Where There Is No Dentist (Hesperian Foundation, 1983, 210 p.) (introduction...) PREFACE THANKS

Where There Is No Dentist (Hesperian Foundation, 1983, 210 p.) (introduction...) PREFACE THANKS
Where There Is No Dentist (Hesperian Foundation, 1983, 210 p.)
Chapter 1: Your Own Teeth and Gums
Chapter 2: Teaching Family and Friends In Your Community
Chapter 3: Teaching Children At School
Chapter 4: School Activities for Learning About Teeth and Gums
Chapter 5: Taking Care of Teeth and Gums
Chapter 6: Examination and Diagnosis
Chapter 7: Treating Some Common Problems
Chapter 8: Scaling Teeth
Chapter 9: Injecting Inside the Mouth
Chapter 10: Cement Fillings
Chapter 11: Taking Out a Tooth
The Dental Kit
Records, Reports, and Surveys
Story Telling
Dental Health Teaching Materials
by Murray Dickson
with an Introduction by David Werner,
author of Where There Is No Doctor
Library of Congress Cataloging in Publication Data
Catalog card No. 82-84067
Dickson, Murray
Where there is no dentist.
Includes index.
Palo Alto, CA: Hesperian Foundation
ISBN: 0-942364-05-8
First edition, November 1983
Ninth printing, January 1999
The Hesperian Foundation
P.O. Box 11577
Berkeley, California 94712-2577
Copyright © 1983 by The Hesperian Foundation
This book is certainly not intended to be the last word in community dental care. It is only a beginning. The
author hopes to rewrite and improve the book with suggestions from readers.
Note on the use, adaptation, and translation of this book:
Each country is special, with its own particular customs, health needs, and ways of caring for
This book, therefore, must be adapted by dental workers in each country, using the language that
is common to the local health workers there.
The author would be pleased to assist in any way with those who would translate or adapt the
The Hesperian Foundation encourages others to copy, reproduce or adapt to meet local needs, any or all parts
of this book, including the illustrations, provided the parts reproduced are distributed free or at cost not for profit.
Any organization or person who wishes to copy, reproduce or adapt, any or all parts of this book for
commercial purposes, must first obtain permission to do so from the Hesperian Foundation.
Please contact the Hesperian Foundation before beginning any translation or adaptation to avoid
duplication of efforts, and for suggestions about adapting the information in this book. The foundation would
appreciate receiving a copy of any materials in which text or illustrations from this book have been used.
We would like to rewrite this book and incorporate many of your ideas. If you have a suggestion, please write
to Murray Dickson at The Hesperian Foundation. Better yet, if you write your own manual, please set aside two
copies and send one to the The Hesperian Foundation, P.O. Box 11577, Berkeley, California 94712-2577, USA.
Send the other to AHRTAG (Appropriate Health Resources and Technologies Action Group), 29-35 Farringdon
Road, London EC 1M 3JB, England. Both organizations would like to help pass along your ideas to others.
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 better.
Michael Blake deserves special mention. As editor of Where There Is No Dentist, it was he who took the
manuscript and nursed it along to completion. Michael’s commitment to finishing the book was vital, and I
sincerely appreciate it.
My thanks go to Maggie Leung for typing the final draft, and to those dedicated persons who helped get the
book into final form: Annaloy Nickum (page design); Hal Lockwood (typesetting and paste-up); Paul Chandler,
Serena Clayton, and Elaine Rossi (proofreading); Pat Bernier (typing); and Howard Uno (photostats).
For their outstanding drawings, I am exceedingly grateful to: June Mehra, Janet Elliott de Jacques, Michael
Marzolla, Joan Thompson, Mindy Mead, Arlene Ustin-Cartagena, and Lynn Gordon. My own drawings in the
manual appear amateurish in comparison.
I want to thank the many persons who reviewed the manuscript and offered valuable suggestions: Ken
Cripwell, Bill Bower, Jeff Vore, Aaron Yaschine, Rosalie Warpeha, Norma Francisco, Mike Muller, Marcia
Anderson, Phil Haskett, Bert Ball, 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 (6 Canonbury Place, London N1
2NJ, U.K.) for permission to use parts of David Halestrap’s book Simple Dental Care.
This book is based upon several years of practical experience, made possible by the Canadian Organization
CUSO. For this opportunity, and for CUSO’s active interest and involvement in this book, I most gratefully say
Finally, I want to acknowledge my family’s contribution. For weeks on end, my wife, Gerri, faithfully read and
discussed with me each part of the book as it changed and was rewritten. She did this cheerfully, at a time
when she was fully occupied in a graduate study program. For much longer than I had anticipated, Gerri and
our two boys, Michael and Brennan, had to tolerate my preoccupations.
My parents endured my wanderings and search for answers to human problems with love and a growing sense
of understanding. It is my only disappointment that they did not live to see this book in its final form.
by David Werner
A healthy tooth is a living part of the body. It is connected by ‘life-lines’ of blood and nerve to a person’s heart
and brain. To separate the tooth from the body, or even to interrupt those ‘life-lines’, means death to the
tooth. It also means pain and injury to the body, to the person.
Let us look at it another way. The health of the teeth and gums is related to the health of the whole person,
just as the well-being of a person relates to the health of the entire community.
Because of this, the usual separation between dentistry and general health care is neither reasonable nor
healthy. Basic care of the teeth and gums - both preventive and curative - should be part of the ‘know-how’ of
all primary health care workers. Ideally, perhaps, Where There Is No Dentist should be a part of Where
There Is No Doctor. Think of it as a companion volume, both to Where There Is No Doctor and Helping
Health Workers Learn.
Murray Dickson has taken care to write this book in a way that will help the readers see dental care as part of
community health and development. The approach is what we call ‘people centered.’
Where There Is No Dentist is a book about what people can do for themselves and each other to care for
their gums and teeth. It is written for:
• village and neighborhood health workers who want to learn more about dental care as part
of a complete community-based approach to health;
• school teachers, mothers, fathers, and anyone concerned with encouraging dental health in
their children and their community; and
• those dentists and dental technicians who are looking for ways to share their skills, to help
people become more self-reliant at lower cost.
Just as with the rest of health care, there is a strong need to ‘deprofessionalize’ dentistry - to provide ordinary
people and community workers with more skills to prevent and cure problems in the mouth. After all, early
care is what makes the dentist’s work unnecessary - and this is the care that each person gives to his or her
own teeth, or what a mother does to protect her children’s teeth.
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 foot-pedal 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 recently was tested when, in the town of Trujillo, a dentist tried to put a
technician out of business. The local technician had removed an infected root left mistakenly by the dentist.
The technician had commented on the dentist’s carelessness, and the dentist heard about it. The dentist sent a
policeman who shut down the technician’s office and took away his tools. However, the dental technicians’
union took this to court. They argued their rights to practice dentistry, because they are the only persons
working in marginal communities where dentists’ prices are too high for the people. The court decided in favor
of the technicians, and ordered the dentist to return the technician’s tools and pay him for work 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.
We hope that this will be only the first volume of Where There Is No Dentist. It takes the reader as far as
simple extraction (pulling) of teeth and placement of temporary fillings. As we have seen, village workers can
also learn a wide range of more difficult dental skills. We hope that later volumes of Where There Is No
Dentist will include permanent fillings, homemade portable drilling equipment (many kinds have been
developed), the making of false teeth, and root canal treatment. There is no reason why village workers
cannot learn all of these skills and practice them at low cost to serve the millions who are unserved today.
The people must answer to the people’s needs. The health of teeth and gums, along with general health, will
improve only when people take the lead in caring for themselves. The challenge for dentists and other health
professionals is to allow and encourage this to happen.
Where There Is No Dentist (Hesperian Foundation, 1983, 210 p.)
Chapter 1: Your Own Teeth and Gums
Next time you look in a mirror, look at your teeth and the skin (gums) around them. Look in your children’s
mouths, too. Look at both gums and teeth, because the health of one often depends on the health of the
other. To be strong, teeth need healthy gums. Healthy gums need clean teeth.
What can good teeth give you?
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
You can usually tell if your teeth and gums are healthy or not. Look at the pictures on Chapter 6 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.
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
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.
If you do not clean properly, the food that is left on your teeth can hurt the teeth as well as the gums near
Bits of food stay longer in grooves and ‘hiding places’. This is where both tooth and gum problems start.
To prevent problems you must take special care to keep these protected places clean.
It is better to clean your teeth carefully once every day than to clean poorly many times a day.
Here are 3 places where problems start.
Use a soft brush to clean your teeth. Buy one from the store (be sure it says soft on the package), or make a
brush yourself. To make a brush:
1. Use a small branch, 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 Cleaning between the teeth is very
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.
Toothpaste is not necessary. Charcoal or even just water is enough. When your teeth are clean, rinse away
the loose pieces of food.
‘Cavities’ are holes in teeth. Cavities are made by the infection called tooth decay. If you have a black spot
on your tooth, it might be a cavity. If that tooth hurts some of the time, such as when you eat, drink, or
breathe cold air, it probably has a cavity in it.
You will get cavities in your teeth if you eat sweet food and then do not clean your teeth. If you see a cavity
starting in your mouth or feel a tooth hurting you, get help right away. A dental worker knows how to
fill the cavity so you can keep that tooth. Do this before the pain gets worse.
If you do not fill a cavity, it grows bigger. It also grows deeper.
When decay touches the nerve inside, the tooth aches, even when you try to sleep.
When infection reaches the inside of a tooth, it is called a tooth abscess.
A tooth with an abscess needs treatment at once, before the infection can go into the bone. 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 for pain.
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 yourself!
A tooth abscess can cause swelling like this.
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 How do germs make holes in the teeth).
Infection from gum disease can spread into the root fibers and bone. 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
1. Even if your gums are sore and they bleed, you must still clean the teeth beside them. If more
food collects on the teeth, the gum infection will get even worse. Get a soft brush and use it
gently. This way you will not hurt the gums when you clean.
2. To make your gums stronger and more able to fight the infection:
• Eat more fresh fruits and green leafy vegetables, and fewer soft sticky foods from the
• Rinse your mouth with warm salt water. Do this every day, even after your gums feel
(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.
Painful gums that bleed at the slightest touch need special treatment. If you have this problem, ask for help, A
dental worker can explain what is happening and what needs to be done. A dental worker can also scrape the
teeth and remove the tartar that is poking the gums, making them sore.
At home, you can do some things to help.
1. Clean your teeth near the gums with a soft brush. Gently push the brush between the tooth
and the gum. It may bleed at first, but as the gums toughen, the bleeding will stop.
2. Make your food soft, so it is easier to chew. Pounded yam and soup are good examples.
3. Eat plenty of fresh fruits and vegetables. If it is difficult for you to bite into fruit, squeeze it and
drink the juice.
4. Start rinsing your mouth with a mixture of hydrogen peroxide and water. You can get
hydrogen peroxide from your clinic or your pharmacy (chemist).
The strength of hydrogen peroxide is important. Ask for a 3% solution, and mix it evenly with
water - that is, 1/2 cup of hydrogen peroxide with 1/2 cup of water.
WARNING: Read the label to be sure the solution is 3%. A mixture with more than 3% hydrogen
peroxide can burn the mouth.
Take some into your mouth and hold it there for about 2 minutes. Then spit it out and repeat. Do this
every hour you are awake.
Use hydrogen peroxide for only 3 days. Then change and start rinsing with salt water.
If you take care, you can keep your teeth for a lifetime.
Chapter 2: Teaching Family and Friends In Your Community
Old people can remember when there were fewer problems with teeth and gums. Children’s teeth were
stronger and adults kept their teeth longer.
Times are changing. Today there are more tooth and gum problems than ever before. In many countries,
tooth decay and gum disease are two of the fastest growing health problems.
This unhealthy situation is getting worse, for two reasons: changes in the kind of food people now are eating,
and not enough cleaning after they eat.
BEFORE, the food people ate was their own, grown and
prepared by themselves.
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.
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.
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.
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.
Other people like to watch what you do before they try something different. First show members of your family
and then they will be an example to others in your community. For example:
1. Instead of buying all your foods from the store, buy fresh fruits and vegetables from the
market. It is even better to grow food in your own garden.
Learn to use several different kinds of foods in each meal. Mixing foods is a healthy idea. Invite
friends to share your meals and see the number of different foods you have at each meal.
2. Do not buy fizzy drinks like Coca-Cola or Fanta. They have a lot of added sugar which quickly
makes children’s teeth rotten.
Also, do not sweeten your child’s milk or tea.
When she is young she can learn to enjoy drinks that are not sweet.
Clean, cool water, tea with little sugar, milk, or water from a young coconut are best to drink.
Fresh fruits are delicious when you are thirsty.
Most important: do not give your child a feeding bottle, especially one with a sweet drink
inside. (See Eat only good healthy foods)
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.
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.
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 Reference pages - Surveys.
2. Build New Ideas Onto Old Ones
People find their own ways to stay healthy. Many traditions are good, helpful, and worth keeping. But some
are not.
When you teach, start with what people already understand and are doing themselves. Then add new ideas.
This method of teaching is called ‘association of ideas’. It helps people to understand new ideas because they
can compare them with what they already are doing.
In this way people can more easily accept, remember, and do what you suggest.
Just as sweeping the compound makes it a
clean and healthy place to live.
