means do not swallow it. It is safe to let it melt in the mouth,
making sure it covers the whole inside of the mouth, and then spit it
out. Do this 2 times a day for 7 days (14 days if the infection is very
bad). OR,
Depending on how bad your problem is, suck one or two 100,000 unit
nystatin lozenges, 4 or 5 times a day for 10 to 14 days.
If thrush is very bad, or if it moves into your throat and makes it hard to
swallow, you may try one of these stronger medicines instead of the
remedies above. (But do not take either of these medicines if you are
pregnant or breastfeeding):
Take 400 mg of fluconazole by mouth. The next day take 200 mg of
fluconazole once each day for 14 days. But if you do not feel better in 3
to 5 days, increase the dose to 400 mg once each day. OR,
Take one 200 mg tablet of ketoconazole, by mouth, once a day with
food for 14 days.
Some people get relief from thrush
when they paint the inside of the
mouth with a little tea tree oil or yogurt.
tea tree
182 Where There Is No Dentist 2010
2. Sores of the skin of the mouth (ulcers)
Open sores (ulcers) that
can appear anywhere in
the mouth. Usually the skin
around the sores is red. The
sores in this picture are on
the inside of the top lip.
Most people from time to time have had a small open sore (ulcer) in the
mouth caused by an infection that has destroyed the skin in that area. It is
usually painful and can make eating and speaking difficult for 1 or 2 weeks.
The ulcer heals if the mouth is kept clean. For people with HIV infection,
the healing process can be very slow and sometimes the sore area in the
mouth becomes very large. This is especially true if the person is taking
anti-retroviral medicines to weaken HIV, such as zidovudine (AZT).
The skin lining the mouth or on the tongue is broken and will probably look
much redder than the skin that is not broken.
Keep the area clean to control the infection and to help the skin heal. Clean
the sores with a cotton swab dipped in 1% povidone iodine. Or use any of the
methods described in the “General Treatment” box on pages 178 and 179.
Also give antibiotics if:
• the skin around the ulcer is very swollen, AND
you feel soft lumps (lymph glands) underneath the lower jaw bone.
Give 500 mg of amoxicillin by mouth, 3 times a day for 7 days. (Not
safe for people allergic to penicillin. Anyone who is allergic to
penicillin will also be allergic to amoxicillin and ampicillin).
OR 100 mg of doxycycline by mouth, 2 times a day for 7 days. (Not
safe for women who are pregnant or breastfeeding).
OR 500 mg of tetracycline by mouth, 4 times a day for 7 days. (Not
safe for women who are pregnant or breastfeeding).
OR 500 mg of erythromycin, 4 times a day for 7 days.
Where There Is No Dentist 2010 183
3. Infection of the gums
(Vincent’s Infection, trench mouth)
The skin around the teeth
(the gums) is painful, red
and puffy with oozing
yellow liquid (pus).
Many people have some infection of the gums around their teeth. The
amount of infection depends on how clean the mouth is kept and how
well a person’s body can fight off disease. If the mouth and gums are
not kept clean, the infection may get so bad that it will spread to the jaw
bone and other tissues nearby and the teeth will eventually loosen and
fall out.
Because the body of someone with HIV infection is less able to fight off
disease, any gum infection will quickly get worse if the person does not
keep his mouth and teeth clean. This can be very serious. If a person
with HIV loses his teeth and cannot eat, he will become even more ill.
The gums are red, puffy, and very painful.
There may be yellow liquid (pus) oozing from the gum around one
or more teeth.
The gums between several teeth have sores (ulcers).
The person’s mouth smells very bad.
If the infection of the gums is very bad and advanced (as it can be for a
person with HIV), the signs may include:
red, raw ulcers of the gums.
the roots of the teeth will show.
pieces of the jaw bone can be seen at the bottom of the ulcers.
some teeth are loose.
184 Where There Is No Dentist 2010
Keep the area clean to control the infection
and to help the skin heal. Use any of
the methods described in the “General
Treatment” box on pages 178 and 179.
Very gently remove the tartar around the
teeth. Be especially careful not to cause
damage to the gums (see “Scaling Teeth”
on pages 127 to 133).
Also give antibiotics if:
• the neck is sore or stiff, and there are soft lumps just underneath the
lower jaw bone.
Give 500 mg of amoxicillin by mouth, 3 times a day for 7 days.
Women who are pregnant or breastfeeding can use this treatment.
OR for persons allergic to amoxicillin, give 100 mg of doxycycline by
mouth, 2 times a day for 7 days.
OR give 500 mg of tetracycline by mouth, 4 times a day for 7 days.
Do not give tetracycline to pregnant women because it can harm a
baby’s developing teeth.
OR for women who are pregnant or breastfeeding, and are allergic to
amoxicillin, give 500 mg of erythromycin by mouth, 4 times a day for
7 days.
the gums between the teeth have ulcers, and the person’s mouth
smells bad.
Give 500 mg of metronidazole by mouth, 2 times a day for 7 days.
Once the area is clean and the infection is controlled, take out any teeth that
are very loose (see pages 157 to 161).
Where There Is No Dentist 2010 185
More serious gum infection
(gangrene of the face, Noma, Cancrum Oris)
In the most severe gum infection, the jaw bone will
become infected and this can spread through the cheek
to the face. This will be very easy to see, as parts of the
face and jaw rot away and smell bad. It happens mainly
to very sick children (usually one to four years old), but
can also happen to adults with HIV infection.
Get medical help as quickly as you can—in a hospital if possible.
In the meantime, use the information on pages 122 to 124 for cleaning and
treating the gangrene.
The medicines (antibiotics) listed on page 123 are for children. For an adult,
give the following:
For an adult who is able to swallow:
give 400 mg of
metronidazole by mouth,
3 times a day for 10 days,
if you cannot get
metronidazole give 450 mg of
clindamycin by mouth, 4 times a
day, for 5 days.
• OR
if clindamycin is not available give 500 mg of erythromycin by
mouth, 4 times a day, for 10 days.
Note: Clindamycin, erythromycin, and metronidazole are OK to use
for women who are pregnant or breastfeeding.
For an adult who cannot swallow:
inject 2,000,000 (2 million) units of penicillin G into a large muscle,
3 times a day, for 7 days.
For an adult who is allergic to penicillin,
inject 600 mg of clindamycin into a large muscle, 4 times a day,
for 5 days.
If you give the medicines by injection, change to medicines by mouth
once the person starts to feel better. But do not stop giving the medicines
until the 7 to 10 days have passed.
186 Where There Is No Dentist 2010
4. Cold sores or fever blisters
Painful red blisters on
the gums that have burst
open and become small,
open sores.
Many people get cold sores or fever blisters caused by the herpes virus.
People who become infected with herpes carry the virus forever. Most
people are infected as children. The herpes sores can come and go. For
more information, see page 104.
The herpes sores usually heal after 1 or 2 weeks. But for persons
infected with HIV, the sores come more often and last much longer.
1. One or more small, sometimes painful, red blisters appear on the
lips and skin around the mouth. In people with HIV infection, they
also appear just inside the lips, and on the gums and the roof of the
2. The blisters burst and become small open sores that often spread
into each other.
3. After the blisters on the lips burst, a yellow crust
forms over them.
The herpes sores can pick up other infections,
particularly in people with HIV infection. Also, the
liquid inside the sores and blisters can spread
infection. If herpes is spread to the eyes, it can
cause blindness. Keep fingers and hands away
from sores because they contain very active
virus. It is very important to wash the hands
before and after touching the face or eyes.
Where There Is No Dentist 2010 187
Medicine cannot kill the herpes virus. Keep the area clean to control any
infection in the sores and to help them heal. Keep fingers and hands away
from the sores, and drink lots of fluids. Use any of the methods described
in the “General Treatment” box on pages 178 and 179.
Begin treatment as soon as you feel a
tingling, before the cold sore appears. This
may stop the sore from developing or
developing so severely.
A medicine called acyclovir may also help.
Give 200 mg by mouth, 5 times a day
for 7 to 10 days. You can also apply a
small amount of acyclovir ointment on
the sores 6 times a day for 7 days. It is
OK to use them both at the same time.
Acycolvir works best if taken or used early
in the infection, before the blisters burst, if
If the sores are infected, give 500 mg of amoxicillin, 3 times a day
for 7 days.
OR for persons allergic to amoxicillin, give 100 mg of doxycycline,
2 times a day for 7 days.
OR for a woman who is allergic to penicillin, and is pregnant or
breastfeeding, give 500 mg of erythromycin, 4 times a day for 7 days.
Antibacterial ointments such as neomycin or bacitracin can also help to
prevent and control other infections that get into the sores. Stop using
the acyclovir and spread a small amount of anti-bacterial ointment on
the infected skin outside the mouth (not in the mouth) 2 to 5 times a
day for about 5 days.
To help ease the pain of sores outside the mouth, stop using acyclovir
and cover the area with a dry powder, like baby powder, talc, or
cornstarch. Do not use medicated powders as they can make the open
sores sting very badly. Wash hands carefully before and after using
188 Where There Is No Dentist 2010
5. Red or purple patches in the mouth
(Kaposi’s sarcoma)
Painless, red-, brown-,
or purple-colored
patches (that look like
swollen bruises). They
can appear anywhere in
the mouth. The patches
in this picture are on the
top (roof) of the mouth.
Some people infected with HIV will get red- or purple-colored patches in
the mouth. These patches are called Kaposi’s sarcoma and they can also
appear elsewhere on the body. Kaposi’s sarcoma can be an early sign of
HIV infection.
Painless patches that look like swollen bruises around or inside the
mouth. The red or purple color is more obvious in the mouth. The
patches rarely become infected and painful, usually only if they burst.
