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:

Figure

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.

Figure

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.

GUM BUBBLE

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.

Figure 1. A sore on the gums may be from an infected tooth.

Figure 2. Sores on the inside of the lip or cheek may be from a virus.

Figure 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 person.

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

WHERE TO EXAMINE

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

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

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

Figure

Use an old chair with a strong back.

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

THE INSTRUMENTS YOU NEED

Three instruments are really enough:

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.

Figure

A GOOD DIAGNOSIS

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

Learn all you can about the person’s problem: 1. Ask questions about the problem. 2. Look at the person’s face. Think about the person’s age. 3. Examine the mouth more carefully than before. 4. Touch the place that is sore.

1. Ask the person about the problem.

Figure

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 feeling.

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

· When do you have the most pain? Find out if it happens all the time or only some of the time.

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

· Have you had an accident or injury lately? Infection still inside the bone from an old injury in the mouth can make a sore on his face, or start swelling.

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

· How old are you? Think about a new tooth coming into the mouth.

After you hear the answers to your questions, decide if your original idea is the correct diagnosis. If not, try to think of another possibility and ask more questions. This is the scientific method of making a diagnosis. For a good explanation of scientific method, see Chapter 17 of Helping Health Workers Learn.

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
Figure	Figure	Figure
CHILD	YOUNG PERSON	ADULT
Swelling can come from · mumps · an infection in the spit gland · a tooth abscess	Swelling can come from · a new tooth growing in · a tooth abscess	Swelling can come from · a tooth abscess · a broken jaw · a tumor

A SORE
Figure	Figure	Figure
CHILD	YOUNG PERSON	ADULT
A sore can come from · impetigo · Vincent’s Infection	A sore can come from · fever blisters · a tooth abscess	A sore can come from · 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 area.

Figure

Look at the teeth:

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

Look at the gums:

· Are they red?
· Is there any swelling?
· Do they bleed?
· Are the gums eaten away between the teeth?

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

4. Touch the sore place.

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

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

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

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

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

LEARN TO TELL SIMILAR PROBLEMS APART

If a person comes to you with a toothache or a sore or a loose tooth, there are many possible causes for each problem. The first thing you notice - the toothache, sore or loose tooth - is your first step to a diagnosis. To this you must add more information before you can point to the most probable cause.

Figure

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.

IF THE PERSON HAS	AND YOU FIND OUT THAT		HE/SHE MAY HAVE
A TOOTHACHE	It hurts only after eating or drinking. There is a cavity, but the tooth does not hurt when you tap it.		a cavity
	Part of the filling has fallen out, or is cracked and ready to fall out. Eating and drinking make the tooth hurt.		a cavity under an old filling
	The tooth hurts when chewing food. It may hurt when tapped, but there a no cavity and the tooth looks healthy.		tartar between the teeth
	It hurts all the time - even when person tries to sleep. The tooth hurts when you tap it and it feels a bit loose.		an abscess
	It hurts when person breathes in cold air. The tooth was hit recently.		a cracked or broken tooth
	He cannot open his mouth properly. Steady pain and a bad taste are coming from the back of the mouth.		a new tooth growing in
	Several top teeth hurt, even when you tap them. She had a head cold and can only breathe through her mouth.		an infected sinus
A SWOLLEN FACE	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 opening her mouth.		a new tooth growing in
	He was hit on the face or jaw. The bone hurts when you touch it. The teeth do not fit together properly.		a broken bone
	The swelling is under or behind the jaw. It gets worse when he is hungry and smells 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
A LOOSE TOOTH	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 abscess
	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. Figure		a broken bone around the tooth’s roots
			OR
			infection inside the bone from Vincent’s Infection
	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 another
A SORE MOUTH from INFECTED GUMS	The gums are red and swollen. They bleed when the teeth are cleaned.		gum disease starting
	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 infection)
	The gums are bright red and sore, but between the teeth they are still pointed.		fever blisters on the gums - from Herpes Virus
or A SORE MOUTH from a SMALL SORE in another place	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 sucking.		thrush
	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.		malnutrition
	Small painful blisters on the lips soon break and form dry scabs.		fever blisters - from Herpes Virus
A SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER
A SORE ON THE FACE	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 medicine.		cancer
TROUBLE OPENING THE MOUTH	He is young, between 16-24 years, with some smelling behind his jaw.		a new tooth growing in
	He recently had an accident.		a broken jaw - probably in front of the ear
	He had a toothache before in a back tooth with some swelling.		an abscess in a back tooth
	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.		tetanus
TROUBLE CLOSING THE MOUTH	After opening wide to eat or yawn, his mouth became stuck there. He has many missing back teeth.		a dislocated jaw
	He had an accident, and now something is stopping the teeth from coming together.		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.