- builds →
- in the → Brushing the teeth and gums keeps them clean and
A small child cannot find his own lice. Mother - in the → A small child cannot see the food on his teeth. He
knows she must help him.
needs help with that also.
Different vegetables when planted together - - in the → Eating different kinds of food helps people to grow.
like maize and yams - help each other to
Eating them several times a day makes your teeth
and gums, as well as your whole body, grow
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 Finding the best way to teach). 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 Chapter 3 - Part 2: Making learning exciting, visual,
and fun 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
Talk to women at health
clinics, in the market, and
at their church meetings.
Talk to men as they sit together
and discuss important issues. Also
go to their business and farming
Teach men and women at reading groups.
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 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.
Chapter 3: Teaching Children At School
Children want to learn. They want to know more about things that are real to them. Family, friends, and
teachers are all important sources of new knowledge for the children.
It is important to keep alive their desire to learn, so that children can continue to ask questions, discover, and
learn more for themselves.
When children are interested in something, they will work hard to learn 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 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.
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
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
He can learn by doing. Give him a chance to eat good food and clean his teeth at school.
Learning about teeth and gums can be fun. When the teaching is real and practical, students love to learn.
Here are some ideas:
Teaching so that learning can take place
Teach and learn together with your school children.
Start with what the students already know.
Let students see and then do.
Let children help each other.
Teach about teeth and gums together with other subjects.
Be a good example.
Make the community part of your classroom.
1. Teach and Learn Together with School Children.
Share ideas instead of always giving information. Children learn more when they are involved.
A lecture transfers your own notes to the children’s notebooks without ever passing through their minds.
A discussion draws out information and opinions.
It helps you to learn more about the school children, what they already know and believe to be true.
But it also allows you to introduce important information that is related to the discussion.
2. Start with What the Students Already Know.
To have meaning, learning should be a part of daily living. Talk with your students. Find out what they know
about teeth and gums, and what questions they might have.
Add information by building upon what a person already knows.
Do not use big words. Scientific names and textbook explanations are confusing, and you usually do not need
them. Talk about teeth and gums using words that a school child can understand and use later at home.
This way makes students feel stupid.
This way lets the students feel good, because it makes sense and they know something about it.
When you can understand new information, you gain confidence and you look forward to learning more.
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.
4. Let Children Help Each Other.*
For more ideas on how school children can help each other, write to CHILD-to-child Program,
Institute of Child Health, 30 Guilford Street, London WC1N 1EH, England.
In most families, older children have important work to do - taking care of their younger brothers and sisters.
These older children can do much to teach the younger ones about care of teeth and gums. For example:
(1) When they feed their younger brothers and sisters they can encourage them to eat good food,
like fruit instead of candy.
(2) They can do a play or puppet show about care of teeth and gums.
(3) They can check the teeth and gums of the younger children and ‘score’ them on how healthy
they are.
(4) 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 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 same time.
Eating good food can be part of a discussion on nutrition, teeth, farming methods, and the politics of who
owns the lands.
Cleaning the teeth can be part of a discussion on hygiene, clean water, and traditions and customs.
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 Helping Health Workers Learn.
6. Be a Good Example.
Children watch people around them. They pay attention to what you do, as well as to what you say.
Be a good example. Take care to do yourself what you are teaching to your students.
Your family can be a good example for others.
• Clean your teeth carefully every day. Also, help your children keep their teeth clean.
• Make a garden near your house and plant a variety of vegetables and fruits in it.
• Buy only good, healthy food from the store. Do not buy sweet foods and drinks for yourself or
your children.
7. Make the Community Part of Your Classroom.
A child’s home and his community are really more important to him than his school. Learning will be more
interesting for a student if the day-to-day needs of his home and his community are part of school discussion.
Let students find out more about problems at home and in their community.
For example:
• How many small children have cavities or red, bleeding gums?
• How many stores have mostly sweet snack foods on their shelves?
• Why do the people not grow and eat more local food?
Back in the classroom, students can record what they find. Ask the children to think of ways to solve the
problems they found. If they can think of a program to help solve a health problem, let them go back into their
community and try it.
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. 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 Reference pages - Story telling.
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’.
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.
You can use pictures on posters, flip charts, and on flannel-boards.
Pictures that school children draw themselves are best. They learn simply by drawing them. Also, school
children will draw local people and local experiences, and the people will understand their pictures better than
the ones sent from a central office far away.
Photographs of local people and events are also good. If there is a photography club in a local secondary
school, have them take some pictures for you. They may even print the photographs larger so that you can
use them as posters.
Ask the children to make pictures big enough so that a person can stand far away and see them easily.
Let each child carry her poster home to show her family and friends.
Hang up other posters in the store, church, or other places where people will see them.
Pictures can be made to stick to cloth and then used to tell a story. Cover a board with a piece of flannel cloth
or a soft blanket, to make a flannel-board.*
For more ideas on flannel-boards, see Helping Health Workers Learn.
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.
Flip charts are excellent for telling a story with pictures. Often, people can guess what the story is about just
from the pictures. When showing the pictures on a flip chart, ask as many questions as you can, to get the
people to tell you the story.
This is part of a flip chart presentation on mothers’ and children’s health. Notice the rings at the top that hold
the flip chart together. They are made from old electrical cords.
Here a health worker from Mozambique is holding a flip chart with pictures about care of teeth and gums.
There are no words with the pictures.
But he can read a short message written on the back of the page before. There are also examples of questions
to ask. This way, anyone who can read can tell the ‘flip chart story’ to others.
There is also a small copy of the big picture on the back of the page before.
Find a way to attach the sheets of heavy paper. Here are two ways:
with 2 thin pieces of wood
with metal or wire rings
Dental workers in Mozambique created this flip chart presentation for teaching in schools.
1) Here is a healthy, happy schoolboy. In the circle you see the inside of his mouth. His teeth are
white and clean. Look at his gums. What color are they? Are they tight or loose? Between the
teeth, are the gums pointed or flat?
2) This is an unhappy, sick boy. What color are his teeth? Not only are they yellow, there are black
spots. These are cavities.
What color are his gums? Are they pointed? Loose, red, swollen gums are signs of gum disease.
Both cavities and gum disease can be treated.
3) What happens if tooth and gum problems are not treated?
a) The black hole grows bigger on the tooth and a sore forms on the gums near the
root. The tooth hurts whenever you touch it.
b) The red, loose gums pull away from the tooth. Infection gets to the bone and eats
it. The tooth loses the bone and the gum around it.
The first problem is a tooth abscess. The second is advanced gum disease. If either of these
things happens, the tooth must be taken out.
4) Why does the boy have cavities and gum disease? There are 2 reasons.
a) He eats too many sweet foods.
What foods do you see here?
What other foods hurt the teeth?
b) He does not clean his teeth regularly.
The germs in his mouth eat sugar from his food and make acid. Acid causes both cavities and gum
5) What foods can the boy eat to keep his teeth and gums healthy? What do you see in this
Natural foods, with no sugar added, are the best. The foods you grow yourself and local foods from
the market are better than sweet foods from the store.
6) How can we clean our teeth? Carefully is the important word to remember. Clean your teeth at
least once a day, carefully brushing every part of every tooth - outside, inside, and top. Be very
careful to push your brush between your teeth. That is where the germs and food collect to
make acid.
If you do not have a toothbrush, you can make one from a stick. Toothpaste is not necessary.
Clean water is enough.
Chapter 12 in Helping Health Workers Learn is full of ideas on how to make and use pictures effectively.
Once you have a good original, you do not need to be an artist to make a good copy. Here is an easy method
that can involve every student.
Place thin see-through paper over the original drawing. Carefully trace a copy.
Now place the copy on a new sheet of heavy paper. Pressing firmly with a pencil, retrace all of the lines on the
thin copy paper.
Remove the tracing paper. Pressure from the pencil has made lines on the poster paper. Redraw them with a
pencil so they stand out clearly.
Your copy is now ready for coloring. And you can use your copy paper again to make another copy.
Use puppet shows to act out the messages of eating good food and keeping teeth clean.
Students can make their own puppets to look like people or animals.
Using puppets, it is often easier to say things that people themselves cannot. For example, they can talk
openly about the bad food sold at the village store.
Children can make puppets easily from paper bags. They are good for showing teeth because you can make a
wide-open mouth.
A puppet made from a sock looks alive.
1. Fit the sock over your hand.
2. Make the mouth by pushing in the cloth between your thumb and fingers.
3. Add eyes, nose and hair to the sock or to a box that fits over it.
Loosely fill a cloth bag with old cotton or paper. Put the end of a stick inside, and tie the bag to it with tape or
string. Make a sad or happy face to fit the story. Dress the puppet with an old piece of cloth.
For another example of a puppet show, and more suggestions for making puppets, see Helping
Health Workers Learn.
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
2) Pedro, a schoolboy, is sad. His friends looked into his mouth
and saw two teeth with big holes in them. He tells his brother he
wants to walk home alone.
3) On the way, Pedro meets Maria, a friend who is a dental
worker. “I’m not sad because the others are laughing,” says
Pedro. “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.
4) One day later.
(Note how the scene behind the puppets changes. It is a
flipchart with pictures to show the different places the puppets
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.”*
To learn how to make a temporary filling, see Chapter 10.
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, “I’ll put some cement in those
7) Four months later, Pedro visits the dental worker in the city.
“Maria’s good fillings saved your teeth,” he says. “These
permanent fillings will last for years.” “Terrific!” says Pedro.
8) After the show, the puppets played a game. Throwing a ball
into the audience, they asked questions like “How do you keep
cavities from happening?” Each child who caught the ball
answered the question and threw it back. Then the children in
the audience began asking questions for the puppets to answer.
“Why did you get rotten teeth?” one child asked Pedro. The
puppet looked down and said, “Too much candy!”
Chapter 4: School Activities for Learning About Teeth and Gums
We can help school children in two ways. First, they need treatment now for problems they already have.
Second, they need to learn how to prevent problems from hurting them (and their families) later.
Treatment and prevention go together. It is a mistake to emphasize only prevention and to forget about
treatment. In fact, early treatment is the first step to prevention because it usually meets a person’s
most strongly felt, immediate need.
As a community dental worker, you can visit a school and find out what the felt needs are. Begin with the
teacher. Examine for cavities, bleeding gums, or other problems. Then look at the students.
Chapter 6 tells you how to examine a person. It also helps you decide what treatment to give, and who should
give it.
Then teach how to prevent dental problems. Give the teacher ideas to help students learn why they have
problems, and how to keep the problems from returning. The best way to learn is by doing - through activities,
not lectures. This chapter has many suggestions for activities.
The best health practice is to prevent cavities and gum disease from even starting. With these activities,
children can do something to guard their health.
Teacher, each day at school:
Suggest ways for your students to eat good healthy kinds of food.
Give your students time to clean their teeth.
A Note To Teachers:
Do not wait for a dental worker. This book, and especially this chapter, is written to help you learn and do
things yourself. But do ask your dental worker to work with you. He probably has suggestions that would fit
your situation. After examining the children, he can help you follow their progress. You can then find out how
much they are learning and how healthy they are becoming.
To begin, talk with your students to find out what they think and what they already know. What are their
traditional beliefs? Some may be helpful, and others may need changing. At first it is best simply to discuss.
Ask the kind of questions that get students talking. Later they will take part in discussions more easily.
Add new information as you go along, changing some ideas but usually building upon what the students
already know.
This chapter asks nine questions:
Why do we need teeth and gums?
Why do some teeth look different?
What holds the teeth?
How often do teeth grow in?
What makes teeth hurt?
How do germs make holes in the teeth?
What makes the gums feel sore?
What does it mean if a tooth is loose?
How can we prevent cavities and sore gums?
For each question, there is an activity to help students discover answers for themselves. The questions are not
in any particular order, nor are they written for any particular grade level. Make your own lesson plan, using
the main idea to help you. Shorten the lesson and make it easier for younger children. Add more information
for older students and let them do more activities.
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.
Make a picture of a person who has lost all of his teeth. He looks old.
Talk about how hard it is for him to eat properly or speak clearly.
2. Have the students say words that use teeth to make sounds.
“v” and “f” - friend, fever - the lower lip touches the top teeth.
“th” - the, teeth - the tongue touches the top teeth.
“s” - sun - air goes between the teeth.
Now, try saying the same words again, but do not let the tongue or lips touch the teeth.
3. Have students draw pictures of good foods we use our teeth to eat. Then draw foods that we can eat if we
lose our teeth.
Need Teeth
No Teeth Needed
And Many
Much More!
Talk about this together. Try to eat a mango or some maize without using your teeth, or using only your front
Why Do Some Teeth Look Different?
We need two different kinds of teeth to help us eat our food.
The outside of a tooth is the hardest and strongest part of your body. When a tooth is healthy, it can chew
hard food, even bone. The shape of a tooth allows us to swallow food when the small pieces can slide down its
smooth sides.
Small bits of food often get caught inside deep lines, or grooves, in a tooth.
Look for them on the top and the sides of back teeth.
Food that is not cleaned away from the grooves can make a cavity (hole) in them.
A tooth with a cavity is weak and often hurts.
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
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
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.
2. Show your students how infected gums can cause teeth to fall out.
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:
Enrique was sleeping on a cold night when suddenly he had diarrhea. Still dreaming, he went outside, and
afterward, he forgot to close his pants tightly. Suddenly, he saw an ugly monster coming after him! He ran
away without thinking of his pants. Finally he could not run because his pants were around his knees, and the
monster caught him.
