Social Science & Medicine 54 (2002) 229–244

‘‘Tooth worms’’, poverty tattoos and dental care conflicts in

Northeast Brazil
Marilyn K. Nationsa,b,*, Sharm#enia de Arau! jo Soares Nutob
a
Department of Social Medicine, Harvard University Medical School, 641 Huntington Ave., Boston, MA 02115, USA
b
Health Sciences Center, University of Fortaleza (UNIFOR), Av. Washington Soares 1321, CEP 60.811-341 Fortaleza, Ceara!, Brazil

Abstract

While medical anthropologists have studied doctor–patient clinical conflicts during the last 25–30 years, dentist–
patient communication clashes have received scant attention to date. Besides structural barriers and power inequities,
such conceptual differences further dehumanize dental care and lower service quality. Potential for dentist–patient
discordance is greater in developing regions}such as Northeast Brazil}where there exists a wider socio-economic gap
between professionals and laypersons. A critical anthropological evaluation of oral health services quality is undertaken
in two rural communities in Cear!a, Brazil where the PAHO-inspired Local Oral Health Inversion of Attention Program
was implemented in 1994. This 6-month qualitative field study utilized ethnographic interviews with key informants,
participant-observation and projective techniques to probe professionals’ and patients’ explanatory models (EMs) of
oral health. Despite the recent expansion of services into rural regions, the authors conclude that the quality of dental
care remains problematic. Patients’ culturally constructed EMs of teeth rotted (estraga) by ‘‘tooth worms’’ (lagartas)
differ substantively from dentists’ model of dental decay by Streptococcus mutans. ‘‘Exploding chins’’ (queixo
estourado), ‘‘spoiled, rotting teeth’’ (dente po#di) and ‘‘false plates’’ or teeth (chapas) tattoo and stigmatize the poor,
reinforcing gross class inequities. Dentists’ dominant discourse largely ignores lay logic, ridicules popular practices and
de-legitimates, even castigates, popular healers despite their pivotal role in primary oral health care. Poor parents are
not only barred from clinics but are blamed for children’s rotten teeth. In sum, universal access to dental care is more a
myth (even nightmare) than a reality. Dentists all too often ‘‘avert’’}not ‘‘invert’’}attention from poor Brazilian
patients. In order to improve oral health in this setting, both ‘‘societal decay’’ and bacteria-laden plaque deposits must
be removed. # 2002 Published by Elsevier Science Ltd.

Keywords: Social dentistry; Dentist–patient relationship; Quality of care; Northeast Brazil

Cavities and conflicts in Northeast Brazil
‘‘Yank (arrancar) all of them out at once, doctor! It’s
better to suffer one big pain than to be bothered with
that fine, shooting one every time you eat sweets!’’
ordered 24-year-old, illiterate Dona Rosa in rural
Beberibe, Brazil. ‘‘You want to extract all of your
teeth?’’ countered her stunned dentist. ‘‘Yeah, yank
*Corresponding author. Av. Santos Dumont 1740/Sala 1214,
Fortaleza, Cear"a 60.150-160, Brazil. Tel./fax: +55-85-261-
0958.
E-mail addresses: nations@fortalnet.com.br (M.K. Na-
tions), nuto@ultranet.com.br (S.A.S. Nuto).
out every single one (tudinho) and put in that plate or
false teeth (chapa) . . . It’s the prettiest thing in the
world. . . all the teeth so white, straight, even and
perfect. . .. Looks like a rich person’s thing! Besides,
they say yanking them out is the only way to kill the
tooth worm (lagarta) . . . just patching it up with that
putty (massa) isn’t good for anything!’’ ‘‘Woman,
have you lost your mind or what?’’ fought back the
exasperated dentist. ‘‘Listen up doctor, I might be
poor, but I’m not ignorant!’’ furiously defended
Dona Rosa.
Clinical showdowns such as this one between Dona
Rosa and her dentist in poor rural Northeast Brazil are

0277-9536/02/$ - see front matter # 2002 Published by Elsevier Science Ltd.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 0 1 9 - 3
230 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
all too common. Patients and professionals hold
differing}often conflicting}beliefs about a myriad of
topics, from what causes tooth decay to the meaning of
rotten teeth. Dona Rosa’s world of tooth worms
(lagartas), rotting teeth (estragaça*o) and designer-label
false teeth (chapas) is little known to wealthier,
university-trained dentists, whose scientific explanations
are experience-distant from the hard surfaces of life in
rural poverty. Such grave cognitive conflicts, com-
pounded by stifling structural barriers, block people’s
access to dental clinics and dehumanize oral health care.
For nearly half of Brazil’s 140 million people who live
in painful poverty (Valla & Stotz, 1993, p. 63), oral
health is highly precarious. Economic recession, un-
employment, class disparity, faulty public education,
export-geared agriculture, hunger, protein-calorie mal-
nutrition, exaggerated sugar consumption (51.1 kg/year
person1 compared to 18.6 worldwide) and absence of
dental services contribute to the problem (Pinto, 1997).
The high incidence of dental caries and periodontal
disease}causing the needless loss of some 40 million
teeth annually}has won Brazil the dubious distinction
as the ‘‘World’s Toothless Champion’’ (Narvai, 1997;
Pinto, 1997). While Brazil hosts 11% of dentists
worldwide, only 5% of its population receive public
dental care (Narvai, 1997). Perversely lopsided, the bulk
of highly trained specialists compete for the few private-
paying patients in capital cities while the rural poor lack
basic preventive care. While the 1994 implementation
of the ‘‘Inversion of Attention}Local Oral Health
Systems’’ Program in Cear!a extended coverage to
underserved rural areas (Loureiro, 1998),1 the quality
of dental practice remains problematic. The mere
extension of a high-tech, disease-fixated and clinic-
centered paradigm into rural areas failed to provoke a
parallel ‘‘inversion’’ in the way (quality) dentistry is
practised in this setting (Nuto, 1999). Although a
number of factors explain this failure, this article will
focus on one: the head-on confrontation of dentists’ and
patients’ cultural constructions of reality. Professionals’
biomedical disease focus often violates the attitudes,
values, sentiments, rhythms and decencies of patients’
daily lives. Such symbolic aggression often provokes
patients’ ‘‘non-compliance’’, revolt or even flat-out
rejection of services. The imposition of positivistic
disease models often deadens laypersons’ incentive, spoil
personal identities and break human spirits (Nations &
Monte, 1996). To construct humanistic health interven-
tions in hierarchically structured Northeast Brazil,
people’s participation (Freire, 1970; Valla & Stotz,
1993) and inclusion of their subjective interpretations,
rationalities and valuations is fundamental (Mull &
The Program is described in Estaça*o Sau! de documents (the
1
Minas Gerais consulting firm responsible for program imple-
mentation and evaluation in Cear!a).
Mull, 1988; Nations & Rebhun, 1988; Nitcher, 1988).
This study aims, then, to cut to the core of dentists’ and
patients’ interior, meaning-laden worlds of lived experi-
ence, confronting popular and professional explanatory
models (EMs) of dental care (Kleinman, Eisenberg, &
Good, 1978) in order to identify conflicts and con-
vergences. Improving dental care quality in Northeast
Brazil demands such a probing ethnographic analysis.
Beberibe and Itapeim: tropical tourism to desolate
destitute
This study was designed as a critical investigation
(Singer, 1989) of the quality of dentist–patient relation-
ships and oral health services in the context of rural
Cearense culture. Beberibe County (pop. 38,000) was
selected as our study site because local technical staff
unanimously considered it ‘‘the best’’ Inversion of
Attention pilot project in Cear!a. Located 81 km from
the state capital, Fortaleza, in Brazil’s impoverished
Northeast, Beberibe is a county of striking socio-
economic contrasts. Of its 38,000 inhabitants, 29% are
clustered into its hustling commercial center, bound by a
lush tropical coastline. The remaining 71% are dispersed
in vast outstretches of desert backlands or serta*o. Two
specific locations}Beberibe’s town district and the
Itapeim rural district}were identified for intensive
study.
At first glance, Beberibe evokes a picture-postcard-
fantasy of an exotic tropical paradise. Palm fronds rustle
in soothing trade winds. White virgin sand beaches
stretch for miles. Wind-sculptured, pastel-colored dunes
tower in the distance. And bellowing, triangular-shaped
cloth sails propel traditional wooden fishing rafts
(jangadas) out to sea. Beberibe’s indigenous Tupi-
Guarani name means ‘‘a place where sugar cane grows
with abundance’’. Today, however, tourist hotels have
replaced sugar plantations. Pulsating Axe! and forro!
rhythms and sensual, sun-bronzed, string-bikini-clad
girls attract not only tourists to this picturesque seaside
town, but increasingly drugs and prostitution.2 For
locals, life in Beberibe is far less romantic. The average
monthly family income is US$30.00. Malnutrition
afflicts 12% of children under the age of 2. The illiteracy
rate of 11–17 year olds is 30.5% and 1636 school-age-
2
Drugs (73%), infantile prostitution (56.7%) and early
pregnancy (46%) were among the top risks for children and
adolescents identified by a population survey in Beberibe. No
institutionalized sex industry is identified in Beberibe. Informal
prostitution, however, is growing with increased tourism from
Fortaleza, where an international network of child prostitution
has been recently uncovered by an official parliamentary
investigation (CPI) (C#amara Municipal de Fortaleza, 1993;
Dio! genes, 1999).
 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244 231

children, or nearly 10%, do not study (Nuto, 1999, p. (rapadura) and chibe or manioc cereal with coffee.