Get advice from a health worker
or doctor who is experienced
with the problems of HIV.
People who are taking antiretroviral medicines (ARVs) tend
not to get this kind of cancer.
And starting treatment with
ARVs can keep it from getting
worse. Sometimes very strong
anti-cancer medicines are used.
Also, some medicines for
treatment of varicose veins can
be helpful.
Where There Is No Dentist 2010 189
6. Dry or painful mouth and throat
Many people with AIDS have difficulty eating near the end of their lives
because of a dry or painful mouth and throat. But it is important to eat
nutritious food during a sickness, even a serious sickness like AIDS. The
person will feel much more comfortable and have less pain and infection
if he or she can eat well.
A dry mouth can be caused by an infected swelling in the glands of the
mouth that usually make spit (saliva). This is most common for people
taking ARVs (anti-retroviral medicines). A painful mouth can be caused
by other infections and problems that come with HIV and AIDS.
For information about how to treat an infection of the spit gland, see
page 119. For help with eating if the mouth is very dry or sore, try the
Eat soft foods in small pieces that are easy to chew and swallow.
Cook foods until they are soft and tender.
Mix foods with liquids to make them easier to swallow.
Keep a small bottle of drinking water with you all the time.
Use a straw to drink fluids.
Do not eat hot or spicy foods. They can irritate
a sore mouth and throat.
If it is difficult to swallow, tilt the head back a
little, or move it forward.
Rinse the mouth with clean water often. This
will remove food and germs, and help with
190 Where There Is No Dentist 2010
Helping People with HIV
in Your Community
As a dental worker or health worker, you can make a great difference in the
well-being of both the person with HIV and his or her family. Take a special
interest in them and help them find ways to get the care and companionship
they need.
Care During the Final Days
During the final days of their illness, most people with AIDS prefer to be at
home with their families. Both the sick person and the family need a lot of
care and help during this time. This includes care for health problems and
personal needs, as well as help with social and legal issues.
You can support the family if you organize volunteers in the community to:
provide food and cook meals.
help with daily household chores.
look after babies and children whose parents are dying,
or who may have already died.
help with funeral arrangements.
It may also help to ask other family members, friends, or a religious leader to
visit the family and the person who is dying. This support can help the sick
person to die with dignity, and the family to cope with losing a loved one.
Where There Is No Dentist 2010 191
Working for Change In Your Community
By teaching and talking about HIV, dental workers can play an important role
in helping to stop the spread of the disease.
Treating people with HIV infection helps to prevent its spread.
You can help if you:
Learn as much as you can about HIV, how it is spread, and how to
prevent it.
Share your knowledge about HIV with others in community meeting
places—like schools, stores, religious meetings, restaurants and bars,
and military bases.
Teach people how to practice safer sex to stop the spread of HIV. Safer
sex is when no body fluids pass from one person to another during
Educate people about the importance of using clean needles for
injections. In hospitals and health centers, make sure your needles
come out of a sealed, sterile packet. Set up needle exchange programs
for IV drug users in your community.
Practice Safer Sex
Safer sex means to:
have sex with only one partner who has sex
only with you.
always use condoms during sex, and help
women learn how to ask men to use them.
think of other ways to have pleasure, such
as touching genitals with the hands, and
rubbing or massaging different parts of the
not have sex with someone who shares
drug injection needles.
If the whole community has good information about HIV and safer sex, men
and women and their partners may feel more comfortable making changes
in their sex lives to protect themselves. No one has become infected with
HIV because he or she spoke openly and honestly about safer sex.
192 Where There Is No Dentist 2010
Although it can be difficult to speak openly about sex, to help prevent the
spread of HIV it is necessary to talk about what is risky sex and what is safer
How risky are different kinds of sex?
sex in the anus without a condom
sex in the vagina without a condom
sex with many people
sex when the vagina is dry
sex with someone who has had sex
with many people
sex without ejaculation
(“pulling out”)
sex using a diaphragm
sex with only one person who
only has sex with you
oral sex
(mouth on penis or vagina)
sex using a condom
kissing or touching
mutual masturbation
Treat Everyone with Respect
All people have a right to be respected, including people who have HIV. Set
an example in your community by supporting people with HIV, their partners,
and their families. Some people think AIDS is a “disease of outsiders“ or of
“bad” people. They think HIV does not affect “good” people like them. But
HIV affects rich and poor people, men and women, people of all races and
religions, health workers, and religious leaders.
Many people are afraid to take the HIV test or seek treatment because they
think they will be treated badly. We must all take care not to let our fear of
HIV and AIDS make us treat people unfairly. Anyone who is ill should be
cared for with kindness and respect.
Where There Is No Dentist 2010 193
As a health and dental worker, you and other
community and religious leaders can help people
with HIV get health services, housing and jobs.
You can help people treat each other with
respect, and you can encourage people who
have HIV to become involved in their treatment
and in their community’s activities.
Remember, you can help support the human rights of
people living with HIV or someone who people think
is living with HIV. Discriminating against them violates
HIV is not a curse or a
their human rights.
Set an Example and Share Good Information
The example you set and the information you share will help fight the fear
people have of knowing, touching or living with someone who has HIV.
Make sure people know that HIV is not spread by ordinary daily contact. HIV
is not spread by hugging, touching, holding or shaking hands, by dancing,
using the toilet after someone with HIV, or eating food prepared by a person
with HIV. People can share dishes, towels, and bed sheets and not become
infected with HIV. Also, it is not possible to get infected from someone’s
tears, sneeze or spit, or from a mosquito bite.
Other viruses such as measles or chicken pox are spread easily through the
air. But HIV spreads only if certain body fluids of a person with HIV get inside
another person.
As a health worker, you can help people make decisions based on good
information and not fear. A good way to begin is to plan a meeting to discuss
HIV with other health workers in your area or region and with someone from
a regional HIV organization. He or she can help health workers learn about
HIV so they will be able to provide accurate, consistent information to the
people in their communities. They can also learn about the best ways to
treat the infections that people with HIV often get.
A person with HIV can get sick very easily
with many common health problems such
as pain, cough, skin rashes, fever and
diarrhea. For information about these
problems, see Where There Is No Doctor, or
another general medical book.
194 Where There Is No Dentist 2010
Follow your Own Advice
As a dental worker and health leader, you can have a great impact on your
community’s health and well-being if you set a good example. It is not
enough just to give health education talks and tell people how to behave. As
you talk to people about the importance of practicing safer sex, you must
remember to also practice safer sex with your own sexual partner. A dental
worker who does not practice safer sex can become infected with HIV and
pass the virus to others.
Here is an example of what can happen to dental workers if they do not
follow their own advice:
Two years ago, in one region of a country, there were 15
health centers that provided dental services. Today, 5 of the
centers can no longer provide these services because their
dental workers—all men—have died from AIDS. Also, 2 of the
15 students in a recent dental training course—a man and a
woman—have HIV. No one knows exactly how each one got
infected with HIV, but most people believe it was because
they were not careful with their sexual partners. The dental
workers and students gave many health education talks to tell
people how to behave, but people in the community could see
that they did not follow the advice themselves.
Where There Is No Dentist 2010 195
Think of Yourself as a Teacher
As a dental worker, you will be able to improve the health of the people in
your community and help prevent the spread of HIV if you think of yourself
as a teacher. The knowledge you share can have a more lasting impact on
the health and well-being of a community than your skills as a dental worker.
By making connections with people and organizations working on different
aspects of HIV , you will learn new information that can help you and your
community. Contact local, regional, and national groups who work on HIV
education and prevention, on providing service for people with HIV, and on
expanding access to ARVs and other medicines.
Help people with the
resources you have,
and think about where
you might find more
resources to help meet
people’s needs.
If all health workers can give the same correct, up-to-date information, it will
help prevent the fear caused by wrong ideas about AIDS. If their neighbors are
not afraid of them, people with HIV—as well as those who care for them­—
can become more accepted in the community. Then they can help others
understand every person’s real risk of getting HIV. So learn as much as you
can about HIV and share the information with everyone.
Remember to:
Give advice to the people you treat, especially those most at risk for
getting infected, such as young people, migrants and refugees, sex
workers, drug users who share needles, and anyone having sex with
more than one faithful partner.
Fight for improvements in the social and legal services available for
people with HIV. Remember, the fight is against the conditions that
lead to the spread of HIV, and not against people who have HIV.
Fight to end discrimination against those
infected with HIV. Discrimination is an obstacle
to care. It may stop people from coming for
treatment and it may stop people from learning
how to prevent the spread of infection.
Where There Is No Dentist 2010
Where There Is No Dentist 2010
Get Rid of Wastes Safely. . . . . . . . . . . . . . . . . . . . . . 199
The Dental Kit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Medicines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Records, Reports, and Surveys. . . . . . . . . . . . . . . . . 212
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Vocabulary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Other Books from Hesperian. . . . . . . . . . . . . . . . . . . 229
Get Rid of Wastes Safely
Every time you examine a person’s mouth, fill a cavity,
or extract a tooth, you are left with some waste. For
example, used cotton or gauze, disposable needles and
syringes, plastic gloves, and other materials must be
thrown away. But do not put them in the trash. These
wastes carry germs and can spread infections to you
and to people in the family and community. Wear gloves
when you touch wastes, and get rid of them carefully.
How to dispose of sharp
Sharp wastes must be put into a container so
they will not injure anyone who finds them. A
container made of metal or heavy plastic, with a
lid or tape to close it, works well.
When the container is half full, add 5% bleach
solution, then seal it closed and bury it deep in
the ground.
Make a box to dispose of needles safely
Find a metal or hard plastic box. Make a long hole in the lid of the
box that is wide on one side and gets narrower on the other side.
