Congratulations! You made it through your first dental visit. The exam and x-rays seemed uneventful and you feel like you and the staff are beginning to develop a nice rapport. All of a sudden, the dentist or hygienist drops the dreaded news – you need a deep cleaning!
Your mind starts racing…
“This sounds painful – to both me and my bank account!”
“Are they just trying to pad the bill?”
“My other dentist only did regular cleanings. What gives?”
In order to understand why you may or may not need a deep cleaning, I need to give you a little dental education. But I’m warning you – some of these images are graphic. You may not want to read this right before a meal!
Not all cleanings are the same so let’s break down what kind of cleanings dentists and hygienists do and why.
1. The Basic Prophylaxis
This is the simplest and least time-consuming cleaning for the dentist or hygienist. The gums are healthy or mildly inflamed (gingivitis). The gum (periodontal) exam reveals normal gum pockets (space between the gum and tooth) of 2 – 3 millimeters with some 4 millimeter pockets where the gum is puffy from inflammation. The inflamed areas may bleed when the pockets are measured with a probe. There is some light build up of tarter and stain above the gum line.
Healthy pink gums and clean teeth!
Gingivitis with slightly red, inflamed gums and light stain between the teeth
You will see dental codes D1110 (adult) or D1120 (child) on your itemized bill or insurance claim.
2. Full Mouth Debridement
Maybe it’s been a long time since you’ve had a teeth cleaning or possibly never. Maybe brushing your teeth isn’t a priority in your life. When there is so much build up of tarter, plaque and food debris on the teeth that an exam can’t even be done, then a full mouth debridement must be done first. The goal here isn’t getting the teeth perfectly clean in one visit. We just want to get the bulk of debris cleaned off so the dentist and hygienist can see what’s going on.
Heavy tartar and stain on the inside of the lower front teeth
This patient never had any previous dental care and never brushed his teeth
As you can see, it is impossible for the dentist to identify cavities, broken teeth or even probe the gums when all this plaque, tartar and debris is present. The Full Mouth Debridement will have to be done first – before a proper exam can be completed – so the dentist can diagnose problems with confidence. You will also be given personalized oral hygiene instructions so you can get your teeth and gums “in shape” before your next visit.
You will see dental code D4355 on your itemized bill or insurance claim.
3. Scaling and Root Planing
This is what dentists and hygienists are talking about when they say, “You need a deep cleaning.” Tartar and plaque that is not removed over time can work its way under the gums and harden onto the root. This dark tartar under the gums (subgingival calculus) is firmly attached to the root – like barnacles on the hull of a ship – and needs to be removed with special instruments.
But first, let’s look at a model and compare health and disease.
Health
Normal, healthy gums and teeth
Gums peeled back showing normal bone support of the teeth with clean roots. The roots are normally more yellow and darker than the tooth crown. People with gum recession will show more of the darker tooth root which may be a cosmetic concern.
Disease
Puffy, inflamed gums with some recession and rings of dark tartar around the necks of the teeth
Gums peeled back showing dark tartar and loss of bone support around the teeth (periodontitis)
It’s important to understand that scaling and root planing is used to treat periodontitis. Your dentist needs to have diagnosed this previously and documented it in your record. Periodontitis is a more destructive disease than gingivitis because it destroys the tooth-supporting bone and can lead to tooth loss.
Reaching dental instruments under the gums to scrape or vibrate off tartar can be uncomfortable or downright painful. The dentist or hygienist frequently uses local anesthetic to numb the areas they are working on to keep you comfortable.
Scaling and root planing takes more time, labor and skill than other types of cleanings. For those reasons, it is more expensive. Expect to be scheduled for two appointments – usually 90 minutes each – if you have most all of your teeth with moderate to heavy build-up of tartar under the gums.
For billing and insurance purposes, the mouth is divided into quadrants – upper right (URQ), upper left (ULQ), lower left (LLQ) and lower right (LRQ). Each quadrant is further broken down by how many teeth need to be treated. If there are 1 to 3 teeth being treated in the quadrant, then the insurance code D4342 will be used. If there are 4 or more teeth being treated in the quadrant, then the code will be D4341.
4. Scaling in the Presence of Moderate to Severe Inflammation
Some people may have gums that are inflamed, puffy and bleed easily but have no loss of the underlying jaw bone. This disease is called gingivitis and, when it is moderate to severe, the patient will require more than just a basic prophylaxis. The teeth will have some plaque and tartar on them but the amounts won’t look anything like those pictures above. The dentist is able to do a proper exam first.
The hygienist needs to be skilled and patient to clean around the porcelain crowns on these lower front teeth. Note the inflamed gumline which bleeds easily to the touch.
The code for this procedure is D4346.
5. Periodontal Maintenance
This can also be viewed as “deep cleaning” maintenance for patients that already had scaling and root planing in the office that is coding for this procedure. The patient must have a diagnosis of periodontitis. The hard work of root planing has already been done but the deeper gum pockets still accumulate soft plaque, tartar and bacteria over time and are more time-consuming to clean out – hence the higher fee than a standard prophylaxis. Local anesthetic may also be necessary to provide comfort during the procedure.
The code for periodontal maintenance is D4910.
How Often Do I Need My Teeth Cleaned?
Short answer: There is no set interval for teeth cleanings!
You and your dentist and dental hygienist need to make this decision together based on your risk of disease progression. Two main dental diseases affect the population – tooth decay (caries) and gum diseases (gingivitis/periodontitis). Less common but even more important is oral cancer. Catching tooth decay and gum disease early can save your teeth. Catching oral cancer early can save your life. Consider the following when deciding how often to see your dentist and hygienist:
Your genetic history: Did your parents or siblings lose teeth earlier in life?
Your dental history: Do you have extensive dental work in your mouth? Have you lost some teeth already? Do you form tartar quickly?
Your medical history: Heart disease, diabetes, respiratory disease and auto-immune disease increase your risk for dental problems.
Medications can dry your mouth and increase your risk for cavities.
Smoking and alcohol consumption increase your risk for oral cancer.
Do you clean your teeth properly and thoroughly on a daily basis?
If we look at the science, people with gum disease or a lot of tooth decay do best with more frequent recall cleanings – every 3 to 4 months. As a matter of fact, consistent periodontal maintenance visits are the most important factor in controlling progression of these diseases and helping people keep their teeth for as long as possible. Putting off a maintenance cleaning for too long may cause your gum disease to worsen and you may even need another round of scaling and root planing – an uncomfortable and expensive proposition!