Edith Maurer Mütsch is a dental hygienist at prophylaxis-oriented practices in Reinach (in the canton of Basel-Landschaft) and Basel in Switzerland. She came to the country from the Netherlands in 1978, secured a job at a private practice and became actively involved in the profession in the local area. Yet, after almost 30 years as a dental hygienist, she decided she wanted to develop her skills further and went in search of a new challenge, which she found as an iTOP (individually trained oral prophylaxis) trainer and an employee of Curaden Switzerland. In this interview, she explains why being involved in iTOP is as enjoyable to her today as ever.
Dental Tribune International: Ms Maurer Mütsch, you teach the iTOP system at universities, but you also present the iTOP philosophy and method to colleagues and dentists. On a personal level, you had been working as a dental hygienist for decades before you decided to focus on prophylaxis. What prompted this change of approach?
Edith Maurer Mütsch: Everyone thinks they clean their teeth perfectly, of course. I used to think exactly the same thing myself. I have been a dental hygienist for 40 years. I gained my degree in 1976 and worked at an orthodontic practice and a periodontal practice in the Netherlands. Then I asked myself: where do I want to go? At that time, prophylaxis was not a major topic yet, of course, but I had always been interested in it. After a couple of years in Holland, I moved to Basel in 1978. Training for dental hygienists had only been available there for two years. I worked for various dental practices.
And after a few years had passed, you thought that you wanted to do something different?
Yes, I liked working with patients, but I wanted to do more to help the general public, so I became involved in the Swiss Dental Hygienists association, Zahnmännli healthy teeth campaign and Zahn-Bus mobile dental prophylaxis scheme. In 2004, my attention was drawn to an advert for an oral hygiene promoter for CURAPROX and I learnt about Dr Jiri Sedelmayer and his iTOP philosophy. He gave a 1-hour presentation as an introduction. What he said was exactly what I had been trying to impress on my patients at the practice: one can become more aware of one’s own teeth by doing more than simply brushing them. Discovering the touch to teach (T2T) concept made me realise what I had been lacking up to that point. I completed my training as an iTOP instructor in 2008. Since 2005, I have had the opportunity to help introduce the topic of dental prophylaxis to dentistry students at the University of Basel. This is a great initiative, but unfortunately there is not enough time or space in the curriculum to convey the most important information on maintaining teeth and health. Theory is one thing, but practical exercises—this T2T element—is another. Consider that, 30 years ago, an introduction to the theory and practice of prophylaxis was virtually unheard of in dentistry degrees. I would love to help change this. Prophylaxis has a crucial role to play in dentistry. Healthy teeth do not develop disease!
Many practice teams say prevention is too expensive. What do you think?
I used to work at a practice where barely any attention was paid to prevention. Things are different now. If I have an hour to spend with a patient as a dental hygienist, there are now two approaches I can take. I can show the patient prophylactic techniques based on the T2T method and demonstrate how he or she can improve his or her oral health, removing a bit of calculus in the process and giving the teeth a polish and so forth. Alternatively, I can spend an hour simply removing calculus, polishing, applying fluoridating treatments and so on. Working with the patient and the practice team on prophylaxis produces much more successful results and is ultimately cheaper. Patient satisfaction is automatically enhanced. The patients are grateful that having their teeth cleaned is a painless experience because they have much less inflammation and calculus. They are also healthier because they have finally learnt the correct cleaning techniques. These are the basic principles of prevention—and they are priceless!
What is important when it comes to prevention?
Brushes and tools should not simply be handed out to patients. They need to be explained to them and used to help them practise the correct technique in their mouth using the T2T approach. This technique then needs to be repeated and checked at the next follow-up appointment. Individual prophylaxis is tailored to the patient and practised with him or her. Another important factor is the level of pressure a patient should apply with a toothbrush. This is something that can be practised. One of my fellow dental hygienists wanted to know how the T2T method worked, so she brushed my teeth once in the way she had learnt. Then I told her she ought to brush less firmly, making the correct motions but with hardly any pressure at all. We practised together until I was happy. Two days later, my gingivae were sore. She had used far too much force. I brushed her teeth so that she could feel the way I applied the technique with much less pressure. She found it far more pleasant and cleaner afterwards. Just like physiotherapy, it requires practice, explanation and repetition. The results have been very successful. Sometimes, it takes a bit of patience, but when my patients realise how easy it actually is to stay healthy without any painful treatment, they are happy to come back.