(continued on next page)
200 Where There Is No Dentist 2010
When you have finished using a disposable syringe, put the needle
into the box and slide it down to the narrowest point.
Then pull up on the syringe and the needle will fall off
into the box. The plastic syringe can be sterilized and
thrown into a waste pit (see below).
When the box is half full, pour 5% bleach
solution into the box, seal it closed, and
then bury it deep in the ground.
Other wastes
Other wastes, like plastic gloves, syringe barrels, or cloth soaked in blood,
should be sterilized and then buried deep in the ground. You can sterilize
them by soaking them in bleach for 20 minutes.
WARNING: Do not burn plastic gloves, syringes, or any other
plastics. Burning plastic wastes is dangerous—when plastic
burns, it makes smoke and ash that is very poisonous.
Burying wastes
Find a place away from where
people get their drinking water
and away from where children
play. Dig a safe waste pit to
bury wastes.
The Dental Kit
In the next 10 pages, there are lists of medicines, instruments, and other
supplies recommended in this book. Keep them together in a kit. You may
want to change some of them, or add others to meet your own needs.
As a dental worker, you will be able to get many of the items on the lists
from your government medical stores. Some things you will have to buy
yourself. That can be expensive, so we make several suggestions to help
you save money.
Before you order, decide how many of each thing you need. Ask yourself: How
many persons do I treat each day? For what problems? Then order enough
medicines and supplies for three months.
Note: As more people learn about the treatment you can give, more
will come to ask for your help. Remember this when you
order. Remember, also, that some persons may need more
than one treatment.
On pages 202 to 207 we give an example. We recommend how many
medicines, supplies, and instruments you will need if you see 10 people a
day—200 a month. You cannot be exact, of course, because you cannot predict
exactly what problems will arise. However, we can say that, on the average:
In a group of 10 persons with urgent problems:
6 persons need you to take out 1 or more teeth (so you must inject)
2 persons need cement fillings
2 persons need medicine before you can treat them.
Many of these persons must return for another visit:
• 5 persons need you to scale their teeth and teach them how to care
for them better
1 person will need a cement filling
2 persons will need treatment after taking medicine.
202 Where There Is No Dentist 2010
Amount you
need in 3 months
Amount to
keep in kit
1. aspirin,
300 mg tablets
2. acetaminophen
500 mg tablets
1. penicillin,
250 mg tablets
2. erythromycin,
250 mg tablets
12 small
2 small
Proper Name
3. nystatin
drops or
gentian violet
local name
(write in here)
Another antibiotic, tetracycline, is not recommended for any of the
treatments in this book because it is a broad-spectrum antibiotic. Narrow
spectrum antibiotics (see ‘antibiotics,’ page 217) are usually safer and just as
effective for most dental problems. If you do use tetracycline, read page 356
of Where There ls No Doctor and remember, do not give tetracycline to
a pregnant woman or to a young child. Tetracycline can make a young,
developing tooth turn yellow.
1. Compare prices before you buy medicines. Often the same medicine
has many different names. The generic name (the name we use on
this page) usually is cheapest, and the medicine is just as good as the
‘brand-name medicines’. Use the generic name to order and buy, not
the brand name.
2. Always look for a date on the package. It is called the expiration date (or
expiry date). If today is Iater than that date, do not buy or use that
3. Be careful to give the correct dose. Read the next two pages carefully,
as well as the ‘Treatment’ section of each problem in Chapter 7. If
pages 203 and 204 are not clear to you, read Chapter 8 (pages 59 to 64)
of Where There ls No Doctor.
4. For serious infections or serious pain, see page 204.
Where There Is No Dentist 2010 203
The Correct Dose
Before you give medicine, think about the sick person’s weight and age. The
smaller children are, the less medicine they need. For example, pain medicine
such as aspirin (300 mg tablets) or acetaminophen (500 mg tablets) can be
broken up into smaller tablets:
Four times a day:
take 2 tablets
Childen 8–12
take 1 tablet
Children 3–7
take ½ tablet
Babies take
only, ¼ tablet
Notes:Do not hold aspirin on the bad tooth. Aspirin has acid that can hurt the
tooth. Always swallow aspirin immediately. For severe pain, when
aspirin does not help, an adult can take 30 mg of codeine 4 to 6 times
a day, as needed.
Antibiotics: To Fight Infection
Antibiotics kill bacteria that cause infections. Some antibiotics work better than
others on certain bacteria. If you can, test the pus (page 220) to find which
antibiotic works best.
Do not give penicillin to a person who is allergic to it. Ask about the
person’s allergies before you give penicillin pills or injections. When you inject
penicillin, always keep epinephrine (Adrenalin) ready to inject if the person
shows signs of allergic shock. Stay with the person for 30 minutes. If you see
these signs…
cool, moist, pale, gray skin (cold sweat)
weak, rapid pulse (heartbeat)
difficulty breathing
loss of consciousness
… immediately inject epinephrine: .5 ml for adults or .25 ml for children.
If necessary, inject the same dose again after 20 or 30 minutes. For more
information on allergic shock, see Where There Is No Doctor, pages 70 to 71.
Always give the full dose of penicillin or any antibiotic, even if the
person feels better. See page 94 for the correct dose of penicillin or
erythromycin. Erythromycin also comes in liquid form. It has 125 mg in 5
ml, so 10 ml of liquid (about 2 large teaspoons) is the same as one 250 mg
It is important to take a strong first dose of penicillin or erythromycin, and
then smaller doses 4 times a day for 3 to 5 days after that. Carefully read the
instructions on page 94.
204 Where There Is No Dentist 2010
It is always safer to take medicine by mouth.
Sometimes, however, an infection is so bad that
you need to give medicine by injection. Learn
how to give injections from an experienced
health worker. The injections described on this
.5 1 1.5 2 2.5
page are not like the anesthetic injections in
3 ml syringe
Chapter 9 of this book—you must inject these
medicines into a large muscle in the buttocks or
arm. For more instructions on this kind of injection,
see Chapter 9 (pages 65-74) of Where There Is No Doctor.
For severe infection: There are 2 kinds of penicillin to inject.
For very severe infections, give
‘crystalline penicillin’ every
6 hours for the first day. It acts
quickly and for a short time only.
You will usually use
‘aqueous procaine
penicillin’. Give only
1 injection per day.
Amount you need
in 3 months
Amount to
keep in kit
1. procaine
bottle with
300,000 units
per ml
4 bottles
2. crystalline
bottle with
units per ml
1 bottle
Proper Name
(over 40 kg)
4 ml
2 times/
3 ml
4 times/
Child 6–12
years old
(22–39 kg)
Child 1–6
years old
(10–22 kg)
2 ml
2 times/day
1 ml
2 times/day
1.5 ml
4 times/
1 ml
4 times/
Where There Is No Dentist 2010 205
Proper Name
To make
1. clean
cotton gauze
2. clean
cotton rolls
3. oil of
4. zinc oxide
To treat
5. flouride
To give
of local
6. lidocaine
2% 1.8 ml
7. disposable
27 gauge long
8. lidocaine
Local name
(write in here)
Amount you need in
3 months
Amount to
keep in kit
8 packages
of 100
20 pieces
10 packages
of 50
8 rolls
50 ml
1 small
500 grams
1 small
1 tube
1 tube
8 boxes of 100
8 boxes of
100 needles
5 small
You can use a special solution of fluoride (if available) or any fluoride toothpaste,
which is much cheaper and more common (see above, number 5), in 2 ways:
To treat a sensitive tooth: Put cotton rolls between the lip and gum on
each side of the bad tooth. Dry the bad tooth with cotton and look for
the small groove that is causing the pain. Cover the groove with a smear
of fluoride toothpaste and tell the patient not to spit or rinse it out for
several minutes. One week later, give the same treatment again, or have
the patient do it himself.
To help prevent cavities, in children who do not clean their teeth with
fluoride toothpaste, once a week have children bring their toothbrushes or
toothsticks to school. Put some fluoride toothpaste on each child’s brush
or stick and have them brush and coat their teeth, leaving the paste in their
mouths for at least one minute. Then they can spit it out. Do not eat or
drink for 30 minutes.
On page 24, children are shown using a twice‑yearly application of a special
paste, a ‘topical fluoride gel’. This is good, but the weekely treatment with
fluoride paste is even better for the teeth.
206 Where There Is No Dentist 2010
Weight (how heavy something is)
Volume (how full something is)
10 x 100
1 cup
1 teaspoon
1000 ml = 1 liter
236.5 ml = 1cup
5 ml = 1 teaspoon
1 Kilogram = 1000 grams
1 gram = 1000 mg
Amount you need
in 3 months
to keep in kit
2 kilograms
100 grams
3 liters
500 ml
1. 95% alcohol
disinfectant solution
18 liters
1.5 liters
2. bleach for
disinfectant solution
2.5 liters
125 ml (½ cup)
To keep
sharpening stone
1 stone
1 stone
wooden tongue
8 boxes of
50 per box
Proper Name
To make
1. salt
2. hydrogen
To keep
local name
(write in here)
1 ml = 1 cubic
centimeter (cc)
If you order your supplies in bulk long before you need them, you probably
will pay lower prices. If you have a place to store supplies that is clean, dry,
and free from cockroaches and rats, consider ordering enough for one year
instead of only 3 months.
Where There Is No Dentist 2010 207
When you are treating several people on the same day, you will need to
clean some instruments (see pages 86 to 89) at the same time that you
are using others. Therefore, it is necessary to have several of each kind of
instrument, to be sure that the instrument you need will be ready (clean or
sterile) when you need it.