215). Seasonal fishing and tourism are the economic Dental services in Itapeim are likewise scarce, restricted
mainstays in Beberibe, where unemployment is a to tooth extractions in a crowded one-room clinic.
staggering 58.4%. Existing jobs fall mostly under the
category of low-skill manual labor: maids, cooks,
gardeners, waiters, security guards, tourist guides,
handicraft artists, and beach vendors. The Town Square
An anthropological inquiry
is the hub of daily life. Here everything imaginable is
bartered: vegetables, meat, domestic utensils, radios,
Between November 1998 and April 1999, the authors
clothes, hammocks, shoes, counterfeit tape recordings of
conducted an ethnographic study in Beberibe and
popular music, etc. Before dawn breaks, open-bed
Itapeim, Cear!a to explore dentists’ and patients’
trucks arrive from the interior bringing into town the
subjective evaluations of dental care quality since
retired, widowed and disabled to receive pension checks,
‘‘patient satisfaction scales’’ have proven inadequate
housewives to purchase groceries, agriculturists to sell
(Atkinson, 1993; Oliveira, 1990)5 Based on Kleinman
crops, and children for haircuts, new shoes and
(1980), EMs of three groups}private-clinic dentists,
vaccinations. Visitors seek refuge from the piercing
program dentists and laypersons (e.g. patients, families,
midday sun beneath large-leaf shade trees lining the
healers, etc.)}were elicited and confronted to identify
plaza. There they chat, snack and nap until vehicles,
convergences, differences and conflicts. To what degree
loaded-down with goods, return home. Migrations swell
do EMs of the three groups differ? Do the EMs of new
during weekends, vacations and carnival, one of Cear!a
Program dentists differ significantly from those of
largest and liveliest. Until 1995, dental care in Beberibe
private-clinic dentists? Do professionals’ EMs converge
was concentrated in three clinics: one private and two
with laypersons’? What are the implications of conflict-
public. The Program3 extended coverage to 8571
ing dentists’ and patients’ EMs for dental care quality?
children, added a dentist to each of the two Family
Special precautions were taken to protect informants
Health teams, built a modern clinic with state-of-the-art
against possible reprisals from authorities, clinic per-
technology, including children’s easy-to-reach teeth-
sonnel or family health teams. Personal identities of all
brushing sinks and mirrors (Prefeitura Municipal de
informants were disguised to encourage candid and
Beberibe, 1995). Today, tooth extractions and restora-
critical responses. Names of laypersons, traditional
tions are provided. Fluoride mouth washing is con-
healers and professionals cited in this article are also
ducted weekly at elementary schools and check-up
fictitious. Written, or when inappropriate, verbal in-
exams, dental plaque detection, supervised brushing
formed consent for interviewing, tape recording, photo-
and toothbrush distribution is conducted bi-annually.4
graphing and reproducing images and drawings was
Itapeim district, our second study site, is located
obtained from all informants before proceeding.
25 km from Beberibe’s center. Here, life is barren.
Dentists’ EMs were constructed based on content
Unrelenting poverty, poor infrastructure and chronic
analysis of local university dental training course
drought take their toll. The harsh sun keeps people
curricula, Regional Council of Dentistry reports, docu-
inside. Streets are empty, except for an occasional
ments, advertisements and brochures, an ethnographic
roaming donkey, pig or stray dog giving an eerie
interview (n ¼ 1) with the Council’s inspector and
American-Far-West-ghost-town-like impression. The
participant observations6 of university classes, regional
deadening silence is momentarily broken by the rum-
council meetings, and state and national dental con-
bling sound of an outdated school bus}the only form
ferences. Construction of Program dentists’ EMs was
of public transportation. The only ‘‘real’’ paying jobs
based on project documents and ethnographic inter-
are in government-supported public schools, health
views with 14 key informants}Project coordinators
posts and with the telephone company. Others depend
(n ¼ 1), Beberibe dentists (n ¼ 5), dental assistants
on government pensions. While residents yearn for high-
(n ¼ 4), and community health agents (n ¼ 4). Partici-
status goods displayed in Beberibe’s store windows, cash
pant observation included County Health Council
is scarce. Life is hard and people are hungry. Survival
meetings, Family Health and Community Health Agent
depends on eating subsistence foods: rice, beans, fried
Program activities, waiting patients, token distribution,
eggs, macaroni, tapioca, fish, crude brown sugar
5
Having never experienced the luxury and quality of private
3
‘‘The Program’’ refers to the Inversion of Attention dental practice, poor patients have no comparative basis on
Program. which to judge their treatment in poorly equipped and managed
4
Although activities are conducted bi-annually, Program public clinics. They are ‘‘satisfied’’ not necessarily with care
staff refer to ‘‘tri’’ periods giving the erroneous impression that quality, but with access to any care at all.
6
activities occur every 3 months, as stipulated in project As a dental surgeon, the second author has participated in
objectives. training courses, Regional Council meetings and conferences.
232 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
dentists attending patients, teachers instructing students
in tooth brushing and mouth washing.
To elicit popular EMs, 36 key informant interviews
were conducted. Sixteen informants in Beberibe’s town
center participated, 15 in Itapeim, 4 in nearby Uruau!
beach and 1 in Fortaleza. Key informants included clinic
patients (n ¼ 13), school mothers (n ¼ 10), elementary
school teachers (n ¼ 3), traditional healers (rezadeiras)
(n ¼ 5), a popular denture maker (n ¼ 1), a popular
dentist (n ¼ 1) and his patients (n ¼ 2), and a herbalist
at Fortaleza’s S*ao Sebasti*ao Market (n ¼ 1). In all, 50
ethnographic interviews were conducted. A modified
version of Kleinman’s questions to elicit patients’ EMs
guided our initial interviewing (Kleinman, 1975). The
Corin, Ucho# a, Bibeau, and Koumare (1992) approach
to studying ‘‘signs, meaning and actions’’ was utilized to
detail the lay diagnostic process and help-seeking
behavior related to rotting teeth (estragaça*o). Projection
techniques described by Adair, Deuschle, and McDer-
mott (1969) and Snow (1977) were used to capture lay
concepts of anatomical structures and pathophysiologi-
cal functioning. Residents and school children in
Itapeim were invited to draw and color pictures of
‘‘healthy and sick teeth’’ and to interpret the significance
of their drawings. To enrich interview data, participant
observations were made of a wide range of related
events. These included: school brushing and fluoride
sessions, health agents’ home visits, traditional curing
rituals for tooth problems, clinic visits, food purchasing
at market day, denture making and fitting, parents
purchasing remedies at pharmacies and herbal stands
and children storing toothbrushes at home, etc.
Detailed field notes, observations, questions, doubts,
difficulties, and descriptions of physical environments
were noted in a field diary. This data was organized in a
word-processing program and analyzed as a backdrop
to contextualize interview data. Triangulation was
utilized to crosscheck the consistency and validity of
documentary, interview and observational data (Denzin,
1970). Based on a detailed first reading, interviews were
separated into four groups depending on informant
type: 1) Program professional; 2) health agent; 3)
Beberibe patient or member; and 4) Itapeim patient or
member. A second transverse reading gave general
impressions of each groups’ EMs. We identified 62
distinct topics, clustering into six general themes: 1)
process whereby teeth rot; 2) prevention of rotting; 3)
dental service access and functioning; 4) clinical
assistance; 5.) ethnoanatomy of dental disease; and 6)
meaning of teeth. Each topic was assigned a code. All
text was re-read, hand coded and sorted according to
codes utilizing a search-and-retrieve data processing
program. Data was analyzed against a theoretical
backdrop in medical anthropology, especially critical
anthropology (Singer, 1989), ethnomedicine and eco-
nomic development.
Results
Rotting teeth (Estragaça*o): popular explanatory model
of tooth decay
Tooth decay or rotting (estragaça*o) is readily recog-
nized by our informants, contrary to dentists’ opinion
that self-diagnosis is delayed until ‘‘pain’’ presents
(Martins, 1993; Moraes & Ongaro, 1998). Our patients
note rotting by ‘‘running tongues over teeth’’, feeling a
‘‘hole’’, ‘‘little fault’’ or ‘‘pit’’, observing a ‘‘thin blackish
line’’ or smelling bad breath. Signs and symptoms of
rotting, however, do not provoke a quest for dental care,
giving the false impression that lay people are uni-
formed, disinterested or downright neglectful of rotting
teeth. To dentists’ dismay, care is sought only after pain
onset. ‘‘Silent teeth’’ signify health. Making sense of this
apparent paradox}early recognition of rotting and
decay yet delayed help seeking}demands delving into
patients’ world of shared meaning and lived experience,
culturally constructed and interpreted.
That no dental professional we interviewed knew of
‘‘tooth worms or caterpillars’’ (lagartas) does not
diminish the worm’s importance in patients’ eyes. Until
the 18th century, ‘‘dental worms’’ were believed by the
Aztecs, Babylonians, Greeks and Romans (Ring, 1998)
to cause tooth decay. A French ivory carving from the
1780s of a human molar depicts a ‘‘dental worm’’
devouring a human figure tormented by hellish pain
(Fig. 1). Belief in ‘‘dental worms’’ persists in rural Cear!a,
where microscopes are largely lacking. Despite Martin’s
(1993) assertion that laypersons are unaware of dental
disease pathophysiology, we find a striking similarity
between the lagarta and the caries-causing microorgan-
ism, Streptococcus mutans. The popular EM of rotting
teeth centers on the lagarta’s food preferences and daily
habits. The lagarta grows strong and active feasting on
favorite foods: heavily sweetened cakes, candy, bubble
gum, icing-filled cookies, brown sugar cakes (rapadura),
and sugar-coated, plastic pacifiers. It’s a lagarta glucose-
high diet. Even though parents know that lagartas’
survival depends on devouring heavily sweetened foods,
they permit, even encourage, children to eat bagulho
(junk food). They have their reasons. Sugar-laced foods
show affection (Helman, 1990), reward and punish
(Moraes & Ongaro, 1998), pacify fussy infants, ‘‘kill’’
hunger pains by ‘‘tricking the stomach into thinking it
has real food’’, fatten the skinny, energize the mal-
nourished, and appease the parasitic worm Ascaris
lumbricodes’ food cravings.7 That lagartas fatten up on
bagulho is less important.
7
Mothers are obligated to appease the intestinal worm’s
appetite, least he become agitated and begin wandering
restlessly throughout the child’s body, poking out of nostrils,
in search of sweets.
 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
Fig. 1. Similarities are seen between a French 1780s ivory carving of a human molar with a ‘‘dental worm’’ (Ring, 1998) and 7-year-old
Marcelo’s drawing of a personified ‘‘crying’’ tooth with a lagarta (tooth caterpillar).
Food hidden in tiny cracks and crevices between teeth
and gums forms a ‘‘yellow ring’’ at the tooth’s ‘‘foot’’
(pe!) or base, attracting skinny lagartas. Feasting on the
yellow food deposits, they grow larger and stronger.
Like a ground rodent, the lagarta gnaws a hole in the
tooth’s base and enters painlessly deep inside. Hole
gnawing is easier and quicker in soft tooth mass of
‘‘organisms weakened’’ by poor nutrition, aging, ther-
mal shocks, and antibiotics. Strong teeth, nourished by
rich circulating blood, resist lagarta penetration. Con-
trary to dentists’ opinion that tooth decay is greater at
night due to lower saliva production, daylight hours are
popularly believed to be lagarta-feasting prime time. The
worm awakes famished, craving a hefty tooth-pulp
breakfast. Devouring bite-size chunks of live tooth mass,
the mischievous, well-fed lagarta frantically wiggles its
tail. Our informants attribute toothaches to lagarta tail
wagging, as it wanders from the tooth’s interior to its
base to eat leftover food (especially sweets) tapped
between teeth. Dona Vilman, 34 and a mother of five
explains:
Q: How does the lagarta start to make a hole in the
tooth?
