Interview: In many European countries, dental hygiene is still not recognised as a profession
Trained at Eastern Washington University in the US in its pioneering dental hygiene programme, Dr Tracey Lennemann has been living in Europe since 1988, working as a dental hygienist, lecturer, trainer, coach, author and motivational speaker. In this interview, Dental Tribune International asks Dr Lennemann about differences between American and European dental hygiene and how to offer patients the best available home care.
Which differences have you noticed between dental hygiene in Europe and America?
In many European countries, dental hygiene is still not recognised as a profession in its own right. Take Germany, for instance, where dental hygiene is a building-block-style continued education course that dental assistants can take, but it is not recognised as an individual profession. In the UK, however, most dental hygienists are self-employed and can have their own practices. There is a lack of uniformity and consistency. Each European country has a different level of training and scope of duties. As a result, what a dental hygienist is allowed to do is not the same everywhere. In North America, dental hygienists form a separate registered and licensed profession and dentists and hygienists work together as co-therapists. They share in treatment planning and in the overall maintenance and care of the patient. In some states, dental hygienists are licensed to diagnose disease, give local anaesthesia, place fillings, use lasers and administer nitrous oxide, among many other expanded duties.
Do you feel that what you learnt in the US was different from what was taught in Europe at the time?
Absolutely! Dental hygiene as a profession has been recognised in the US for over 100 years now. At the time I was at university in the mid-1980s, Eastern Washington University had the most advanced dental hygiene programme in the world. We were expanded-duties dental hygienists, fully licensed by the State of Washington once we had passed the university exams and the state board exams. The programme was a four-year university degree course and all medical and dental students studied the same prerequisite courses, such as anatomy, physiology, biology, chemistry, psychology and sociology. We had many advanced duties and were intensively trained and tested to enable us to give full block anaesthesia, place fillings and rubber dams, take periapical and panoramic radiographs, administer nitrous oxide, perform full intra-oral exams for oral cancer and extra-oral exams, checking for swollen lymph nodes and other oral conditions, as well as take vital signs such as blood pressure, and heart and breathing rates. In periodontics, we learned full detection and diagnosis of the disease alongside full root planing with hand instruments, as ultrasonic instruments were still in the developmental stage then. We were taught mini-flap surgery and how to suture an area and worked in community settings and in unsupervised situations. Pharmacology and the prescription medications patients might be taking and how they correlate to oral disease were also part of the dental hygiene programme. It was quite advanced even in comparison with what is being taught today. On a side note, it was dental hygienists from Eastern Washington University who assisted Prof. Ulrich Saxer in setting up his dental hygiene programme in his homeland, Switzerland. In Europe, Sweden, Holland and England are the most progressive countries for dental hygiene, whereas France still does not recognise the profession of dental hygienist.
You are a trainer not only in prophylaxis, but also in so-called non-surgical periodontal therapy. Can you elaborate on what this is exactly, and how you teach it?
We have two main goals in periodontal therapy. One is reduction of inflammation—via biofilm management and better oral homecare—and the second is regeneration of the periodontal ligament and supporting dental tissue. Most clinicians focus on cleaning teeth, polishing, whitening and maintaining biofilm. Non-surgical periodontal therapy is about getting to the bottom of the pocket, working in the last 2–3 mm of a pocket to eliminate any hard deposits in order to achieve regeneration of the surrounding periodontal tissues, the periodontium.
I always try to add an interactive part to my lectures and actually prefer hands-on courses, as I believe that you learn more effectively by doing. This promotes active participation. My participants are amazed when I teach them how to get to the bottom of a pocket and feel the residual deposits. How to use hand instruments properly is not taught intensively in the basic courses nowadays. I hold their hand and guide them into the depth of the pocket, teaching them how to feel the deposits and remove them. They see instant results and improve their hand skills, which they can immediately implement the following day.
Have you noticed a trend from restorative dentistry towards preventative dentistry?