THE FIRST RULE FOR TREATMENT: STAY CLEAN!

No matter what problem you are treating, be sure that your workplace, your instruments, and you are always clean. For example, prevent infection by always washing your hands before you examine or treat someone.

Wash your hands in front of the person, in the same room. You will show that you are a careful and caring health worker. Also, you will demonstrate just how important cleanliness really is.

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

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

Figure

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

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

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

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

Boil any instrument that has touched blood.

That means always sterilize with steam all syringes, needles, and instruments you use when scaling teeth (Chapter 8) or when taking out a tooth (Chapter 11).

Be safe: When in doubt, sterilize!

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

· Add 5 spoonfuls (20 ml.) of oil to every liter of water you boil.

· Then lay the hot instruments on a dry, clean (sterile, if possible) cloth, so the water can evaporate.

Never put an instrument away while it is wet.

Sterilizing with steam under pressure is the fastest and surest method. It kills harmful germs in 15 minutes. You need a strong pot with a tight fitting lid. But be sure to make a small hole in the lid so steam can escape when the pressure becomes too great.

A special pot called a pressure cooker is perfect for this. It even has a safety hole on it to release extra steam.

1. Put 2 cups of water and 2 spoonfuls of oil into the pot.	Figure
2. Place the handles together. Put on high heat until a loud hissing noise begins.	Figure
3. Put on lower heat. Begin timing now. Leave the hissing pot on the low flame for 15 minutes.	Figure
DO NOT LET THE COOKER BOIL DRY!
4. Cool the pot under water, open, and lay the instruments on a clean towel to dry.	Figure
	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

Figure

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.

Figure

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.

PART 1: PROBLEMS YOU WILL SEE MOST OFTEN

CAVITIES AND LOST OR BROKEN FILLINGS

A cavity can occur in any tooth. A cavity can also start around an old filling, especially if it is dirty. The deeper a cavity gets inside the tooth where the nerve lives, the more the tooth hurts.

SIGNS:

· pain when drinking water or eating something sweet
· 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

Figure

TREATMENT (when there is no abscess):

Try to remove any loose piece of filling with a probe. Then, following the steps in Chapter 10, put in a temporary filling.

Now:

1. Fill the hole with cement. If you have no cement, put some cotton into the hole to keep food out.

2. Look for cavities or broken fillings in the other teeth. Fill each one with cement before it gets worse and starts to hurt.

Soon (within a few months):

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

Figure

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.

TOOTH ABSCESS

A cavity that is not filled grows bigger and deeper until it touches the nerve. Germs travel inside the tooth’s root and start an infection called an abscess.

Pus forms at the end of the root, inside the bone. As the pus increases, it causes great pressure. This is why an abscess causes severe pain.

SIGNS:

· pain all the time, even when trying to sleep

· 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

Figure

TREATMENT:

If there is no swelling, take out the tooth immediately (unless you are able to give root canal treatment). This allows the pus to escape and relieves the pain. See Chapter 11.

If there is swelling, treat the swelling first. Take out the tooth only after the swelling goes down. This is necessary because an anesthetic (see Chapter 9) will not work if there is swelling. If the anesthetic works, then it is safe to take out the tooth.

To treat the swelling, give an antibiotic. Penicillin by mouth is best. Use an injection only when the person is in immediate danger. For example, inject penicillin when the person has a fever or if the swelling is pressing against the throat. But remember you can treat most serious infections with simple penicillin by mouth. For the doses for serious infections, look below the box on the next page. If you still think an injection is necessary, look at the section on ‘aqueous procaine penicillin’.

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.

