Would You Like Scaling and Root Planing With That?


[dropcap]A[/dropcap]ngela, a bright, pretty, 30 year old came to me for a TMJ exam last week and when I asked her who her general dentist was, she told me she didn’t have one.

“I just moved to San Diego from the east coast and I am looking for a new dentist. I went to Acme Dental Clinic (not the real clinic name) for a dental exam but I’m not going back there. I think they’re a scam.”

“Really? What happened?”

“They told me I needed 4 visits of deep cleaning for my periodontal disease and that I should also get my teeth whitened. They were selling those things pretty hard. I just got a bad feeling about them.”

I did six-point perio probing. This young lady had no visible calculus and I found one place—mesial of #3—that had a probe score of 4 mm. All the other scores were 2 or 3 mm. Healthy, normal gum tissue and no bleeding points whatsoever. Four quadrants of root planning? Totally unnecessary.

I put down my perio probe and Angela looked up at me. “Well?”

“Well, I’m just trying to find a polite word for BS. Sorry, I can’t think of one.”

She smiled.

“There are plenty of straight-up honest guys and gals around who won’t try to sell you unnecessary treatment. I can give you the names of some people in your neighborhood. What you experienced is called up-selling. Heck, it works for French fries, right? The difference is, you might want the French fries.”

Angela isn’t alone of course, or there’d be no need for me to write about her experience. The over-selling of periodontal treatment is all too common.

At the same time, I’m not slamming the concept of multiple visits of scaling and root planning. Not at all. For some people, it’s absolutely the right thing to do. Click this link for a good explanation: http://health.howstuffworks.com/wellness/oral-care/procedures/root-planing-and-scaling.htm

But scaling root planning is over-recommended as a routine in many places. So what is a patient to do? And over and above that, what is causing this trend?

To the patient: If you have gums that bleed when you brush or floss, if your gums are red and sensitive, tender, puffy or swollen and you are told you should have periodontal treatment starting with a few visits of scaling and root planning, then it is very likely the correct call. You have every right to get a second opinion, but with those signs and symptoms, by all means you should treat the problem.

But let us suppose that you have had a long association with a dentist you trust, and you have never had tender, bleeding gums, and then you change insurance (or it gets changed for you—thanks Boss). Now you’re told you have to change dentists—to one of the few names on a short list. When you go to the new place for your bi-annual cleaning, you’re told you have gum infection that needs treatment. Now you may well have some healthy skepticism. Go out and get a trustworthy second opinion. Oh, I see. You’re saying that you have new insurance and you have to go this particular clinic to have your exams covered. What to do? Ask your friends and neighbors for the name of a dentist they like and trust and pay for that second opinion out of pocket. I know that paying for stuff out of pocket when it’s supposed to be covered by your insurance may be against your religion. Do it anyway. If that unexpected diagnosis of gum disease is wrong, don’t treat it. I’d actually say that if you find out the new clinic gave you improper advice, you should stick with your old trusted dentist. Yes, stay with him or her even if the new insurance doesn’t cover your visits there. What’s trust worth?


It’s not just gum disease that is often over-diagnosed, but teeth with cavities that need fillings or crowns as well.

Nine seems to be the usual number, as in Mrs. Jones you have nine cavities. Or Mr. Smith, you need nine crowns and also one root canal.

Funny, your last dentist didn’t think you had any problems. Who’s correct? And what is going on? The diagnosis of nine cavities when six months ago at your regular dentist—before you got that new insurance—you had none, well, that should make you pause. And get a second opinion from a third dentist—not your previous dentist and not the new one, but an independent source. Yes, the exam will cost a few bucks, but what’s it worth to save a few teeth from unnecessary drilling? Quite a bit, in my opinion.*

What is going on here, anyway? Here’s a behind the scenes look. Every dentist receives a few letters from insurance companies every year. Not the household names, mind you, but low-cost special insurances that have forged agreements with groups—usually labor unions. To avoid naming names, I’ll just call one such insurance company El Cheapo Insurance Company Ltd. The letter to the dentist goes something like this:

[box] Dear Doctor:

I represent El Cheapo Insurance and wanted you to know that we have 10,000 members in your area who are covered by our dental plan. If you would just review our approved fees on page two of this letter and then sign on the dotted line, I can assure you that we can fill your schedule with thousands of new patients. Yes, you will be doing dentistry at a small discount, but I’m sure you’ll make up for it in volume.


