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Where There is no Dentist
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Where There Is
No Dentist
by Murray Dickson
updated and expanded
with information about HIV and AIDS
by Richard Bebermeyer,
Martin Hobdell and Gene Stevenson
Introduction by David Werner,
author of Where There Is No Doctor
Berkeley, California, USA
www.hesperian.org

Hesperian encourages others to copy, reproduce, or adapt to meet local needs any
or all parts of this book, including the illustrations, provided that the parts reproduced
are distributed free or at cost - not for profit.
Any organization or person who wishes to copy, reproduce, or adapt any or all parts
of this book for commercial purposes must obtain permission from Hesperian.
Before beginning any translation or adaptation of this book or its contents, please
contact Hesperian for suggestions, updated information, and to avoid duplication of
efforts. Please send us a copy of any materials in which text or illustrations from this
book have been used.
Copyright (c) 1983, 2006, 2010 by the Hesperian Foundation. All rights reserved.
Library of Congress
Catalog card No. 82-84067
Dickson, Murray
Where there is no dentist.
Includes index.
Berkeley, CA: Hesperian Foundation
ISBN: 978-0-942364-05-7
First edition, November 1983
13th printing (updated), September 2010
Printed in Canada on acid-free, 100% recycled paper by Transcontinental 100%
Hesperian
1919 Addison St., #304
Berkeley, California 94704
USA
tel: 1-510-845-1447
fax: 1-510-845-9141
bookorders@hesperian.org
www.hesperian.org

THANKS
Where There Is No Dentist, updated edition, 2010
Thanks from Hesperian
We continue to be inspired by Murray Dickson and his tireless efforts to
encourage health and dental promoters and community members to respond
self-reliantly to their health needs. A few years ago, Murray introduced us to
Richard Bebermeyer, Martin Hobdel , and Gene Stevenson, whom we thank for
volunteering their time to write and develop the manuscript for Chapter 12 in
this book, "HIV and Care of the Teeth and Gums." That material was original y
published in 2002 and distributed as a supplement to the previous edition of
Where There Is No Dentist. We also thank Jane Maxwel , who edited the
supplement with assistance from Darlena David, Julie Gerk, and Todd Jailer.
Hesperian is lucky to be able to draw upon a large pool of people committed
to grassroots health, and we owe a debt of gratitude for their insightful
comments and suggestions to: Jean Arthur, Alma Carolina Blanco Reyes,
Claire Borket, Roman Carlos, Stephen Cox, Belinda Forbes, Jo Frencken,
Monica Gandhi, Gene Gowdey, Gerardo Gutierrez, Martin Hobdel , Marie
Klaipo Patcharin Lekswat, Brian Linde, Theresa Noe, Francina Lozada Nur,
Stephen Moses, Foluso Owotade, Francis Serio, Michael Terry, Garth von
Hagen, and P. Wanzala.
New il ustrations in this edition of the book are by: Silvia Barandier, Sara
Boore, Heidi Broner, Jose de Jesus Chan, Gil Corral, Regina Faul-Doyle, Anna
Kal is, Susan Klein, Gabriela Nunez, Mona Sfeir, Sarah Wal is, Lihua Wang, and
Mary Ann Zapalac.
Editing and updating of the 2006 edition was coordinated by Kathleen Vickery
with assistance from Todd Jailer and Susan McCal ister, production by Inaki
Fernandez de Retana and Leana Rosetti, and additional writing by Fiona
Thomson. For the 2010 edition, coordination by Dorothy Tegeler, with support
from Deborah Bickel, Matthew Crimp, Jacob Goolkasian, Shu Ping Guan, Todd
Jailer, Susan McCal ister, and Kathleen Tandy.
Thanks from Murray Dickson, 1983
Where There Is No Dentist is here to fil 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 fil s 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 chal enge 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 Bil 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 El iott de Jacques, Michael Marzol a, Joan Thornpson, Mindy Mead,
Arlene Ustin-Cartagena, and Lynn Gordon. My own drawings in the manual
appear amateurish in comparison.
I want to thank the many persons who reviewed the manuscript and offered
valuable suggestions: Ken Cripwel , Bil Bower, Jeff Vore, Aaron Yaschine,
Rosalie Warpeha, Norma Francisco, Mike Mul er, Marcia Anderson, Phil
Haskett, Bert Bali, Tom Coles, Sunil Mehra, and John Rogers. In particular,
thanks to Chris Lennox who, faced with stressful times in Papua New Guinea,
found time to read through two drafts; and to David Morley for his ideas for
improving the book and his assistance with its eventual publication.
For their financial help, I am grateful to the El a Lyman Cabot Trust, Muttart
Foundation, the Canadian Organization for Development through Education,
and the James C. Penney Foundation.
I thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to
adapt several drawings from the Handbook of Clinical Pedodontics, and the
Medical Missionary Association (244 Camden Road, London NW1 9HE, U.K.)
for permission to use parts of David Halestrap's book Simple Dental Care.
This book is based upon several years of practical experience, made possible
by the Canadian Organization CUSO. For this opportunity, and for CUSO's
active interest and involvement in this book, I most grateful y say thanks.
Final y, I want to acknowledge my family's contribution. For weeks on end,
my wife, Gerri, faithful y read and discussed with me each part of the book
as it changed and was rewritten. She did this cheerful y, at a time when she
was ful y 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.

