Is a Dental Deep Cleaning Ever Really Necessary?

This article was originally published on tonic.vice.com by Denny Watkins on Oct. 27, 2017

You come in for your regular dental visit—already putting you ahead of the 34 percent of Americans who skip their yearly checkup. After the usual prodding and scraping, the hygienist tut-tuts and informs you that because you were lax on brushing and flossing, you'll need to come back to the dentist chair again next week for a "deep cleaning" under the gumline.

Suddenly, asked to pony up for an extra service from the dentist that you've never heard of before, you might ask yourself: Is it a scam?

First of all, the deep cleaning itself is very much an established dental treatment. The technical term is a "root scaling and planing," and it's long been part of a dentist's standard procedures. "This was old already when I was trained," says Paulo Camargo, chair of periodontics at the UCLA School of Dentistry, who graduated dental school in 1984.

The dentist or hygienist will use their tools to scrape away plaque and tartar on the surface of the enamel up under the gums—not just along the gum line like in a regular cleaning. They'll also reach up along the roots of your teeth to smooth the softer cementum on the surface to prevent plaque from forming in uneven spaces. The entire process takes about 45 minutes per quadrant of your mouth—upper left, upper right, lower left, or lower right. It may even take multiple sessions to treat all four afflicted quadrants.

If that sounds a little uncomfortable and unpleasant, it is. Patients typically receive a local anesthetic to numb the sensation of dental tools probing under their gums.

While it's far from the most fun way to spend an hour, root scaling and planing is a necessary treatment for advanced gum disease. The early stages are called gingivitis, when bacteria living in the plaque along your gums release toxins. Those toxins trigger an immune response that leads to inflammation. Your gums become red and puffy and they bleed easily. "It's like a tight sleeve on a shirt," Vera Tang, a professor of periodontology at New York University. "If you're not cleaning debris out on a regular basis, that collar gets stretched out further and further and the debris goes deeper and deeper."

Usually gingivitis will clear up once the dental hygienist scrapes off the plaque during your regular cleaning and you take it upon yourself to be more disciplined with brushing and flossing. If not, gingivitis can progress to periodontitis.

Periodontitis, by definition, means the inflammation in your gums has become so severe that the over-aggressive immune response is attacking bone and tissue in your mouth. The resulting bone loss is apparent in visible gaps that form along your gums, and your teeth can become loose. Left untreated, your teeth might eventually have to be pulled.

Root scaling and planing aims to halt that process. Once the plaque and food particles are cleaned out, your gums will begin to heal themselves and re-form the tight seal around your teeth within six to eight weeks.

Unfortunately, once you've undergone a root scaling, it's probably not going to be the last time. "It's a long-term diagnosis, very much like hypertension and diabetes," Tang says. "It goes into remission, but it has a tendency to come back depending on how you care for your teeth." The bone loss from periodontitis is irreversible, making it easier for plaque to creep back under your gums and cause more inflammation. If you're diabetic or a smoker, you generally have reduced blood flow to your gums that diminishes the region's ability to heal. Your dentist may even ask you to come in more frequently for follow-ups—as often as every three months.

Which is to say that if your dentist says you need a deep cleaning or root scaling, you should listen. But just because the procedure itself is legitimate doesn't always mean that you truly need it. "Can this be overused, can this be overprescribed? Yes," Camargo says.

Like any profit-earning business, dentists are under pressure to boost revenue. "Sometimes solo practitioners have a hard go of it, because they don't have the marketing support or the infrastructure to allow the dentist to thrive more easily," says Jim Quiggle, director of communications at the Coalition Against Insurance Fraud. "Corporate practices can also be subject to so much pressure to perform that they feel they have to cut corners to succeed."

There are any number of ways to squeeze patients—and their insurance companies—for extra bucks, including charging for services that weren't performed, breaking down services into separate components, or offering purely cosmetic treatments while billing for medically-necessary procedures. "Upcoding can be very lucrative if the dentist knows how to play the system well," Quiggle says.

Camargo warned that the opposite problem can also happen—dentists might clean your teeth and fill cavities, but they'll ignore gum problems until it's too late. "They never treat periodontal disease, then you go to the next dentist and he says you're going to lose all your teeth," he says.

Most often a dentist—and not the hygienist—should make the diagnosis of periodontitis, although in some states dental hygienists are allowed have their own private practice. They'll use a perio probe, which looks almost like a type of dental pick, except it's marked with lines to measure the space between your gums and teeth in millimeters. Up to 3 mm is considered acceptable, while between 4 and 6 mm means you'll need the deep cleaning. "Anything beyond 6 and you might need to come back for surgery, depending on the anatomy and the contour of the teeth," Tang says.

If your dentist doesn't use the probe to make a diagnosis, you have good reason to be skeptical. "Any patient should walk away from a dentist that doesn't do a probing, because that's the standard of care," Camargo says. They should also chart the probe measurements throughout your mouth, and be able to explain to you what everything means and how the deep cleaning will proceed.

If your dentist's recommendation for a deep cleaning sounds fishy, the smart move is to seek out a second opinion. The extra time in the dentist chair could save you from an unnecessary procedure—or confirm that you need a treatment that will save your smile.