Ms. T. Dixie,

El Cheapo Insurance LTD.


And what happens? The dentist (or a group of dentists in a large clinic setting) signs the contract and indeed his schedule fills with a ton of new patients. But sadly he finds out that with light, heat, staff salaries, equipment payments, lab fees, and rent costing close to 70% of his usual fees, a 30% discount is a break-even point. Therefore, no money left over for the dentist to have any take home pay. UNLESS…unless he can find some work that isn’t covered by El Cheapo Insurance (bleaching, cosmetic crowns and so on), or he learns how to do dentistry really fast so he can make that hourly overhead even on El Cheapo’s reimbursement rates. Four quadrants of root planning done in one visit (instead of the standard four) works pretty well. Or he up-sells treatment. Or uses his explorer creatively so that an appointment to correct one cavity turns into a visit to fill four.

Whenever I hear from one of my colleagues that a patient has left his private practice and gone elsewhere, and that a bunch of new work has been diagnosed, there has ALWAYS been a change to a PPO insurance or similar discount plan. Always.

To the dentist: If you are not a member of El Cheapo Insurance and their ilk, just don’t join. I don’t care how many union members they promise to send you.

If you are already a member, and that low reimbursement is driving you crazy, quit or get some good management help. There are ways to run such a practice ethically and still get paid. Look up Tom Orent, the Thousand Gems guy. He can probably guide you. http://www.gemsguy.com/GAPSITE#

To the patient: If your employer informs you that your old insurance plan will no longer be available and that next year you’re going to be covered by El Cheapo Insurance LTD, ask if you can take the premium he would be paying for you as cash instead. Then just use the money to pay for your care out of pocket. If your employer is not willing to do that for you, decide whether you will even use the insurance. You may choose not to if it requires that you go to a clinic that is not a good fit for you. And if you choose to go to the plan doctor anyway, just make sure you have a reasonably functional crap detector and that it’s turned on.

Years ago, when I was a new dental graduate, dentists were ranked second only to clergymen in public trust. Over the last thirty-plus years our trustworthiness ranking has sunk so that we’re closer to used car salesmen in the public view. At least we’re not ranked as low as congressmen.

What changed? I happen to place a lot of the blame on the concept of managed care or dental PPO insurance. Of course the culture has devolved drastically and the strong values that once held sway have gradually diminished as well. But I do think that insurance has victimized both the dentists and their patients. Back in 1972, when I was a new graduate, one of my first mentors in dentistry urged me not to join Delta Dental. This was at a time when everybody was a member of Delta.

“Look. Mark my words. In a few years, the insurance companies, including Delta, are gonna be the tail that wags the dog. They’ll have way too much power. They will reduce reimbursement and they’ll change the rules over and over.”

Delta, of course, is not El Cheapo Insurance LTD (they may be heading that way however—how much did they cut your reimbursement this year, Doctor?), but still his prophetic words from 40 years ago have come true. Want to do dentistry? You almost have to play by the insurance company rules. Unfortunately, both you and your patients are victims. There’s no easy answer, I’m afraid, but maybe the dentists and the public will both have to learn to say, “No.”

*Is it possible you have complex issues that go beyond the ordinary? Sure. In that case you will need to seek the advice of specialists who may or may not be covered on your plan.

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William F. Halligan, DDS

William F. Halligan is a 1972 graduate of the University of Southern California’s School of Dentistry. He practiced general dentistry during most of his career with an emphasis on restorative dentistry. He is a member of the American Academy of Craniofacial Pain ( aacfp.org ) and a founding member of the Academy of Clinical Sleep Disorders Dentistry. Dr. Halligan’s consulting practice is located in California's Eastern Sierra, where he advises on dental and TMJ issues.

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