Explain to the children that when the gums are red near a tooth, they are like Enrique’s pants - not tight
enough around the tooth. When germs come near the tooth, they will go inside and the gums will ‘fall down’
and show part of the root of the tooth. When this happens, the germs attack not only the top of the tooth, but
also the bone and root.
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
In the 6 years between ages 6 and 12, the 20 permanent teeth replace the 20 baby teeth. In addition, 8 other
teeth grow in behind the baby teeth.
At 6 years the four 1st permanent molars start to grow in at the back of the mouth. This means an 8-yearold child should have 24 teeth, or spaces for them.
At 12 years, the four 2nd permanent molars grow in behind the 1st molars. This means a 14-year-old child
should have 28 teeth, or spaces for them.
Between 16 and 22 years, the four 3rd permanent molars grow in. This means that an adult should have a
total of 32 permanent teeth: 16 on top and 16 on the bottom.*
(Note: the third molars often do not grow in correctly. This is a very common cause of tooth
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.
Here the children are only counting the teeth. They can also learn to check for cavities and gum
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.
Discuss the number of teeth children have at different ages. Young children 6 to 12 years old, for example,
have 24 teeth; older students, 28 teeth; and adults, 32 teeth.
At home, students can count brothers’ and sisters’ teeth to learn how many teeth small children have. Count
only the teeth and not the spaces.
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 How can we prevent cavities and sore gums.
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 Why baby teeth are important to find answers to
questions like these:
• Can Chenia, who is six months old and has no teeth, eat soft foods? Should she have more than
just breast milk?
• When Chenia’s teeth grow in, will they give her diarrhea and fever?
• Will a 2-year-old girl get more baby teeth?
• Why do we care for baby teeth, when we only need them for a few years?
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, comes from the brain and carries the message of pain. The
other is the blood vessel. It comes from the heart and carries blood to the tooth.
If you could peel away the gum and look inside the bone, you would see that a nerve and a blood vessel go
into each one of a tooth’s roots,
They give the tooth life and feeling.
The hard cover of the tooth protects the nerve and blood vessel inside it. But when tooth decay eats through
that cover, the nerve and blood vessel are unprotected. A cavity lets food, water and air get closer to the
nerve, and that can make the tooth hurt.
The sugar in food makes tooth decay possible. Sweet food that is also sticky is the worst of all because it glues
itself to the teeth. Germs inside your mouth use the sugar to grow and to work harder at making cavities.
See the next section for more discussion of how germs and sugar combine to cause cavities.
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.
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
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.
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 grind it for you.
1. Take a hammer.
2. Gently break open a tooth.
3. Look inside.
See how much bigger the cavity is on the inside. It spreads under the hard cover.
Cut through a rotten yam. See how the rotten part spreads under its skin in the same way.
4. Do a project in class.
• 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.
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.
The main reason for cleaning teeth is to break up these colonies so they cannot make acid. Also, if you forget
to clean your teeth, tartar will form, and you will need a dental worker to scrape it off. This is why it is
important to clean your teeth at least every 24 hours, so the tartar can never form on your teeth.
Here is a game called “Scatter!” that students can play outside. You need:
• Five ‘bases’ (a tree, rock, or the corner of a house can be a base) in a half circle, 12 meters
apart. Each base must have a ‘monitor’ who stays at the base. Note: children who cannot run can
be good monitors.
• One person with a broom. This person is the ‘decolonizer’.
Children in Jocuixtita, Mexico, beginning a game of “Scatter!.” The ‘decolonizer’ is the girl in the center with
the broom.
The Game:
20 students called ‘colonizers’ stand facing the decolonizer. When the decolonizer says “go!” they try to ‘form
colonies’ around the bases before the decolonizer can touch them with the broom.
The ‘decolonizer’ (with broom) has lost the game. The children behind him have formed a ‘colony’.
The colonizers win if they make a colony. There are two kinds of colony: (1) 15 people touching one monitor at
a base, or (2) a chain of 12 people holding hands, touching two monitors.
Play two games: one with children trying to form the first kind of colony, one with the 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.)
Here the decolonizer stops a boy from completing a chain.
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 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!
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, 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. Also, if the coating on the teeth becomes hard, it is called tartar.
Tartar can be very sharp and hurt the gums. Also, the ‘colonies’ of germs can make a coating on top of tartar
more easily than on a clean tooth. When the colonies are new, they make more acid to cause tooth and gum
problems. After 24 hours, they harden and make a new layer of tartar. The tartar gets bigger and bigger.
Here is a larger picture of the teeth in the box above:
Sore gums are infected. Infected gums are red and bleed easily.
Infected gums are round and swollen between the teeth. They are also loose instead of tight
against the teeth.
Infected gums have a deep gum pocket which catches even more food.
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.
2. Eat more fresh fruits and vegetables.
3. Rinse your mouth with warm salt water.
4. Clean between your teeth with dental floss or string. At first your gums may bleed when you do this. But
when the gums are stronger the bleeding will stop.
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.
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 now show the younger ones the best way to clean teeth. Let the younger ones see in
the mirror if they are getting the colored juice from their teeth. They will learn that it is most difficult to get rid
of the color between their teeth. Give them some string, dental floss, or even the soft stem from a young palm
leaf, and show them how to use it between their teeth. Remind them to be gentle, or they will hurt their gums.
You should clean between your teeth every day.
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
Touch the gum and bone beside the loose tooth. You can feel a bump - it is the new permanent tooth growing.
Save the baby tooth after it has fallen out. Look to see how the permanent tooth has eaten away its root by
pushing against it.
2. Look for teeth that have cavities or gum disease around them. The students can do this with each other,
and then later at home, (Remember they must wash their hands!)
A tooth that has some of its root showing is probably loose.
Using your fingers or the handles of two spoons, rock the tooth back and forth gently. See how much it moves,
and ask how much it hurts.
Tell the person what he can do to prevent other teeth from becoming loose. (See the next section.)
How Can We Prevent Cavities and Sore Gums?
Eating good food and carefully cleaning the teeth prevents both tooth decay and gum disease.
Food from your own garden and local food from the market is best. These foods are good for your
body, your teeth, and your gums.
Vegetables, especially those
with dark green leaves.
Peas and beans, like green beans,
soybeans, winged beans, and mung
Oil, from palm nut kernels,
ground nuts, and coconut.
Fruits, like banana, guava,
oranges, and papaya.
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 quickly.
Children who eat a lot of sugar lose their appetite for other foods - the foods that help them grow strong, stay
healthy, and learn well in school.
Store foods are also expensive. You can usually get better food, and more of it for the same money, from your
garden or in the market.
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. 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 to see how you can do this. Older children can care for younger brothers and
sisters at home.
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
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.
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.
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.
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. 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. One day a week, the whole class can rinse with fluoride
water to prevent cavities.
Have the students score each other’s progress. Do not make it hard to judge, or they will not do it. In the
example below, the tooth is either clean or not clean.
Pick 4 teeth, a back tooth and a front tooth - two on top and two on the bottom.
Use the same 4 teeth for each person. Look for food on each tooth near the gums.
A clean tooth = 2 points
A dirty tooth = 0 point
Total possible points each day is 4 teeth x 2 = 8 points.
In this example the score is:
Tooth 1 = 2 points
Tooth 2 = 0 point
Tooth 3 = 0 point
Tooth 4 = 2 points
Total = 4 points
Have each student put his daily score on a chart. At the end of the month he can see how much he has
Chapter 5: Taking Care of Teeth and Gums
We can prevent most tooth and gum problems. This chapter gives more information about how teeth
grow in and how to keep teeth and gums healthy. Share this information and you will prevent problems from
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 problems.
In order to help a person it is important to know what the problem is and what is the best treatment. But just
as important is knowing what you are not able to do, and when to seek help.
In this chapter, you will learn more about teeth, gums, and problems affecting them, but you must never be
too proud to get help from more experienced dental workers.
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
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
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 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. That cavity should not be
filled with cement. Instead, the tooth needs to be taken out (Chapter 11) before the infection can get worse.
For baby teeth to grow strong, mother and baby must stay healthy.* Help her to understand how important
this is. A pregnant mother should:
1. Eat enough good kinds of foods, both for herself and her baby growing inside (see Where
There Is No Doctor, Chapter 11, and Helping Health Workers Learn)
2. Attend health clinic each month, so the health workers can examine her regularly and she can
receive important medicines (see Where There Is No Doctor).
3. Not use the medicine tetracycline, because it can cause the teeth to turn dark. You, the health
worker, must remember - do not give tetracycline to a pregnant woman or to a young
child. If she needs an antibiotic, use a different one.
See the story about pregnancy and dental care.
For baby teeth to stay strong, and to prevent marks from turning into cavities, mother should:
1. Continue to breast feed and never feed her child juice or sweet tea from a bottle. Start
adding soft foods, mashed banana or papaya when the child is 4 months old.
2. Wipe her baby’s teeth with a clean cloth after the baby eats. This cleans the baby’s teeth, and
helps the baby get used to teeth cleaning. Later he will be happy with a brush.
Around 1 year of age, there will be several baby teeth. At that time, mother should start using water - not
toothpaste - on a soft brush or brushstick. (With toothpaste, you cannot see the child’s teeth clearly because
of the bubbles it makes.) She should scrub the sides and tops of each baby tooth as well as she can.
The child can also try to clean his own teeth. That should be encouraged. However, since he is too young to
clean properly, mother (or father, or older brother, sister) must clean his teeth once a day for him. Continue
helping in this way until the child is old enough to go to school.
You can make a large brush smaller, to fit more easily into a young child’s mouth.
Pull out some of the back hairs, or cut them with scissors.
Why Baby Teeth Are Important
Baby teeth are just as important to children as permanent teeth are to adults. They help a child to eat, talk,
and look good.
However, many people feel that it is not worth the effort to look after baby teeth. Nor is it worth fixing them.
After all, parents think, the permanent teeth will take their place.
This kind of thinking is understandable. The problem is that we are forgetting one other useful purpose of baby
teeth. Baby teeth keep space in the mouth for the permanent teeth to grow in. If there is not enough
space, the new teeth will grow in crooked, and cavities grow faster around crooked teeth.
Under each baby tooth a new permanent tooth is growing.
At the same time, extra permanent molars are forming at the back of the mouth, inside the bone.
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
Permanent molars (PM) come in behind the baby molars (BM).
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.
Between the ages of 6 and 11, a child needs healthy baby molars to guide the first permanent molars into
position and then to hold them there. When the first permanent molars grow into the right place, this is a good
sign. It means the other permanent teeth will also grow in properly, because they will have enough space.
Note: Some people are born without enough space. But most people are not born with this
problem - they lose the spaces when they remove baby teeth instead of fixing them.
help →
to make
10 years
10 years
help →
to make
Tell mothers why baby teeth are important. Good food and regular cleaning keeps them healthy. They should
know that new teeth coming in do not cause diarrhea and fever, but that a child may have diarrhea or
fever at the same time.
If there is a cavity, fix it so the tooth can be kept in the mouth to do its important work (see Chapter 10).
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
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 mouth.
If it does appear serious (severe pain, swelling, not able to open the mouth).
This book often repeats an important message: eat good food and clean your teeth. It is repeated because
this is the most important thing you can learn from this book. Later chapters will discuss what to do
when problems occur, but if you follow these two suggestions, you will almost never have problems with your
teeth and gums. This is true because good food keeps your whole body healthy, including your teeth. Also,
with no ‘colonies’ of germs or harmful factory sugar 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.
The MAIN FOOD is at the center of every meal.
Good nutrition (eating well) means two things:
One, eat a mixture of different kinds of foods every time you eat. Look at the pictures on How can we
prevent cavities and sore gums. There are several groups of foods. Every time you eat, try to eat one or
two foods from each of the groups. This way, you will get three important kinds of food: GROW FOOD (bodybuilding food) to give you the protein you need; GLOW FOOD (protective food) to give you vitamins and
minerals; and GO FOOD (concentrated energy food) to give you calories to be active all day.
Two, be sure you eat enough food to give your body the energy it needs. This is even more important
than the first suggestion. We get half or more of our energy from our MAIN FOOD. In most parts of the world,
people eat one low-cost energy food with almost every meal. Depending on the area, this MAIN FOOD may be
rice, maize, millet, wheat, cassava, potato, 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.
Be sure always to eat GROW FOODS and GLOW FOODS to get the vitamins and protein you need.
Your energy foods give you the most important part of your diet - calories. Half or more of our calories come
from the MAIN FOOD, and most of the other calories come from GO FOODS.
WARNING ABOUT ‘GO FOODS’: Although GO FOOD gives us the energy we need, some GO FOODS are
worse than others. Honey, molasses and especially white sugar can be very bad for the teeth, even though
they have the calories we need. Fruits, nuts, and oils all give us energy (calories) without attacking the teeth.
2. Clean Your Teeth
Cleaning teeth requires time and care. If you hurry, you will leave food and germs behind, and they continue
to make cavities and sore gums.
You may find that different dental workers recommend different ways of brushing teeth. Some ways are
definitely better, but often they are harder to learn.
Teach a method of cleaning that a person can learn and will do at home. Let him start by scrubbing his teeth
(and his children’s teeth) back and forth, or round and round. Encourage him to improve his method only
when you think he is ready.
