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Why do I need a “Deep Cleaning”?

By: Alon Dori, DDS

I can’t tell you how many people come up to me exasperated, saying “My dentist says I need a deep cleaning…Do you think I need a deep cleaning!?” This, of course is a loaded question because I need a lot more information to diagnose. My quick response usually is, “Not from where I’m standing.” My long response usually goes like this…

A “Deep Cleaning” or more appropriately – Scaling and Root Planning is an involved periodontal (gums) procedure which involves removing plaque and calculus (hardened plaque) from the DEEP pockets between the teeth and gums and then smoothing the surface of the roots. Please note that I emphasized the word deep. A deep pocket is anything that is 5mm or more (4mm in select cases). So, the first question a patient needs to know is – Do they have deep pockets? If the answer is “No”, well…then a DEEP cleaning is not indicated.

I am disheartened that many dentists incorrectly diagnose a deep cleaning just because there is a lot of debris. Large amounts of calculus in the absence of deep pockets requires a cleaning, but scaling and root planning is rarely the appropriate treatment.*

A “deep cleaning” is expensive. It requires a good amount of time, dexterity and often times numbing the mouth; unlike regular cleanings. With the right instruments and gentle hands, removing debris from the teeth above the gums is generally painless. Discomfort usually comes from removing debris from below the gums which are already inflamed, swollen and tender.

So why do some dentists treatment plan a deep cleaning when there are no deep pockets, but there is a lot of calculus? It’s simple, they want to be compensated for their time and use of materials.  We want the same in our office, but we need to be fair. If an involved cleaning is in order in the absence of deep pockets, we will generally perform a bulk debridement procedure followed by a fine scaling (prophy). This way the patient gets the proper treatment without breaking the bank.

*Calculus below the gums that can be detected on an x-ray is very tough to remove, even though the pockets are shallow. These cases may require anesthesia for patient comfort and localized deep cleaning.

What is Plaque, really?

By Alon Dori

Here’s the scientific answer:  Dental plaque is a soft deposit that accumulates on the teeth. Plaque can be defined as a complex microbial community, with greater than 10¹⁰ bacteria per milligram. It has been estimated that as many as 400 distinct bacterial species may be found in plaque. In addition to the bacterial cells, plaque contains a small number of epithelial cells, leukocytes, and macrophages. The cells are contained within an extracellular matrix, which is formed from bacterial products and saliva. The extracellular matrix contains protein, polysaccharide and lipids.

Here’s what it means in English: Dental plaque is basically comprised of three things: Food, Saliva and Bacteria…lot’s of bacteria (10¹⁰ = Ten Trillion per milligram!!). After we brush our teeth, the microscopic bacteria that did not get washed away begin to re-colonize our mouth almost immediately.  Foods that are rich in sugars (not just the sweet stuff) like carbohydrates are fuel for many species of oral bacteria and help the germs to reproduce and grow. That’s why we brush our teeth; to keep the amount of germs in our mouth under control.

How can we get rid of the bacteria once and for all, you ask? This has two answers: 1) You can’t!, 2) Some bacteria is good.  Let’s start with answer #1. Bacteria is everywhere. It can be found on every surface on Earth, you included. It has been around for billions of years and has evolved as the dominant organism on Earth as it has survived for so long and continues to survive. Generally, we think of bacteria as being bad because they cause disease and even death in other living things. But, this is not always true, which brings me to answer #2. Bacteria compete with each other for valuable real-estate. It’s kinda like the saying; “Better the devil you know than the devil you don’t”. The main bacteria that live in our mouth are Streptococcus sanguis, Streptococcus mutans, and Actinomyces viscosu. If they disappear (as a result of antibiotic drugs) other organisms like fungus can fill in the void and cause big problems like Thrush.

So, what’s the take home message? Our mouth is the perfect home for bacteria; it’s always warm, moist and food is delivered at least three times a day (exactly like a Petri dish, image 1 and 2). The main purpose of brushing (and flossing) is to keep the amount of bacteria in your mouth low. If you can scrape the plaque off your teeth with your fingernail, you are way past due for a good brushing.