There are 3 instruments you will need for each person who comes to you,
no matter which treatment is needed. They are: a mirror, probe, and cotton
pliers. Keep them together. Below we recommend that you have 15 of each
of these, so you can keep one in each treatment kit. You do not need to
buy all of these instruments. You can make several of them—see pages
208–210. If you like, buy only one example of each of the instruments
below, and use them as models to copy when you make your own extra
To examine
or to
give any
To inject
To scale
To place
To remove
to buy or
1. dental mouth
2. explorer
3. cotton pliers
Aspirating dental
syringe to use with
1.8 ml cartridges)
Proper Name
Local name
(write in here)
1. lvory C-1 scaler
2. Gracey 11–12
1. spoon excavator
2. filling instrument
3. cement spatula
1. spoon excavator
2. straight elevator
(no. 34)
3. upper universal
forcep (no.150)
4. lower universal
forcep (no.151)
Note: See pages 155–156 for recommendations of other elevators and forceps that are good to
have if you can afford them.
*If you want the help of a charitable organization in buying instruments, see page 211.
208 Where There Is No Dentist 2010
Here are a few ideas for making instruments at low cost. Try to use
materials that are available where you live.
Can you think of any other materials you can use?
Each instrument has two parts: a handle and a working piece at the end.
Join them together:
… with wire:
… with glue or even wax:
If you make the end flat, it can prevent the working piece from turning.
Pound the working piece with a hammer and make a flat slot in the handle
so the working piece cannot turn.
bottom of
in this
*I am grateful to Aaron Yaschine for the ideas in this section.
Where There Is No Dentist 2010 209
Making the Three Instruments You Use Most
Mirror: Use old pieces of mirror or a shiny piece of tin. You even can use a
polished silver coin. A tongue depressor is the handle.
Probe: Use the end of a paper clip, pin or needle for the working piece. Rub
it against a smooth stone to sharpen it. Bend it so it can reach around to the
back of a tooth. Attach the working piece to a smooth stick handle (p. 208).
Tweezers: Draw the shape on a piece of tin and then cut it out with strong
scissors. Use a file or a smooth stone to make the edges smooth. Bend in
half to make the tweezers.
210 Where There Is No Dentist 2010
Making Other Instruments and Supplies
Spoon: Bend a paper clip or needle. Flatten the end. Then pound a small
stone against the end, to make it hollow. Make 2 bends and attach to a stick
Filling Tool: Remove the heads from 2 long screws. With a file and
hammer, make the end of one screw flat and the end of the other screw
round. Bend each end in the direction of the edge (not the face) of the flat
side. Attach both working pieces to a small stick handle.
Dental Floss: When using string to clean between your teeth (pages
71–72), you may have trouble getting this string down in between your
teeth. Sometimes, also, the string gets caught there, forming a kind of
‘bird’s nest’. Three things can cause problems with
dental floss:
1. An incorrectly made filling—flat and
rough instead of round and smooth.
Replace the filling.
2. Teeth too tight together. Use the floss
on a tooth. Then pull the string out from
between the teeth as you press the
free end down against the gum with the
fingers of your other hand. If there is a
sharp filling on a tooth, the string will
pass under the filling as it comes free.
3. String that is too thick. Make thinner
but stronger floss by waxing as in this
picture. The wax also will make the floss
easier to slide between your teeth.
(1) Soak thin string in hot wax.
(2) To remove the extra wax, pull
the string between your fingers.
Where There Is No Dentist 2010 211
Buying Dental Instruments
When you do not have much money,
you must spend wisely. Dental
instruments are very expensive,
especially when you buy them at
commercial prices. Ask other health
workers in your area where you can get
instruments at lower prices. You can
also try contacting the national dental
association in your country. If you do not
know how to locate your national dental
association, contact the World Dental
FDI – World Dental Federation
Tour de Cointrin
Case Postal 3
1216 Geneve-Cointrin
tel: 41-22-560-81-50
fax: 41-22-560-81-40
website: www.fdiworldental.org
e-mail: info@fdiworldental.org
There are many organizations that
donate health supplies—including dental
instruments—or that distribute them at
low cost. Some of these organizations
prefer to help church-sponsored
health projects, but others will provide
instruments to anyone who needs
Durbin PLC, a company in England, may
sell the instruments mentioned in this
book at lower than commercial prices.
For more information, contact:
Durbin PLC
180 Northolt Road
South Harrow, Middlesex HA2 0LT
tel: 44-20-8660-2220
fax: 44-20-8668-0751
website: www.durbin.co.uk
e-mail: cataloguesales@durbin.co.uk
Other organizations that may
be able to help:
World Dental Relief
PO Box 747
Broken Arrow, OK  74013-0747
tel: 1-918-251-2612
fax: 1-918-251-6326
website: www.dentalrelief.com
e-mail: dentalreliefinc@aol.com
Project HOPE
255 Carter Hall Lane
Millwood, VA 22646
tel: 1-540-837-2100
fax: 1-540-837-1813
website: www.projecthope.org
e-mail: webmaster@projecthope.org
Direct Relief International
27 S. La Patera Lane
Santa Barbara, CA 93117
tel: 1-805-964-4767
fax: 1-805-681-4838
website: www.directrelief.org
e-mail: info@directrelief.org
MAP International
4700 Glynco Parkway
Brunswick, GA 31525-6800
tel: 1-800-225-8550
website: www.map.org
Giles Lane, Landford,
Salisbury, Wilts SP5 2BG
tel: 44-1794-324249
fax: 44-1794-323871
website: www.dentaid.org
e-mail: info@dentaid.org
212 Where There Is No Dentist 2010
Records, Reports, and Surveys
For record keeping, you can divide the
mouth into 4 parts:
Upper Right (UR)
Upper Left (UL)
Lower Left (LL)
Lower Right (LR )
In each part there are 8 teeth (fewer in
children—see page 43).
Here are the short names of 4 teeth.
Can you find the tooth named LL5?
You can call each tooth by its short name,
for example, UR3.
Keep a record of each person you see. Write some brief information about
the person and the problem. This way, if the person returns, you remember
what you did to help.
When a person needs to come more than once to take care of a problem, it
is better to keep a special record for that person. With all the treatments on
one page, you can follow that person’s progress more easily. Below is an
example for a person named Yupere. Yupere has a bad tooth that has hurt
from time to time for 2 months. One day when he woke up, his face was
swollen. Yupere decided to wait a day to see if the swelling would go away.
The next day it was worse, so he went to the medical post for treatment.
Where There Is No Dentist 2010 213
You need to write a report whenever you send a person for medical help.
Give as much information as possible so that your treatment can continue
and new treatment starts as quickly as possible. If you cannot go along,
always send a report with a sick person.
The story of Niame: After drinking for several hours, Niame’s husband
returned home asking for money. She had none and told him so. He did
not believe Niame, so he beat her with his hands and then a knife. Naime’s
friends carried her, unconscious and bleeding, to the aid post. The front part
of her lower jaw was hanging out of position.
214 Where There Is No Dentist 2010
It is a good idea to know how many persons in your community have cavities
and gum disease. Look in the mouths of children and adults and make a
record of what you see. Here is an example that is used in Mozambique:
Put a line through the circle for each person with:
cavities Ø
red, swollen gums Ø
The dental workers in Mozambique do a quick
survey in 2 schools, 2 mother-and-child health
clinics, and 2 cooperatives or factories in their
In each place, they examine 50 persons. This
is enough to give an idea of the general health
of teeth and gums in the community.
They make a paper for each age group.
Each paper has 3 sections. They make
a mark for each person they see, until
all 50 circles have marks in them. They
make extra marks if they see a tooth
and/or gum problem.
In this example, you can see that
children have more problems with
cavities, while adults suffer more from
gum disease. This is often true.
This survey helps the dental worker
in three ways:
(1) it shows how serious tooth
decay and gum disease are in
the community.
(2) it shows which age group is
suffering the most. To these
people the dental worker must
plan to give the most attention.
(3) it gives the dental worker
something to show the people
when they are discussing why
to change some old habits and
adapt some new ideas.
Teaching materials
Common Oral Diseases, slide set.
An introduction to oral disease including periodontal disease and dental caries and
their prevention. Also describes how a health worker should examine a patient’s
mouth and gives details of the common problems that a dental worker meets.
Order from:
PO Box 49, St Albans
Herts, AL1 5TX
tel: + 44 1727 853869; fax: + 44 1727 846852
e-mail: info@talcuk.org; website: www.talcuk.org
Guide for Safety and Infection Control for Oral Healthcare Missions
This is a practical guide to providing safe dental care in low-resource settings.
Available from:
OSAP — Organization for Safety & Asepsis Procedures
A Global Dental Safety Organization
P.O. Box 6297
Annapolis, MD 21401
tel: 1-800-298-6727; fax: 1-410-571-0028
e-mail: office@osap.org; website: www.osap.org
A Teacher Resource to Support Dental Health Education, an illustrated manual for
teachers of Kindergarten through Grade 5. Includes lesson plans and activities.
Can be downloaded from the internet here:
More information from:
Government of Saskatchewan
3475 Albert Street
Regina, SK S4S 6X6
Dental Aid Organizations
A listing of organizations around the world that provide different types of assistance
for oral health education, training, and care can be downloaded from the internet
here: www.fdiworldental.org/public_health/assets/partners/aid/Aid_organisations.pdf
216 Where There Is No Dentist 2010
Other Oral Health Resources
FDI World Dental Federation
Tour de Cointrin
Case Postal 3
1216 Geneve-Cointrin
tel: 41-22-560-81-50
fax: 41-22-560-81-40
e-mail: info@fdiworldental.org
website: www.fdiworldental.org
World Health Organization (WHO)
Oral Health Programme
Avenue Appia 20
1211 Geneva 27
tel: 41-22-791-3475
fax: 41-22-791-4866
website: www.who.int/oral_health
WHO has a Focal Point for Oral Health
in each of its regional offices around
the world. This web page gives contact
information for each regional office, as
well as other resources:
WHO Collaborating Centre for
Promoting Community-based Oral
Health Models, Intercountry Center
for Oral Health (ICOH)
Ministry of Public Health
548 Ban Nong Hoi,
Chiang-Mai-Lamphun Road,
Muang, Chiang Mai 50000
tel: 66-53-801160, 66-53-277027
fax: 66-53-281909
e-mail: icoh@icoh.org, icoh@loxinfo.co.th
website: www.icoh.org
This website includes treatment
information and training resources to
improve oral health for people with HIV.
