Spending time observing a roadside dentist at work in India gave Meera Patel and Nakul Patel a unique opportunity to see dentistry at its most basic and to evaluate the crucial role that these unqualified ‘dentists’ play in helping to alleviate pain.
As part of our elective, we spent three weeks in India, observing the practices of an unqualified dentist working at the roadside. This article gives you a flavour of what we saw. India has the largest number of dental schools in the world at a staggering 122, producing around 6,000 qualified practitioners every year. Yet, despite the existence of 26,000 dentists, there are still too few qualified dentists to provide an adequate service to India's one billion population. Indeed, on average there is just one dentist to every 40,000 inhabitants. (1)
One often overlooked and largely undervalued source of dental treatment is the unqualified ‘roadside tooth-puller’, with his simple folding chair, protective awning, bowl of water, rudimentary instruments and traditional post-operative potions. Countless thousands of such ‘tooth-pullers’ provide a readily accessible and affordable peripatetic service to their patients, who are among some of the poorest and most deprived members of the community.
Although Indian dentistry is as sophisticated as any in the world, extraction remains the most common form of treatment among the poor. Since the services of a qualified practitioner are not easily accessible to the vast majority of the population, the gap is filled literally at the roadside by the ubiquitous unqualified practitioner, whose affordable, manly extraction services are available to anyone, without prior appointment. (2)
Kesavbhai G Patel is 52 and an agricultural farmer by caste. Sent away by his father at the age of 15 to train under an experienced roadside practitioner, he returned at 18 to begin his roadside practice, continuing to learn from his father and in turn teaching both his daughter and his son. With no formal qualification, he believes he is blessed from God with a talent for painless extraction, which he uses to help the socially deprived in the community.
He practises in the southern part of Gujarat State, close to Bombay on the west coast of India, visiting four towns in three districts with a combined population of five million. His surgery, as such, is limited in both premises and equipment. He stands to treat his patients, who sit on a folding chair under a simple awning for protection from the scorching sun and monsoon rain. A bowl of Dettol-infused water is used for disinfecting instruments and a bucket of cold water and steel cup for hand-washing and mouth-rinsing.
Patients turn up at the roadside clinic without appointment and, on payment of a flat rate of 20 rupees (£0.30 - for potentially up to 32 extractions), they join a queue to wait their turn. The dentist asks each patient what is wrong and to indicate the affected tooth with their finger. He then examines the troublesome tooth with his fingers and gives his opinion on the need for extraction. With the patient seated in the folding chair, the dentist uses only pressure from fingers or thumb around the extraction site and no local anaesthesia. Pressure is applied to the area following extraction. The area is also rubbed vigorously. Finally, the patient is asked to stand up and spit out any saliva or blood from their mouth on to the ground.
The dentist claims no mantras or special powers for painless treatment. "It's all in my technique", he says. "Getting a firm grip and being as quick as possible is how I make painless extractions without local anaesthetic."
Following treatment, the patient is given a teaspoon of homemade black powder to hold on the extraction site for ten minutes and then told to rinse with water. This is believed to alleviate pain and achieve haemostasis. Where bleeding continues, a back-up homemade liquid is placed on cotton wool on the extraction site. Of the 50 patients we observed, only two had complications, fractured teeth. After trying unsuccessfully to remove the roots, the dentist discharged the patients and told them to return if they were in pain.
Consent and litigation
By UK standards, consent is not obtained from the patient. The dentist simply confirms in each case the tooth in question and asks if that is correct. If the patient agrees, extraction takes place, with no further explanation or warning. Where adjacent teeth are affected, these too are extracted if the patient agrees. Patients consider themselves lucky to be free from pain at minimal cost and post-operative complications such as swelling, pain or fracture are accepted.
Patients respect the dentist enormously. Some believe he has special powers from God and some female patients tie a rakhi (string bracelet) on his wrist, symbolising a brother-sister relationship. Most of his patients are reluctant to visit the hospital or dental clinic for reasons of social class, status or the language barrier. They visit him because they feel comfortable discussing their problems with a ‘local man’, who they feel is one of them.
Health and safety
The dentist's clinic has no safe method for disposing of clinical waste. He gathers all the extracted teeth in a cardboard box, which he disposes of on any roadside rubbish pile at the end of the day. Patients spit out blood and saliva on to the ground. Yet, far from being fined or closed down, his practice is flourishing.
While all is not quite as it should be, with little in the way of formal qualification, infection control, or health and safety precautions, the roadside tooth-puller with his basic tools continues to fulfil a popular and indispensable role in the Indian community, relieving masses of deprived people of constant dental pain.
Locker. D. (1989). An Introduction to Behavioural Science and Dentistry (chapter 9). Travistock/Routledge
Anderson & Morgan. Marketing Dentistry: A Pilot Study in Dudley. Community Dental Health, 1992: 9 (supplement 1); 23-3
Meera Patel is a Barts and the London dental school graduate. Nakul Patel is a Barts and the London medical school graduate.