THE BEST CHOICE		SECOND CHOICE (for those allergic to penicillin)
Penicillin G or V: 1 tablet = 250 mg. Give enough tablets for 3 days		Erythromycin: 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 (2000 mg.)	Adults and children over 25 kg.	4 tablets (1000 mg.)
Children under 25 kg.	4 tablets (1000 mg.)	Children under 25 kg.	2 tablets (500 mg.)
Then every 6 hours for 3 days (12 doses)		Then every 6 hours for 3 days (12 doses)
Adults and children over 25 kg.	2 tablets (500 mg.)	Adults and children over 25 kg.	2 tablets (500 mg.)
Children under 25 kg.	1 tablet (250 mg.)	Children under 25 kg.	1 tablet (250 mg.)
IMPORTANT: to allow it to best fight infection, take penicillin before eating.		IMPORTANT: to avoid upset stomach, take erythromycin with meals.

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.

INFECTED SINUS

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

SIGNS:

· toothache in several top teeth. The teeth look healthy, but hurt when you tap them.

· a head cold, and plugged nose. She can only breathe through her mouth.

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

Figure

TREATMENT:

Figure

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.

TOOTH INJURIES

1. Broken tooth

It is possible to save a broken tooth. It depends on where the tooth is broken and whether its nerve is still covered.

SIGNS:

· pain when breathing air or drinking water
· blood from the gums around the tooth
· tooth moves when you touch it

Figure

TREATMENT:

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 treatment.

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.

Figure

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.

Figure

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.

Figure

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 treatment.

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

LOOSE TOOTH

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

IF THE TOOTH IS LOOSE BECAUSE ¯	THE BEST TREATMENT: ¯
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 moves when you push against the tooth.)	Do not take out the tooth. If you do, the bone will come out with it. Instead, hold the tooth with wires.

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

SIGNS:

· you can feel the tooth move when the upper and lower teeth meet.
· that tooth hurts.

Figure

TREATMENT:

You need to remove a bit of each of the teeth that are biting too hard. Use either a dental worker’s drill, a small file, or a hard stone.

Figure

1. Smooth the inside edge of the upper tooth.
2. Smooth the outside edge of the lower tooth.

NEW TOOTH GROWING IN

A new tooth cuts through the gums when it grows into the mouth. Germs can easily go under the gums in that place and cause an infection. When the opposite tooth bites against the sore gum it can make an infection worse.

SIGNS:

· 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.

TREATMENT:

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

What you can do

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

· 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.

TEETHING

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

Figure

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

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

TREATMENT:

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

1. Give acetaminophen or aspirin for pain and fever.

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

GUM DISEASE STARTING

Infection can start in the gums whenever the teeth near them are not clean. For example, there may be swelling (called an epulis) between only 2 teeth or between many teeth. 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.

SIGNS:

· 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.

TREATMENT:

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

1. Show her how to clean her teeth better near the gums.

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).

MORE SERIOUS GUM DISEASE

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

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

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

SIGNS:

· 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.

Figure

TREATMENT:

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

1. If the person is already sick, give penicillin for 3 days.

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 beginning.

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

Figure

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.

FEVER BLISTERS

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

When the sores are inside the mouth, it is a serious problem. It usually affects children between 1 and 5 years old. A child with fever blisters in his mouth can become very sick. He will not be able to eat properly. If he does not drink enough fluids, he can become dehydrated (lose his body water). This is dangerous!

SIGNS:

· sore throat

· 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

TREATMENT:

Medicine cannot kill the Herpes virus. The sores will go away by themselves in about 10 days. The treatment is to help the person feel more comfortable and to be sure he gets enough to eat and drink.

1. Give aspirin or acetaminophen for fever.

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

Thrush is a kind of infection. It often appears when a person is weak and poorly nourished, or sick and taking medicine like tetracycline or ampicillin. In a baby, thrush usually appears on the tongue or top of the mouth. It can stop the baby from sucking. In an adult, thrush often occurs under a denture.

SIGNS:

· 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.

Figure

TREATMENT:

There is usually something else present which is helping thrush to grow. Try to find what it is and deal with it. For example, treat the malnutrition, change or stop the antibiotic medicine, or leave the denture out of the mouth for a while. Then:

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

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

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

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

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

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

CANKER SORES

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

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

SIGNS:

· 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.

Figure

TREATMENT:

A canker sore goes away by itself in about 10 days. Medicine does not make that happen any faster. (However, smoothing a denture does help.) The treatment is simple. Tell the person how to feel more comfortable while waiting for the 10 days to pass:

Eat foods that are soft and not likely to hurt the sore. Do not eat food with a lot of pepper. Drink lots of water. Chew food on the other side of the mouth, away from the sore.

figure

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.