Regional Centre for Oral Health
Research & Training Initiatives
No 3c CBN Road
PMB 2067, Jos
Plateau State, NIGERIA
tel: 234-73-462-901
fax: 234-73-462-901
e-mail: hdanfillo@yahoo.com,
website: www.rcortiafro.org
Basic Package of Oral Care is a
WHO‑affiliated program that aims to
include preventive and curative oral
health into the primary health care
system in a way that is affordable and
achievable for low-income communities.
It includes urgent treatment (pain relief
and emergency treatment), affordable
fluoridated toothpaste, and Atraumatic
Restorative Treatment (ART) which
removes cavities and diseased parts
of teeth without drilling. For more
Department of Global Oral Health,
Radboud University
Nijmegen Medical Center
P.O. Box 9101
6500 HB Nijmegen
The Netherlands
e-mail: info@globaloralhealth-nijmegen.nl
tel: 31-24-361-6995
fax: 31-24-354-0265
website: www.globaloralhealthnijmegen.nl
International No-Noma Federation
c/o Winds of Hope Foundation
20 avenue de Florimont
CH 1006 Lausanne
tel: 41-21-320-77-22
fax: 41-21-320-77-00
e-mail: info@nonoma.org
website: www.nonoma.org/en
This vocabulary is listed in the order of the alphabet:
Most names of sicknesses are not in this vocabulary. Find the name of a
sickness in the Index and read about it in the book.
There are many words in this vocabulary that are not in the rest of the book,
but you may see them in other books or hear dentists use them.
Abscess A sac of pus caused by an infection.
For example, a boil.
Acid A strong liquid that is produced from
certain foods left in the mouth. Acid causes
both tooth decay and gum disease.
Acute Sudden and short-lived. An acute illness
is one that starts suddenly and lasts a short
lime. The opposite of ‘chronic’.
Adrenaline Also called epinephrine. A drug
which stimulates the heart, used for severe
allergic shock.
Adult teeth See Permanent teeth.
Allergy A bad reaction after breathing in,
eating, touching, or being injected with
something. The reaction may be itching,
sneezing, or difficult breathing.
Analgesic Medicine to calm pain. Aspirin,
acetaminophen (paracetamol), and codeine
all are analgesics.
Amalgam A special metal used in permanent
Anemia A disease in which the blood gets
thin. Signs include tiredness, pale skin, and
lack of energy.
Anesthetic A drug that causes the mouth or
other part of the body to feel numb.
Antibiotic Medicine that fights infections
caused by bacteria. A broad-spectrum
antibiotic such as tetracycline kills many
kinds of bacteria, while a narrow-spectrum
antibiotic like penicillin kills only a few
kinds of bacteria.
Appropriate Something that is the easiest,
safest, and most likely to work in a
particular situation or condition.
Arkansas stone A special stone used to
sharpen dental instruments.
Aspirate To breathe. An ‘aspirating syringe’ is
one that can ‘breathe’, or allow liquid to go
both in and out of the needle tip.
Baby teeth
The first set of teeth. There are
20 baby teeth, which are also called milk
teeth or primary teeth.
Bacteria Tiny germs that you can only
see with a microscope and that cause many
different infectious diseases.
Beeswax Wax made by honey bees.
The teeth between the canine
teeth and the molars; premolars.
Bite (1) To cut with the teeth. (2) The way the
upper and lower teeth fit together when
they close.
Blood pressure The force, or pressure, of the
blood flowing through the blood vessels
(veins and arteries).
Blood vessels Tubes that carry blood through
the body. Veins and arteries.
Boil (1) To heat water until it bubbles. (2) A
swollen, inflamed lump with a pocket of
pus under the skin. A kind of abscess.
Brand name Trade name, the name
a company gives to its product. A
brand‑name medicine is sold under a
special name and is often more expensive
than the same generic medicine.
False teeth that are glued onto
several nearby healthy teeth.
Of the cheek. The buccal face of a
tooth is the side facing the check.
Large quantity or amount.
Calcium A nutritional element which makes
teeth strong and hard.
Calculus Tartar.
Calories Units of heat found in food, giving
energy for the body to use.
218 Where There Is No Dentist 2010
Cancer A tumor or lump that grows and may
keep growing until it causes death.
Canine teeth Also called cuspids, dog teeth,
and eye teeth. These teeth have the longest
roots of any tooth.
Carbohydrates Starches and sugars—foods
that give energy. In this book they are
called GO foods.
Caries Cavities; tooth decay.
Cavity A hole in a tooth where bacteria have
Cement filling A temporary filling, which
may protect a tooth for up to 6 months. Also
see Filling.
Cementum The outer covering of the tooth’s
Chronic Long-term or frequently recurring
(compare with ‘acute’). A chronic disease is
one that lasts for a long time.
Colony Germs grouped together in one
Contagious disease A sickness that can be
spread easily from one person to another.
Contraindication A situation or condition
when a particular medicine should not
be taken, or a certain treatment not
given. For example, many medicines are
contraindicated during pregnancy.
Crown The top 1/3 of the tooth, the part that
is protected with hard enamel.
Curette A scaling instrument.
Cuspids Canine teeth.
Cyst An abnormal, sac-like growth in the
body which is often filled with water.
Decay See Tooth Decay.
Dentition A whole set of teeth.
Dental floss See Floss.
Dental worker A health worker who works
for healthy teeth and gums.
Dentist A professional who has advanced
formal education in care of teeth and gums.
Dentures False teeth.
Diagnosis A decision made by a health
worker about what a person’s illness is.
Diet The kinds and amounts of foods that a
person should eat or avoid eating.
A bone that has slipped out of
place at a joint.
Distal The side of the tooth that faces the
back of the mouth. The opposite side from
the ‘mesial’ side.
Drill An instrument used to change the
shape of a cavity before placing a filling.
A tube that carries liquid. For
example, ducts carry spit from the spit
gland to the mouth.
Elevator An instrument used to loosen a tooth
before you take it out.
Enamel The protective layer that covers the
crown (top part) of a tooth. The enamel is
the hardest part of the body.
Epulis A tumor of the gums, usually found
between the teeth.
Eruption The moment when a new tooth cuts
through the gums and becomes visible in
the mouth.
Evaluation A study to find out the value of
something, or to find out what has been
accomplished. Evaluations often compare
different conditions before and after a new
activity begins.
Examination A careful look at something; an
Expiration date The month and year
marked on a medicine that tells when it
will no longer be good. Throw away most
medicines after this date.
See Probe.
Extraction Taking out a tooth.
False tooth A ‘tooth’ made of plastic or other
material, used to replace a tooth that has
been taken out.
Fever A body temperature higher than
Fiber A fine, threadlike piece. A fibrous food
like coconut contains a lot of fiber.
Filling Material put into the cavity in a tooth
to prevent further decay.
First aid Emergency care or treatment for
someone who is sick or injured.
Floss Special string used to clean between
the teeth.
Fluoride A chemical which strengthens the
teeth. Painted on the teeth, as an ingredient
in toothpaste, or added to water for drinking
or rinsing, fluoride enters and hardens the
enamel. It is especially good for children’s
Forceps Instruments used to pull teeth
Fracture A broken bone.
Where There Is No Dentist 2010 219
Gauze A material made of cotton, woven into
an open mesh.
Generic name The scientific name of a
medicine. Usually different from the brand
names given it by the different companies
that make it.
Germs Very small organisms that can grow
in the body and cause some infectious
diseases; bacteria.
Gram A metric unit of weight. There are
about 28 grams in an ounce. A paper clip
weighs about 1 gram.
Groove A long, narrow cut on the surface of
back teeth. Grooves are ‘protected areas’
because food and germs can hide and
remain in them longer.
Gum bubble Also called a gum boil. A small
abscess on the gums.
Gum disease Illness that causes gums to
become loose, red, and swollen, and to
bleed when the teeth are cleaned.
Gum pocket The space between the tooth
and the flap of gums around it, forming a
small pocket.
Gums The skin around the teeth.
Hemorrhage Bleeding.
Hemostat A needle holder, used for putting in
Herb A plant, especially one valued for its
medicinal or healing qualities.
History (Medical history) What you can learn
through asking questions about a person’s
sickness—how it began, when it gets better
or worse, what seems to help, whether
others in the village or family have it, etc.
Hydrogen peroxide A liquid used to clean
wounds and kill certain bacteria.
Hypertension High blood pressure.
Immunizations(vaccinations) Medicines that
give protection against specific diseases. For
example, there are immunizations against
diptheria, tetanus, polio, tuberculosis, and
Incisors The four front teeth on the top and
Infection A sickness caused by bacteria or
other germs. Infections may affect part of
the body only (such as a sinus infection) or
all of it (such as measles).
Infectious disease A disease that is easily
passed from one person to another;
contagious disease.
Inflammation An area that is red, hot, and
painful, often because it is infected.
Inject To give a medicine such as an
immunization or anesthetic, using a syringe.
Joint The place where two bones meet.