R: Well. . .the rest of the food is trapped there. . .and she
goes circling around it.
Q: Where does the lagarta stay?
R: At the tooth’s base, at its foot (base).
Q: Are there foods the lagarta likes most?
R: Yes, I think it’s sweets!
Only then does the unbearable ‘‘fine’’ (fina), ‘‘prickly’’
(friv!ıa), ‘‘sharp’’ (pontada), ‘‘pulsating’’ (lateja) tooth
pain begin, as vividly depicted in 7-year-old Marcelos’
personified ‘‘crying’’ tooth drawing (Fig. 1). As the
lagarta boroughs an exit tunnel}gnawing upward
through live pulp}the throbbing intensifies. Pain can
also be exacerbated by small traumas: biting down on an
233
uncooked bean or eating blood-inflaming reimosa
(polluting) or carregada (heavy) foods. Eventually,
the determined lagarta exits through a large cavity
gnawed through the tooth’s surface. Lagartas’ chopping
and chewing, not bacterial surface decay, triggers
help-seeking behavior and explains patients’
apparent delay in treating decayed teeth. A patient
explains:
If the lagarta eats sugar or whatever little food grain,
she grows strong. . . has the power to destroy-
. . .gnawing at the tooth’s foot (base) . . . making that
hole. . . and goes inside. It starts rotting inside. . .you
can see it’s something eating the tooth. . . it starts
hurting and decaying. The lagarta is very thin, but
she wiggles and prickles inside our teeth. When it’s
pulsating with pain, you can be sure it’s the
lagarta!. . .I think everybody in the world has
lagartas! (Beberibe patient)
In Beberibe, as elsewhere in Brazil (Cano & Botazzo,
1986; Barreto & Cavalcante, 1987), laypeople resort to a
variety of eclectic therapies before extracting teeth.
Agonizing patients do almost anything to sedate, or
better, ‘‘kill’’ insatiable lagartas and halt head-throbbing
pain. Self-regulating the pain’s intensity}culturally
constructed and subjectively experienced (Helman,
1990; Martins, 1993; Zborowski, 1952)}is now first
priority. Suffering patients eagerly ingest the most
potent lagarta-sedative: faith. Before dentists, people in
pain seek Catholic folk healers or rezadeiras to
symbolically soothe and sedate frantically wiggling
lagartas. Having a direct spiritual channel to God, the
rezadeira evokes divine forces to alleviate pain. ‘‘If you
have faith in God, the pain stops. . .because it’s he who
cures!’’ God is chief anesthesiologist. He banishes fright,
deadens pain and relieves suffering. The rezadeira also
appeals to Jesus Christ, the Virgin Mother and Saint
234 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244

Francis of Canind!e8, Saint Peter, and especially,

Apollonia, Brazil’s Patron Saint of Dentists and Tooth-
ache Sufferers (Barreto & Cavalcante, 1987; Novaes,
1998)9. Recounts rezadeira Dona Maria:
Saint Apollonia was the only saint who suffered
toothaches. She pleaded to God to relieve this
suffering and pain, promising God that, in exchange,
she would cure whoever knocked on her door with a
toothache. (traditional healer)
She then plants her thumb on the patient’s
cheek, presses down firmly on the throbbing tooth,
blesses herself, confesses her sins, asks forgiveness, then,
on behalf of the suffering person ‘‘knocks on God’s
door’’ (Fig. 2). She beseeches Saint Apollonia and
Saint Peter to alleviate the pain, praying in a low
monotonous tone:
Jesus and Peter came walking up. . . and Jesus spoke,
‘‘Apollonia, what’s wrong with you?’’ She replied,
‘‘My Lord, three nights I’ve not slept because of these
horrible pains inside my tooth!’’ Jesus replied,
‘‘Hurry Peter and cure this poor woman’s tooth!’’
Peter said, ‘‘My Father, I knock on your door to cure
the healthy tooth with pain (sa*), with holes (furado)
and sharp pain (dor de pontada). (traditional healer)
Dona Maria offers the prayer to the patient’s
guardian angel and Saint Francis. ‘‘After my powerful
prayer,’’ she observes, ‘‘the tooth sleeps and becomes as
if it has been anethesized. It’s people’s faith that cures!
Afterwards, I teach them how to clean their mouth and
how to prepare a plant medicine (reme!dio do mato),
too’’. Besides symbolically taming the wild lagarta with
prayers, corrosive products are massaged into the tooth
or, for quicker penetration, dripped inside the blackened
cavity. Warmed coconut husk oil is the most popular
remedy used to ‘‘eat the carie’’ (comer a carie) and kill
8
Two cities in Cear!a’s interior, Juazeiro do Norte and
Canind!e, are religious pilgrimage centers, where Father Cicero
and Saint Francis grant graças or miracle cures to faithful
followers. According to Barreto and Cavalcante (1987), the
poor view social institutions and living authorities as ‘‘dead’’
and unresponsive, while ‘‘dead’’ saints are ‘‘alive’’. protecting
and helping them to confront the hardships of rural poverty.
9
In 249 AD in Egypt, 40-year-old Apollonia was martyred.
The few historical accounts of her life and death differ: she was
brutally beaten in the face, had all her teeth broken and was
burnt alive; her breasts were slashed, teeth pulled, and she threw
herself into the flames; she destroyed pagan idols’ images with
her bad breath, was imprisoned and had all her teeth broken
with pointed rocks. Imprisoned, she prayed for toothache
sufferers, who flocked to her for relief. Saint Apollonia was
canonized as the Patron Saint of Tooth Sufferers and she is
remembered on February 9th of each year (Barreto &
Cavalcante, 1987; Novaes, 1998; Sgarbossa & Giovannini,
1996).
Fig. 2. Folk-Catholic healer (rezadeira) prays on aching tooth
to relieve pain. Beberibe, Cear!a, Brazil, 1999.
the wandering worm burrowed deep inside the tooth’s
pulp. When used in excess, the highly corrosive oil can
splinter teeth, warn healers. Other common lagarta-
killers used include battery acid, fingernail polish
remover, gasoline, black tar, pipe ash, perfume, rubbing
alcohol, sugar-cane liquor (cachaça), garlic, cloves,
sesame seed oil, leite de urtiga, black pepper, jua!
(Ziziphus joaseiro) peelings, lemon, toothpaste, sodium
bicarbonate, oxygenated water, Vick’s Vapo-Rub1 and
Gelol1. Explains rezadeira Dona Ismar:
Take the outer dried husk (quenga) of the coconut
and clean it well. . . put it in the metal pan of a shovel
and hold it over the fire. . . burn it. . . burn it
completely until it makes that oil. Soak a piece of
cotton in the oil and stuff it inside the cavity.
(traditional healer)
To numb throbbing, tail-wagging lagarta-pain, com-
mercial analgesics (Anador, Dorflex, and Dipirona) and
old-time patented remedies (‘‘1 Minute,’’ ‘‘Pass Now’’
and ‘‘Stop Dent’’) are utilized. To treat inflamed ‘‘hot’’
teeth, patients apply ‘‘cooling’’ ice, potato starch,
cidreira mint tea to swollen, pus-filled gums and take
baths to ‘‘cool’’ down over-heated bodies and re-balance
an out-of-kilter thermal equilibrium (Foster & Ander-
son, 1978). Antibiotics}Espectrim, Tetrex, Ampicilina,
Meracilina}are also ingested and mouths washed with
warm salt water and ‘‘sour cashew’’ (cajueiro azedo),
ata fruit-peel or cabelo de negro root teas. These are just
three, among some 30 medicinal plants in Cear!a that
have scientifically proven, pharmacological activity
against tooth inflammations, pain, bad breath, mouth
sores, ulcers, gingival abscesses, etc. (Matos, 1988).
When protective saints, prayers, perfume or plants fail
to paralyze or kill the lagarta, she gnaws upwards,
widening the escape tunnel until it forms a gapping,
deep, black, caçimba or well in the blackened tooth. Po#di
 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
or ‘‘rotting’’, the tooth has no more pulp, pain or pesky
worm. And to dentists’ utter dismay, patients feel no
need to extract the blackened tooth. What concerns
people is preventing rotting}and the lagarta}from
‘‘passing to neighboring or unborn’’ teeth. Like a spoiled
slice of ham, a rotting tooth (dente estragado) turns
brown around the edges, smells ‘‘sour’’ (azedo) and
contaminates the other slices. Quickly, the entire stack
may be unfit for human consumption. Even starving
food scavengers at Fortaleza’s garbage dump fear
spoiled food (comida estragada) and unceremoniously
‘‘toss it out in the bush’’ (rebolar no mato) to avoid
‘‘fluffy or broken belly’’ (barriga fofa or bucho
quebrado) (Nations, 1982) and its telltale vomiting,
abdominal cramps and diarrhea. A poor and astutely
observant mother attests:
Ruined food has a sour smell. I know when it’s
spoiled right away because we feel that bad sourness
smell. . . that’s it! You just don’t eat it anymore! Toss
it out in the bush. . .because it will ruin the rest (of the
food)! (Itapeim mother)
Just as impoverished housewives do not hesitate to
throw out a stack of rotten sliced ham to avoid food
poisoning, patients toss out rotting teeth to prevent
lagarta ‘‘poisoning’’.
Tales of torture, ‘‘irons’’ and fear: quality care?
While patients unanimously respond that dental
services are ‘‘great’’ in Beberibe and Itapeim, their
outward ‘‘approval’’ largely veils hidden disenchant-
ment. Thirty-seven-year-old Dona Ana’s beat-around-
the-bush answer to our question about ‘‘patient
satisfaction’’ is suggestive:
Q: What do you think could be improved in dentist’s
attendance?
R: He is attending very well.
Q: There’s nothing to improve?
R: No, it’s more than good!
Q: Have you ever filled a tooth?
R: No, I pull it because if we fill it, it’s the same pain
afterward. I prefer to pull it right away.
According to Scott (1990), oppressed people often
fear that complaining about services will provoke
backlashes by authorities and worsen their already
miserable situation. Senhor Antonio}popular denture
maker (prote!tico) for more than 30 years}very cau-
tiously replied to our question, lowering his expectations
of care quality. ‘‘For our poor place, it’s good enough.