Image 1: Plaque developing on teeth                           Image 2: Same bacteria developing in a Petri dish

Referrences:

1) Susan Kinder Haake, Microbiology of Dental Plaque, Dental Plaque: Structural, Microbiological and Developmental Characteristics. http://www.dent.ucla.edu/pic/members/microbio/mdphome.html

2) Carranza, Newman, Clinical Periodontology, 8th edition, Etiology of Periodontal Disease, page 83-206.

3) Martin S. Spiller, http://doctorspiller.com/Periodontal_Disease/Gum_Disease.htm

A few months back I had a 17 year old boy in the dental chair. He came in with his mother and was crying.  He was gaunt, pale and in obvious pain. I really felt bad for him. The young man was suffering from a toothache. Actually, he was suffering from several toothaches. When I interviewed him, I learned that he had been “dealing” with this pain on and off for a year. Finally, his mother couldn’t stand the whining and finally “forced” him to come to the dentist.

I examined him and his x-rays and easily diagnosed multiple abscesses (infections) and several severely decayed teeth which reached the pulp (nerves).  It was amazing to me that this patient had been able to suffer through all these infections until now. Luckily for him, it was 2011 and not 1911, all but one tooth was savable and had a good prognosis. And if we acted fast, he could be pain free and back on his feet in no time….but of course, that is not how this story ends.

With considerable effort the office prepared a very conservative treatment plan outlining the cost associated with saving the young man’s teeth.  In almost one fluid motion, the mother looked at the estimate and tossed it back declaring, “we can’t afford that…how much to pull the bad teeth?”.  As a father of 2 boys, I was caught off guard and was at a loss for words.  With all the chairside manner I could muster, I replied, “Pull all the bad teeth!?…that’s….6,7,8…9 teeth! Most of them are molars. He is going to have a hard time eating”. “Well,” she replied matter of factly, “we just can’t afford that much right now. He’ll just have to deal with it.”

I was saddened to hear of their financial difficulties and considered proposing a financial arrangement because lacking teeth this early in life was going to be a life changing event for the young man. Just as I was about to speak, a cell phone rang. It wasn’t the ring tone, “Don’t stop believin’” so I knew it wasn’t mine. By the second ring, the boy sitting in my chair reached into his pocket and pulled out his iPhone4 and turned the ringer off. “Who was that?” asked the mother. “Dylan”. “You better tell him you’re not going to be able to go snowboarding with him this weekend, if they pull your teeth,” she threatened and reached into her purse, “That reminds me…”. Out of her bag came another iPhone4 and she quickly began texting someone as I sat there taking it all in.

This patient interaction got me thinking. I too have an iPhone4.  It cost me about $200 for the phone and $120 a month for the service.  It’s not cheap (about $1,400 a year) but I rely on it quite a bit for communication and entertainment.  But then again, I rely entirely on my teeth for the same things and more.  In fact, my healthy teeth (and gums) give me considerably more pleasure than my iPhone4.  I can eat and taste everything and anything.  I can smile with confidence and speak clearly. I can even whistle.  Simple as these things are, they make our lives easier and enjoyable. We all take them for granted until we can’t do them.

To sum up, people are always happy to pay for things they enjoy, like videos, apps and the ability to talk to a friend whenever they feel like it.  Equally, people dislike paying for things they don’t enjoy, like x-rays, cleanings and dental work. This is because they don’t derive pleasure from the dental treatment itself.  However, it’s not actually the treatment that they are paying for, it’s what the treatment affords them.  A confident smile, the ability to eat wonderful foods, and peace of mind that they are doing their best to stay healthy and strong.

As for the 17 year old boy…he went though with the extractions and is now wearing two temporary partial dentures.  He is infection free but very dissatisfied with his false teeth.  He complains that he can’t eat the foods he once enjoyed and wishes he saved his teeth. It breaks my heart.