When this book talks about the ‘pain in
the joint’, it means the joint (called the
‘temporomandibular joint’) where the cheek
and jaw bones meet.
Kilogram (kg) One thousand grams. A ‘kilo’
weighs a little more than 2 pounds.
Labial Of the lips. The labial side of a tooth is
the face of the tooth nearest the lips.
Ligature wire A thin, strong wire that bends
easily, used to attach a loose tooth to a
strong tooth.
Lingual Of the tongue. The lingual side of a
tooth is the face of the tooth nearest the
Malnutrition Health problems caused by not
eating enough of the foods that the body
Mandible The lower jaw bone.
Maxilla The upper jaw bone.
Mesial The side of the tooth that faces the
front of the mouth; the opposite of ‘distal’.
Milligram (mg) One thousandth of a gram.
Molar The back teeth, used for grinding.
Molars are the largest teeth in the mouth,
with 2 or even 3 roots each.
220 Where There Is No Dentist 2010
Nerves Thin threads or strings that run from
the brain to every part of the body and carry
messages for feeling, pain or movement.
There is a nerve, along with a blood vessel,
in every root of every tooth.
Numb Without feeling; anesthetized. When
teeth and the gums around them are numb,
they cannot feel pain.
Nutrition The mixture of foods the body
needs to grow, be healthy, and fight off
Occlusal The biting surface, or top, of the
Oral Of the mouth. An oral medicine is one
taken by mouth.
Organisms Living things (animals or plants).
Palate The roof or top part of the mouth.
Permanent filling A filling using a special
metal or ceramic material which lasts for
Permanent teeth The 32 adult teeth which
grow into the mouth to replace the baby
Petroleum jelly (petrolatum, Vaseline) A
grease-like jelly used in preparing skin
Plaque A film or coating of germs that can
form on the teeth, mix with food and make
acid. You cannot see plaque unless you stain
Plate A set of false teeth.
Premolars The teeth between the molars and
the canine teeth; bicuspids.
Prenatal Before birth.
Action taken to stop sickness
before it starts.
Probe An instrument for examining teeth for
tartar or other problems.
Protective foods
Foods that are rich in
vitamine and minerals. They help build
healthy bodies and make people more able
to resist or fight diseases. ln this book they
are called GLOW foods.
Body-building foods necessary for
proper growth and strength. In this book
they are called GROW foods.
Pus A yellow-white liquid found inside
Records, reports Written information about
sick persons and the treatment they receive.
Records are for the personal use of the
health worker, reports are written by one
health worker to another to describe an
illness and ask for further treatment.
Resistance The ability of something to defend
itself against something that would normally
harm or kill it. Many bacteria become
resistant to the effects of certain antibiotics.
Rinse To hold a liquid in the mouth, moving
around inside the mouth.
The possibility of injury, loss, or harm.
The lower part of the tooth, under the
gum, connected to the bone.
Root canal The hollow part of every root of a
tooth, which has a blood vessel and a nerve
Root canal treatment
A special operation
on a dead tooth to remove material from
the root canal and replace it with filling
Root fibers Tiny fibers which hold the root of
the tooth to the jaw bone.
Saliva Spit. Saliva helps us to swallow our
Scab The crust of dry blood that forms over a
Scale To scrape the tartar off the teeth. A scaler
is an instrument for scaling.
Scientific method A way of learning
something. It begins with information, then
an idea, and then the idea is tested against
the information available.
Side effects Problems caused by using a
Signs The things or conditions to look for
when you examine a sick person, to find out
what sickness the person has. In this book
the symptoms (the problems a person feels)
are included with signs.
Sinus A hollow place inside the bone.
Socket The wound left after you take out a
Soft drinks Fizzy, carbonated drinks like
Where There Is No Dentist 2010 221
Spatula An instrument used for mixing cement
for fillings.
Starches Energy foods like maize, rice, wheat,
cassava, potatoes, and squash.
Sterile Completely clean and free from living
micro-organisms. Things usually are not
sterile until you boil them or steam them.
Sterilize To make things sterile by boiling or
steaming for 30 minutes.
Sugars Sweet foods like honey, sugar, or fruit
that give energy but often cause tooth and
gum problems.
Survey A collection of facts about a small
group of persons or things in the community.
If the small group is not unusual, the survey
results will describe the whole community.
Suture A stitch made with needle and thread
to sew up an opening or wound.
Swelling An area of the skin that is abnormally
large, puffed up. A swollen area is one that
has swelling.
Symptoms The feelings or conditions that
sick persons report about their sickness.
ln this book, symptoms are included with
Syringe An instrument with a small sharp
needle, for giving injections.
Top of the tooth The part of the tooth that
bites on food. For both upper and lower
teeth, the biting surface is the ‘top’ and the
root is at the ‘bottom’.
Topical On top of the skin. A topical
medicine is put on the skin.
Traditions Practices, beliefs, or customs
handed down from one generation to
another by example or word of mouth.
Treatment Care given by a health worker
to fight an illness, attend to an injury, or
prevent a new problem.
Tropical Having to do with the tropics—the
hot regions of the world.
Tumor An abnormal mass of tissue without
inflammation. Some tumors are due to
Tweezer Small metal instrument for picking
up cotton or small objects. Some persons
use the word forceps for tweezers, but in
this book, forceps are instruments for taking
out a tooth.
Tablespoon A measuring spoon that holds 3
teaspoons or 15 ml.
Tartar A hard, rocky coating on the tooth near
the gums, also called calculus or toothstone.
Tartar forms when old plaque mixes with
calcium in the spit.
Teaspoon A measuring spoon that holds 5 ml.
Three teaspoons equal one tablespoon.
Teething The action of new teeth cutting
through the gums. Also see Eruption.
Temperature The degree of heat of something,
such as the air or a person’s body.
Temporary filling A filling meant only to last
until a permanent filling can be placed.
T.M.J. The temporomandibular joint. See
Tooth abscess See Abscess.
Vaccinations See Immunizations.
Vaseline See Petroleum jelly.
Vessels See Blood vessels.
Virus Germs smaller than bacteria, which
cause some infectious diseases, like measles
or the common cold.
Tooth decay Damage to the tooth caused by
acid; cavities.
Toothache Pain in a tooth.
Toothpaste A paste for cleaning teeth.
Tongue depressor A tongue blade; a piece
of wood used to keep the tongue out of the
way when examining or treating the teeth.
Ulcer A break in the skin or mucus
membrane; a chronic open sore that can
appear on the skin, gums, or gut.
Vitamins Protective foods that our bodies need
to work properly.
Volume The amount of space a thing occupies.
We measure volume in liters, ml, gallons, etc.
Weight The heaviness or lightness of a thing.
We measure weight in kilograms, mg,
pounds, etc.
Wisdom teeth
The 3rd molars, which grow
into the mouth when a person is 16-22 years
X-ray A special photograph that allows you to
see bone, roots of teeth, etc., under the skin.