Ignorant people complain. But since I know, I don’t
complain, no!’’ Access to any service is better than none.
235
Such outward complacency and passive acceptance of
the status quo, however, may be a clever ‘‘cover-up.’’
Unable to confront authorities head-on, poor people
often make underground commentaries or ‘‘hidden
transcripts’’ to denounce their subordination and to
resist domination by the elite (Scott, 1990). While
outwardly ‘‘satisfied’’ with services in Beberibe, patients
inwardly told us chilling tales of fear, medieval ‘‘irons’’
and torture sessions.
‘‘Nobody ever grows accustomed to dentists or death.
Everybody is afraid of them!’’ nervously jokes popular
dentist Senhor Jo*ao. Fearing pain, patients are said to
‘‘need courage’’ to visit the dentist. Continues Senhor
Jo*ao: ‘‘Women are more courageous animals. . . have
more courage to go to the dentist because they know
childbirth pain.’’ Informants tell of masked dentists
engaging in ritual displays of authority, ordering
obedient patients to ‘‘open wide’’, ‘‘spit’’, and ‘‘sit still’’.
They describe high-tech, stainless steel precision dental
instruments as heavy, sinister medieval torture appara-
tuses: ‘‘the irons’’ (os ferros), ‘‘the tools’’ (as ferramen-
tas), ‘‘pliers’’ (alicate) and ‘‘hammer’’ (martelo). Waiting
to be attended by dentists is likened to a death-row-like
anticipation of execution. Tension and fear are said to
mount in the ‘‘tooth extraction’’ line as ‘‘victims’’
approach ‘‘the chair’’ and are met by sinister-looking,
masked, syringe-slinging dentists. The closer one ad-
vances, the soberer the mood grows. Innocent victims’
muffled whimpers turn into outright cries. Children’s
annoying skirt-tail-clinging turns into desperate leg
clutching, as attendants pry them loose from their
mother’s protection. Fear turns into cold sweat as
tearful, jaw-gripping, gum-bleeding, lip-trembling post-
extraction patients parade past victims-in-waiting, de-
parting through the only entrance}exit door. Patients’
imaginations transform dentist visits into real-life
mutilating, terror-stricken torture sessions by unidentifi-
able, masked pain-inflicters. Disguised by hair caps,
wrap-around glasses, facial masks, plastic gloves and
full-length gowns}necessary bio-security precautions
against HIV and other infections}dentists resemble
black-hooded medieval executors or masked, death-
squad exterminators. When ‘‘the torture’’ begins,
patients routinely stiffen bodies, tremble, faint, whim-
per, scream, become speechless, lock lips, and clutch
dentists’ arms to prohibit drilling. Cano and Botazzo
(1986) also observed such ‘‘exaggerated’’ fear reactions.
Patients’ apparent ‘‘hysterical’’ or ‘‘over-reaction’’ may
be fueled, however, by symbolic metaphors of meaning
unknown to practising clinicians. Lurking beneath
dentist-inflicted pain and torturous clinic visits is a
metaphor of military dictator-inflicted political torture
and executions. While Brazilian citizens have vocifer-
ously screamed out ‘‘never again!’’ to political torture or
‘‘the intentional infliction of physical or mental pain on
defenseless, immobile captives to exhort information,
236 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
confessions or for whatever reason’’ (Arquidiocese de
S*ao Paulo, 1985)10, horrors of the military dictatorship
during the 1960s remain alive in patients’ imaginations
today. Memories of interrogation, dissidents, electric
shocks, ‘‘truth drug’’ injections, bloody beatings and
death squads flash into patients’ minds during dentist
visits. Political torture is like dentist-inflicted pain and
revolver-flashing military interrogators are like syringe-
armed dentists who intentionally torture innocent,
immobilized, tube-tied victims against their wills.
Inflicted pain is just punishment.
Two terrorizing dental forms of ‘‘tortures’’, according
to patients, are anesthesia injections and tooth extrac-
tions. Patients panic that no (or not enough) anesthesia
is injected. ‘‘To make sure the anesthesia takes’’, patients
need more time between injection and drilling or
extraction than dentists’ deem necessary. A Program
dentist justifies that no topical anesthesia}a simple,
low-cost procedure to numb prickling needle pain}is
injected:
The topical anesthesia was outdated besides what’s
sent is so little. . . it is not enough for hardly anybody!
So as not to apply it on some and not others. and
because every time they are going to ask for it . . . I
don’t put it on anyone. (Program dentist)
The popular image of dentist-as-torturer punishing
lying, dissident, and disobedient patients, is reinforced
by procedures that are, at best unethical and, at worse,
downright malicious. Anesthesia is withheld to test if
patients’ pain is ‘‘invented’’ or ‘‘real’’. Admits a
Program dentist:
I pretend I’m anesthetizing. . . I put an empty tube
with a needle. . . with nothing inside. . . and give a
little pick and withdraw. . . there you have it. . . it’s
anesthetized! There is no way it can hurt! (Program
dentist)
A second fear is ‘‘putting out blood’’ (botando sangue)
or hemorrhaging after tooth extraction. Activities which
‘‘agitate’’, ‘‘heat’’ or ‘‘thin’’ the body’s blood}lifting
weight, riding a bicycle or walking in the sun}cause it
to circulate wildly, raise upwards to the head and
‘‘escape’’ through tooth alveoli. Dona Maria explains:
10
For 21 years (1964–1985), a conservative, right-wing
military dictatorship ruled Brazil. To escape political persecu-
tion large numbers of left-wing dissidents and sympathizers,
Communist party members and intellectuals, including Brazil’s
current President (sociologist Fernando Henrique Cardoso),
were forced to seek exile in foreign countries. Thousands of
Brazilian citizens were detained and jailed. Some 10,000 sought
political exile and 125 disappeared [official number, actual
numbers are said to be much higher] during this period
(Arquidiocese de S*ao Paulo, 1985).
I forced myself, applied a lot of force. . . my blood
became agitated and the hole was already open-
ended. . . it’s certain the blood will leave. (poor
Beberibe woman)
‘‘Closed bodied’’ pregnant, amenorrheaic women or
those with ‘‘suspended’’ menstrual flow are particularly
afraid.11 Opened-bodied, menstruating women ‘‘can
hemorrhage either from above (mouth) as below
(vagina).’’ When pulling teeth, backed-up, bogged-
down, ‘‘prisoner’’ blood gushes forward through the
gingival opening. Dona Geralda, a 25-year-old, illiter-
ate, mother with three decayed teeth, surprised Itapeim
dentists when she staunchly refused extraction and
abruptly left the clinic. ‘‘I know my teeth are all rotten
and I need to pull them, but I can’t because I’m that way
(menstruating) . . . it’s bad to pull teeth. . . I’m not going
to pull them now!’’ Because blood loss ‘‘weakens’’
(enfraquece) the hungry, tired and over-worked poor,
rezadeiras pray to halt blood flow and apply
‘‘tightening’’ remedies–aroeira with lemon juice, banana
‘‘milk’’, and cashew water. Based on The Hippocratic
Doctrine of Opposition,12 ice water is applied to ‘‘cool
down’’ the heated, agitated blood.
That torture-inflicted fear is a central cultural
construct in patients’ imaginary world’s is unappreciated
by dentists. They know not of dictator’s interrogations,
‘‘torture irons’’ and truth injections nor of ‘‘agitated
blood’’, tooth hemorrhages and ‘‘suspended menstru-
ation’’. These phenomena, however, are as real to
patients as clinic lines. Dentists accuse hysterical
patients of being ‘‘over-emotional’’, ‘‘out-of-control’’,
or even ‘‘liars’’. Conflict between patients’ lived experi-
ences of suffering and dentists’ technical evaluations is
evident when we confront their discourses:
Patient: Oh my God. . .. I came to pull my tooth and
the dentist said for me to stop my nervousness and let
him pull my tooth or leave without extracting it. You
see, I get very nervous. You can see the panic inside
of me. I become very frightened. After he finished
pulling the tooth, I ran out into the middle of
the street crying. (23-year-old female patient)
11
Suspended menstruation is a folk illness in Northeast
Brazil described by Nations, Misago, Fonseca, Correia, and
Campbell (1997). Menstruation ceases causing discharge to
back-up into women’s abdomen, breasts, and head. Symptoms
are similar to pregnancy. Considered serious, women take
potent ‘‘regulators’’ to ‘‘let down’’ stopped-up menstrual blood.
12
The Principle of Oppositions is derived from ancient Greek
humoral pathology and described by Hypocrates. To avoid
thermal shocks and balance bodily humors, ‘‘hot’’ conditions
are treated with ‘‘cold’’ foods, remedies and therapies and vice
versa. Introduced by Spanish and Portuguese conquistadors,
today this popular medical belief is found throughout Latin
America (Foster & Anderson, 1978).
 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
Dentist: The frightened adult, she becomes ill. . .
make-believes she is ill. . . she becomes breathless,
falls out of the chair. . . becomes dizzy, cries. . . it
causes hemorrhaging. . . it causes everything! When I
am restoring a tooth and the patient says it’s hurting
and they want anesthesia. . . because they are afraid
of the pain. . . well, I turn the drill bit on the patient’s
mouth without drilling the tooth. . . and she says it’s
hurting! Well, then, I say she is lying because I didn’t
drill on her tooth! (Project dentist)
Lay evaluations of professional competence also
differ. Patients judge dentists’ quality, not on post-
graduate degrees, but on four subjective counts.13
Competent dentists should: (1) have a pleasing person-
ality; (2) show sensitivity toward patients’ suffering; (3)
be technically proficient and (4) give sufficient time and
attention to patients. A ‘‘good dentist’’ is a ‘‘kind’’
person that ‘‘pulls aching teeth even without a token’’.
She/he is calm, caring and careful, having time and
patience to ‘‘calmly treat teeth’’ and ‘‘apply numbing
cream’’. A ‘‘good dentist’’ is identified by his/her delicate
hand (ma*o maneirinha) and soft touch which, never-
theless is skilled at ‘‘injecting anesthesia without
hurting’’ and ‘‘putting in fillings that don’t fall out’’,
‘‘cleaning deep inside the decayed tooth’’, and
‘‘removing all pieces of splintered teeth when extract-
ing’’. In contrast, a ‘‘bad’’ dentist ‘‘has a scary face’’,
‘‘treats patients like horses, scrapping teeth’’, ‘‘gives five
injections at one time’’, ‘‘plants his hand on our
forehead’’, ‘‘pulls off heads with teeth,’’ and ‘‘causes
crazy (medonha) bleeding’’. While patients have clear-
cut criteria of competence, these lay evaluations are
generally ignored, planting the seeds of popular
dissatisfaction. Even so, patients are reluctant to
publicly criticize dentists, whose services they need after
all.
