Abused Dental Procedures Part 1: Deep Cleanings

In my last post, I discussed seeking a second opinion if you have doubts about your dental treatment plan.  I also explained the way HMO and PPO practices work and why they may not represent the most cost effective way to get your treatment done.  I would like to add that just because a dentist is fee-for-service, doesn’t mean they are a “better” dentist so please do not ever hesitate to go with your instincts and ask for a second opinion if things just don’t add up in your mind.  That’s not being disrespectful, that’s being a smart consumer.

In my next few posts, I would like to discuss some of the most abused “procedures” in the dental world.  Typically, these are procedures that dental offices know they can get away with billing to insurance and getting the patient to buy into treatment acceptance.  Keep in mind that if you should receive a treatment plan that has these procedures doesn’t mean your dentist is being dishonest, but rather you should be able to ask the right questions to justify in your mind that these procedures really need to get done.  Again, if in doubt, get a second opinion.  And if still in doubt, get a third opinion.  It’s worth your time to give yourself peace of mind that you are doing the right thing for your body.

“Deep Scalings” aka “Periodontal Scalings” or “Deep Cleanings”

By far, the most commonly abused procedure in dental offices today.  It is very common amongst dental practice consultants to recommend that dental practices become more aggressive in treating their patients for periodontal disease.  There is very good evidence that completely supports that periodontal disease has a significant effect on a patient’s general health.  So there is definitely science backed studies that show that as a profession, we must be diligent about identifying and treating periodontal disease.  However, some offices will use this as a scare tactic and convince patients that they need this treatment when in fact, the diagnosis is completely incorrect.  

The criteria for diagnosing periodontal disease (early-moderate-advanced) are:

1.     Generalized Pocket depths over 4 mm: Pocket depths are determined by using an instrument called a periodontal probe which is gently slipped between the tooth and gums.  It should not hurt to do periodontal probings although with some patients, it does feel a little uncomfortable. I had a patient come into our Valencia dental practice the other day whose previous dentist recommended deep scalings without ever doing probings.  That is like a physician diagnosing heart disease without ever listening to your heart.  You cannot diagnose periodontal disease without getting probing depths – impossible.

2.     Bleeding pockets: Your gums bleed on probing.  On healthy gums, gums do not bleed when they are gently probed. With periodontal disease, they bleed when probed.  If the dentist or hygienist is probing your gums and it hurts like heck and bleeds, then they are probing you too hard and getting false reading and causing you unnecessary pain.

3.     Generalized bone loss: You need a full mouth series of x-rays to diagnose periodontal disease.  You will see the bone level lower on all the teeth indicating that there is some process that is causing the bone to recess.

4.     Subgingival Calculus: Also known as “Tartar” in the mainstream media.  These are deposits of calcifications which harbor colonies of bacteria.  When they are trapped below the gumline, they cause inflammation of the gum tissue, bone loss and gum recession. On x-rays, they look like spikes stuck on the tooth below the gum tissue.

When three or all four of these criteria are met, then periodontal scalings are needed.  This procedure should involve using local anesthetic to numb a quadrant and always using hand scalers (and sometimes water scalers but never just water scalers) to clean out the affected areas.  If your dental office is completing a periodontal scaling of four quadrants in just one hour without any anesthetic, you are not receiving periodontal quadrant scaling.

Why do practices like to do periodontal scalings?  Because they can bill you and your insurance company much more than they can get for just a regular cleaning.  If a typical dental cleaning costs $100, a periodontal scaling costs over $1000 dollars.  The money is much better for the practice but in so many cases it’s a procedure that is completely unnecessary for the patient.

Don’t be scared to ask questions of your dentist and make sure the explanation makes sense to you.  And again, if in doubt, ask for a second opinion.