Index A-B-C
222 Where There Is No Dentist 2010
Abscess, 93, 217
and gum bubble, 74
begins with a cavity, 6, 47
diagnosis and treatment, 93
flip chart presentation, 30-31
treat at once before infection reaches the
bone, 6
treat pregnant women, now, 15-16
Acetaminophen (paracetamol)
dental kit supply, 202
dose for pain, 94-95
causes tooth decay and gum disease, 7, 50,
some sugars make acid more easily, 55
Adrenaline (epinephrine), 136, 137, 203
AIDS, Chapter 12, 169
Alcohol, for disinfecting without heat, 89
Allergies to medicines
and extractions, 153-154
penicillin warning, 203
Amoxicillin, 94,182,184,187
Ampicillin, 94, 105
Anemia, 16, 105, 123, 217
Anesthetics, local, 135-142
dental kit supply, 205
Antibiotics, 94, 217
dental kit supply, 202, 204
doses for tooth abscesses and other
problems, 94
injections, 203-204
precautions, 203
sulfadimidine, 123
warning on tetracycline, 63
Anti-retrovirals (ARVs), 171, 188
Arkansas stone, 128
Aspirating syringe, 136, 207, 217
Aspirin, 94
correct dose for pain, 94-95, 203
dental kit supply, 202
do not hold against teeth, 203
Atraumatic Restorative Treatment, 92, 144, 151
Baby teeth, 62-65
ages when baby teeth come in, 43, 64
Begin forming before birth, 62
do not cause diarrhea and fever, 65
how baby teeth grow and stay strong, 63
knocked out: diagnosis and treatment, 97
loose, 54
make space in mouth for permanent teeth, 64
marks on baby teeth, 62
why baby teeth are important, 64
Bacteria (See Germs)
Bandage, head, for a broken jaw, 110
Berry juice
used to show coating of germs on teeth, 53
Bicycle-powered dental drill, 151
and extractions, 77, 153-154
from socket: diagnosis and treatment, 118
how to place a suture, 161-162
in the mouth: possible causes (chart), 116
Bleach, for disinfecting without heat, 89
boil any instrument that has touched blood,
(Also see Bleeding)
Blood pressure, 77, 118
Blood vessel, 46
bone chips inside tooth socket, 166
broken: diagnosis and treatment, 108-112
damage from gum disease, 42
three main bones in the face, 108
Bones of animals, 41
Books on dental care, 215-216
Bottle feeding, 3, 63
Breast feeding, good for teeth, 3
Broken bone, 108-112
Broken root, 165
Broken tooth, 96
Brushing teeth (See Cleaning teeth)
Brushstick (homemade toothbrush), 4
Bubble (See Gum bubble)
Cancer, 125, 218
can begin with white lines inside mouth, 105
diagnosis, 125
Kaposi’s Sarcoma, 188
look for a sore that does not heal, 106
Candy, 9
(Also see Sweet foods)
Cancrum oris (noma)
diagnosis and treatment, 121-124, 185
Canker sores, diagnosis and treatment, 106
Index C-D-E
Cartridges of injectable anesthetic, 135-136,
Cavities (caries), 218
can begin as marks on baby teeth, 62
can become abscesses, 47
can make teeth hurt, 46
caused sometimes by baby bottles, 3
diagnosis and treatment, 92Cavities
fill cavities before abscess forms, 6
flip chart presentation, 30-31
on neck of tooth, 92, 205
puppet show about, 33-34
school survey, 49
Cement fillings (See Fillings)
Chair for examinations and extractions, 75, 156
Cheek bone, 108
CHILD-to-child program, 24
as health workers, 24
can clean their own teeth, 58
cannot learn well if their teeth hurt, 20
want to learn, 19
young children should not take aspirin, 94, 203
Chlorhexidine gluconate, 179, 181
Cleaning instruments, 75, 87-91
after extractions, 167
after filling a tooth, 150
after scaling, 134
disinfecting without heat, 89
how to sterilize syringes, 138
pressure cooker, 88
sterilizing with steam, 87-88
wash your hands, too, 86
Cleaning teeth, 56, 69-72
can help sore gums, 7
CHILD-to-child activities, 24, 53
especially important for persons who take
certain medicines, 115
experiment to find the best way, 58
flip chart presentation, 31
how to clean a baby’s teeth, 63
how to clean between teeth, 71-72
how to make a brushstick, 4
how to make a child’s toothbrush, 63
how to make waxed floss, 210
make it part of a daily school activity, 59
parents should clean children’s teeth, 11,
18, 63
pregnant women must take special care,16
‘protected areas’ that are hard to clean, 4
soft toothbrush is best, 4, 70
(Also see Gum disease, Scaling teeth)
Clindamycin, 123, 185
Where There Is No Dentist 2010 223
Clotrimazole, 181
Coating of germs on the teeth, 50
Cola drink, in experiment on decay, 48
Cold sores (fever blisters)
diagnosis and treatment, 104, 186-187
‘Colonies’ of germs on the teeth, 50, 218
Comparative diagnosis (telling similar problems
apart), 80-83
Cotrimoxazole, 178
Cotton rolls, 146, 205
‘Cowhorn’ forceps, 155
do not use on baby teeth, 160
Curette (for scaling teeth), 128
Demonstration, 26, 48
Dental floss, 71-72, 210
Dental kit, supplies for, 201-211
Dental mirror, 75, 209
Dental tools (See Instruments)
Dental workers, can visit schools, 35
Dentures, 163-164
bad dentures cause sore mouth, 107
sores under, diagnosis and treatment, 106
and extractions, 153-154
and thrush, 105
Diagnosis (See Examination and diagnosis)
Diagnosis charts, 80-83
loose tooth, 81
sore mouth, 82
sores 82-83
swelling, 81
toothache, 80
trouble opening or closing mouth, 83
(Also see Comparative diagnosis)
Diet (See Nutrition)
Dilantin (diphenylhydantoin), 115
Dislocated jaw
after extraction, 167
diagnosis and treatment, 113
Disinfectant, cold
for cleaning certain instruments, 89, 206
Doxycycline, 77, 182, 184, 187
Drama, for teaching about tooth problems, 26
Drawing pictures, 31
Drill, dental, 151-152
Dry socket, diagnosis and treatment, 117
Elevators for extractions, 155-156, 207
how to use, 158
224 Where There Is No Dentist 2010
and swollen gums: diagnosis and treatment, 115
Epinephrine (adrenaline), 136, 203
Epulis, 133
Erythromycin, 94, 182, 184, 185, 187
dental kit supply, 202-203
Eugenol (oil of cloves), 145, 205
Examination and diagnosis, Chapter 6, 218
bleeding in the mouth (chart), 116
different problems come at different ages, 78
examining inside the mouth, 79
four steps to a good diagnosis, 76
and HIV, 174-176
how to check the gums, 74
look for sores, 74
questions that help you make a diagnosis, 73, 76
telling similar problems apart, 80-83
tetanus, 118
touch the sore place, 79
wear protective equipment, 174
where to examine, 75
(Also see Diagnosis charts)
Excavator, 145
Expiration date, 218
Extractions, Chapter 11
before you begin—ask questions! 153
four problems to watch for, 154
how to take out a tooth, 157-163
instructions: what to do afterward, 163-167
instruments needed, 154-156
for people with HIV, 177
pregnant women need not wait, 15-16, 77
problems afterward, 116-117, 165-167
three reasons to take out a tooth, 153
False teeth, 163-164
(Also see Dentures)
Fever blisters,
diagnosis and treatment, 104, 186-187
Filing teeth to correct a bad bite, 99
Filling tool, 145
Fillings, Chapter 10
filling material, 145, 205
how to place, 146-150
instructions for after you place a filling, 150
instruments needed, 145
lost or broken: diagnosis and treatment, 92
permanent fillings, 151-152
puppet show about, 33-34
two kinds, 144
what a filling can do, 144
when not to place a filling, 143
when to place a filling, 144
Index E-F-G-H
Fish bone
can get caught under gums, 133
Flannel-boards, 28, 218
Flesh, left inside socket after extraction, 166
Flip charts, 29-31, 218
example, 30-31
Flossing (cleaning between teeth), 71-72, 210,
Fluconazole, 181
Fluoride, 24, 70, 218
on neck of tooth, 92, 205
rinse and paste to prevent cavities, 205
Food (See Nutrition)
Forceps for extractions, 155, 207
Fracture (See Broken bone, tooth, root)
Game (‘Scatter!’), 50-51
Generic name, 202
Gentian violet, 105, 179, 181, 202
Germs, 219
discussion about, 51
health workers must not spread germs,
impossible to kill all germs in mouth, 50
where they hide, 87
Gingivae, gingivitis (See Gums, Gum disease)
Gloves, 86, 174, 200
‘Go foods’ (energy foods), 67-68
warning about, 68
Grooves on teeth, 92, 205, 219
Gum boil (See Gum bubble)
Gum bubble, 47, 74
Gum disease, 52-53
description, 42, 52
diagnosis and treatment, 101-103
flip chart presentation, 30-31
home care for, 53
how gum disease makes teeth fall out, 42
learning activity about, 53
noma: diagnosis and treatment, 121-124
picture of, 7
possible cause of a sore mouth, 82
prevent gum disease during pregnancy, 16
serious gum disease: diagnosis and
treatment, 8, 102-103, 121-124
Gum pocket, 52, 131, 219
definition, 219
importance of, 1, 37
infected gums (noma): diagnosis and
treatment, 121-124
healthy and unhealthy gums: description, 52
how to examine, 74
Where There Is No Dentist 2010 225
Index H-I-J-K-L-M
swollen gums and epilepsy medicine, 115
swollen gums and pregnancy, 16, 77, 102
why gums can feel sore, 7, 52
wash before you touch someone’s mouth, 86
Head bandage for a broken jaw, 110
Heart disease, and extractions, 153-154
Heat, can lower swelling, 94
Hemorrhage, and extractions, 153-154
Hemostat, 161
Herpes virus, can cause fever blisters, 104,
HIV, Chapter 12, 169
common problems, 178
definition, 171
dental care, 177
and food, 189
how it spreads, 172
general treatments, 178-179
prevention, 191-195
Hydrogen peroxide, 8, 179
warning: do not use too much, 8
Hygiene (keeping clean), 82-85, 86-90, 178-179
Incisors, 39
Infection, 219
can pass from tooth to bone, 47
dental workers can infect others, 85
description of infected gums, 52
during pregnancy, 15-16, 77, 96, 148
in sinus: diagnosis and treatment, 95
in spit gland: diagnosis and treatment, 119
Injections, Chapter 9, 204, 219
how to give injections to children, 141
injections of antibiotics, 204
instructions for after you give an injection, 142
safe disposal, 199
sterilization of syringes, 138
two types of syringe, 135-136
use an aspirating syringe, 138
what to do after extracting, 163-167
what to do after injecting, 142
what to do after placing a temporary
filling, 150
what to do after scaling, 133
Instruments, 207-211, 219
boil any instrument that has touched blood, 87
buying instruments, 211
for examination, 75
for extractions, 155-158
for filling teeth, 145
for scaling, 128
making your own instruments, 208-210
(Also see Cleaning instruments)
Iodine Solution, 103, 123, 179, 182
I.R.M. (Intermediate Restorative Material), 145
dental workers’ description of gum disease,