Professionals, by contrast, assess quality care based
on technical skill, emphasized in dental training. More
than 80% of required credits in Fortaleza’s university
dentistry programs are in biomedical and technical
subjects. The paucity of social and humanistic14 subjects
is a grave lacuna in dental training, as Cordo! n (1996)
has pointed out. Students’ attraction to dentistry as a
profession is often tied to financial and status rewards
that technical expertise commands. ‘‘Dentistry is a
promising career. . .a question of status. Who wants to
be poor all your life?’’ remarks a recent graduate. Yet,
13
Unlike physicians who must have ‘‘studied’’, it is popularly
believed that no specialized training is needed to pull teeth. The
belief that ‘‘anyone can learn to pull-out teeth’’, is reflected in
the population’s frequent lack of distinction between popular
‘‘tooth-yankers’’ and professional dentists. Both are called
‘‘Doctor’’.
14
Ceara’s dentists invest heavily in technical specialization. In
1998, 706 or 27% enrolled in 47 post-graduate courses.
237
saturated markets, few paying patients, and cutthroat
competition in the private sector have lowered the elite
status of high-tech dentistry. ‘‘The dentist is a post-
modern hairdresser. . . every corner has one! He offers
rock-bottom prices and there are so many, people select
the cheapest,’’ laments a Program dentist. A regular
paycheck, not necessarily interest in public health,
attracts many dentists to rural service.
Everyone wants to work in the interior. It’s a
necessity. . .you have to find a job and if it’s not in
the interior, it’s in one of these clinics with pre-paid
insurance! (Program dentist)
‘‘Token’’ access and rationed relief
Because demand for dental care outpaces availability,
relief is rationed. A pre-distributed token (ficha), not
suffering severity, determines who gets care. The fixed,
limited supply of prized tokens is numbered, indicating
line-up order. No token, no care. Tokens are imbued
symbolically with power (Bourdieu, 1989). Token
distributors}community health agents}are gate-
keepers to privilege. They distribute the right to relief.
Token distribution is a public display of power. As in
any game, pre-established rules determine winners and
losers. In the Tooth Token Game,15 rules reward tooth-
salvaging winners and punish snagged-teeth (bangelas)
losers. The line rule permits two moves to win a token:
be first in line or receive one directly from a community
health agent. This simple rule is invariably complicated
in practice. Arriving at dawn or sleeping overnight does
not guarantee a token. Waiting can take hours, days,
months or longer, as one exasperated women com-
plained: ‘‘It’s so many people, there are never enough
tokens. . .I waited more than a year in that line and never
got a chance to fill my tooth!’’ A token in hand does not
reduce waiting time. No appointments are pre-sched-
uled. Patients arrive early and wait. A long line of weary
women and children form outside the clinic. Exposed to
direct afternoon sun, the narrow, enclosed waiting
corridor and cement benches become unbearably hot.
Mothers stand clutching squirming, crying, irritated
infants or sit uncomfortably on the cement floor. The
day is spent talking, preparing food and bathing
children in the clinic’s water faucet}a dramatic display
of dehumanized care. The ‘‘Line Rule’’ catch: there are
15
The authors, with UNIFOR dental student Thiago Pelu! cio
Moreira and popular artist Jos!e Neves Brand*ao, created
Quebra-Cara#. This educational game alerts students to
barriers poor communities must face and fight to gain access
to dental clinics and empowers patients to readily identify
obstacles and minimize their negative impact.
238 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
different lines and different days for different proce-
dures. Selecting the correct line depends on astute self-
diagnosis. The penalty for choosing the wrong proce-
dure (and, hence, the wrong line) is more wasted time.
Tooth filling tokens are invalid for the tooth pulling line.
The unlucky patient must return to the start. A second
catch: each token is good for only one procedure. Five
problems require five tokens and five lines. Another
catch: if service is interrupted for whatever reason}sick
dentist, energy blackout, or equipment breakdown}the
patient is penalized: he/she must return to ‘‘go’’ and
repeat the token-line ritual. Mounting frustration, anger
and exhaustion cause patients to abandon treatment, as
in Senhor Jos!e’s case. An energy blackout interrupted
his tooth extraction procedure and, hence, cancelled his
‘‘turn’’. In order to avoid a second token hassle, Jos!e
sought a popular ‘‘tooth-yanker’’ (arrancador de dentes,
atira dentes)16 to finish the job. He explains:
I was in the chair, numb with anesthesia and the
dentist pulled my tooth when the energy went off. He
said if he’d left a piece of tooth inside, for me to
return when the energy was repaired. After a bit, a
little tooth point appeared and the only thing to do
was extract it. . . I tried to find another token, but no
luck! You see they only pull it if you have a token. . .
It’s very difficult, a huge fuss! Being only a little piece,
I went to a tooth-yanker. (patient)
The personalized greeting on the door plaque}’’
Enter Only By Invitation’’}immediately humbles the
few lucky ‘‘winners’’ who finally gain access to the
dental clinic. Complains a 19-year-old mother, ‘‘To
speak to the dentist you have to have a token.’’
According to the ‘‘Exclusion Rule,’’ at no time can
parents accompany children inside the clinic or talk with
dentists. Attendants usher terrified token-toating chil-
dren inside while anxious mothers wait outside in
silence. Five-year-old Roberto was an exception to the
‘‘Exclusion Rule.’’ He and his mother journeyed in
darkness to the clinic, arriving at 3:00 a.m. At 7:30 a.m.,
he received a token. Not until 3:30 p.m. was Roberto
ushered inside alone. Frightened, Roberto refused to
pinpoint his aching tooth. Unable to drill, attendants
summoned his mother to identify the correct tooth,
dismissing her immediately afterwards. When school
authorities refer children to the dentist, teachers, not
parents, accompany. Confused parents, like the follow-
16
Popular terms referring to lay dentists and signifying a
liberator or reliever of suffering and pain. The term
‘‘Tiradentes’’ refers to one of Brazil’s most celebrated national
martyrs, Joaquim Jos!e da Silva Xavier (1746–1792), who lead
the independence fight against Portuguese colonial powers
during the Conjuraça*o Mineira in Minas Gerais in 1789.
Joaquim’s nickname was ‘‘Tiradentes’’ because he pulled teeth
in private life.
ing mother, are unaware of procedures preformed
behind closed clinic doors. ‘‘I don’t know if they pulled
or filled his tooth. . . seems like maybe they filled it? He
doesn’t go crazy anymore with that pain, no!’’ Exclusion
from clinics is poignantly illustrated by 37-year-old
Dona Lurde’s interview excerpt:
Q: Have you ever gone to the dental clinic?
R: Yeah.
Q: What do you think could improve there?
R: Inside the clinic? I’ve never entered inside, no!
Poverty, personal stigma and the political power of
decayed teeth
Teeth tell the status story. The number and condition
of one’s teeth says more about earning power, privileges
and social mobility in Northeast Brazil than, perhaps,
any check stub, bank statement or country club
membership card. Because of striking class disparity in
this rapidly developing region, people are distinguished:
those having money, power and privilege}the ha-
ve’s}from the have-nots. Telltale status symbols like
family name, address, car make, and brand labels
become revealing ‘‘status emblems’’ (Fussell, 1992),
publicly announcing social standing. Like a red-hot
branding iron on cowhide, body marks}surgical inci-
sions, scares, stretch marks, and crow’s feet}etch social
standing into flesh, visually distinguishing rich from
poor. Two embodied status symbols in Beberibe and
Itapeim are false teeth and ‘‘cheek scars’’ caused by a
queixo estourado or ‘‘exploding chin’’. False teeth cover
up fake status. When attractive, flirtatious 18-year-old
Eliane smiles seductively}revealing two, upper, front
false teeth}interested, wealthy young men shy away
(from any serious intentions), perceiving her ‘‘poor’’
status instantly. For unemployed 37-year-old Senhor
Neves, stigmatized by four missing front teeth as a
bangela (snagged-tooth), getting hired during the present
economic recession is a remote possibility. A round
lower cheek scar, too, is a poverty tattoo. Decayed teeth
become so abscessed they ‘‘explode’’ through the chin,
perforating the skin. The ‘‘explosion’s’’ force or inser-
tion of a drainage tube, etches into facial skin a deep,
pitted round scar}a visible brand of ‘‘poor-ness’’. False
teeth, like ‘‘exploded chins’’, reflect and reinforce social,
economic and dental care inequity in Northeast Brazil.17
17
For the upper class, ‘‘exploded chins’’ and false front teeth
reveal low social standing. Shinny, metal corrective braces and
white porcelain fillings, by contrast, indicate upper class
identity. Ironically, for the poor, perfectly straight, white,
decay-free teeth, even if false, reveals ‘‘richness’’ and act as an
entry ticket to upward mobility.
 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
While poverty is undeniably linked to malnutrition
and poor dental health in Cear!a, no dentist we
interviewed mentioned this association. For them,
prevention is restricted to brushing teeth, applying
fluoride and filling cavities not combating unemploy-
ment, chronic hunger and social exclusion. Dentists’
(even Program dentists’) EMs are decidedly disease-
fixated: Streptococcus mutans rots teeth. Reductionistic,
technical-rational and decontexualized, dentists’ micro-
biological models, not unlike physicians’, exclude the
political economy of disease (Kleinman, 1995). But for
Beberibe’s 42-year-old popular dentist, ‘‘poor-ness’’ has
everything to do with poor oral health. Societal
decay}poverty, hunger and inequity}are as corrosive
as any bacteria, he argues:
The poor are born to be smoked on (levar fumo) like
a pipe (i.e. be stepped on). The number of poor with
swollen, inflamed teeth is unbelievable! You don’t see
this in high society. . . not one single rich person with
an ‘‘exploded chin’’ (queixo estourado) . . . his tooth
outside. . . that scar on his chin! You don’t see evil
eye, Macumba in the rich. But all these things happen
to the poor. . .we’re born hexed (azarado) . . . every-
thing bad happens to us! Our teeth rot (estraga)
because we don’t have money to eat. . . one thing bad
attracts another. . . poor nutrition together with poor
hygiene. . . and, that’s it! To visit the dentist, we need
a token. . . if it’s free, we go but we have to wait in
line. Do the rich wait in line? No, only if it’s a bank
line! And if the bank teller knows him. . . well, it’s to
the front of the line! Is it any wonder that most 15-18
year-old kids use dentures? (Popular dentist)
A remarkably accurate social status indicator, de-
cayed, lost, and abscessed teeth purchase political
power. Politicians in rural Cear!a trade aching teeth for
votes. At election time, incumbents hire itinerant
‘‘dentists’’18 to extract poor voters’ teeth during massive
outdoor marathon public pulling sessions. Re-election is
guaranteed with free denture fitting. No voter appeal in
low-visibility teeth brushing or fluoride application. It is
more persuasive to exchange votes for something
concrete in hand}a pulled tooth or set of false teeth.