Toothpaste is not necessary. Some people use charcoal or salt instead. But it is the brush hairs that do the
cleaning, so water on the brush is enough.
Scrub the outside, inside, and top of each tooth carefully.
When you finish, feel the tooth with your tongue to make sure it is smooth and clean.
Finally, push the hairs of the brush between the teeth and sweep away any bits of food caught there. Do this
for both upper and lower teeth.
Sweep away in the direction the tooth grows: sweep upper teeth down and lower teeth up.
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 storekeeper that hard toothbrushes do not help the people in the
community. Ask him to order and sell only soft toothbrushes.
Note: Another important way to reduce cavities is by adding fluoride to teeth. Fluoride is a
substance which, like calcium, makes teeth harder and stronger.
Fluoride in drinking water, toothpaste, vitamins, and mouth rinses, helps to prevent cavities. These methods
are sometimes expensive. Perhaps the most effective and inexpensive method is the weekly rinse at school.
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:
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 learn how to ‘floss’ your teeth is to have someone show you. Ask a dental
worker who has experience.
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.
With your fingers pull the string against the side of one tooth. Now move the string up and down. Do not
pull the string back and forth or it will cut the gum.
Lift the string over the pointed gum and clean the other tooth.
When you have cleaned both teeth, release the string from one finger and pull it out from between the teeth.
Then wrap it around your two middle fingers once again, and clean between the next two teeth.
Remember: clean teeth and good food will prevent almost all dental problems.
Chapter 6: Examination and Diagnosis
Whenever you do an examination, remember to examine the mouth.
You can prevent much suffering and serious sickness when you notice and treat problems early. Whenever you
hold a health clinic, try to find out how healthy each person’s mouth is.
Ask if she is having a problem now, or has had a problem recently.
Always write down what you find out, so you remember what treatment that person needs.
When you look inside someone’s mouth, ask yourself three questions.
1. Are the teeth healthy? Look for:
2. Are the gums healthy?
Look at page What makes the gums feel sore 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.
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.
2. Sores on the inside of the lip or
cheek may be from a virus.
3. Sores on the lips or tongue
may be cancer.
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
Share your knowledge - explain things to people. Help them learn how they can prevent and even
manage their own problems with their teeth.
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 gum.
If you have many people to examine, it is helpful to have more than one of each instrument. But be sure they
are clean.
Dirty instruments easily can pass infection from one person to another. After you finish an
examination, clean your instruments in soap and water and then leave them in a germ-killing solution.
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:
Ask questions about the problem.
Look at the person’s face. Think about the person’s age.
Examine the mouth more carefully than before.
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 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
• Where does it feel that way? See if he can put his finger on the tooth or place that is
bothering him.
• When do you have the most pain? Find out if it happens all the time or only some of the time.
• When did it start? Find out if he has already had this problem before. Ask how he took care of
• 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.
When you talk to a woman, find out if she is pregnant. A pregnant woman’s gums can easily become
infected. The gums may bleed and she may have more tooth decay. But this is not necessary. If a pregnant
woman takes extra care of her teeth and gums, she can prevent most dental problems. But if she already has
a problem, do not wait for the baby’s birth before you help her. You can treat a pregnant woman’s mouth
problems now. In fact, this may be an important way of protecting her baby as well.
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 Swelling can come from
• mumps
• a new tooth growing in • a tooth abscess
• an infection in the spit gland • a tooth abscess
• a broken jaw
• a tooth abscess
• a tumor
A sore can come from A sore can come from A sore can come from
• impetigo
• Vincent’s Infection
• fever blisters
• a tooth abscess
• a tooth abscess
• a bone infection (osteomyelitis)
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
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
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.
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.
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
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
The tooth hurts when chewing food. It may hurt
when tapped, but there a no cavity and the
tooth looks healthy.
tartar between the
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
a new tooth growing
Several top teeth hurt, even when you tap them.
She had a head cold and can only breathe through
her mouth.
an infected sinus
He had a toothache recently. The bad tooth hurts
when you tap it.
a tooth abscess
She is young, about 18 years old, and has trouble
a new tooth growing
opening her mouth.
He was hit on the face or jaw. The bone hurts
when you touch it. The teeth do not fit together
a broken bone
The swelling is under or behind the jaw. It gets
worse when he is hungry and smells food.
an infection inside
the spit gland
The swelling has been there for a long time. It
does not seem to get better
a tumor
Food and tartar are attached to the tooth. The
gums around it are loose and swollen.
infection inside the
root fibers - from
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 bone
- from 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 move.
a broken bone
around the tooth’s
infection inside the
bone from Vincent’s
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 against
The gums are red and swollen. They bleed when
the teeth are cleaned.
gum disease starting
from a
in another place
Between two teeth the gums are sore and swollen,
like a small tumor.
something 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.
Vincent’s Infection (a
more serious gum
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 refitted
A kind of white cloth seems to be stuck to the top
of the mouth or tongue. It may stop a baby from
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 scabs.
fever blisters - from
Herpes Virus
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 mouth.
a condition called
Noma - starting from
Vincent’s Infection of
the gums
A 1-month-old sore on the lips is not healing with
TROUBLE OPENING He is young, between 16-24 years, with some
smelling behind his jaw.
a new tooth growing
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 swelling.
an abscess in a back
When she tries to open her mouth, there is a
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 joint where 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.
TROUBLE CLOSING After opening wide to eat or yawn, his mouth
became stuck there. He has many missing back
He had an accident, and now something is
stopping the teeth from coming together.
a dislocated jaw
a broken Jaw
Chapter 7: Treating Some Common Problems
You must make a good diagnosis to treat a problem so it finishes and does not return. Why treat a sore on the
face by cleaning it when the sore is from pus draining from a tooth with an abscess? You need to know the
cause of the sore to give the best kind of treatment.
After you make the diagnosis, you must decide whether you or a more experienced dental worker should
provide the treatment.
Know your limits. Do only what you know how to do.
In the following pages, we describe the kinds of problems you as a health worker may see, and we also give
the treatment for each problem. Use the table below to help you find the right page.
Before you touch the inside of anyone’s mouth, learn how to keep clean. See the next rules.
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
Wash your hands in front of the person, in the same room. You will show that you are a careful and caring
health worker. Also, you will demonstrate just how important cleanliness really is.
The mouth is a natural home for germs. They usually do not cause problems because the body is used to
them. In fact, many germs are helpful. For example, when we eat, some germs break down chewed food into
parts small enough for the body to use.
There are problems when the number of these ordinary germs increases greatly, or when strange, harmful
germs come into a healthy body from outside. Fever and swelling follow. It is an infection.
When we regularly clean the mouth, the number of germs stays normal. You can teach others to clean teeth
and gums, but cleaning is each person’s responsibility.
However, dental workers have one serious responsibility. You must not spread germs from a sick person
to a healthy person. You must do everything you can to make sure your instruments are clean.
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
Sterilizing means killing germs. The best way to sterilize is with heat. High heat kills almost all harmful
germs - especially those that cause hepatitis, tetanus, and mouth infections. Wet heat (steam) is always more
effective than dry heat from an oven.
Here is a simple rule to use in deciding when to sterilize:
Boil any instrument that has touched blood.
That means always sterilize with steam all syringes, needles, and instruments you use when scaling teeth
(Chapter 8) or when taking out a tooth (Chapter 11).
Be safe: When in doubt, sterilize!
Instruments left in boiling water need 30 minutes to become sterile. A pot with a cover to trap the steam can
act faster. The inside becomes hotter and 20 minutes is enough. But remember that water can rust metal
instruments. To prevent rust:
• 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
Never put an instrument away while it is wet.
Sterilizing with steam under pressure is the fastest and surest method. It kills harmful germs in 15 minutes.
You need a strong pot with a tight fitting lid. But be sure to make a small hole in the lid so steam can
escape when the pressure becomes too great.
A special pot called a pressure cooker is perfect for this. It even has a safety hole on it to release extra steam.
1. Put 2 cups of water and 2 spoonfuls of oil into
the pot.
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 left inside it.
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%) and 3 parts clean water. Keep the
container tightly covered to prevent evaporation.
2. Keep a covered pan half filled with this mixture. You will have to add some more of the mixture
from the large container (#1) to the pan each day.
3. Leave your clean instruments in the pan, completely covered with the liquid, for 30 minutes.
Bleach (sodium hypochlorite) solution
Find the cheapest brand name in your area for bleach. Examples are Javex, Clorox, Purex, and Cidex. Make
1 liter of solution with a mixture of 1/2 cup (100 ml) of bleach and 3 1/2 cups (900 ml) of clean water.
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.
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.
A groove on the neck of a tooth is a more difficult cavity to fill. For the temporary cement to hold properly, you
need to shape the groove with a drill. To help temporarily, you can paint the groove with fluoride water. Do
this once each week until the inside part of the groove is stronger and the tooth hurts less. Or, you can paint
the inside of the groove with oil of cloves (eugenol) to reduce the pain.
To avoid making the problem worse, (1) do not use a hard toothbrush; (2) do not brush back and forth along
the gums; and (3) do not chew betel nut and do not hold it against the teeth.
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. If the anesthetic works,
then it is safe to take out the tooth.
To treat the swelling, give an antibiotic. Penicillin by mouth is best. Use an injection only when the person
is in immediate danger. For example, inject penicillin when the person has a fever or if the swelling is pressing
against the throat. But remember you can treat most serious infections with simple penicillin by mouth. For
the doses for serious infections, look below the box on the next page. If you still think an injection is
necessary, look at the section on ‘aqueous procaine penicillin’.
Adults and children over 25 kg. (60 pounds) of weight should take the same amount of oral penicillin. Children
under 25 kg. should take 1/2 as much. For most infections, penicillin by mouth is taken 13 times: a very large
first dose and 12 smaller doses every 6 hours for 3 days. The person should take all of the penicillin,
even if the pain or swelling goes down. For the correct doses, see the next page.
(for those allergic to penicillin)
Penicillin G or V:
1 tablet = 250 mg.
Give enough tablets for 3 days
1 tablet (or capsule) = 250 mg.
Give enough tablets for 3 days
First Dose (take all at once)
First Dose (take all at once)
Adults and children over 25 kg.
8 tablets Adults and children over 25 kg.
(2000 mg.)
Children under 25 kg.
4 tablets Children under 25 kg.
(1000 mg.)
Then every 6 hours for 3 days (12 doses)
4 tablets
(1000 mg.)
2 tablets
(500 mg.)
Then every 6 hours for 3 days (12 doses)
Adults and children over 25 kg.
2 tablets Adults and children over 25 kg.
(500 mg.)
2 tablets
(500 mg.)
Children under 25 kg.
1 tablet Children under 25 kg.
(250 mg.)
1 tablet
(250 mg.)
IMPORTANT: to allow it to best fight infection, take
penicillin before eating.
IMPORTANT: to avoid upset stomach, take
erythromycin with meals.
For serious infections, it may be necessary to take the antibiotics for a longer time. Take the same first
dose as above, then take 1/2 the first dose every 6 hours until the condition begins to improve. Then take the
second, smaller dose every 6 hours until the end of five days, or seven days if it is very serious.* Usually you
can take out the tooth 1 or 2 days before the end of the antibiotic treatment, but the person must continue
to take all of the tablets, even after you have taken out the tooth.
If the infection does not heal, penicillin may not be the best antibiotic. Take some pus from the
infection and have it tested, to see which antibiotic is best.
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 two-day supply will be enough, because the penicillin and the heat
will reduce the pressure and that will reduce the pain. The best medicines for pain are aspirin, which comes in
300 mg. tablets, and acetaminophen (paracetamol), which comes in 500 mg. tablets. Aspirin is usually
cheaper, but acetaminophen does not cause stomach pain and it is safer than aspirin for children. (To avoid
stomach pain, take aspirin with food, milk, or water.)
Take aspirin or acetaminophen 4 times a day. Every 6 hours, adults can take 2 tablets, children 8 to 12 years
take 1 tablet, and children 3 to 7 take 1/2 tablet. Children 1 to 2 years should only take acetaminophen,
1/4 tablet 4 times a day.
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 them.
• a head cold, and plugged nose. She can only breathe through her mouth.
• hurts when you press against the bone under her eyes.
Do not take out any teeth. They will feel better after you treat the sinus infection.
1. Give penicillin for 3 days.
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.
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
• pain when breathing air or drinking water
• 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 spit 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.
You can save a broken tooth if the nerve is still covered and the root is not broken. To do this, use a
file on the sharp edges around the break. This makes them smooth so they do not cut the tongue. Later, an
experienced dental worker who has the equipment can cover the broken part with a cap or a filling. Until this is
possible, tell the person how to protect the tooth:
• Give the tooth a rest. Use other teeth to eat.
• Do not drink things that are very hot or cold, and do not eat spicy food.
• Watch the tooth. See if it changes color (gets darker). Also watch the gums near the root. See if
a sore (gum bubble) develops.
A dark tooth and gum bubble are signs that the tooth is dying. Take it out, unless you can give special nerve
2. Tooth knocked out
When a tooth is knocked out of the mouth, you should ask two questions: (1.) Was it a baby tooth? and (2.)
How long ago did it happen?
Baby tooth. There is no reason to try to put a baby tooth back into the socket. Tell the child to bite on some
cotton to stop the bleeding. Then wait for the permanent tooth to replace it. Warn the mother that the
permanent tooth may take more time than usual to grow into the mouth.