SORES AT THE CORNERS OF THE MOUTH

Teeth support the lips. When they come together for chewing, the teeth stop the person’s chin from moving any closer to the nose.

A person without many teeth looks old. A person with a poor fitting denture also looks old.

Figure

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 sore.

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

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

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.

PART 2: SOME SPECIAL PROBLEMS

You will find some problems that are too serious for you to treat. If you can, send the sick person to a more experienced dental worker as soon as possible.

Sometimes, however, it is better to start some of the treatment yourself. Early treatment can prevent some problems from becoming more serious. Also, if you know what to do when someone returns from the hospital, you can help that person to get well faster.

Sometimes, you will find it impossible to get help. Therefore, we will discuss each of these more serious problems in detail, so you can give as much help as necessary.

BROKEN BONE

Three main bones form the face and lower jaw.

Figure

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.

Figure

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.

Figure

TREATMENT:

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: 1. Be sure the person can breathe. 2. Stop the bleeding. 3. Put a bandage on the person’s head. 4. Give penicillin to stop infection. 5. Give aspirin for pain.

1. Be sure the person can breathe.

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

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

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

Figure

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.

Figure

Now join the wires. Twist and tighten them together. This may be painful. You can inject local anesthetic - see Chapter 8. You must twist the wire tight enough to hold the broken parts together.

Bend the end of the twisted wire toward the teeth. Now it cannot poke the person’s lips or cheek.

3. Put on a head bandage.

Gently close the person’s jaw so that his teeth come together. Support it in this position with a head-and-chin bandage.

Figure

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 teeth.

Caring for a person who cannot eat properly (see below): 1. Give him liquids containing food for both strength and energy. 2. Show him how to keep his teeth clean and his gums tough.

1. Give liquid foods for strength and energy.

Prepare food in two ways: (1) First, a milk-oil drink to build strength; and then (2) a special soup to keep him strong and give him energy.

To build strength: Milk-oil drink

Mix for him each day at your clinic:

· 9 cups of water
· 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

Figure

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

Figure

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.

Figure

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.

Figure

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.

Figure

4. Cut the ends of the ligature wire. Turn them toward the teeth, so they will not cut the lip.

Figure

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 treatment.

DISLOCATED JAW

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

SIGNS:

· 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.

Figure

TREATMENT:

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

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

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

Figure

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.

PAIN IN THE JOINT

A joint is the place where one bone joins another. The jawbone has two joints, for it joins the head in front of each ear.

The mouth opens and closes because:

· muscles pull the jawbone; and
· the jawbone slides against the head bone, inside the joints.

Figure

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.

TREATMENT:

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

1. Tension.

Talk with the person and help, if you can, to find a solution to her personal problems. This can do much to help her and her muscles relax. In addition, explain how to care for the sore joint:

(a) Eat only soft foods until it no longer hurts to chew.

(b) Hold a hot, wet cloth against the jaw, to help relax the muscle. Do this as often as possible, but be careful not to burn the skin.

(c) Take aspirin 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 opens.

When you see teeth that do not fit properly:

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

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

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

SWOLLEN GUMS AND EPILEPSY

Figure

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.

BLOOD IN THE MOUTH

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

IF YOU SEE: ¯	TO STOP THE BLEEDING: ¯
a large red clot growing out of a socket where you have taken out a tooth	1.	Remove the clot with cotton tweezers.
	2.	Ask the person to bite on a piece of cotton.
sore and bleeding gums and the mouth smells bad (Vincent’s infection)	1.	Rinse with a mixture of hydrogen peroxide and water.
	2.	Remove as much tartar as you can.
a red, bleeding growth inside the cavity in a tooth	Take out the tooth; it has an abscess.
a loose tooth with bleeding gums around it	Hold the tooth with wires, or if the root is broken, take out the tooth.
torn gums with broken bone and bleeding	1.	With wire, hold the broken parts of the bone together.
	2.	Send the person to an experienced dental worker.

PROBLEMS AFTER YOU TAKE OUT A TOOTH

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

Figure

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.

TREATMENT:

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

Figure

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.

Figure 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.

Figure 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 blood.

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.

Figure

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.

TETANUS

This is a very serious infection. Tetanus germs enter the body when a wound, like a wound on the bottom of the foot, gets dirty. Germs can also be carried to the socket when you use a dirty instrument to take out a tooth. To avoid this, carefully read the rules in Chapter 7.