CONTENTS
Introduction by David Werner
Part One: Learning and Teaching about Teeth and Gums
Chapter 1: Your Own Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Eat only good healthy foods . . . . . . . . . . . . . . . . . . . . 3 Sore bleeding gums . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Clean your teeth every day . . . . . . . . . . . . . . . . . . . . . 4 More serious gum disease . . . . . . . . . . . . . . . . . . . . . 8
Cavities, toothaches and abscesses . . . . . . . . . . . . . 6
Chapter 2: Teaching Family and Friends in Your Community . . . . . . . . . . . . . . 9
Chapter 3: Teaching Children at School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chapter 4: School Activities for Learning about Teeth and Gums . . . . . . . . . . 35
Why do we need teeth and gums?. . . . . . . . . . . . . . 37 How do germs make holes in the teeth? . . . . . . . . . 50
Why do some teeth look different? . . . . . . . . . . . . . 39 What makes the gums feel sore? . . . . . . . . . . . . . . . 52
What holds the teeth? . . . . . . . . . . . . . . . . . . . . . . . . 41 What does it mean if a tooth is loose? . . . . . . . . . . 54
How often do teeth grow in? . . . . . . . . . . . . . . . . . . 43 How can we prevent cavities and
What makes teeth hurt? . . . . . . . . . . . . . . . . . . . . . . 46 sore gums? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Chapter 5: Taking Care of Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Part Two: Treating Dental Problems
Chapter 6: Examination and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Where to examine . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 A good diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
The instruments you need . . . . . . . . . . . . . . . . . . . . . 75 Learn to tel similar problems apart . . . . . . . . . . . . . 80
Chapter 7: Treating Some Common Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
The first rule of treatment: stay clean! . . . . . . . . 86
Dislocated jaw . . . . . . . . . . . . . . . . . . . . . .113
Problems you wil see most often . . . . . . . . . . . 92
Pain in the joint. . . . . . . . . . . . . . . . . . . . . .114
Cavities . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Swol en gums and epilepsy . . . . . . . . . . . . .115
Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Blood in the mouth . . . . . . . . . . . . . . . . . . .116
Infected sinus . . . . . . . . . . . . . . . . . . . . . . 95
After you take out a tooth . . . . . . . . . . . . . . . .116
Tooth injuries. . . . . . . . . . . . . . . . . . . . . . . 96
Swel ing of the face . . . . . . . . . . . . . . . . . .116
Loose tooth . . . . . . . . . . . . . . . . . . . . . . . . 99
Pain from the socket . . . . . . . . . . . . . . . . . .117
New tooth growing in . . . . . . . . . . . . . . . . .100
Bleeding from the socket . . . . . . . . . . . . . . .118
Gum disease . . . . . . . . . . . . . . . . . . . . . . .101
Tetanus . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
Fever blisters . . . . . . . . . . . . . . . . . . . . . . .104
Infection in the spit (saliva) gland. . . . . . . . . . . .119
Thrush . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Sores on the face . . . . . . . . . . . . . . . . . . . . . .120
Canker sores . . . . . . . . . . . . . . . . . . . . . . .106
Noma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
Some special problems . . . . . . . . . . . . . . . . . .108
Tumor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
Broken bone. . . . . . . . . . . . . . . . . . . . . . . .108
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125