The political leverage of pulled and false teeth is greater
in Itapeim where access to dental care is worse. Explains
a resident:
18
Two types of lay dentists}those having no formal
university degree}are found in Cear!a. There is the fixed
practitioner who lives and works in the community and the
itinerate dentist who has no affective ties with the community.
Some lay practitioners also make dentures. Professional dentists
refer to lay practitioners as ‘‘practicals’’ (pra!ticos) and to
denture-makers as ‘‘monkey-men’’ (macaqueiros), attributing
to them a lower evolutionary stage of development.
239
Politicians, councilmen, and candidates for mayor
bring a (popular) dentist. . . he makes dentures for
poor people . . . so they beg politicians. . . who sends
them to the (popular) denture maker who molds false
teeth. . . and the politician pays. (Itapeim resident)
A second resident adds:
When it’s election time the mayor gives false teeth,
but this time of year. . . it’s going to delay. . . We
make the mold . . . it takes 15 days or a month. It’s
difficult to get in! (Itapeim resident)
The sad saga of social outcasts
Besides being locked-out of clinics, parents are barred
from school brushing and fluoride activities which are
entrusted to (and monopolized by) ‘‘more qualified’’
teachers. Arm-tied parents, however, are ironically the
first blamed for program failures}faulty brushing,
meeting no-shows, missed appointments, etc. While
participation is a prerequisite for promoting health
(Valla & Stotz, 1993), we witnessed time and again the
sad saga of social outcasts. The systematic annihilation
of people}their talents, energy, and cleverness}is a
subtle, but no less damaging, process. The autonomous
individual is held solely responsible for their ‘‘poor oral
hygiene’’}sloppy, filthy habits}and personally accoun-
table for their rotten teeth. Decayed teeth are the result
of patients’ free choices, of their ‘‘high risk’’ behavior:
eating sweets, forgetting fluoride, brushing the wrong
way, using the incorrect toothbrush, delaying dental
appointments, etc. Conversely, white, cavity-free teeth
are the result of personal effort, care and pride or zelo.
The truly zelosa person is a stranger to decay. Blame for
treatment failure sits squarely on the disobedient
patient’s shoulders. She/he deserves punishment: long
lines, token run-arounds, torture sessions without
anesthesia, etc. Lazy brushers are embarrassingly ear-
marked}in full public view}when telltale pink-turning
plaque detector liquid is applied to schoolchildren’s
teeth. Laughing, finger-pointing classmates denounce
sloppy brushers. Pink-mouthed kids become instant
social outcasts. Plaque detector zeros in on the victim.
Dentists can now selectively scold and punish the
targeted: ‘‘If I color your teeth again with these drops
and if your mouth is this way again (pink-colored), I
won’t attend you!’’ Stigmatized as ‘‘sloppy’’, ‘‘careless’’,
‘‘filthy-dirty’’, or ‘‘fowl-mouthed’’, the patient can be
socially excluded, disenfranchised and disentitled. They
are unceremoniously stripped of human dignity, ex-
plains British anthropologist Mary Douglas (1992, p.
86). ‘‘The regular strategy of rejection starts with the
libel. . . Imputing filth to the victims enables them to be
240 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
rejected without a qualm’’. Inculpating ‘‘unhygienic’’,
poor patients exculpates elite, professional dentists. By
‘‘blaming the victim’’, the burden of guilt shifts from
macrosociological forces to ‘‘the culture of poverty’’
(Farmer, 1992; Valentine 1968). Says Ryan (1971, p. 25):
The ‘‘multiproblem’’ poor suffer the psychological
effort of impoverishment, the ‘‘culture of poverty,’’
and the deviant value system of the lower classes;
consequently, though unwittingly, they cause their
own troubles. From such a viewpoint, the obvious
fact that poverty is primarily an absence of money is
easily overlooked or set aside (Ryan, 1971, p. 5).
He continues:
Typical is the swerving away from the central target
that requires systematic change and, instead, focusing
in on the individual affected. The ultimate effect is
always to distract attention from the basic causes and
to leave the primary social injustice untouched. And,
most telling, the proposed remedy for the problem is,
of course, to work on the victim himself. Prescrip-
tions for cure are invariably conceived to revamp and
revise the victim, never to change the surrounding
circumstances. They want to change his attitudes,
alter his values, fill up his cultural deficits, energize
his apathetic soul, cure his character defects, train
him and polish him and woo him from his savage
ways (Ryan, 1971, p. 25).
Structural violence (Farmer, Connors, & Simmons,
1996) as a powerful determinant of tooth decay, is
glaringly absent from dentists’ (including The Pro-
gram’s) EMs. Their discourse does not decry pathogens
of societal decay}poverty, social inequity, food ex-
portation, corruption, racism, etc.}along with sloppy
brushing, missed appointments or Streptococcus mutans.
No mention is made of starving infants sucking sugar-
coated pacifiers to deaden hunger pains; of non-
compliance with the ‘‘brush-three-times-a-day-after-
each-meal’’ recommendation because there is no food
at home; of unfluoridated teeth because children are not
enrolled in schools; or of clinic no-shows because
mothers are pregnant, tired, or overworked. The
political economy of rotten teeth is forgotten.
Similarly, popular dentists and denture makers are
stigmatized and denounced as ‘‘tooth-yankers’’ (arran-
cadores, tira-dentes) and ‘‘monkey-men’’ (macaqueiro),’’
rather than embraced by professionals as partners-in-
health.19 ‘‘Teeth-yankers’’ and ‘‘monkey-men’’ are
tracked-down, labeled ‘‘criminals’’, fined, imprisoned
and prohibited from practising based on The Illegal
19
Ironically, Cear!a is home to world-renowned primary
healthcare models that empower traditional healers and mid-
wives and blend popular and biomedical practices (Arau! jo,
1984; Nations & Rebhun, 1988; Nations & Souza, 1997).
Practice of Medicine, Dentistry and Pharmacy Law
4.324/64, Penal Code number 282.20 In 1998, Fortaleza’s
Regional Dentistry Council spearheaded an effort to
denounce and prosecute lay dentists, characterized as a
‘‘cancer that for centuries has corroded society and
interferes harmfully in the work marketplace.’’21 A
publicity campaign alerted the public about their
potential malice. Public bus rear windows were plastered
over with life-size posters depicting an agonizing patient
clutching his baseball-size swollen cheek. The caption
read: ‘‘False Dentist: It could cost you more than you
imagine!’’ A toll-free number was provided for anon-
ymous denunciations.22 From June to October 1998, 32
‘‘false dentists’’ were identified in 27 counties of Cear!a.
All were processed and four had equipment confiscated
as evidence of illegal activity. Far from collaborating
with popular practitioners}most viewed by locals as
trusted and accessible ‘‘relievers of pain and suffer-
ing’’}professional dental associations headhunt them
as law-breaking criminals. The educational interventions
we observed largely reinforced, rather than transformed,
the existing inequitable social structure (Barreto, 1999).
‘‘Hammering-the-point’’ pedagogy
Despite the impact of poverty and social exclusion on
the social genesis of tooth decay, dentists routinely
attribute the problem to patients’ ‘‘ignorance’’,
‘‘backwardness’’ (atrasos) and ‘‘lack of education’’.
Seemingly oblivious to Brazilian educator Paulo Freire’s
(1970) criticisms of such ‘‘pedagogy of the oppressed’’,
Beberibe and Itapeim dentists we observed largely
continue to take a top-down ‘‘banking’’ approach to
‘‘educating’’ their patients. To improve compliance with
recommendations, for instance, all-knowing profes-
sionals make regular deposits of technical, scientific
20
Council inspectors identify lay ‘‘dentists,’’ its lawyers
submit a formal indictment based on violation of Law 4.324/
64, Legal Code 282, to the Cear!a’s State General Attorney’s
Office. The District Attorney’s Office is responsible for
prosecuting the case. If found guilty of illegal professional
practice, lay dentists can be fined and imprisoned from 6
months to 2 years.
21
This quotation is extracted from Cear!a’s Regional Den-
tistry Council Directorship’s annual letter reproduced on the
front page of its 1998 agenda, given as a Christmas gift to
members. Highlighting the year’s achievements, the letter
emphasizes their campaign to ‘‘validate the dentist and
reactivate the inspection process of illegal practitioners with
the contracting and training of inspectors’’.
22
Subsequent posters show a smiling dentist with the caption
‘‘Dental-surgeon: A health professional qualified to care for
your mouth.’’ The telephone number of the Regional Dentistry
Council was included, but no hot-line telephone number to
denounce incompetent dentists.
 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
knowledge in laypersons’ poor, passive and unknow-
ledgeable brains}empty bank accounts. It is reasoned
that if enough dentists repeat enough scientific messages,
enough times, with enough force, eventually they will
sink into people’s (thick) skulls. Confirms a Project
dentist:
Education prevents as much as cures. . . from the
moment you become educated you know how to
prevent. . . Teeth-brushing is a fundamental point.
We (dentists) stay there, show them, and order them
to brush on themselves. So, you see, we hit a lot on
top of this key (bate muito em cima dessa tecla)
(English equivalent: ‘‘hammering this point’’). (Pro-
ject dentist)
The result of such ‘‘hammering-the-point-pedagogy’’,
however, is more often dentists’ frustration than
patients’ motivation, as seen here:
At school, I gave lectures to the kid’s mothers. . . You
(mothers) think you know everything. If you know
everything. . . why don’t you do it? (Project dentist)
We observed the practice of an authoritative, reward-
and-punishment pedagogy where ‘‘good, obedient’’
toothbrushers}who learn their lessons well}are
praised, while ‘‘bad, disobedient’’ ones are censured,
reprimanded and symbolically spanked. Explains a
Project dentist:
When we get a mouth that is real clean, we give a lot
of advice and incentive. But when we get rotten or
dirty teeth we say. . .. ‘Boy, for the love of God, what
are you doing? You didn’t brush these teeth, did
you?’ We really call it to their attention! (Project
dentist)
For Naidoo and Wills (2000), the dentist’s discourse
above reflects the so-called ‘‘medical’’ and ‘‘behavioral
change’’ theoretical models of health education. In the
‘‘medical’’ model, persons with disease risk are identi-
fied. Experts then instruct obedient patients how to
reduce this risk. ‘‘Behavioral change’’ models encourage
people to take responsibility for their own health,
choosing healthier lifestyles. But, again, a technical
expert instructs the ‘‘correct behavior’’ to dependent
patients, who are blamed for any treatment failures.