SIGNS:

· the jaw becomes stiff and tight
· it is hard to swallow
· the whole body becomes tight, with sudden spasms

Figure

TREATMENT:

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

INFECTION INSIDE THE SPIT GLAND

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

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

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

SIGNS:

· 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.

Figure

TREATMENT:

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 short-acting 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 duct.

SORES ON THE FACE

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

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.

Figure

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.

Figure

TREATMENT:

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 antibiotic.

· take an X-ray to see if there are dead pieces of bone which are keeping the infection alive. If there are, they must be removed.

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

NOMA

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

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.

Figure

SIGNS:

The infection starts in the mouth.

Figure

Then it passes to the gums.

1. Sore mouth with itching gums.
2. Swollen, sore gums.
3. Gums bleed when eating or when teeth are cleaned.
4. Bad breath, spits a lot.

Then it reaches the jaw.

5. Loose teeth.
6. Loose pieces of bone around the teeth.

Figure

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.

TREATMENT:

You must start treatment for noma immediately in order to prevent the hole from getting bigger. The bigger the hole, the tighter the scar that forms after you close the hole. A tight scar will prevent the child from opening his mouth and chewing the food he needs to grow stronger.

1. Give fluids.

The child needs to overcome both the lack of body water (dehydration) and his lack of resistance to disease.

Start giving the Milk-oil drink.

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.

Figure

2. Treat the anemia.

Start giving iron now. The child should continue taking the tablets or mixture for 3 months.

	Ferric Ammonium Citrate Mixture	OR	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.

Weight	Dose (give 4 times a day)
5 to 10 kg.	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.

Figure

PREVENTION of Noma:

Noma need not occur. We can prevent it. Always give special attention to the mouth of a sick child, to be sure to keep his teeth clean.

Whenever someone is nursing or caring for 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 (dehydration).

Such a child should always:

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

(2) rinse his mouth with a warm salt water solution, 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.

Figure

TUMOR

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 tumor.

TREATMENT:

Do not waste any more medicine or any more time. A tumor may be cancer. Send for medical help. Surgery is needed to remove a tumor.

CANCER

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.

Figure

Cancer is deadly.

Medicine cannot help.
It wastes time to use it.

Cancer can spread quickly to the inside of the person’s body where you cannot see it. This can lead to the person’s death.

TREATMENT:

Whenever you treat a sore and it does not get better, send the person for medical help immediately. A doctor can cut out a piece from the sore, look at it under a microscope, and decide if it is cancer.

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.

Figure

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 again.

However, gums remain healthy only when we keep the teeth beside them clean. If we are not careful about cleaning our teeth after they are scaled, tartar will soon return. Instead of being healthy, the gums will become sore and infected again.

Scale a person’s teeth, but also teach how to keep teeth clean.

You must remove something caught under the gums 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.

THE INSTRUMENTS YOU NEED FOR SCALING

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:

Mirror

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 instruments.

Keep everything in a Scaling Kit.

HOW TO SCALE TEETH

Tartar starts to form inside the gum pocket. There it builds up, because the gums protect it. So you often must feel rather than see the tartar when you scale a tooth.

You must remove all of the tartar so the gums can heal. New tartar grows faster when there is old tartar left behind for it to build upon.

Lay out what you need ahead of time.

	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: 1. Explain to the person what you are going to do. 2. Feel under the gum for rough spots (tartar). 3. Place the scaler under the tartar. 4. Pull the scaler against the side of the tooth. 5. Check to be sure the tooth is smooth. 6. Explain what you have done and what the person should now do.

1. Explain what you are going to do. Tell the person what to expect. There will be some bleeding and possibly some pain. However, you can stop and rest, or inject local anesthetic, if it is painful. Remember: first wash your hands and your instruments!

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.

Figure

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.

Figure

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.

Figure

Rest your 3rd finger against a tooth. This will steady your hand and let you slide the sharp scaler under the gum with care.

Figure

FOR AN UPPER TOOTH

Figure

Figure

FOR A LOWER TOOTH

Figure

The edge of the gum, near the tooth, folds under to form a pocket. This gum pocket goes completely around each tooth. The gum pocket can be shallow or deep. A deep pocket means there has been an infection for a while.

Figure

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.

