Teeth: prevent decay, and catch the abscess that spreads

Bacteria on the teeth turn sugar and cooked starch into acid, and each exposure keeps the mouth acidic for about 20–30 minutes. Enamel dissolves while it is acid and repairs in between. So how often matters more than how much.

The Vipeholm study in Sweden (1945–53) found that sugar eaten with meals added little decay, while sticky sweets eaten between meals added a great deal.

• Keep sugar, honey, dried fruit and sticky starch to mealtimes.
• Finish a meal with something that cleans or neutralises — raw vegetables, a mouthful of water, a piece of cheese.
• No sweet drinks sipped through the day, and nothing sweet after the last cleaning at night.

A frayed twig is a toothbrush that grows on trees, used across Africa, the Middle East and South Asia. WHO has recognised it as an effective cleaning tool.

1. Cut a pencil-thick twig about 15–20 cm long from a known, non-toxic tree: Salvadora persica (miswak or arak), neem, or acacia.
2. Peel 1–2 cm of bark from one end and chew it until the fibres splay into a brush.
3. Brush along the gum line — where the gum meets the tooth — outside, inside and on the chewing surfaces, for about 2 minutes, twice a day.
4. Cut off the used end every day or two, and chew a fresh one.

Water is enough; no paste is needed. Do not scrub with ash, charcoal or sand — they wear the enamel and the gums. Where fluoride toothpaste exists (1,000–1,500 ppm fluoride), use a pea-sized amount twice a day and spit without rinsing: it cuts decay by about a quarter.

• Clean from the first tooth, with a soft frayed stick or a clean cloth wrapped round a finger.
• Never leave a baby or small child with a sweet drink or a sweetened dummy at night. Milk or juice pooling round the teeth all night destroys the front teeth in months.
• Baby teeth matter. An abscess in a baby tooth can damage the adult tooth forming beneath it, and a baby tooth lost early lets the others drift into its space.

A tooth abscess: throbbing pain, often worse lying down; the tooth tender when tapped; a swelling or a pimple on the gum beside it; a bad taste as pus leaks; sometimes fever.

It is spreading, and is an emergency, if any of these appear:

• Swelling under the jaw or along the jaw line, or spreading up toward the eye.
• The floor of the mouth swollen, the tongue pushed up, or drooling.
• Difficulty opening the mouth, swallowing or breathing.
• High fever and feeling very ill.

A deep neck infection from a tooth (Ludwig's angina) killed more than half of those it struck before antibiotics. It needs the pus drained surgically, antibiotics, and the tooth removed — as fast as the most skilled person and the strongest medicine available can be reached. Sit the person upright; keep the airway open.

• Rinse with warm salt water — about ½ teaspoon of salt in a cup of warm water — held in the mouth and spat out, several times a day.
• If a swelling on the gum points and bursts, let it drain and keep rinsing.
• Relieve pain by swallowing a pain reliever if one exists; never put aspirin or crushed tablets on the gum — it burns.
• Antibiotics, where they exist, control spread, but they do not cure a tooth abscess. The infection lives in the dead tooth; it returns until the tooth is removed or its root is treated.

Watch twice a day for the spreading signs in entry 4.

An adult tooth knocked out can often be saved if it goes back fast — ideally within 15 minutes, and rarely after an hour:

1. Find it and hold it by the crown, never the root.
2. If dirty, rinse for no more than 10 seconds in milk or clean cold water. Do not scrub it.
3. Push it back into its socket the right way round and have the person bite gently on a cloth.
4. If it cannot go back, keep it in milk, or in the person's own saliva, and get it replaced as soon as possible. Do not let it dry.

Never put a baby tooth back — it can damage the adult tooth beneath. A tooth broken into the pink centre (the pulp) needs covering and will usually need removing later.

The blood clot in the socket is the dressing. Everything after an extraction is about keeping it there:

• Bite on a folded clean cloth for 30–45 minutes. If it is still bleeding, a fresh pad and another 30 minutes of firm biting; a damp black-tea bag helps.
• For 24 hours: no rinsing, spitting, sucking through a straw, hot drinks or smoking.
• From the next day, rinse gently with warm salt water after meals for a week.
• Dry socket: pain that gets worse on day 2–4 instead of better, often reaching the ear, with an empty-looking socket and a bad taste. Rinse it clean with warm salt water after every meal. It is painful but not dangerous, and heals in 1–2 weeks.

This step does not teach extraction technique. A broken root left in the jaw, a fractured jaw or a tooth pushed into the sinus is worse than the tooth was. Technique is learned by hand from someone trained; the manual to learn it with is Hesperian's Where There Is No Dentist.

What is needed:

• At least one person trained, and practising on the teeth that need it, not waiting for the emergency.
• Forceps and an elevator forged and hardened by the smith — shaped for upper and lower, front and back teeth — boiled before each use.
• Good light, a firm head rest, clean cloth, salt water.
• Local anaesthetic where it exists — see anaesthesia.