Chapter 8: Scaling Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Chapter 9: Injecting Inside the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Chapter 10: Cement Fillings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Chapter 11: Taking Out a Tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
The instruments you need . . . . . . . . . . . . . . . . . . . 154
False teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Where you work is important . . . . . . . . . . . . . . . . 156
Problems that can occur . . . . . . . . . . . . . . . . . . . . 165
How to take out the tooth . . . . . . . . . . . . . . . . . . . 157
Clean your instruments after you finish . . . . . . . . 167
How to place a suture . . . . . . . . . . . . . . . . . . . . . . 161
Chapter 12: HIV and Care of the Teeth and Gums . . . . . . . . . . . . . . . . . . . . . . . 169
What is HIV? . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
White or yellow patches in the mouth . . . . . . . 180
How is HIV spread? . . . . . . . . . . . . . . . . . . . . . . 172
Sores of the skin of the mouth . . . . . . . . . . . . . 182
Who gets HIV? . . . . . . . . . . . . . . . . . . . . . . . . . 173
Infection of the gums . . . . . . . . . . . . . . . . . . . . 183
How HIV affects the mouth. . . . . . . . . . . . . . . . 173
Cold sores or fever blisters . . . . . . . . . . . . . . . . 186
How to examine the mouth for
Red or purple patches in the mouth . . . . . . . . . 188
signs of HIV or AIDS . . . . . . . . . . . . . . . . . . . . . 174
Dry or painful mouth and throat . . . . . . . . . . . . 189
Dental care for a person with HIV . . . . . . . . . . 177
Helping people with HIV in
Common problems caused by HIV
your community. . . . . . . . . . . . . . . . . . . . . . . . . 190
and how to treat them . . . . . . . . . . . . . . . . . . . 178
Working for change in your community . . . . . . 191
Appendices
Get Rid of Wastes Safely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199
The Dental Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201
Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .202
Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205
Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207
Records, Reports, and Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215
Vocabulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .222
Other Books from Hesperian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230

INTRODUCTION
by David Werner
A healthy tooth is a living part of the body. It is connected by `life-lines' of
blood and nerve to a person's heart and brain. To separate the tooth from the
body, or even to interrupt those `life-lines', means death to the tooth. It also
means pain and injury to the body, to the person.
Let us look at it another way. The health of the teeth and gums is related to
the health of the whole person, just as the well-being of a person relates to
the health of the entire community.
Because of this, the usual separation between dentistry and general health
care is neither reasonable nor healthy. Basic care of the teeth and gums--
both preventive and curative--should be part of the `know-how' of all primary
health care workers. Ideally, perhaps, Where There Is No Dentist should be
a part of Where There Is No Doctor. Think of it as a companion volume, both
to Where There Is No Doctor and Helping Health Workers Learn.
Murray Dickson has taken care to write this book in a way that will help the
readers see dental care as part of community health and development. The
approach is what we call `people centered.'
Where There Is No Dentist is a book about what people can do for
themselves and each other to care for their gums and teeth. It is written for:
* village and neighborhood health workers who want to learn more
about dental care as part of a complete community-based approach to
health;
* school teachers, mothers, fathers, and anyone concerned with
encouraging dental health in their children and their community; and
* those dentists and dental technicians who are looking for ways to
share their skills, to help people become more self-reliant at lower cost.
Just as with the rest of health care, there is a strong need to
`deprofessionalize' dentistry--to provide ordinary people and community
workers with more skills to prevent and cure problems in the mouth. After
all, early care is what makes the dentist's work unnecessary--and this is the
care that each person gives to his or her own teeth, or what a mother does
to protect her children's teeth.

While dental disease is decreasing in richer countries, it is on the increase
in most poor countries. One reason for this is that people are eating fewer
traditional (unrefined) foods and more pre-packaged commercial foods, often
sweetened with refined sugar.
Even as the need for dental care is growing, there are still far too few
dentists in poor countries. Most of those few work only in the cities, where
they serve mostly those who can afford their expensive services.
People in many countries cannot afford to pay for costly professional dental
care. Even in rich countries, persons who do not have dental insurance often
do not get the attention they need--or go into debt to get it.
Two things can greatly reduce the cost of adequate dental care: popular
education about dental health, and the training of primary health workers
as dental health promoters. In addition, numbers of community
dental technicians can be trained--in 2 to 3 months plus a period of
apprenticeship--to care for up to 90% of the people who have problems of
pain and infection.
Dentists' training usually includes complicated oral surgery, root canal
work, orthodontics (straightening teeth), and other complex skills. Yet most
dentists rarely do more than pull, drill, and fill teeth--skills that require a
fraction of the training they have received. The simpler, more common
dental problems should be the work of community dental technicians who
are on the front lines (the villages), with secondary help from dentists for
more difficult problems.
Would this reduce quality of service? Not necessarily. Studies have shown
that dental technicians often can treat problems as well as or better than
professional dentists. In Boston (U.S.A.), for example, a study showed many
of the basic treatments commonly given by dentists to be done just as well,
and often better, by dental technicians with much shorter training.
Fortunately, in some countries skilled dental technicians have managed to
become the major providers of the most needed dental services. In India,
there are still `street-corner' dental technicians with footpedal drills, who drill
and fill teeth at remarkably low cost.
In Honduras, dental technicians (who learn largely from each other,
starting as helpers) have formed their own union. Their political strength
was tested when, in the town of Trujillo, a dentist tried to put a technician
out of business. The local technician had removed an infected root left
mistakenly by the dentist. The technician had commented on the dentist's
carelessness, and the dentist heard about it. The dentist sent a policeman
who shut down the technician's office and took away his tools. However,
the dental technicians' union look this to court. They argued their rights to