Both models deaden popular participation. A more
current and progressive model of health education is the
so-called ‘‘empowerment’’ model (Naidoo & Wills,
2000). According to this paradigm, laypersons are
valued as transformers, forging the path of social
change. Professionals, by contrast, are viewed as back-
seat facilitators stimulating the clients’ or communities’
own capacities. Similarly, Beattie (1991) argues that the
theoretical underpinnings of negotiated, participatory
health models are interventions which empower indivi-
241
duals to develop their own capacities and confidence and
take control of their own health. Empowerment is the
antithesis of the ‘‘hammering-the-point’’ pedagogy we
witnessed in Beberibe, Brazil.
Implications and conclusion
Confronting dentists’ and patients’ explanatory models
The popular EM of oral health subjectively shapes the
experience of pain, timing and sequencing of help-
seeking behavior, choice of healers, rituals and remedies,
and, importantly, lay acceptance of cavity prevention
practices. Because popular and professional EMs of
tooth decay often clash, clinical communication is
truncated, dentists feel frustrated, and patients often
resist recommendations. Lay preference for tooth
extraction (distraça*o, as it is popularly called) over
restoration, for instance, is incomprehensible to Beber-
ibe’s dentists. ‘‘In my own consciousness, I can’t bring
myself to pull a tooth if it can be restored!’’ laments one
dentist. Patients become ‘‘angered’’ and ‘‘outraged’’
when dentists insist on fillings, refusing to pull caried
teeth. Says one frustrated dentist of this clinical show-
down:
The patient just stopped short of hitting me. He
kicked the dental chair demanding that I pull his
tooth. . . I said, no way. . . he slammed the door
saying for me to just wait and see. . . threatening me!
(Beberibe Project dentist)
An overriding desire to extract painful teeth, even
among the young, was revealed in Dona Rosa’s opening
comments and echoed by Dona Sara’s responses below:
Q: Have you ever filled a tooth?
R: No.
Q: If you had a tooth to fill, would you prefer to fill or
pull it?
R: I would pull it. . . because many people say that you
feel the sharpest pain. . .after that putty (massa) falls out,
it’s another pain!
Q: You prefer to pull it right away?
R: Yeah.
Q: And if the filling doesn’t fall out?
R: People say it falls out. . . eat something sweet and it
falls out! It’s better to pull it.
Q: Are you going to pull all your teeth?
R: Yeah, I’m going to pull every single one, because I
want to put in dentures.
Although most dentists view Dona Rosa’s and Sara’s
attitudes as irrational, uninformed, and backward
(atrasada), the women prefer tooth extraction to
242 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
restoration. Like the Cano and Botazzo (1986) patients,
our Itapeim informants complain that tooth restoration
is unavailable and unfamiliar. Patients must self-
diagnose ‘‘cavities’’ and select the correct restoration
line. Besides, sugar-searching lagartas can invade
neighboring or ‘‘unborn’’ teeth. As an incredulous
dentist protests, ‘‘The mother arrives here and orders
me to pull two or three teeth. . . and it’s not like that!’’
The most efficient method to get rid of a painful, tail-
wagging lagarta is extracting its protective cocoon}the
tooth. ‘‘The only thing left, after pulling the tooth, is the
gum. . . and that’s it! No more worry! The lagarta will
not appear anymore!’’ explains young Dona Sara, fitting
her full denture. Restoration, or sealing-off the exit
tunnel, does not kill the lagarta inside. Feeling the first
hunger pain, she gnaws again! Determined, the lagarta
crawls forcefully upward, butting her head against the
silver filling until it falls out. Explains skeptical rezadeira
Dona Irismar:
Q: What’s done to kill this lagarta?
R: Pull the tooth!
Q: Filling the tooth. . .does that kill the lagarta?
R: The dentist s-a-y-s putting that putty inside kills the
lagarta. . . (tone of disbelief)
Q: Dona Irismar, do you believe the tooth must be
pulled to kill the lagarta?
R: Only by pulling it! (So! arrancando!).
Owing to an underlying oppositional ‘‘intrusive-
extractive’’ logic,23 the aggressive, sugar-craving,
tooth-devouring lagarta intruder must be definitively
extracted. The lagarta-infested tooth must be pulled.
Filling-up the cavity with putty contradicts this princi-
ple. Restoration is an illogical, improvised, stop-gap,
patch-over job. What needs doing is exterminating the
pesky, intrusive lagarta once and for all! Tooth
restoration, say people, is ‘‘the cheap way out, that
ends up expensive!’’ (O barato que sai caro!)
A second serious conceptual clash also exists between
the conceptualization of rotting and popular acceptance
of fluoride mouth washing. In this world where starving,
sugar-crazed lagartas feast on leftovers trapped between
teeth, brushing makes perfect sense. Poor parents, who
purchase toothbrushes or prepare jua! paste, encourage
children’s brushing ‘‘to rid of the lagarta’s food and stop
her from growing’’. Even before the Program, people
‘‘cleaned’’, ‘‘whitened’’ and ‘‘protected’’, teeth with salt,
lemon, jua! and tobacco. ‘‘Chewing tobacco protects
23
Therapies, drugs and procedures to treat invasive disease-
s}evil eye, spirits (encosto), arrowheads (flechada) and
lagartas}must be reductive, subtracting or removing (either
physically or symbolically) the agent. Conversely, treatments
against extracting agents}soul loss (susto) or diarrheal
dehydration}are additive.
against rotting and doesn’t let the lagarta penetrate or
bore holes into teeth,’’ explains popular dentist, Senhor
Anto# nio. ‘‘Jua! paste doesn’t sting, burn, or have a bad
taste. . . so children brush teeth like they’re playing!’’ His
homemade recipe is cheap and simple:
Peel the jua!. . . for it’s a big plant. . .dry it in the sun
for three days. . .toast it in a frying pan to take away
the bitterness. . .grate, strain and store it in an empty
jar. . . put some in a small cup, wet the toothbrush
and roll it in the powered jua!. . . that’s it! (popular
dentist)
Fluoride is a different story. While epidemiological
studies confirm that fluoride treatment is more efficient
than tooth-brushing in reducing the incidence of dental
caries (Murray, 1992), parents are skeptical of its
benefits. Applied topically, fluoride is believed neither
‘‘strong’’, ‘‘corrosive’’ nor ‘‘bad tasting’’ enough to
penetrate inside the tooth and kill the lagarta. Dubious
Dona Vilma replies:
Q: Does fluoride help in some way with the lagarta?
R: It helps. . . but if you don’t brush. . . this fluoride
doesn’t help anything!
Q: The fluoride at school. . . the mouthwash without
brushing?
R: I don’t believe in that!
Q: Because they don’t brush?
R: Yeah. . .because it’s the toothbrush that cleans
between teeth!
For disbelieving parents and children not enrolled at
school, fluoride interventions continue to have little, or
no, perceived purpose or value.
Beyond these two examples, innumerable aspects of
dentists’ and patients’ EMs}fear, competency, access,
etc.}are at odds and beg resolution in the future.
Health belief or KAP (knowledge, attitudes and
practices) studies that target patients’ cultural and
conceptual baggage conclude (quite logically) that the
heart of health problems rests on laypersons’ folkloric
notions. Patients’ teeth rot because they believe in such
exotica as lagartas and estragaça*o. Shedding culture-
bound beliefs and practices, in favor of biomedical ones,
is the proposed cure. Medical anthropologists Foster
and Anderson (1978), however, argued more than 20
years ago that an exclusive focus on patients’ knowl-
edge, attitudes and practices is short-sighted. Beyond
popular beliefs, structural/institutional forces exert
powerful influences over the human condition. Re-
searchers, they argue, must correct their impaired vision
by adopting a panoramic view of all actors involved}of
their patterns of social interaction and of the historical/
political/economic context in which the clinical encoun-
ter is embedded. Negotiating dentist–patient disparities
 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
and creating humanized clinical care requires far more
than changing patients’ ‘‘quaint’’ or ‘‘superstitious’’
mindsets. What is called for is a Kuhnian paradigmatic
revolution (Kuhn, 1970). This shift in the construct of
dental practice should begin among power-wielding
professionals and influential health institutions.
Removing societal decay and plaque deposits
In spite of increased tooth-brushing and fluoride
treatments among schoolchildren and a likely reduction
in the incidence of dental caries after three years of The
Program,24 grave conflicts in dentist–patient commu-
nication persist in rural Cear!a. Practising quality
dentistry, as if people mattered, remains more of a
dream than a reality. Instead of inverting attention,
professionals’ eyes are mostly averted from, even
blinded to, patients’ pain, suffering and meaning-laden
world of lagartas and relentless searches for remedies
and relief. High-contrast images of dentists and patients
continue to reveal socially perverse snap-shots of
dehumanizing, and at times humiliating, care. Immacu-
lately groomed, white-starched-linen-skirted dentists in
high-heel shoes attend dirt-poor, toothless women in
bargain-basement rubber tongs. Health agents distribute
eight precious tokens while turning away crowds of
agonizing patients. Professional associations headhunt
‘‘monkey-men’’ while dentists overrun Fortaleza, refus-
ing to relocate inland. And concerned mothers wait for
hours in the seething tropical heat, only to be locked-out
of dentists’ air-conditioned offices. Even ‘‘successful’’
school-based prevention activities, on deeper analysis,
employ a victimizing ‘‘hammering-the-point’’ pedagogy
that punishes, rather than empowers, poor parents.
24
DMFT is an epidemiological index that refers to ‘‘decayed,
missing and filled teeth’’. A DMFT of 5.8 indicates that, on
average, 12-year-olds will have 5.8 teeth with caries, needing
extraction or pulled due to cavities or restorations. The World
Health Organization’s DMFT goal for the year 2000 was 3.0. A
county-wide epidemiological survey conducted in June 1995,
before the implementation of The Program, consolidated
Beberibe and Itapeim data and found an county-wide DMFT
of 5.8, which reportedly fell to 2.4 three years later (Prefeitura
Municipal de Beberibe, 1995). While The Program probably
diminished the DMFT index in this setting, the study’s serious
methodological flaws raise doubts about the reported decline.