Jaw bone, 41
broken: diagnosis and treatment, 108-112
dislocated: after an extraction, 167
dislocated: diagnosis and treatment, 113
three main bones in face, 108
Joint, 219
pain in: diagnosis and treatment, 114
Kaposi’s Sarcoma, 188
Ketoconazole, 181
Learning (See Teaching)
Lidocaine (lignocaine), 136
dental kit supply, 205
Ligature wire, 110, 219
Loose teeth, 54
diagnosis and treatment, 99
possible causes (charts), 81, 99
Main food, 67-68
Malaria, can contribute to noma, 121
Malnutrition, 219
cavities can help cause, 62
often made worse by Vincent’s Infection, 102
(Also see Nutrition)
Mango string, can get caught under gums, 133
can cause dry, sore lips, 107
can contribute to noma, 121
Medicines in dental kit, 201-204
Mepivacaine, 137
Metronidazole,123, 184, 185
226 Where There Is No Dentist 2010
Milk-oil drink
for persons who cannot eat properly, 111
Mirror, 75, 209
Molars, 39, 43, 219
ages when molars grow in, 43
baby molars, 64
first permanent molar is often the first
permanent tooth, 64
infection in new molar: diagnosis and
treatment, 100
new molar can cause face to swell, 66
often grow in badly, 43
taking care of, 66
dry or painful, 189
trouble opening and closing (chart), 83
white lines inside the mouth can be
cancer, 105
Mouth wash, 103, 177-179, 181
Neck of a tooth, grooves in, 92
Needle, hypodermic
disposable, for oral anesthetic, 205
safe disposal, 199-200
used to wire a broken jaw, 112
Nerve of a tooth, 46, 220
main trunks and small branches, 136-137
Noma (cancrum oris)
diagnosis and treatment, 121-124, 185
prevention, 124
Nutrition, 67-68, 220
eat a mixture of foods, 11, 67-68
eat enough food, 67
flip chart presentation, 30-31
foods for persons who cannot eat properly,
111, 189
foods that make gums stronger, 7, 8
foods that we cannot eat without teeth, 38
good and bad foods, 55
good and bad sweets, 3
grow foods in your own garden, 11
and HIV, 189
pregnant women need Vitamin C, 16
tooth pain can interfere with nutrition, 62
Nystatin, 105, 107, 181, 202
prevents rust when sterilizing instruments, 87
Oil of cloves, 145
Index N-O-P-R-S
aspirin or acetaminophen can help, 94
mouth and throat, 189
Patches (red or purple) in the mouth, 188
Penicillin, 93-94, 202-204
almost always taken by mouth, 93
dental kit supply, 202
dose taken by mouth, 94, 202
injectable, 204
precautions, 203
take entire dose, 93, 203
Permanent teeth, 43, 54, 220
knocked out: diagnosis and treatment, 97
need good baby teeth before them, 64
Phenytoin (See Dilantin)
as a teaching aid, 28, 37-38
tracing, 31
Plaque, 50, 220
disclosing solution (berry juice), 53
Plays, 26
Posters, 28
Povidone iodine, 103, 123, 179, 182
Pregnancy, 15-16
and dental problems, 15-16, 77, 102, 154
women must take special care, 101
story about, 15-16
Pressure cooker for sterilizing instruments, 88
Prevention, 35, Chapter 5, 220
early treatment is a form of prevention, 61
foods that are good and bad, 55
HIV, 191-195
(Also see Cleaning teeth, Nutrition)
Probe, 75, 209
Pronunciation, why teeth are important for, 37
Puppet shows, 32-34
example, 33-34
Puzzles, 27
Records, 212, 220
Reports, 213, 220
Rinsing the mouth
during pregnancy, 16
with hydrogen peroxide, 8, 179
with salt water, 7, 178
various rinses, 178-179
Root of the tooth, 41
broken: diagnosis and treatment, 165
count roots before taking out a tooth, 159
has a nerve and blood vessel, 46
Index S-T
Where There Is No Dentist 2010 227
pushed into sinus, 166
Root fibers, 41, 220
Safe disposal of dental waste, 199-200
Safer sex, 191-192
Salivary gland (spit gland)
infection in: diagnosis and treatment, 119
Salt water rinse, 7, 178
Scalers, 128
Scaling teeth, Chapter 8
instruction for after you scale teeth, 133-134
instruments for, 128, 207
only scale teeth of someone who will keep
teeth clean, 127
‘Scatter!’ (game), 50-51
cleaning teeth can be a daily health activity,
59-60, 205
school lunch program, 57
(Also see Teaching)
Scientific method for making diagnosis, 76
Sewing up a wound (suturing), 161-163
Sharpening stone, 128
Shots (See Injections)
infected, diagnosis and treatment, 95
root pushed into sinus, 166
Slides for teaching about dental health, 215
Socket, 220
broken root inside, 165
painful (dry socket): diagnosis and
treatment, 117
painful, 167
Soreness in mouth, possible causes (chart), 82
around the mouth, 107
at corners of mouth: diagnosis and
treatment, 107
different problems come at different ages, 78
from a denture: diagnosis and treatment, 106
on the face, 120
on lips, cheek, and tongue, 74, 182
types of face sores (chart), 83
types of mouth sores (chart), 82, 182
Spatula, for cement fillings, 145
Spit gland
infection in: diagnosis and treatment, 119
for extractions, 155
for fillings, 145
making your own, 210
Sterilization, 87-89, 211
with steam, 88
Story telling, 15, 26
about pregnancy and dental care, 15-16
some kinds make acid more easily, 55
sugar cane is not as bad as candy, 9
(Also see Sweet foods)
Sulfadimidine, 123
Surveys, 214, 221
as a way of learning numbers, 24, 25
counting cavities, 49, 214
counting teeth, 44-45
to find the best way to clean teeth, 58
Sutures, 161-162
Sweet foods, 9, 46, 55
avoid fizzy drinks, 11
can cause cavities and gum disease, 6-7
learning activities, 48
some are called ‘go foods’, 67-68
and epilepsy medicine, 115
and pregnancy, 102
after extractions, 116, 166
different problems come at different ages, 78
from a tooth abscess, 6, 47
heat can lower swelling, 94
may be a new molar coming in, 66
possible causes (chart), 81
aspirating, 136, 207
for injections: two kinds, 135-136
(Also see Injections)
Tartar, 52, 221
can be a sign of gum disease, 79
how to scale, 129
makes gums sore, 8
can teach without dental worker’s help, 36
‘association of ideas’, 14
by example, 57, 193-194
community can be part of classroom, 25
each person can teach another, 12
finding the best way to teach, 13-18
finding the best place to teach, 17
learn from the people, 13
let students discover for themselves, 20, 24
repetition helps people remember, 17
teach yourself before teaching others, 2, 195
teaching family and friends, Chapter 2
Index T-V-W-X-Z
228 Where There Is No Dentist 2010
teaching school children, Chapters 3, 4
teaching so that learning can happen, 20-24
with demonstrations, 26
with drama, 26
with posters and pictures, 28
with puzzles, 27
with story telling, 15-16, 169-170
(Also see School)
and gums, 1
broken, 96
four problems to watch for, 73
how many teeth we should have, 43
importance of, 1, 37
injuries to: diagnosis and treatment, 96-98
learning about anatomy, 49
loose: diagnosis and treatment, 54, 99
naming teeth with numbers, 212
new tooth coming in:
diagnosis and treatment, 100, 101
rotting in cola drink (experiment), 48
what holds teeth, 41
what makes teeth hurt, 46
why some teeth look different, 39
(Also see Baby teeth, Loose teeth)
Teeth, false, 163-164
(Also see Dentures)
Teeth, taking out, Chapter 11
(Also see Extractions)
Teething: diagnosis and treatment, 101
can cause pain in joint, 114-115
diagnosis, 118
Tetracycline, can hurt baby teeth, 63, 77, 202
Theater, 26
Thrush: diagnosis and treatment, 105, 180-181
Tongue blade (tongue depressor), 75, 206
Tools (See Instruments)
Tooth (See Teeth)
Tooth abscess (See Abscess)
possible causes (chart), 80
why teeth hurt, 46
(Also see Abscess)
how to make your own, 4-5, 23
how to make a brush smaller for a child, 63
soft is best, 4
Tooth decay
can touch nerve and cause an abscess, 6
flip chart presentation, 30
(Also see Cavities)
Tooth injuries
broken tooth: diagnosis and treatment, 96
tooth knocked out: diagnosis and treatment
Toothpaste, 5, 69
Tracing pictures, 31
Traditional beliefs, 10, 13, 221
about pregnancy, 15
building new traditions from old ones 14
Treadle-powered dental drill, 151
Treatment, Chapter 7
can be given during pregnancy, 15-16, 77,
102, 154
early treatment prevents serious problems, 2
Trench mouth:
diagnosis and treatment, 102, 183
Tumor, diagnosis and treatment, 125
Tweezers, how to make, 209
Vegetable soup (special drink)
for those who cannot eat properly, 111
Vincent’s Infection of the gums
can worsen and become noma, 121-124
diagnosis and treatment, 102-103, 183-184
Vitamin C, 16, 103, 124
Wax, to replace a knocked-out tooth, 98
Wire ligature, 110
Wisdom teeth (3rd Molars) (See Molars)
for knocked-out teeth, 98
to look at new tooth growing in, 100
warning about pregnant women, 77
Zinc, 103
Zinc oxide, 145, 205
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build the communication skills of young children who do not hear
well. Covers language development through both signed and
spoken methods, assessing hearing loss, exploring causes of
deafness, and more. 250 pages.
Disabled Village Children, by David Werner, covers most common
disabilities of children. It gives suggestions for rehabilitation and
explains how to make a variety of low-cost aids. Emphasis is placed
on how to help disabled children find a role and be accepted in the
community. 672 pages.
A Community Guide to Environmental Health,
by Jeff Conant and Pam Fadem, helps urban and rural health
promoters, activists, and others solve environmental problems
to improve health. 23 chapters with dozens of activities and
instructions provide information about reducing harm from
pollution protecting water and watersheds, farming sustainably,
solid and health care waste, and more. 600 pages.
To order books in English or Spanish, or to learn more about our work, contact:
Hesperian · PO Box 11577 · Berkeley, California, 94712-2577 · USA
tel: (1-510) 845-4507 · fax: (1-510) 845-0539 · email: bookorders@hesperian.org
Where There Is No Dentist and other Hesperian books have also been translated
into many languages by groups and individuals around the world. Please write to
Hesperian or visit our website at www.hesperian.org/publications_translations.php
for information on how to order editions of Where There Is No Dentist in Bengali,
Burmese, Dari, English for Africa, English for India, Farsi, French, Korean, Miskito,
Nepali, Pashto, Portuguese, Sindhi, Spanish, and Thai.
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