This principle is in line with the philosophy of established dentist Dr Jiri Sedelmayer, past professor at the University of Hamburg. He teaches that correct prophylaxis results in healthy teeth for life. However, keeping teeth and gingivae healthy in the long term relies on a combination of knowledge, training and checking the correct cleaning technique.
Yes, Dr Sedelmayer based his entire philosophy on this principle. He looked at the condition of his students’ teeth, saw signs of bleeding gingivae in some cases, and could not believe it possible for prospective dentists to have bleeding gingivae and not be able to clean their teeth properly. He thus began teaching them and using simple exercises to show where there was bleeding and where there was none. ITOP is all about conveying scientifically founded knowledge of prophylaxis in an easily comprehensible way. He then started instructing his students on how they should use toothbrushes and dental floss. There are six techniques for cleaning teeth with a toothbrush, including the Bass and Charters techniques, the Stillman’s method, as well as the rotation and scrub method. There are many variations on these as well. However, the Bass technique is the only method for cleaning the gingival line, which is where all the nasty stuff sets in. Dr Sedelmayer’s students had to take an examination on practical toothbrushing. That was unprecedented at the time. Even today, the training given to students involves very little teaching on prophylaxis. It is mostly theory based, with hardly any practice. Yet, practical exercises are extremely effective for learning. In practice, things are often shown on a demonstration model rather than in the mouth. Imagine doing that in physiotherapy—one would then find oneself standing in front of the mirror at home with no idea of what to do. Students should be given the opportunity during the therapy itself to experience and practise what the exercises should feel like. Only by using their own hands and being guided by the hands of an expert will they understand what they are trying to achieve. This practical approach leads to a rethinking and that is what makes Dr Sedelmayer’s insight and approach so brilliant.
So would you recommend this prophylaxis training to older dentists too, for example?
Absolutely! No practice team should be operating without any individual training and coaching in prophylaxis. Giving patients a toothbrush is simply not enough!
Just a few months ago, I went with the iTOP team to Sweden, where we visited representatives from the Faculty of Odontology—or more specifically the Department of Periodontology—at Malmö University. Our lecturer, Kirsten Warren, Professor of Periodontology at Aarhus University in Denmark, took care of the theoretical part of the training. We iTOP trainers then dealt with the practical part—the T2T element. When reviewing the full-day course afterwards, one colleague said that her teeth had never been so clean—that was the highest praise and underlines how successful the training was. If dental professionals really want to experience individually trained prophylaxis, they should give it a go and judge it for themselves. They should not believe that they can already do everything and have nothing more to learn. Human beings are creatures of habit.
How should the team work together in practice?
There are many dentists who do not take enough of an interest in the work of their dental hygienists and prophylaxis assistants and just let their colleagues get on with it. My dentist at the practice where I work is very interested in prophylaxis and appreciates her team’s iTOP knowledge. The entire practice team is on the same level and we all give the same instructions in line with the iTOP philosophy. As far as we are concerned, there are four key tools: the toothbrush, the interdental brush, dental floss and the single brush. Using interdental brushes correctly always leads to a Eureka moment. The follow-up and coaching are discussed as a team.
Who is permitted to practise prophylaxis in Switzerland?
In Switzerland, there are prophylaxis assistants and dental hygienists and, of course, dentists, who treat patients.
Prophylaxis assistants are dental assistants with additional training in prophylaxis. They are only actually allowed to use instruments to remove calculus in the supragingival area, so they can polish patients’ teeth and should give them a proper clean. They do not treat periodontal patients and they always work under a dentist’s supervision.
Dental hygienists undergo four years of training. They look after patients largely independently, working closely with their dentists, and have different and much more extensive skills than prophylaxis assistants do. Prophylaxis assistants therefore assist dental hygienists and work with them. Unfortunately, however, the training programme for prophylaxis assistants is too short to include the kind of thorough T2T training we offer.
How can one teach prophylaxis if one has not mastered the basics?
If we could integrate iTOP into all of these training programmes, it would make a big difference. The quality of prevention would improve, oral health would be much better and a great deal of money could be saved on dental treatment.