Go Dental, Your Valencia Dentist

When in Doubt, Get a Second Opinion

I’ve been a dentist for 24 years and it still amazes me that the number one reason people leave their last dentist was that “they did work on me that I really didn't think I needed.” This statement always elicits two questions I usually keep to myself.  First, “What kind of dentist would do that?” and secondly, “What kind of patient would allow someone to do that to them if they had doubts?”  If you have any doubts about what your dentist is telling you that you need, you should never be scared to get up and walk out BEFORE treatment is done.  Dentists can have differing opinions about what needs to get done and how to go about treating it but any dentist worth their salt will welcome a second opinion and facilitate forwarding their treatment plan and relevant x-rays to you so you can get a second opinion.  However, if you sense there might be tension in the room, just do whatever you can to leave that office.  A high-pressure dental office is usually up to no good.

Why would dentists have such varied opinions on what needs to be done in your mouth?  In some cases, there is a legitimate debate on how to approach a particular issue. For example, if you have large amalgams (silver fillings) in your mouth which are over 20 years old and show tangible signs of decay, some dentists may treat the tooth by doing a large filling, some may choose an onlay and others may recommend a crown. The dentist should be able to show you where the defect is by use of x-rays and intraoral photos and explain to you in a way that makes sense to you, what needs to get done.  For reference, in our practice all of our Valencia dentists will approach any tooth hoping to do the most conservative treatment (a filling) but if we start working on the tooth and find there is little tooth structure left, we will resort to doing a crown.  However, there should be recognition that there will be some varying opinions by different dentists on how to treat a particular issue.

Sadly, there are dentists out there that are just plain dishonest and will recommend treatment that you really don’t need.  Their primary reason for doing this is for money.  We see this more often than I would care to admit especially as more and more dental insurances move toward “in network PPO’s” and HMO’s.  Not all dentists that are PPO or HMO dentists are bad – in fact, there are some very good dentists that accept PPO plans and maybe even HMO plans.  But the temptation to over diagnose or just lie about the treatment that is needed is certainly there in these practices.

PPO dental networks work by having a dentist sign a contract that they will agree to charge a certain fee for certain procedures that are being done.  The dentist is then considered in network.  The fees that the dentist can charge are often 35 to 50% less than usual and customary fees.  That means that the PPO dentist is pressured to use cheaper inferior materials, hire lower paid, less experienced staff and do a greater volume of work in order to still remain profitable.  There are certain procedures that are not covered by PPO plans thus if the patient wishes to do them, it will be completely out of pocket at a price set by the dentist and not by the PPO.  Often times these prices are outrageous and the treatment wasn't necessary in the first place.  Dental cleanings may only last 15 minutes and may not even be performed by a registered dental hygienist.

HMO dental networks work by recruiting dentists to accept a number of patients and take care of basic needs for free or a nominal co-payment.  In turn, the HMO network will pay them a set fee every month regardless if the patients come in for their care or not.  There are many dental procedures that are not covered through the HMO plan and if the patient needs them the patient will pay for them out of pocket.  This is where a HMO practice can make money.  By performing minimal “free” preventative work and “diagnosing” procedures not covered by the HMO, the HMO dental practice can turn a profit.  As is the case with PPO’s, HMO practices are pressured to use cheaper inferior materials and hire inexperienced low cost staff in order to bring costs down.  Profitability lies in increasing volume of patients and diagnosing procedures that are not covered.

Not all PPO or even HMO dental practices are bad. To the contrary there are many that probably good that our practice never sees because their work is good and their patients are happy.  And I am certainly not advocating that everyone reading this blog post come to our practice because I am well aware there are plenty of well qualified and an honest dentists out there who do amazing dentistry.  The message I would like all dental patients out there to understand is that it is ok to ask for a second opinion.  Trust yourself as an intelligent being to make sure you can see and understand the treatment your dentist is proposing for you.  Listen to that little voice in your head if something doesn't feel right to you.  Don’t be afraid to say “no” to doing any extensive and expensive treatment at the time it is being diagnosed.  And finally, don’t be afraid to ask for a copy of all your records.  They are your records and x-rays and by law, the dentist must release them to you in a format that is diagnostic quality for a reasonable fee for duplication (usually 10-50 dollars).  Since many offices now use digital x-rays, it is very easy to get accurate x-rays through email or on DVD.

In my next post, I will outline specific criteria to look for on the most common dental procedures and how to avoid receiving inappropriate treatment.

Go Dental, Your Valencia Dentist