Similarly, there is no need for treatment if the baby tooth is pushed up under the gum.
The tooth may grow back into the right place later, or it may turn dark and die. If you see a darkened tooth or
a gum bubble, 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.
1. Wash the tooth gently with clean water. There should not be any bits of dirt on the root of the tooth.
Keep the tooth damp with wet cotton gauze.
Do not scrape away any skin from the root or from the inside of the socket.
2. Gently push the tooth up into the socket. As you push it up, use a slight turning movement back and forth.
The biting edge of the loose tooth should be at the same level as the teeth beside it.
Hold it in place with your fingers for about 5 minutes.
3. Soften some beeswax and form it into 2 thin rolls. Place 1 roll near the gums on the front side of five teeth:
the loose tooth and the two teeth on each side of it. Press the wax firmly, but carefully, against these teeth.
Do the same with the second roll of wax on the back side of the same teeth, again near the gums.
It is good if the wax on the back side is touching the wax on the front side. This helps the wax hold the teeth
more firmly. To do this, you can push the wax between the teeth with the end of your cotton tweezers.
Keep the wax in its position for at least 3 weeks.
Tell the person with the injured tooth to return to see you several times. The tooth may die several
months or even several years later. If that happens, you must take out the tooth, unless you can do root canal
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.
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 child.
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 Do not take out the tooth. If you do, the bone will come
moves when you push against the tooth.)
out with it. Instead, hold the tooth with wires.
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.
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
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.
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. 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.
Give penicillin if there is fever, a swelling, or if he is only able to open his mouth a little.
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 or aspirin for pain and fever.
2. Give the child something hard to bite against. This will help the tooth to grow through the gums
faster. For example, let him chew on a dry hard biscuit.
Infection can start in the gums whenever the teeth near them are not clean. For example, there may be
swelling (called an epulis) between only 2 teeth or between many teeth. In addition, gums that are weak from
poor nutrition are not able to resist the infection. This is why a pregnant woman must take special care
to eat well and clean her teeth carefully.
• 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 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.
Explain to the person the cause of her gum problem and what she can do to help herself.
1. Show her how to clean her teeth better near the gums.
2. Tell her to rinse her mouth with warm salt water. 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).
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.
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 two-week period. Start some treatment NOW:
1. If the person is already sick, give penicillin for 3 days.
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 5% solution of hydrogen peroxide. Rinse with
warm water. For a child, use a weaker solution. Mix 1 part hydrogen peroxide with 5
parts water and wipe the child’s gums with it.
• 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. Give Vitamin C (ascorbic acid), 2 tablets a day for 7 days. (1 tablet = 500 mg.)
4. Teach the person how to care for the gums at home:
• Rinse at home for 3 days with a weak solution of hydrogen peroxide. Try to hold the
solution in the mouth for several minutes. The longer the solution touches the gums,
the better it is for the gums. Rinse once every hour. After 3 days, change to salt water,
4 cups a day. If you have no hydrogen peroxide, rinse with salt water from the
For a young child who is not able to rinse, Mother or Father can wipe his gums with the
weak solution of hydrogen peroxide 4 times a day.
Show parents how to do this. Give them some cotton gauze and hydrogen peroxide to
take home.
• Clean the teeth with a soft brush. Parents can clean children’s teeth. Show them
how, and ask them to do it even if the gums bleed.
• Cook food that is soft (like pounded yam) and not spicy (no pepper). Eat fresh fruits
and vegetables that give strength to the gums.
• Stop smoking and stop chewing betel nut.
One week later, scrape away the rest of the tartar from the teeth. Then use the person’s own brush and
show him how to do a better job of cleaning his teeth.
Herpes virus causes fever blisters. Herpes virus is a kind of germ. Fever blisters are sores that can form
either inside the mouth on the gums, or outside on the lips.
When the sores are inside the mouth, it is a serious problem. It usually affects children between 1 and 5
years old. A child with fever blisters in his mouth can become very sick. He will not be able to eat properly. If
he does not drink enough fluids, he can become dehydrated (lose his body water). This is dangerous!
• sore throat
• fever
• 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.
Inside 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.
2. Wipe milk or yogurt over the sores to protect them before eating. Wash your hands before
touching the inside of someone’s mouth! Then give food that is soft and not spicy. If he
cannot eat, prepare a special milk-oil drink for him.
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.
On the lips
These sores go away in about 1 week. To prevent them from becoming infected, paint the sores with gentian
violet, tincture of benzoin, or petroleum jelly. If you hold ice against the sores for several minutes each day, it
may help them heal faster.
Thrush is a kind of infection. It often appears when a person is weak and poorly nourished, or sick and taking
medicine like tetracycline or ampicillin. In a baby, thrush usually appears on the tongue or top of the mouth. It
can stop the baby from sucking. In an adult, thrush often occurs under a denture.
• 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, change or stop the antibiotic medicine, or leave the denture out of the
mouth for a while. Then:
1. Put some nystatin creme on top of the white patch with a bit of cotton.
adults: put some on 4 times a day
children 5-12 years: put some on 3 times a day
children up to 5 years old: put some on 2 times a day
Show the mother how she can do this in her child’s mouth at home. If you have no nystatin creme, paint
gentian violet on the white area. The mother should paint the child’s mouth 2 times a day.
Do not use penicillin or any other antibiotic unless you need to treat something different. Thrush can
get worse when a person uses an antibiotic for a long time.
2. Continue breast feeding. For older persons, make their food soft and easy to chew.
IMPORTANT: Sometimes white lines appear on the inside of an adult’s cheek or on the roof of the mouth. If
these lines become sore, they can change into a cancer. 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
A virus can cause canker sores, as with fever blisters. Unlike fever blisters, canker sores usually affect adults
rather than children.
One or more sores can appear at any time. These sores hurt, especially when pieces of food touch them.
• A sore can appear on the tongue, roof of the mouth, 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 does help.) The treatment is simple. Tell the person how to feel more
comfortable while waiting for the 10 days to pass:
Eat foods that are soft and not likely to hurt the sore. Do not eat food with a lot of pepper. Drink lots of water.
Chew food on the other side of the mouth, away from the sore.
A denture which does not fit should be remade.
In the meantime, leave the denture out of the mouth for 2-3 days.
Ask the person to rinse with warm salt water, 4 cups each day until the sore is better.
If the sore continues after 10 days, it may be infected. Give penicillin.
A sore that does not heal after antibiotic treatment may be cancer. See a doctor immediately.
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.
A person with missing teeth needs dentures. Dentures will help him chew more food and make him look
younger. They support his lips and open his mouth more.
Note: Making dentures is not easy. We hope to write a book in the future that will tell more about dentures.
A child who has had a fever or measles often has dry lips. The corners of her mouth can crack and become
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.
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.
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.
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.
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 them.
• 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:
Be sure the person can breathe.
Stop the bleeding.
Put a bandage on the person’s head.
Give penicillin to stop infection.
Give aspirin for pain.
1. Be sure the person can breathe.
Lie him on his side so that his tongue and jaw fall forward.
Later, carry him to the hospital in that position. If he goes in a car, be sure he sits with his head forward. His
jaw and tongue will be forward and he will breathe more easily.
Look inside the mouth to see if any tooth is broken and very loose. A broken piece of tooth can fall out and
block the person’s airway, so take out the broken part now. You can leave in the root, but if you do, tell the
dental workers at the hospital. 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). If you gently press cotton gauze against the
bleeding gums, it will usually control the bleeding.
Bleeding inside the mouth, from between the broken parts of the bone, is more difficult to stop. You
must pull the two sides together and hold them in that position. To do this, you need wire that is thin, strong,
and bends easily. ‘Ligature wire’ (0.20 gauge) is best.
Place a piece of wire around two teeth, one on each side of the break. Choose the strongest tooth on each side
- the ones with the longest or the most roots.
Tighten the wire around the two strong teeth with pliers or a 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
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 for 5 days to stop infection inside the bone.
5. Give something for pain. Aspirin may be enough. If there is a lot of pain and the person cannot sleep,
give codeine. The dose for an adult is 30 mg.
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
Caring for a person who cannot eat properly (see below):
1. Give him liquids containing food for both strength and energy.
2. Show him how to keep his teeth clean and his gums tough.
1. Give liquid foods for strength and energy.
Prepare food in two ways: (1) First, a milk-oil drink to build strength; and then (2) a special soup to keep him
strong and give him energy.
To build strength: Milk-oil drink
Mix for him each day at your clinic:
9 cups of water
3 cups of milk powder
150 ml of peanut oil or coconut milk
1/2 cup of honey or 1 cup of sugar
Leave some near his bed, and keep the rest in a cool place.
To keep strength and give energy: Special vegetable soup
Cut into small pieces and cook together in a pot of water:
1/2 tin of fish, or a handful of dried fish
4 small spoonfuls of peanut oil or palm oil
6 sweet potatoes or small yams
1 large handful of green leaves
1 small spoonful of salt
Pour the soup into an empty tin with small holes made in the bottom. Use the back of a spoon to press as
much of the cooked food as you can through the holes. The person can suck the soup between the teeth to the
throat and then swallow it. Clean the tin and set it in boiling water, so you can use it again the next day.
2. Keep the teeth clean and the gums tough.
The person must learn to clean teeth and gums or the gums can quickly become infected and the mouth will
feel sore. So:
• Scrub both the wires and the teeth with a soft brush after drinking soup.
• Rinse with warm salt water, 2 cups every day.
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.
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 1/2 a turn
usually is needed. More, and the wire will break. Always twist in the direction a clock moves. With
this habit, you will remember which way tightens the wire and which way loosens it.
6. Explain to the person that it takes 4 weeks for the bone to heal. The wires must remain on the
teeth for this time. To help the teeth to heal, ask the person to:
give these teeth a rest. Use other teeth for chewing.
clean both the teeth and the wires with a soft brush.
rinse with warm salt water, 2 cups every day.
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
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.
• She is unable to close her teeth together.
She cannot close her lips easily.
Her lower jaw looks long and pointed.
It hurts when you press on the joint in front of her ear.
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
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.
4. Give aspirin for pain.
5. Explain the problem to the person and tell her how to care for her jaw: (1) eat mostly soft foods
for 2 weeks; (2) hold a warm wet cloth against the jaw; (3) remember not to open the mouth wide
anymore. If possible, replace the missing back teeth with dentures.
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 person is tense or nervous.
(2) The jawbone is fractured in the area of the joint.
(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.
1. Tension.
Talk with the person and help, if you can, to find a solution to her personal problems. This can do much to help
her and her muscles relax. In addition, explain how to care for the sore joint:
(a) Eat only soft foods until it no longer hurts to chew.
(b) Hold a hot, wet cloth against the jaw, to help relax the muscle. Do this as often as possible,
but be careful not to burn the skin.
(c) Take aspirin to reduce the pain.
2. Fracture.
If an X-ray shows a fracture, the person needs expert help. A dentist can wire the teeth in a way that will allow
the bone to heal.
3. Teeth do not fit together properly.
Imagine a line that passes between the two middle upper teeth and the two middle lower teeth in the person’s
closed mouth. 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.
These teeth are normal. The line formed between the two middle teeth does not shift when the mouth
When you see teeth that do not fit properly:
(a) Warn the person not to open his mouth wide. Suggest, for example, that he take his food in
small bites.
(b) Tell the person what can be done to help. Often a dentist can grind the teeth 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 Is No Doctor) 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. 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.
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
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
2. Send the person to an experienced dental worker.
Problems like swelling, severe pain, and bleeding can occur after you take out a tooth. Tetanus, a more serious
problem, can also occur, especially if your instruments were not clean.
Swelling of the face
You can expect some swelling after you take out a tooth. But if the swelling continues to grow, and it is
painful, this is not normal. Probably an infection has started. The treatment is the same as for a tooth abscess:
penicillin for 3 days to fight infection, heat to reduce the swelling, and aspirin for pain. See “Tooth
abscess” for the proper doses.
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.
Second, prepare the dressing.
Soak 1-2 small pieces of cotton in eugenol (oil of cloves). Squeeze each piece so that it is damp but not wet.
Note: There may be a local medicine in your area that relieves pain. Use it instead of eugenol.
Third, place the dressing gently inside the socket.
Place one piece of dressing into each root space. Push it down into the root space gently.
Cover the socket with plain cotton gauze, and send the person home biting against it. He can remove the
plain cotton in an hour. The dressing should remain inside the socket.
2. Give aspirin for pain.
Bleeding from the socket
When you take out a tooth it leaves a wound, so you can expect some blood. However, if the person bites
firmly against a piece of cotton, it usually controls the bleeding. To help the wound heal (from a clot), tell the
person not to rinse with salt water or spit for 1 or 2 days after you take out the tooth.
When the first bleeding occurs, put a new piece of cotton on top of the wound and ask the person to close her
teeth against it for an hour. Keep her there with you, to be sure she continues to bite on the cotton. (If it is
too painful, you may want to inject anesthetic. See Chapter 9.) Change the cotton if it becomes soaked with
TREATMENT (if the bleeding continues):
1. Take her blood pressure (see Helping Health Workers Learn). 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.
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.
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 the rules in Chapter 7.
• 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, if you
cannot get help immediately.
Spit glands are places where the spit is made. They are located in front of the ear and under the jaw, on each
side of the head. If there is an infection inside a spit gland, the face will become swollen and the area will hurt.
