"Tooth worms", poverty tattoos and dental care conflicts in Northeast Brazil.

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 Ceará, 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 pĵdi) 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.