Figure

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

Figure

Be careful when you place the rounded end of the scaler inside the gum pocket.

Figure	Figure
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.

Figure

5. Check to be sure the tooth is smooth.

Figure

With your probe, feel under the gum for any place that is still rough. When all the sides of the tooth feel smooth, move to the next tooth.

Do not hurry. It is more important to take your time and carefully remove all the tartar. If the person has a lot of tartar, scale only half the mouth now. Do the other half on another day, as soon as the person can return.

Finally, make the tooth look clean. Use the sharp edge of either scaler. Scrape away the dark material on the front and back sides of the tooth.

Figure

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.

REMOVING SOMETHING FROM UNDER THE GUM

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.

Figure

OR,

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 away.

Figure

KEEP YOUR SCALING INSTRUMENTS SHARP AND CLEAN

A sharp scaler bites into tartar better than a blunt one. Sharpen the edge whenever you feel it sliding over the tartar.

Figure

From time to time, feel the cutting edge to be sure it is sharp. Scrape it against your fingernail. If the cutting edge is not able to cut your nail, it will not be sharp enough to break the tartar free.

Sharpen the cutting edge of the scaler on a fine-grain stone (Arkansas stone). Put a few drops of oil or water on the stone first, so the scaler can slide against it more easily.

Rest your 2nd or 3rd finger against the side of the stone. This is for control. Rub the cutting edge against the stone. Move it back and forth. Turn the round scaler as you sharpen it. This helps to keep the scaler’s round shape.

Figure

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 person.

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.

WHAT YOU NEED TO INJECT

There are two kinds of syringes for injecting local anesthetic inside the mouth. One is made of metal and the other is made of glass. The metal syringe uses local anesthetic in a cartridge. The glass syringe uses local anesthetic from a bottle.

METAL SYRINGE - This is a dental syringe. It uses special needles, and the local anesthetic is sealed inside a glass cartridge. You must throw away both needle and cartridge after injecting.

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 person.

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.

METAL SYRINGE	GLASS SYRINGE
Order:	Order:
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 similar)
One box contains 100 needles, each one inside a plastic cover	3. local anesthetic: 20 ml bottle of lidocaine (lignocaine) 2%
3. local anesthetic: local anesthetic cartridges for a dental syringe	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 page).

WHERE TO INJECT

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.

Figure

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 roots. To make a lower tooth completely numb, you must block the main nerve (a) before it goes inside the jaw bone. Figure 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).

WHEN TO INJECT

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.

HOW TO INJECT*

*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.

Figure

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.

Figure

The local anesthetic must come out against the bone, where the nerve is.

Figure

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.)

Figure

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.

FOR GLASS SYRINGES:

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.

Figure

FOR METAL SYRINGES:

· 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.

Figure

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.

Figure

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.

Figure

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 ‘pressure anesthesia’.)

Figure

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 properly.

Stand in such a way that you can see clearly where you need to inject. Ask the person to open wide.

Figure

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.

Figure

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.

Figure

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. Figure 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.

AFTER YOU GIVE AN INJECTION

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.

Figure

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.

Figure

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.

WHEN NOT TO PLACE A 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.

Figure

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).

WHEN TO PLACE A FILLING

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.

Figure

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.

TWO KINDS OF FILLINGS

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.

THE INSTRUMENTS AND FILLING MATERIAL YOU NEED

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.

Instruments

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.

mirror

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.

HOW TO PLACE THE CEMENT FILLING

Lay out on a clean cloth:

To place a cement filling, follow these 6 steps: 1. Keep the cavity dry. 2. Lift out some, but not all, of the soft decay. (If the tooth hurts, inject local anesthetic.) 3. Mix the cement. 4. Press the cement into the cavity. 5. Remove the extra cement from around the cavity and the tooth. 6. Explain 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.

Figure

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.

Figure

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.

Figure

Figure

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.

Figure

Figure

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.

Figure

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.

Figure

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.

Figure

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.

Figure

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.

Figure

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.

Figure

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.

Figure

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.

CLEAN YOUR INSTRUMENTS AFTER YOU FINISH

You do not need to boil your cement filling instruments. In fact, boiling can weaken the small pointed ends.

Figure

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.

ABOUT PERMANENT FILLINGS

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 low-cost 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, Canada.

How a Dental Drill Works

Figure

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.

Figure

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.