Spit is sent from the gland to the mouth through a thin pipe called a duct. Ducts open into the mouth in two
places: on the inside of each cheek, and under the tongue.
A small stone can often block a duct and cause an infection in the spit gland and swelling of the face. You may
be able to feel the stone near where the duct enters the mouth.
• 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.
Reduce the infection and swelling first. Later try to remove the stone.
1. Give penicillin for 3 days. If the swelling is large and the infection serious, start with shortacting crystalline penicillin.
2. Give aspirin for pain.
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
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.
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 5 days.
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
• 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
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.
You will usually see noma in children. It will only develop if these 3 things are true:
(1) The child’s general resistance is low. Usually, he is undernourished and anemic (lacks iron). He
may have tuberculosis.
(2) The child has Vincent’s Infection.
(3) The child has recently had a serious illness like measles or malaria.
The infection starts in the mouth.
Then it passes to the gums.
Sore mouth with itching gums.
Swollen, sore gums.
Gums bleed when eating or when teeth are cleaned.
Bad breath, spits a lot.
Then it reaches the jaw.
5. Loose teeth.
6. Loose pieces of bone around the teeth.
Finally, it affects the cheek.
7. Skin is tight with dark red swelling.
8. Black spot on the cheek breaks open, leaving a hole into the mouth.
9. A line separates dead tissue from healthy tissue.
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.
If he cannot drink by himself, help him. Use a spoon or syringe.
Place the fluid on the inside of the healthy cheek and ask the child to swallow.
2. Treat the anemia.
Start giving iron now. The child should continue taking the tablets or mixture for 3 months.
Ferric Ammonium
Citrate Mixture
Ferrous Sulfate
Tablets (200 mg.)
over 6 years:
1 1/2 ml. (30 drops) daily
200 mg. (1 tab) 3 times a day
3-6 years:
1 ml. (20 drops) daily
100 mg. (1/2 tab) 3 times a day
under 3 years: 1/2 ml. (10 drops) daily
50 mg. (1/4 tab) 3 times a day
Also give food rich in iron: meat, fish, eggs, dark green leafy vegetables, peas and beans.
Note: a child may have anemia because he has hookworm. It is wise not to wait for a test for hookworm.
Begin now giving hookworm medicine such as thiabendazole and folic acid (see Where There Is No Doctor).
3. Start antibiotics.
Penicillin is the best antibiotic to use. As the child may not be able to swallow pills easily, it is best to start with
penicillin injections.
If you do not have penicillin, you can give sulfadimidine 4 times a day. It comes in 500 mg. tablets or in syrup
that has 500 mg. in 5 ml. To decide how much to give, weigh the child.
5 to 10 kg.
Dose (give 4 times a day)
1/2 tablet or 1/2 teaspoon of syrup
10 to 17 kg. 1 tablet or 1 teaspoon of syrup
17 to 25 kg. 1 1/2 tablet or 1 1/2 teaspoon of syrup
over 25 kg. 2 tablets or 2 teaspoons of syrup
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).
Look for any other illnesses and treat them, too.
5. Clean the sore.
Gently pull away any dead skin with tweezers. Wash the inside of the sore with hydrogen peroxide. (Be sure
you measure the hydrogen peroxide carefully.) Then put in a wet dressing.
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.
7. Keep the mouth clean.
• Use a soft brush gently to clean the remaining teeth. Do this 3 times a day for the child.
• Wipe the gums with a weak solution of hydrogen peroxide. Use cotton gauze that is damp with
the solution. Do this every 2 hours for 5 days.
• Then after 5 days, start rinsing with warm salt water 3 cups a day.
8. Get advice on whether surgery is needed.
Unfortunately, the child will probably need surgery, to release the scar. Without this surgery, the child will not
be able to open his mouth properly.
Send the child for medical help when the infection is finished and the wound starts to close.
You may also need a dentist’s help at this time. The child’s jaws may need to be wired. The wires are put on
the healthy teeth in a way that holds the mouth open while the tight scar is forming. When the wires are
removed, the child will be able to open and close his mouth to chew food.
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:
(1) have his teeth carefully cleaned each day with a soft brush.
(2) rinse his mouth with a warm salt water solution, 2 times a day.
(3) eat fresh fruits and vegetables, especially the kind that have Vitamin C - guavas, oranges,
pineapples, papayas, tomatoes, peas, and dark green leaves.
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, it may be a
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 that does not heal may be cancer. The lips and tongue are the two places in the mouth where cancer
starts most often.
Cancer is deadly.
Medicine cannot help.
It wastes time to use it.
Cancer can spread quickly to the inside of the person’s body where you cannot see it. This can lead to the
person’s death.
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.
Chapter 8: Scaling Teeth
Scaling means ‘scraping away’. You can scale old food, tartar, or even a fish bone caught under the gum. You
usually scale teeth to remove tartar.
We get tartar when the coating of germs on our teeth 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
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 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, 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.
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 Ivory C-1 scaler.
2. Another with two blunt, rounded ends - to remove tartar from the part of the tooth under the gum.
Its proper name is G-11 and 12 curette.
The ends of the scaler are the important parts. One end is bent to the left and the other end is bent to the
right, so you can reach more easily around all sides of the tooth.
The blade at each end of the scaler is sharp. You must keep the blade sharp. A sharp blade can break more of
the tartar away than a blunt blade.
You also need these:
Probe (explorer)
Tweezers (cotton pliers)
Sharpening stone (Arkansas stone)
Note: When you order an instrument, use both its common and proper name. Then you have a
better chance of receiving the instrument you want. You can also make some of your own
Keep everything in a Scaling Kit.
Tartar starts to form inside the gum pocket. There it builds up, because the gums protect it. So you often must
feel rather than see the tartar when you scale a tooth.
You must remove all of the tartar so the gums can heal. New tartar grows faster when there is old tartar
left behind for it to build upon.
Lay out what you need ahead of time.
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.
The steps in scaling teeth are these:
Explain to the person what you are going to do.
Feel under the gum for rough spots (tartar).
Place the scaler under the tartar.
Pull the scaler against the side of the tooth.
Check to be sure the tooth is smooth.
Explain what you have done and what the person should now do.
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!
2. Feel under the gum for tartar. Tartar feels like a rough spot on the root of the tooth. Since tartar can
form anywhere inside the gum pocket, feel for it on all sides of the tooth.
You can check for tartar two ways.
1. Use your probe. Slide the point up and down along the root surface under the gum. Feel for places that are
rough. Teeth without tartar are smooth.
2. Use cotton gauze. Twist a corner and press it between the teeth. The gauze lowers the gum and soaks up
the spit. You can then see more tartar.
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 is very important. The ends of the scalers are sharp. If you are not careful, the blades can cut the
gums. Be gently and do not hurry. Always hold the tip of the scaler on the tooth to avoid poking the gums.
Rest your 3rd finger against a tooth. This will steady your hand and let you slide the sharp scaler under the
gum with care.
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
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.
1. Put the sharp face of the blade against the tooth. Slide
it along the tooth down into the gum pocket.
2. You can feel the edge as it goes over the rough tartar.
Stop when you feel the bottom of the gum pocket.
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.
5. Check to be sure the tooth is smooth.
With your probe, feel under the gum for any place that is still
When all the sides of the tooth feel smooth, move to the next
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.
6. Talk to the person about what you have done and what to expect. The gums will be sore for the next
few days. That is normal.
Then explain to the person what to do to make the gums strong and tough again.
A. Clean your teeth better with a soft brush. Reach with the brush into the gum pocket, and
behind your front teeth. That is where tartar collects most often.
B. Clean between your teeth. Use your brush, the stem from a palm leaf, or a piece of strong,
thin thread.
C. Rinse your mouth with warm salt water. Start with 4 cups a day, to make the gums strong.
Then use 1 cup a day to keep them strong.
D. Eat local foods that give strength to gums. Fresh fruits like guava and oranges, and fresh
vegetables with dark green leaves are good for the gums.
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.
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
A sharp scaler bites into tartar better than a blunt one. Sharpen the edge whenever you feel it sliding over the
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
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) can pass from the blood of one person to the blood of another
Your mirror, probe, and cotton tweezers do not need sterilization. A disinfectant 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!
Chapter 9: 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.
METAL SYRINGE - This is a dental syringe. It uses special needles, and the local anesthetic is sealed inside a
glass cartridge. You must throw away both needle and cartridge after injecting.
Use a new needle and a new cartridge of local anesthetic for each person.
GLASS SYRINGE - This kind of syringe is for injections of medicine like penicillin, but you can use it in the
mouth. Boil the syringe and needles before and after each use. When sterile, the needles are ready for another
Be careful! Do not touch the needle.
Your choice of which syringe to use depends on the local anesthetic you can get. Order needles to fit your
particular kind of syringe.
1. syringe: aspirating dental cartridge syringe, 1.8
ml. (1 ml = 1 cc)
1. syringe: standard glass syringe that holds around 3
ml (1 ml = 1 cc)
2. needles: disposable needles for dental cartridge
syringe (27 gauge, long)
2. needles: 24 gauge, long (40 mm x.56 mm or
One box contains 100 needles, each one
inside a plastic cover
3. local anesthetic: local anesthetic cartridges for a
dental syringe
3. local anesthetic: 20 ml bottle of lidocaine
(lignocaine) 2%
Or, if not available: order 2 ml ampules of
procaine hydrochloride 1%
One sealed tin contains 50 cartridges of
lidocaine (lignocaine) 2%
NOTE: Lidocaine will keep the teeth numb longer if there is epinephrine in it. But this is more
expensive, and you should not use it on persons with heart problems (see the bottom of the next
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.
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
To make a lower tooth completely numb, you must block the main nerve (a) before it goes inside the
jaw bone.
These two injections also make the gums around the teeth numb.
If you are treating a back tooth, you must give a second injection for nerve (b).
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.
*Local anesthetics are the only injections given in the mouth.
For a good, safe injection, remember these 5 things!
1. Do not inject local anesthetic into an area that is swollen. This can spread the infection.
Also, pus inside the swelling stops the local anesthetic from working properly.
Instead, treat the swelling first 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%.
3. Before you push the needle under the skin, be sure its pointed end is facing in the correct direction.
The local
come out
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. Do not pass an infection from one person to another
by using dirty needles.
Boil the syringe and needle in water for 20 minutes in a covered pot. Although it is not as important, 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.
• Break the disposable needle after using it. Then cover the point with its plastic top and
throw the needle into the trash.
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 (1/2 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 1/4 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 (1/4 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
4. Wait 5 minutes for the tooth to become numb.
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
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!) 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 3/4 of the length of a long needle). Pull back on the
plunger of the aspirating syringe to check for blood.
Inject 1½ ml of local anesthetic (3/4 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.
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 1/2 ml of local anesthetic (1/4 of a cartridge).
This injection is not needed for front teeth.
It is enough to block the main nerve.
4. Wait 5 minutes for the tooth to become numb.
Take time with children
1. Put some topical anesthetic on the gum before you inject. But be sure the gums are dry in that
place. If you wipe the gum with cotton, the topical anesthetic will stay on longer. Give the
anesthetic time to work: wait a minute before injecting.
If you do not have topical anesthetic, try using pressure. You can use ‘pressure anesthesia’ whenever you
have to give an injection in a sensitive place, like the roof of the mouth.
Wind some cotton around the end of a match-stick. Press firmly for a minute behind the bad tooth. Then
inject quickly into the depression that formed where you pressed.
2. Be sure the anesthetic is warm when you inject it. Hold the cartridge or bottle in your hands
for a few minutes before you use it.
3. Use a new, sharp needle.
4. Have someone pass you the syringe out of sight of the child. Then the child will not have to
look at it and be frightened.
5. Be ready to stop the child from grabbing the syringe.
6. Inject the anesthetic slowly. Do not hurry. A too-quick injection can cause sudden pressure, which hurts
and frightens the child.
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. Tell Mother that, 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.
Chapter 10: 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 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).
You can fill a cavity if the tooth does not have an abscess. There is 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, probably no abscess.
• the tooth feels the same as the others when you tap against it.
The decay is deep enough for the nerve to feel temperature changes, but not near enough to the nerve to be
infected. So there is not an abscess. You can save the tooth by filling the cavity as soon as possible.
What a Filling Can Do
A filling can help a person in three ways:
• It stops food, air, and water from entering the cavity. This will stop much discomfort and pain.
• It stops the decay from growing deeper. This can prevent a tooth abscess.
• It can 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.
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.
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.
probe (explorer)
tweezers (cotton pliers)
spoon (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.
Lay out on a clean cloth:
To place a cement filling, follow these 6 steps:
Keep the cavity dry.
Lift out some, but not all, of the soft decay. (If the tooth hurts, inject local anesthetic.)
Mix the cement.
Press the cement into the cavity.
Remove the extra cement from around the cavity and the tooth.
Explain things 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.
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.
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 gum.
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.
5. Remove the extra cement before it gets too hard. Press the flat side of the filling tool against the
cement and smooth it towards the edge of the cavity.
As you smooth the cement, shape it to look like the top of a normal tooth.
This way, the tooth above or below it can fit against the filling without breaking it.
After you take out the stem or toothpick, smooth the cement. 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) If 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.
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.
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. 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.
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, because most readers of the book cannot buy the dental drill needed to make them. In a
later book, we hope to give not only instructions for placing a permanent filling, but also ideas for constructing
simple dental drills using low-cost local resources.