practice dentistry, because they are the only persons working in marginal
communities where dentists' prices are too high for the people. The court
decided in favor of the technicians, and ordered the dentist to return the
technician's tools and pay him for work lost.
In other countries dentists and community dental workers work in closer
harmony. In Guatemala, Ecuador, Papua New Guinea, and Mozambique,
dental technicians are now recognized by the Ministries of Health. In Papua
New Guinea and Ecuador, professional dentists train and supervise them
to provide dental care to school children. In Ecuador, they work mostly
as dentist assistants, bringing high quality services to more people while
decreasing costs. The `dental therapists' in Papua New Guinea are trained
to extract, drill, and fill teeth, as well as to work on prevention of dental
problems in school children.
In Guatemala and Mozambique, dentists from the dental school have trained
village health promoters as dental workers who work with people of all ages.
Their training includes community dental health education, cleaning of teeth,
extractions, and drilling and filling. These health workers are provided with
the few basic instruments needed to provide these services.
In Project Piaxtla Mexico (with which I and the Hesperian Foundation have
worked for many years), visiting dentists have also helped train village
`dentics'. They, in turn, now teach basic dental skills to the part-time village
health workers. These village dentics, some of whom have had only 3
to 6 years of primary school, now practice--and teach--a wider range of
dental skills than the average dentist. Their activities include dental health
campaigns with school children, community puppet shows about low-cost
dental self-care, cleaning of teeth, extractions, drilling and filling, and the
making of dentures (false teeth). Several of the dental workers can now do
root canal work--a special treatment to remove the central nerve in order to
save an infected tooth. One of the village dentics, remembering what he had
seen a dentist do, taught himself how to do root canals when his girlfriend
had an infected front tooth that he did not want to pull. (He had also learned
to check the tooth from time to time afterward to make sure this treatment
had been successful.)
We still have much to learn about dental health. Dentists need to learn from
the knowledge of the local people, as well as the people from the dentists.
We have learned that villagers with little formal education often can learn
skills with their hands--such as tooth extractions, puppetry, or surgery--
much faster than university students (who have never learned to use their
hands for much more than pushing pencils). We also have observed that
the best way to learn dentistry is not through school but through practice,
helping someone with more experience who is willing to teach.

Where There is No Dentist has 2 parts. The first part (Chapters 1-5)
discusses teaching and learning about preventive care. It begins by
encouraging the health worker to examine herself and her family. To be a
good example is the best way to teach.
The second part (Chapters 6-11) talks about diagnosing and treating
common dental problems. It is especially for those who live where they
cannot reach or afford a dentist. A poor neighborhood in the city can be
as distant and neglected as a far-off village. This second part is intended
mainly for health workers who have helped organize people to meet their
own needs.
Murray Dickson-- a Canadian with primary care experience in Northern
Canada, Nigeria, Papua New Guinea, and Mozambique--has written this
book in clear, simple language. He takes care to use popular names instead
of unfamiliar scientific words. For example, instead of speaking of `dental
plaque' the author speaks of the `coating of germs on the teeth.' Such
simple language does not weaken the message. The message is stronger
because everyone understands.
The author has said:
I am sure some dentists will disagree with parts of this book.
Some points of disagreement may be small, like the failure to
use accepted dental terminology. Other ideas, particularly the
suggestion that non-dental people can be trained to provide
many kinds of treatments, may make some dentists angry.
The book is meant to be a source for argument and
discussion. This way, it may stimulate others to write the kind
of manual that is really needed in their countries.
The people must answer to the people's needs. The health of teeth and
gums, along with general health, will improve only when people take the
lead in caring for themselves. The challenge for dentists and other health
professionals is to allow and encourage this to happen.

Document Outline

  • Title Page
  • Imprint Page
  • Thanks Page
  • Table of Contents
  • Introduction
  • Chapter 1: Your Own 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 Teeth
  • Chapter 12: HIV and Care of the Teeth and Gums
  • Appendices
  • Vocabulary
  • Index
  • Other Books from Hesperian

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Where There is no Dentist

 

 

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