Figure

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.

Figure

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.

Figure

Chapter 11: Taking Out a Tooth

Figure

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 out.)

· Do you have swollen feet and difficulty breathing? (You may have heart disease.)

· Do you have any allergies? (You may be allergic to some medicines we give when we take out a tooth.)

· Are you a diabetic? (If you have diabetes, your wound will take a long time to heal.)

If the person answers “yes” to any of these questions, you must take special precautions. See the next page.

FOUR PROBLEMS TO WATCH FOR

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 reaction.

A diabetic’s wound may become infected. Watch carefully the place where you took out the tooth and give antibiotics if an infection begins.

BE PATIENT, CAREFUL, AND CONSIDERATE

· Inject local anesthetic slowly in the right place, so the tooth becomes numb and you do not hurt the person when you remove it. If the person says the tooth still hurts, it is probably true! Inject again.

· Use the correct instrument in the correct way. If you are careful you can avoid breaking the tooth. When you take out a baby tooth, be extra careful not to hurt the new tooth growing under it.

· Explain everything to the person. Tell the person if something is going to hurt, even a little. When you take out the tooth, you can explain, for example, that there will be a feeling of pressure. Press on the person’s arm to demonstrate what it will be like. When you finish taking out the tooth, explain what you have done and what the person can do at home to help the mouth heal.

THE INSTRUMENTS YOU NEED

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... Figure Use this to separate the gum from the tooth.

... an elevator... Figure An elevator will loosen a tooth, or lift out a broken root.

and two forceps Figure Use forceps to pull out the tooth. There is one for upper teeth and one for lower teeth.

Other forceps can be useful, especially for taking out a strong back tooth. They have pointed beaks that are made to fit between the roots of a back molar. As a result, you can hold onto the larger tooth better.

Figure

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.

WHERE YOU WORK IS IMPORTANT

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. Figure 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. Figure If he sits on cushions, he will be higher.

HOW TO TAKE OUT THE TOOTH

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:

Figure

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: 1. Explain what you are going to do. 2. Inject local anesthetic. 3. Separate the gum from the tooth. 4. Loosen the tooth. 5. Take out the tooth. 6. Stop the bleeding. 7. Explain to the person what to do at home to look after the wound. 8. Help the person to replace the tooth with a false tooth.

1. Always begin by talking to the person. Explain why you must take out a tooth (or teeth) and tell how many teeth you will take out. Begin working only when the person understands and agrees.

2. Inject some local anesthetic slowly, in the right place. Remember from Chapter 9 that the injection for a lower tooth is different from the injection for an upper tooth.

Wait 5 minutes for the anesthetic to work, and then test to be sure the tooth is numb. Be kind - always test before you start. If the person still feels pain, give another injection.

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.

Figure

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.

Figure

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.

Figure

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.

Figure

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.

Figure YES

Figure NO

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.

Figure

To decide which way to move a tooth, think about how many roots it has.

Figure	If a tooth has 1 root, you can turn it.
	If a tooth has 2 or 3 roots, you need to tip it back and forth.

Take your time. If you hurry and squeeze your forceps too tightly, you can break a tooth.

Removing a tooth is like pulling a post out of the ground.

Figure

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.

Figure

Note: some lower molars come out toward the tongue.

Figure

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.

Figure

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.

HOW TO PLACE A SUTURE

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.

Figure

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.

Figure

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.

Figure

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.

Figure

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.

Figure

· 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

Figure

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

WHY FALSE TEETH ARE HELPFUL

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!

Figure	A person without many teeth looks old.	Figure
Figure	With a new set of plastic ‘false teeth’, the same person looks and feels much younger.	Figure

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 explain:

· how to clean the remaining teeth to prevent them from going bad, and

· how it is possible to get a replacement plastic tooth.

PROBLEMS THAT CAN OCCUR

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.

Figure

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.

Bleeding

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.

Swelling

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!”

CLEAN YOUR INSTRUMENTS AFTER YOU FINISH

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.

Figure	Figure
Use a brush and clean each instrument with soap and water. Be careful to scrub away all bits of old dried blood.	Then kill the germs by placing the instruments into a covered pot of boiling water for 20 minutes.

Keep your sterile instruments together in a clean place.

Wrap them in a clean cloth	OR	Leave them in disinfectant
Figure		Figure
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 disinfectant.

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

Figure

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.