Some Simple Dental Drills
We use a dental drill to remove all decay from a cavity and to change the shape of the hole in the tooth so it
can firmly hold the permanent filling material. The most expensive drills use electricity, but some drills are
powered by people instead of electricity.
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 get so hot that it kills the nerves. 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. Please write to the Hesperian Foundation if you know of a design for a lowcost drill.
We will use these ideas in the next book. We also will answer letters from those interested in ways to make or
buy inexpensive drilling equipment.*
*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,
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 treadle-powered drill. An assistant can spray water on the tooth if
the drill does not have a sprayer.
As the drill bit moves slowly back and forth, it opens the cavity further. This makes it easier to see all of the
decay. The decay is later removed with a spoon instrument.
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.
Chapter 11: Taking Out a Tooth
Not every painful tooth needs to come out. Sometimes it is possible to prevent such a final step. 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 if the pain starts by itself, often waking the person at night)
• It is loose and hurts when you move it.
• It has a broken root 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
• 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
• Are you a diabetic? (If you have diabetes, your wound will take a long time to heal.)
If the person answers “yes” to any of these questions, you must take special precautions. See the next page.
A person who bleeds a lot must know how to prevent bleeding afterward. Explain very carefully the steps
(see Stop the bleeding). You may also want to place a suture (How to place a suture) to hold the gums
tightly together.
Persons with heart disease often take medicine called anticoagulants that do not allow the blood to clot
normally. Ask what medicine the person takes. Heparin is an example of an anticoagulant. 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 (3.6cc) of local anesthetic. The epinephrine inside the anesthetic
can harm a weak heart.
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
A diabetic’s wound may become infected. Watch carefully the place where you took out the tooth and give
antibiotics if an infection begins.
• 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
• 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
• 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.
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.*
* All of the instruments in this chapter are available at low cost from: ECHO, 4 West Street, Ewell
Surrey KT17, 1UL, England.
The Four Basic Instruments
You can take out most teeth with these 4 instruments:
A spoon or probe...
... an elevator...
and two forceps
An elevator will loosen a
tooth, or lift out a broken
Use forceps to pull out the tooth. There is one for
upper teeth and one for lower teeth.
Use this to separate the
gum from the tooth.
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.
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,
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 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.
So the person should be sitting down low.
If you stand on a box, he will be lower.
To take out an upper tooth, you need to push up and then pull down.
So the person should be sitting up high.
If he sits on cushions, he will be higher.
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:
Before you touch your instruments, be sure your hands are clean. Wash with soap and water. Be sure, also,
that your instruments are clean. Prevent infection - keep clean!
To take out a tooth, follow these 8 steps:
Explain what you are going to do.
Inject local anesthetic.
Separate the gum from the tooth.
Loosen the tooth.
Take out the tooth.
Stop the bleeding.
Explain to the person what to do at home to look after the wound.
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.
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.
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.
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 tooth.
The attached gum is strong, but it is also thin. Control your instrument carefully so that it only cuts
through the part that is attached to the tooth. Do not go any deeper.
4. Loosen the tooth. A loose tooth is less likely to break when you take it out. Before you take out a strong
tooth, always loosen it first with a straight elevator.
Caution: if you do not use it properly, a straight elevator can cause more harm than good.
It is important to hold a straight elevator properly. Place your first finger against the next tooth while you turn
the handle. This will control it. Remember that the sharp blade can slip and hurt the gums or tongue.
The blade goes between the bad tooth and the good one in front of it. Put the curved face of the blade against
the tooth you are removing.
Slide the blade down the side of the tooth, as far as possible under the gum.
Turn the handle so that the blade moves the top of the bad tooth backward.
Put pressure on the bone, not the tooth beside it. Do not loosen the good tooth!
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
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.
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 lifts 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 later inside the bone.
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.
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 two 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 twenty minutes.
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 two knots and cut the thread.
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 two ends in opposite directions.
The second knot will form over the first knot.
D. Cut the threads so that about 1/2 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
• 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.
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 an aspirin for pain as soon as you need it, and then one every 3 or 4 hours.
• 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 liquids like tea or coffee, because they encourage bleeding. However, cool
liquids 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 and keep your teeth clean, especially the teeth near
the socket.
False Teeth
After a tooth comes out, it is a good idea to replace it with a false tooth. If you do not, the other teeth soon
start to shift into the open space.
This weakens the bone around their roots. After some years, they too become loose and sore, and they have
to be taken out
When you take out a tooth, it is like removing a brick from the center of a wall. The area around the space
becomes weaker and begins to crumble.
To prevent this, a plastic tooth can fit into the space. This tooth is not for chewing food but to hold the
remaining teeth in their normal, healthy position.
A full set of teeth allows a person to chew the foods needed to stay healthy and feel good. Moreover, teeth
help you look good!
A person without many teeth looks
With a new set of plastic ‘false
teeth’, the same person looks and
feels much younger.
This book does not show how to make false teeth. In a later book, we hope to give instructions for false teeth,
dentures, and permanent fillings. 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
• how to clean the remaining teeth to prevent them from going bad, and
• how it is possible to get a replacement plastic tooth.
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.
Figure 1. Force the blade between the root and the socket.
Figure 2. Move the root away from the socket wall.
Figure 3. Move the root further until it is loose.
Figure 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.
Figure 1. Break away the bone between the root and the blade.
Figure 2. Force the blade between the root and the socket.
Figure 3. Move the root away from the socket wall.
Figure 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.
Root Pushed Into the Sinus
An upper root that seems to disappear may have gone into the sinus. 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.
If the first cotton gauze 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 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.
Painful Socket
The socket area often hurts for a day or so after the tooth has been removed. Aspirin 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 Chapter 7 - Pain from the Socket.
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 Chapter 7 - Dislocated jaw.
------------------•-----------------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 or hepatitis (see Where There Is
No Doctor).
Germs on dirty instruments can also go into the socket and start an infection.
Dental instruments must be not only clean, but also sterile. This means they need to be both scrubbed and
then boiled before they can be used again.
Use a brush and clean each instrument with soap and Then kill the germs by placing the instruments into a
covered pot of boiling water for 20 minutes.
Be careful to scrub away all bits of old dried blood.
Keep your sterile instruments together in a clean place.
Wrap them in a clean cloth
OR Leave them in disinfectant
Mark with tape the names of the instruments inside.
Before you use any instrument again, wash it
with clean water - to remove the taste of the
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 the floor every day, and wipe down the chair and tables as
often as possible.
Staying clean is a part of staying healthy.
After you have read Chapters 1-11, you will want to use the references - to return to later and read when you
want to find information quickly.
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
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.
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.
Proper Name
Local name
(write in
Amount you need
in 3 months
Amount to
keep in kit
For Pain
1. aspirin, 300 mg tablets
2,000 tablets
100 tablets
2. acetaminophen (paracetamol) 500
mg tablets
500 tablets
10 tablets
1. penicillin, 250 mg tablets
2,000 tablets
100 tablets
2. erythromycin, 250 mg tablets
500 tablets
40 tablets
3. nystatin, creme or solution
12 small tubes or
2 small tubes or
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’) are usually safer and just as effective
for most dental problems. If you do use tetracycline, read Where There Is 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
2. Always look for a date on the package. It is called the expiration date (or expiry date). If today
is later than that date, do not buy or use that medicine.
3. Be careful to give the correct dose. Read the next two pages carefully, as well as the
‘Treatment’ section of each problem in Chapter 7. If The correct dose are not clear to you, read
Chapter 8 of Where There Is No Doctor.
4. For serious infections or serious pain, see Injections: For severe infections.
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 like aspirin (300 mg tablets) or acetaminophen (500 mg
tablets) can be broken up into smaller tablets:
Four times a day:
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 a 30
mg tablet of codeine.
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 to find which antibiotic works best.
Do not give penicillin to a person who is allergic to it. Ask about the person’s allergies before you give
penicillin pills or injections. When you inject penicillin, always keep epinephrine (Adrenalin) ready to inject if
the person shows signs of allergic shock. Stay with the person for 30 minutes. If you see these signs ...
• cool, moist, pale, gray skin (cold sweat) • difficulty breathing
• weak, rapid pulse (heartbeat)
• loss of consciousness
... immediately inject epinephrine: 1/2 ml for adults or 1/4 ml for children. For more information on allergic
shock, see Where There Is No Doctor.
Always give the full dose of penicillin or any antibiotic, even if the person feels better. Erythromycin also
comes in liquid form. It has 125 mg in 5 ml, so 10 ml of liquid (about two large teaspoons) is the same as one
It is important to take a strong first dose of penicillin or erythromycin, and then smaller doses four
times a day for 3 to 5 days after that.
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 page are not like the anesthetic injections in 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 of Where There Is No Doctor.
For severe infection: There are two kinds of penicillin to inject.
You will usually use ‘aqueous
procaine penicillin’. Give only 1
injection per day.
For very severe infections, give
‘crystalline penicillin’ every 6 hours for
the first day. It acts quickly and for a
short time only.
Proper Name
Amount you
in 3 months
keep in
(over 40
Child 6- Child 1-6
years old
years old
1. procaine penicillin, bottle with 300,000
units per ml
4 ml
2 ml
1 ml
2. crystalline penicillin, bottle with
1,000,000 units per ml
3 ml
1 1/2 ml
1/2 ml
Proper Name
Local name
(write in
Amount you need
in 3 months
Amount to
keep in kit
1. clean cotton gauze
8 packages of 100
20 pieces
2. clean cotton rolls
10 packages of 50
8 rolls
3. oil of cloves (eugenol)
50 ml
1 small
4. zinc oxide powder
500 grams
1 small
To harden sensitive teeth
5. fluoride water,
50 ml
1 small
To give injections of local
6. lidocaine 2% 1.8 ml
8 boxes of 100
7. disposable needles, 27
8 boxes of 100
10 needles
8. lidocaine topical
5 small tubes
1 tube
To make dressings
To fill cavities
You can use a solution of fluoride and water (above, number 5) in two ways:
To treat a sensitive tooth, make this concentrated To help prevent cavities, especially in children,
mixture (see box above). Mix:
make a solution of fluoride and water using sodium
fluoride powder. Mix 2 grams of the powder with 1 liter
of water. Then, once a week, take a mouthful and
• 500 tablets sodium fluoride (1.1 mg
rinse for 60 seconds with teeth closed together,
each) in 59 ml of water or
‘washing’ every surface of every tooth. Then spit it out
- do not swallow the fluoride water. Also, do not
or drink for 30 minutes.
• 1 gram of sodium fluoride powder with 50 ml of
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.
Wet some cotton with the fluoride water and rub it on
the tooth. Keep the tooth wet with fluoride water for
1 minute. One week later, give the same treatment
Weight (how heavy something is)
School is a good place to do a weekly fluoride
rinse. Students can brush each day at school, and
then on the same day each week, they can each take a
mouthful from the liter bottle of fluoride water. On
“Let Children help each other”, children are shown
using a twice-yearly application of a special paste, a
‘topical fluoride gel’. This is good, but the weekly rinse
is even better, for the teeth.
Volume (how full something is)
1 kilogram = 1000 grams
1000 ml = 1 liter
1 gram = 1000 mg
236.5 ml = 1 cup
1 grain = 65 mg
5 ml = 1 teaspoon
1 ml = 1 cubic centimeter (cc)
To make rinses
To keep instruments
Proper Name
Local name
(write in
Amount you need
in 3 months
keep in
1 salt
2 kilograms
100 grams
1. hydrogen peroxide
3 liters 12 small
500 ml
Zephiran, concentrated
bottles bottle
1 small
Note: You can clean instruments with a homemade.
To keep instruments
Arkansas sharpening stone
1 stone
For examining
wooden tongue depressors
8 boxes of 50 per
stone 10
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.
When you are treating several people on the same day, you will need to clean some instruments 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 three 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 Making your own dental instruments. If you like, buy
only one example of each of the instruments below, and use them as models to copy when you make your
own extra instruments.*
* If you want the help of a charitable organization in buying instruments.
To examine or to give any
To inject
To scale teeth
To place cement fillings
To remove teeth
Proper Name
Local name
(write in
Number to
buy or
1. dental mouth mirror
2. explorer
3. cotton pliers
Aspirating dental syringe (to use with 1.8 ml
1 Ivory C-1 scaler
2. Gracey 11-12 curette
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. 75)
Note: See “The four basic instruments” for recommendations of other elevators and forceps that are good
to have if you can afford them.
* I am grateful to Aaron Yaschine for the ideas in this section.
Here are a few ideas for making instruments at low cost. Try to use materials that are available where you
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:
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.
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
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.
Making Other Instruments and Supplies
Spoon: Bend a paper clip or needle. Flatten the end. Then pound a small stone against the end, to make it
hollow. Make 2 bends and attach to a stick handle.
Filling Tool: Remove the heads from 2 long screws.
With a file and hammer, make the end of one screw flat and the end of the other screw round.
Bend each end in the direction of the edge (not the face) of the flat side.
Attach both working pieces to a small stick handle.
Dental Floss: When using string to clean between your teeth, 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 it.
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 stay under it 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.
Figure (1) Soak thin string in hot wax. (2) To remove the extra wax, pull the string between your fingers.
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. You may want help to find the lowest prices available to
The Dental Health Services Unit of AHRTAG (AHRTAG means Appropriate Health Resources and Technologies
Action Group Ltd.) may be able to help. Write to them and tell them what you are doing and what you need.