Depending upon what country you are in, you see different changes happening. In the US, the trend is moving towards seeing the dental hygienist as a physician’s assistant (PA). Many people just see the PA instead of the doctor for medical appointments. Most of my patients just see me, and if I identify a problem, I then refer them to the dentist or specialist. Also, dentists in the US are more business-minded and see that the revenue brought in by the dental hygienist is beneficial for the entire team.
In the EU however, dental hygienists have tended to be marginalised. This can mean that they are not treated as important but are seen only as the person who cleans teeth. In many countries, the patient does not even know the dental hygienist’s name. In some countries, the dentist does the cleaning, because they want the profit in their pockets and do not want to pay a dental hygienist or because the country’s regulations do not allow it. Unfortunately, many dentists think the dental hygienist is too expensive and just want cheap labour for profit reasons, not considering the importance of providing the highest quality of treatment and service for the patient.
Also, I have noticed an increase in lectures addressing periodontal issues, yet sadly I think many practices have still not updated their treatment protocols and lack a system or planned protocol for treating a patient with periodontal problems. In my practice coaching sessions, I find that most practices in Europe just do the basics of prophylaxis but have not developed an end-to-end solution or concept for periodontics. There has been a huge trend towards biofilm management and reduction in inflammation, which is extremely important at the beginning, but once this has been managed, I still see a lack of clinical skills to actually regenerate pockets. I see supervised neglect, just doing the minimum and not addressing the deeper issues, because of not knowing how to advise the patient on why he or she needs to invest time and money in oral health, or not really knowing how to do the treatment.
In your training sessions and presentations, you talk about patient motivation. What is the importance of motivation in dental hygiene?
First the clinician must be motivated and see the treatment as a therapy and not just tooth cleaning. Secondly, the first things to do when seeing patients are to help them to understand dental disease and why it happens and to guide them in what to do to stabilise it and regain and maintain a healthy mouth.
Whatever it is you want to teach or motivate, always explain the “why” first. Once patients understand why something has happened or why they need a treatment or product, this will guide them in making the right choice for themselves. This motivates people to invest time and money in their health.
"I am a fan of hydrodynamic technology, but edel+white is the next generation. The brush head mechanically reaches under the gum line to remove plaque, whereas other sonic brushes just use fluid dynamics to reach the plaque."
How does effective and proper toothbrushing at home complement dental hygiene and periodontal therapy?
In my opinion, 90 per cent of a person’s oral health is determined by what he or she does at home. A clinician’s duty is to create, or rather re-establish, a healthy oral environment for their patients and fully educate them on how to maintain it at home. Individually assessing a person’s hand skills and selecting the correct products that are effective, non-damaging and easy to use are key to patient motivation and compliance.
You like to work with the Scanderra’s edel+white. How did you find out about it?
From 1999 to 2005, I was a professional educator for sonic toothbrushes and, as such, understood the full function of sonic and electric brushes. Two years ago, Thomas Flatt from edel+white contacted me and wanted to show me the brush and asked if I would try it. I suggested that I test it on ten of my periodontal recall patients to determine what level of improved gingival health they could achieve. The outcome was impressive and surprising. It is a fantastic brush! I am a fan of hydrodynamic technology, but edel+white is the next generation. The brush head mechanically reaches under the gum line to remove plaque, whereas other sonic brushes just use fluid dynamics to reach the plaque.
Can you tell me more about the study you did with it?
I took ten of my periodontal recall patients who were in the maintenance stage of treatment yet still had bleeding upon probing and plaque at gingival margins. Some used another type of electric brush and others used a manual brush. I took baseline photos, pocket depths, bleeding on probing (BOP) scores and plaque indexes with an electronic probe. Then I had them use only the edel+white electric brush, with the sensitive brush head, for one month. No interproximal (IP) cleaning or flossing was allowed. I wanted to see what the brush could really achieve. After one month, I took the scores again. Then I had them continue with the brush and IP tools for another two months, taking final scores at the three-month interval, to determine if the outcome after one month had been sustainable.
To my delight, all patients showed a minimum decrease in BOP scores of at least 30 per cent! Many had decreased pocket depth and most had visible improvement. All patients were very happy with the brush, had no sensitivity or negative feedback, and were motivated to spend more time on oral care. They are still using the brush today.