Different definitions of ‘‘dental carie’’ were utilized in pre- and
post-intervention surveys. Loureiro (1998) of Estaça*o Sau!de
admits that the baseline survey counted incipient decay
processes}white or dark spotting}as ‘‘a carie.’’ After the
application of tooth sealers, the post-intervention survey
considered incipient decay processes as non-decayed teeth.
The prevalence of dental caries, thus, is overestimated at
baseline, resulting in an artificial decline.
243
Improving dental care quality in Northeast Brazil
requires far more than extending curative, disease-
fixated and dentist-controlled practice into rural regions.
Conflicts in clinical communication must be minimized
and patients’ voices heard to humanize care. Above all,
providing quality dental care in poor developing regions
requires improving the living conditions of all citizens.
Only when the dignity-devouring dental worms of
societal decay}injustices, gross inequities, poverty,
unemployment, hunger, sexism, discrimination, exclu-
sion, etc.}are scraped off along with bacteria-laden
plaque deposits, will our attention be truly inverted and
the oral health of poor Brazilians improved.
Acknowledgements
A warm ‘‘abraço’’ for our informants in appreciation
of their candid responses. Comments by anonymous
reviewers were especially helpful in focusing the paper
and strengthening our arguments.
References
Adair, J., Deuschle, K., & McDermott, W. (1969). Patterns of
health and disease among the Navajos. In L. R. Lynch
(Ed.), The cross-cultural approach to health behavior (pp.
83–110). Rutherford: Dickinson University Press.
Araujo, G., (1984). Minha experiencia com as parteiras e as
rezaduras do cear!a. In: TAPS (Ed.), Saude da comunidade:
Um desafio (pp. 92–100). S*ao paulo: TAPS.
Arquidiocese de S*ao Paulo (1985). Brasil: Nunca maisit!
Petro! polis: Vozes.
Atkinson, S. (1993). Anthropology in research on the quality of
health services. Cadernos de Sau!de Pu!blica, 9, 283–299.
Barreto, A. P. (1999). Manual do terpaeuta comunita!rio.
Curitiba: Pastoral.
Barreto, A.P., & Cavalcante, A.M. (Eds.) (1987). Medicina
popular. Fortaleza: Jornal O Povo.
Beattie, A. (1991). Knowledge and control in health promotion:
A test case for social policy and social theory. In: J. Gabe,
M. Calnan, M. Bury (Eds), The sociology of the health
service. Londres: Routledge.
Bourdieu, P. (1989). O poder simbo!lico. Brasil, Rio de Janeiro:
Bertrand.
C#amara Municipal de Fortaleza. (1993). Prostituiça*o infantil:
uma CPI para enfrenta!-la. Fortaleza: The C#amara.
Cano, A. M. G, & Botazzo, C. (1986). Aspectos psicolo! gicos do
tratamento odontolo! gico. Sau!de em Debate, 18, 41–49.
Cordo! n, J. (1996). Dificuldades, contradiçoes e avanços na
inserç*ao da odontologia no sus. Divulgaçao em Sau!de para
debate, 13, 36–53.
Corin, E., Ucho# a, E., Bibeau, G., & Koumare, B. (1992).
Articulation et variations des syst"emes de signes, de sens et
dactions. Psychopathologic Africaine, 24, 183–204.
Denzin, N. K. (1970). The research act in sociology. London:
Butterworth.
244 M.K. Nations, S.A.S. Nuto / Social Science & Medicine 54 (2002) 229–244
Dio! genes, G. (1999). Exploraça*o sexual e comercial de
adolescentes em Fortaleza. Fortaleza: C#amara Municipal
de Fortaleza.
Douglas, M. (1992). Risk and blame: Essays in cultural theory.
London-New York: Routledge.
Farmer, P., Connors, M., & Simmons, J. (Eds.) (1996). Women,
poverty and AIDS: Sex, drugs, and structural violence.
Monroe: Common Courage.
Farmer, P. (1992). AIDS and accusation: Haiti and geography of
blame. Berkeley: University of California Press.
Foster, G., & Anderson, B. (1978). Medical anthropology. New
York: John Wiley & Sons.
Freire, P. (1970). Pedagogia do oprimido. S*ao Paulo: Paz e
Terra.
Fussell, P. (1992). Class: A guide through the American status
system. New York: Simon & Schuster.
Helman, C. G. (1990). Cultura, sau!de e doença. Porto Alegre:
Artes M!edicas.
Kleinman, A. (1975). Explanatory models in health care
relationships. In Health of the family (pp. 159–172).
Washigton, DC: National Council for International
Health.
Kleinman, A. (1980). Patients and healers in the context of
culture: An exploration of borderland between anthropology
and psychiatry. Berkeley-Los Angeles: University of Cali-
fornia Press.
Kleinman, A. (1995). Writing at the margin: Discourse between
anthropology and medicine. Berkeley, Los Angeles: Uni-
versity of California Press.
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness
and care: Clinical lessons from anthropological and cross-
cultural research. Annals of Internal Medicine, 88, 251–258.
Kuhn, T. (1970). The structure of scientific revolutions. Chicago:
The University of Chicago Press.
Loureiro, C. A. (1998). A invers*ao da atenç*ao em sau! de bucal.
In E. V. Mendes (Ed.), A organizaça*o da sau!de no n!ıvel local
(pp. 213–266). S*ao Paulo: Hucitec.
Martins, E.M. (1993). Sau! de bucal, uma necessidade social-
mente constru!ıda: Um estudo da experi#encia da cl!ınica
odontolo! gica S*ao Geraldo [Masters thesis]. Universidade
Federal de Minas Gerais, Belo Horizonte.
Matos, A. ed. (1988). Plantas medicinais. Fortaleza: Jornal O
Povo.
Moraes, A. B., & Ongaro, S. (1998). Contribuiç*ao da psicologia
da sau! de a odontologia. In C. Botazzo, & S. Freitas (Eds.),
Cie#ncias sociais e sau! de bucal: Questo*es e perspectivas (pp.
87–103). S*ao Paulo: Unesp.
Mull, J. D., & Mull, D. S. (1988). Mothers concepts of
childhood diarrhea in rural Pakistan: What ORT program
planners should know. Social Science & Medicine, 27,
53–56.
Murray, J. J. (1992). O uso correto de fluoretos em sau!de pu!blica.
S*ao Paulo: Santos.
Naidoo, J., & Wills, J. (2000). Health promotion: Foundations
for practice. Londres: Billi"ere Tindall.
Nations, M. K. (1982). Illness of the child: The cultural context
of childhood diarrhea in Northeast Brazil [Ph. D. disserta-
tion]. Berkeley: University of California.
Nations, M. K., & Monte, C. M. (1996). I’m not dog, no! Cries
of resistance against cholera control campaigns. Social
Science & Medicine, 43, 1007–1024.
Nations, M. K., Misago, C., Fonseca, W., Correia, L., &
Campbell, O. M. (1997). Women’s hidden transcripts about
abortion in Brazil. Social Science & Medicine, 14, 1833–
1845.
Nations, M. K., & Rebhun, L. A (1988). Mystification of a
simple solution: oral rehydration therapy in Northeast
Brazil. Social Science & Medicine, 27, 25–38.
Nations, M. K., & Souza, M. A. (1997). Umbanda healers as
effective AIDS educators: Case control study in Brazilian
urban slums (favelas). Tropical Doctor, 17, 60–66.
Narvai, P. C. (1997). Recursos humanos para Promoç*ao de
sau! de bucal. In L. Kriger (Ed.), ABOPREV: Promoça*o de
sau!de bucal (pp. 447–463). S*ao Paulo: Artes M!edicas.
Nitcher, M. (1988). From Analu to ORS: Sinhalese perceptions
of digestion and dehydration. Social Science & Medicine, 27,
39–52.
Novaes, H. M. D. (1998). Tecnologia e sau! de: A construç*ao
social da pr!atica odontolo! gica. In C. Botazzo, & S. Freitas
(Eds.), Cie#ncias sociais e sau!de bucal: Questo*es e perspectivas
(pp. 141–158). S*ao Paulo: Unesp.
Nuto, S.S. (1999). Avaliaça*o cr!ıtica e cultural do serviço de sau! de
bucal de beberibe-CE: A vez e a voz do usua!rio. [Masters
thesis] Universidade Federal do Cear!a, Departamento de
Sau! de Comunit!aria, Fortaleza.
Oliveira, C. G. (1990). Introduç*ao a" cr!ıtica das no-co* es
empregadas em pesquisa sobre satisfa-ca* o do usu!ario.
Sau!de em Debate, 30, 32–34.
Pinto, V. G. (1997). Epidemiologia das doenças bucais no
Brasil. In L. Kriger (Ed.), ABOPREV: Promoça*o de sau! de
bucal (pp. 27–41). S*ao Paulo: Artes M!edicas.
Prefeitura Municipal de Beberibe, Secretaria de Sau! de, Co-
ordenaç*ao de Odontologia. (1995). Padro*es e indicadores de
sau!de-doença bucal de 539 indiv!ıduos do munic!ıpio de
Beberibe: 18 levantamento epidemiolo!gico. Beberibe: Pre-
feitura Municipal de Beberibe.
Ring, M. (1998). Histo!ria ilustrada da odontologia. S*ao Paulo:
Manole.
Ryan, W. (1971). Blaming the victim. New York: Pantheon
Books, Division of Random House, Inc..
Scott, J. C. (1990). Domination and the arts of resistance: Hidden
transcripts. New Haven, CT: Yale University Press.
Sgarbossa, M., & Giovannini, L. (1996). Um santo para cada
dia. S*ao Paulo: Paulus.
Singer, M. (1989). The coming of age of critical medical
anthopology. Social Science & Medicine, 27, 25–38.
Snow, L. (1977). Myths about menstruation: Victims of our
own folklore. International Journal of Women’s Studies, 1,
64–72.
Valla, V., & Stotz, E. (Eds.) (1993). Participaça*o popular,
educaça*o e sau!de: Teoria e pra!tica. 2nd ed. Rio de Janeiro:
Relume-Dumar!a.
Valentine, C. (1968). Culture and Poverty: Critique and Counter-
Proposals. Chicago: University of Chicago Press.
Zborowski, M. (1952). Cultural components in response to
pain. Journal of Social Issues, 8, 16–30.