AHRTAG can use the information to develop the right kind of projects in other countries. In return, AHRTAG
possibly can give you good advice to help you buy or make your own low-cost dental equipment. Their address
85 Marylebone High Street
London W1M 3DE
There are many organizations that collect health supplies, including dental instruments. Some prefer to help
church-sponsored health projects, but others will provide instruments at reduced cost to whoever needs them.
One of the best of these organizations is ECHO. They can provide any of the instruments mentioned in this
book. They also sell at lower than commercial prices. For example, for the four instruments for removing teeth
(excavator, elevator, upper forcep, and lower forcep), ECHO’S 1983 price is £17.98, or about 28 U.S. dollars.
Write to them with a list of the instruments you need:
4 West Street
Ewell Surrey KT17 1UL
Other organizations who may be able to help are:
MAP International
P.O. Box 50
Wheaton, IL 60187
Operation California
336 Foothill Road
Beverly Hills, CA 90210
International Human Assistance Programs
360 Park Avenue, South
New York, NY 10010
Direct Relief Foundation
P.O. Box 30820
Santa Barbara, CA 93105
Records, Reports, and Surveys
Here are the short names of 4 teeth. Can you find the tooth named LL5?
For record keeping, you can divide the mouth into 4 parts:
Right (UR)
Left (UL)
Left (LL)
Right (LR)
In each part there are 8 teeth (fewer in children).
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.
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 Naime: After drinking for several hours, Naime’s husband returned home asking for money.
She had none and told him so. He did not believe Naime, 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.
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
Put a line through the circle for each person with:
• cavities Ø • red, swollen gums Ø
The dental workers in Mozambique do a quick survey in 2 schools, 2 mother-and-child health clinics, and 2
cooperatives or factories in their community.
In each place, they examine 50 persons. This is enough to give an idea of the general health of teeth and
gums in the community.
They make a paper for each age group. Each paper has 3 sections. They make a mark for each person they
see, until all 50 circles have marks in them. They make extra marks if they see a tooth and/or gum problem.
In this example, you can see that children have more problems with cavities, while adults suffer more from
gum disease. This is often true.
This survey helps the dental worker in three ways:
(1) it shows how serious tooth decay and gum disease are in the community.
(2) it shows which age group is suffering the most. To these people the dental worker must plan to
give the most attention.
(3) it gives the dental worker something to show the people when they are discussing why to
change some old habits and adapt some new ideas.
Story Telling
Pregnancy and Dental care - 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, I’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.”
“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*, and if you cannot get fresh fruits and vegetables, then (4)
take a tablet of Vitamin C every day.”
* See Sore bleeding gums.
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
“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.”
As we see from the story of Bertine and Lucie, it is possible - and good -to treat a pregnant woman’s
dental problems before she has her baby.
In two situations, it is sometimes better to wait for the baby:
(1) Sometimes the 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. She should have this small operation after the baby is born.
(2) During the last month of pregnancy, a woman may be too uncomfortable to have her tooth taken out.
Control the infection with a 5-day course of penicillin, 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
Train midwives to examine women’s mouths. When they send them to you for dental care, they can give you
any information you need.
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 an extraction. To get this
information, encourage all women to use the Mother and Child clinics.
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 midsection with an apron lined with lead.
3. Always give a careful and complete mouth examination. Tell her what treatment she needs and how to
prevent tooth problems.
4. Be gentle. Show the woman that you care, that you want her to be comfortable, and that you can treat
her without hurting her.
Dental Health Teaching Materials
In many different countries, teachers and dental workers have made their own materials to help them teach
better. Below is a list of some of the materials we know about. We would like to improve this list. Please write
us and let us know what you are doing. We will pass along your good ideas to others.
To receive the materials in this list, write to the addresses on the right.
A. Manuals and Notes
Available from:
1. Common Oral Diseases. A manual for health teachers about
All regional offices of the World
common diseases and emergency treatments. Now available in English Health Organization (main address:
and French. Soon available in Arabic and Spanish.
CH - 1211 Geneva, Switzerland)
2. Dental Therapist Program. This book outlines the content of an
existing 2-year basic dental care program for Native people living in
isolated areas of Canada. English only.
Dr. Keith W. Davey
National School of Dental Therapy
710 - 15th Ave. E.
Prince Albert, Saskatchewan S6V 7A4
3. Saúde Dentária-O Povo Moçambicano. A manual for health
workers, adapted from Where There Is No Dentist, now being field
tested in Mozambique. In Portuguese.
Direcção Provincial de Saúde de
Instituto de Ciências de Saúde da
C.P. 583
Beira, Provincia da Sofala
4. The Good Teeth Book-How to Take Care of Your Mouth. A
manual of ideas, especially for school teachers. In English.
The Good Teeth Book
Box 395
Wewak, East Sepik Province
Papua New Guinea
5. School Health Manual. Health lessons for primary-school
teachers, with a prominent section on dental health. In English.
Gutnius Lutheran Church
P.O. Box 111
Wabag, Enga Province
Papua New Guinea
6. Dental Health: A Teacher’s Guide K-12 Lesson plans for
teaching dental health in Canadian schools, from kindergarten to
Grade 12. In French and English.
Health & Welfare Canada
Room 1970, Jean Mance Building
Tunney’s Pasture
Ottawa, Ontario K1A OL3
B. Slides
1. Two slide sets to accompany Common Oral Diseases. Script in
Teaching Aids at Low Cost
P.O. Box 49
St. Albans, Herts. AL1 4AX
2. ‘How to Take Care of Your Teeth’, slides of the puppet show shown
on pages 27-37 and 27-38 of Helping Health Workers Learn.
The Hesperian Foundation
P.O. Box 1692
Palo Alto, California 94302
C. Flannel-boards
Available from:
‘Happiness is Healthy Teeth’. Presentation on dental health of children Council on Dental Health
- a series of pictures to show the importance of brushing and healthy Indian Dental Association, Audio
Visual Unit
CMC Hospital, Vellore, 630 004 India
‘Taking Care of Your Teeth, and Those of Your Children’. Large
drawings showing local foods and possible ways of cleaning the teeth.
Portuguese script available.
Direcção National Medicina Preventiva
Secção Educação Sanitária
Ministerio de Saúde
Maputo, Mozambique
D. Flipcharts
1. ‘Taking Care of a Small Child’s Teeth’ and ‘Improving Your Dental
Health’ are two separate poster-size sets, using enlarged photographs.
Script, in English and Melanesian Pidgin, can be attached to the back
of each poster.
Immanuel Hospital
P.O. Box 181
Wapenamanda, Enga Province
Papua New Guinea
2. Nutrition/Dental Flipchart. Poster-size flipcharts using photographs. Ministry of Health
Script, in both English and Melanesian Pidgin, is printed on the back of Dental Section
each poster.
P.O. Box 1881, Boroko
Papua New Guinea
3. Flipchart on dental health, in the form of a manual (approx 35 cm x Direcção National Medicina Preventiva
20 cm), for use in small groups. Discusses food and hygiene for adults Secção Educação Sanitária
Ministerio de Saúde
and children. Explanation in Portuguese on the back of each picture.
4. Dental flipcharts for mothers and children in rural areas. Text in
Swedish Free Mission Dental Clinic
both English and Bengali on back of each chart. A booklet with further House 45A Road 16
explanations is also included.
Dhanmondi, Dhaka 9
Write also to these organizations - they have a special interest in teaching aids:
1. Appropriate Health Resources and Technologies Action Group (AHRTAG)
Dental Health Services Unit
85 Marylebone High Street
London W1M 3DE
2. Teaching Aids at Low Cost
P.O. Box 49
St. Albans,
Herts. AL1 4AX
3. Medical Education Unit
Faculty of Medicine
Peradeniya, Sri Lanka
4. Health Education Bureau
Kynsey Road, Colombo
Sri Lanka
5. World Health Organization
Oral Health
1211 Geneva 27
You can write to these World Health Organization Intercountry Centers:
6. Intercountry Center for Oral Health
Ban Nong Hoi, Chiang Mai
7. Training and Research Center for Oral Health
Ministry of Health
Jissr A1 - Abyad Raiss
Damascus, Syria
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.
Abnormal Different from what is usual, natural, or average. Not normal.
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 time. 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 fillings.
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
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
Beeswax Wax made by honey bees.
Bicuspids 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.
Bridge False teeth that are glued onto several nearby healthy teeth.
Buccal Of the cheek. The buccal face of a tooth is the side facing the cheek.
Bulk 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.
Canine teeth Also called cuspids, dog teeth, and eye teeth. These teeth have the longest roots of any tooth.
Cancer A tumor or lump that grows and may keep growing until it causes death.
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 entered.
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 root.
Chronic Long-term or frequently recurring (compare with ‘acute’). A chronic disease is one that lasts for a
long time.
Colony A new place where a group of people start a community. This book speaks of ‘colonies’ of germs where germs group together in a new place.
Community A group of people living in the same village or area who have similar living conditions, interests,
and problems.
Comparative diagnosis A way of looking at symptoms and deciding which of several similar illnesses is
causing the symptoms.
Contact Touch. Contagious diseases can be spread by a sick person who makes contact with (touches or is
close to) another person.
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. Also see Comparative
Diarrhea Frequent runny or liquid stools.
Diet The kinds and amounts of foods that a person should eat or avoid eating.
Dislocations Bones that have 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.
Duct 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.
Emergency A sudden sickness or injury that needs immediate attention.
Enamel The protective layer that covers the crown (top part) of a tooth. The enamel is the hardest part of the
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 investigation.
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.
Explorer 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.
Feces Stools; shit; the waste from the body that is moved out through the bowels in a ‘bowel movement’.
Fever A body temperature higher than normal.
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 or added to water for drinking or
rinsing, fluoride enters and hardens the enamel. It is especially good for children’s teeth.
Forceps Instruments used to pull teeth.
Fracture A broken bone.
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
Gum pocket The space between the tooth and the flap of gums around it, forming a small pocket.
Gums The skin around the teeth.
Health worker A person who takes part in making the community a healthier place to live.
Hemorrhage Bleeding.
Hemostat A needle holder, used for putting in sutures.
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.
Hygiene Actions or practices of personal cleanliness that lead to good health.
Hypertension High blood pressure.
Immunizations (vaccinations) Medicines that give protection against specific diseases. For example, there
are immunizations against diptheria, tetanus, polio, tuberculosis, and measles.
Incisors The four front teeth on the top and bottom.
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.
Injure, injury Harm; hurt.
Instruments Tools that a dental worker uses to examine, clean, fill, or pull teeth.
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 tongue.
Malnutrition Health problems caused by not eating enough of the foods that the body needs.
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
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.
Normal Usual, natural, or average. Something that is normal has nothing wrong with it.
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 disease.
Occlusal The biting surface, or top, of the tooth.
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 material which lasts for years.
Permanent teeth The 32 adult teeth which grow into the mouth to replace the baby teeth.
Petroleum jelly (petrolatum, Vaseline) A grease-like jelly used in preparing skin ointments.
Pharmacy A store that sells medicines and health care supplies.
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 it.
Plate A set of false teeth.
Precaution Care taken in advance to prevent harm or prepare for emergencies before they happen.
Pregnancy The period (normally 9 months) when a woman carries a child inside her.
Premolars The teeth between the molars and the canine teeth; bicuspids.
Prenatal Before birth.
Prevention 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 vitamins and minerals. They help build healthy bodies and make
people more able to resist or fight diseases. In this book they are called GLOW foods.
Proteins Body-building foods necessary for proper growth and strength. In this book they are called GROW
Pus A yellow-white liquid found inside infections.
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 it around inside the mouth.
Risk The possibility of injury, loss, or harm. Danger.
Root 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 inside.
Root canal treatment A special operation on a dead tooth to remove material from the root canal and
replace it with filling material.
Root fibers Tiny fibers which hold the root of the tooth to the jaw bone.
Rotten teeth Teeth with a lot of cavities.
Saliva Spit. Saliva helps us to swallow our food,
Sanitation Public cleanliness. Community sanitation efforts include disease prevention, hygiene, and keeping
public places free of waste.
Scab The crust of dry blood that forms over a wound.
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 medicine.
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 tooth.
Soft drinks Fizzy, carbonated drinks like Coca-Cola.
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 20 minutes.
Stools See Feces.
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. In this book, symptoms
are included with signs.
Syringe An instrument with a small sharp needle, for giving injections.
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 Joint.
Tooth abscess See Abscess.
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.
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
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 cancer.
Tweezers 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.
Ulcer A break in the skin or mucus membrane; a chronic open sore that can appear on the skin, gums, or gut.
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.
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 old.
X-ray picture A special photograph that allows you to see bone, roots of teeth, etc., under the skin.
Where There Is No Dentist is a companion volume to the village health care handbook, Where There Is
No Doctor. Together, the books encourage people to take the lead in caring for their own health. This
approach to health care implies respect for the dignity of all persons, as well as confidence in their
Village health workers can use this book to help people care for their teeth and gums. Health begin with the
felt needs of the people-treating the dental problems they have now. Then they work to prevent the same
problems from returning.
Thus, Where There Is No Dentist shows how to diagnose and treat dental problems and also suggest new
ways to work for better dental health in the community.
ISBN 0 - 942364 - 05 - 8
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF