Dental Health Care

A healthy tooth is a living part of the body. It is connected by
‘life-lines’ of blood and nerve to a person’s heart and brain. To separate
the tooth from the body, or even to interrupt those ‘life-lines’, means
death to the tooth. It also means pain and injury to the body, to the
person.
Let us look a t it another way. The health of the teeth and gums is
related to the health of the whole person, just as the well-being of a
person relates to the health of the entire community.
Because of this, the usual separation between dentistry and general
health care is neither reasonable nor healthy. Basic care of the teeth and
gums-both preventive and curative-should be part of the ‘know-how’ of
all primary health care workers. Ideally, perhaps, Where There Is No
Dentist should be a part of Where There Is No Doctor. Think of it as a
companion volume, both to Where There Is No Doctor and Helping Health
Workers Learn. Murray Dickson has taken care to write this book in a way that will
help the readers see dental care as part of community health and
development. The approach is what we call ‘people centered.’
Where There Is No Dentist is a book about what people can do for
themselves and each other to care for their gums and teeth. It is written
for:
village and neighborhood health workers who want to learn more
about dental care as part of a complete community-based approach
to health;
school teachers, mothers, fathers, and anyone concerned with
encouraging dental health in their children and their community;
and
those dentists and dental technicians who are looking for ways to
share their skills, to help people become more self-reliant at lower
cost.
Just as wlth the rest of health care, there IS a strong need to
‘deprofessronal~ze’ dent~stry-to provlde ord~nary people and community
workers w ~ t hm ore skllls to prevent and cure problems In the mouth
After all, early care IS what makes the dent~st’sw ork unnecessary-and
this is the care that each person glves to his or her own teeth, or what a
mother does to protect her children’s teeth.

While dental disease is decreasing in richer countries, it is on the increase
in most poor countries. One reason for this is that people are eating fewer
traditional (unrefined) foods and more pre-packaged commercial foods,
often sweetened with refined sugar.
Even as the need for dental care is growing, there are s t i l l far too few
dentists in poor countries. Most of those few work only in the cities,
where they serve mostly those who can afford their expensive services.
People in many countries cannot afford to pay for costly professional
dental care. Even in rich countries, persons who do not have dental
insurance often do not get the attention they need-or go into debt to
get it.
Two things can greatly reduce the cost of adequate dental care: popular
education about dental health, and the training of primary health workers
as ‘dental health promoters’. In addition, numbers of ‘community dental
technicians’ can be trained-in 2 to 3 months plus a period of
apprenticeship-to care for up to 90% of the people who have problems
of pain and infection.
Dentists’ training usually includes complicated oral surgery, root canal
work, orthodontics (straightening teeth), and other complex skills. Yet
most dentists rarely do more than pull, drill, and fill teeth-skills that
require a fraction of the training they have received. The simpler, more
common dental problems should be the work of community dental
technicians who are on the ‘front lines’ (the villages), with secondary
help from dentists for more difficult problems.
Would th~sre duce quality of service? Not necessarily. Studies have
shown that dental technicians often can treat problems as well as or better
than professional dentists. In Boston (U.S.A.), for example, a study
showed many of the basic treatments commonly given by dentists to be
done just as well, and often better, by dental technicians with much
shorter training.
Fortunately, in some countries skilled dental technicians have managed
to become the major providers of the most needed dental services. In
India, there are s t i l l ’street-corner’ dental technicians with foot-pedal
drills, who drill and fill teeth at remarkably low cost.
In Honduras, dental technicians (who learn largely from each other,
starting as helpers) have formed their own union. Their political strength
recently was tested when, in the town of Trujillo, a dentist tried to put a
technician out of business. The local technician had removed an infected
root left mistakenly by the dentist. The technician had commented on
the dentist’s carelessness, and the dentist heard about it. The dentist sent
a policeman who shut down the technician’s office and took away his
tools. However, the dental technicians’ union took this to court. They
argued their rights to practice dentistry, because they are the only persons
working in marginal communities where dent~sts’ prices are too high for
the people. The court decided in favor of the technicians, and ordered the
dentist to return the technician’s tools and pay him for work lost.
In other countries dentists and community dental workers work in
closer harmony. In Guatemala;Ecuador, Papua New Guinea, and
Mozambique, dental technicians are now recognized by the Ministries of
Health. In Papua New Guinea and Ecuador, professional dentists train and
supervise them to provide dental care to school children. In Ecuador, they
work mostly as dentist assistants, bringing high quality services to more
people while decreasing costs. The ‘dental therapists’ in Papua New Guinea
are trained to extract, drill, and fill teeth, as well as to work on prevention
of dental problems in school children.
In Guatemala and Mozambique, dentists from the dental school have
trained village health promoters as dental workers who work with people
of all ages. Their training includes community dental health education,
cleaning of teeth, extractions, and drilling and filling. These health
workers are provided with the few basic instruments needed to provide
these services.
In Project Piaxtla, Mexico (with which I and the Hesperian Foundation
have worked for many years), visiting dentists have also helped train
village ‘dentics’. They, in turn, now teach basic dental skills to the parttime
village health workers. These village dentics, some of whom have had
only 3 to 6 years of primary school, now practice-and teach-a wider
range of dental skills than the average dentist. Their activities include
dental health campaigns with school children, community puppet shows
about low-cost dental self-care, cleaning of teeth, extractions, drilling and
filling, and the making of dentures (false teeth). Several of the dental
workers can now do root canal work-a special treatment to remove the
central nerve in order to save an infected tooth. One of the village dentics,
remembering what he had seen a dentist do, taught himself how to do
root canals when his girlfriend had an infected front tooth that he did not
want to pull. (He had also learned to check the tooth from time to time
afterward to ,make sure this treatment had been successful.)
We still have much to learn about dental health. Dentists need to learn
from the knowledge of the local people, as well as the people from the
dentists.
We have learned that villagers with little formal education often can
learn skills with their hands-such as tooth extractions, puppetry, or
surgery-much faster than university students (who have never learned to
use their hands for much more than pushing pencils). We also have
observed that the best way to learn dentistry is not through school but
through practice, helping someone with more experience who is willing
to teach.
Where There 1s No Dentist has 2 parts. The first part (Chapters 1-5)
discusses teaching and learning about preventive care. It begins by
encouraging the health worker to examine herself and her family. To be
a good example is the best way to teach.
The second part (Chapters 6-1 1) talks about diagnosing and treating
common dental problems. It is especially for those who live where they
cannot reach or afford a dentist. A poor neighborhood in the city can be
as distant and neglected as a far-off village. This second part is intended
mainly for health workers who have helped organize people to meet their
own needs.
Murray Dickson-a Canadian with primary care experience in Northern
Canada, Nigeria, Papua New Guinea, and Mozambique-has written this
book in clear, simple language. He takes care to use popular names instead
of unfamiliar scientific words. For example, instead of speaking of ‘dental
plaque’ the author speaks of the ‘coating of germs on the teeth,’ Such
simple language does not weaken the message. The message is stronger
because everyone understands.
The author has said:
I am sure some dentists will disagree with parts of this book. Some
points of disagreement may be small, I i ke the failure to use accepted
dental terminology. Other ideas, particularly the suggestion that nondental
people can be trained to provide many kinds of treatments, may
make some dentists angry.
The book is meant to be a source for argument and discussion. This
way, it may stimulate others to write the kind of manual that is really
needed in their countries.
We hope that this will be only the first volume of Where There 1s No
Dentist It takes the reader as far as s~mplee xtraction (pulling) of teeth
and placemen’t of temporary fillings. As we have seen, village workers can
also learn a wide range of more difficult dental skills. We hope that later
volumes of Where There /s No Dentist will include permanent fillings,
homemade portable drilling equipment (many kinds have been developed),
the making of false teeth, and root canal treatment. There is no reason
why villsge workers cannot learn all of these skills and practice them at
low cost to serve the millions who are unserved today.
The people must answer to the people’s needs. The health of teeth and
gums, along with general health, will improve only when people take the
lead in caring for themselves. The challenge for dentists and other health
professionals is to allow and encourage this to happen.