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Can a hygienist damage my gums?

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Dr. Hall,
Can a dental hygienist cause permanent damage to your gums?
My dentist’s office has seen quite a turnover in hygienists the last couple of years. The last couple of hygienists admittedly spent only minutes cleaning my teeth, so I don’t doubt I had some buildup.
However, when I went in for my cleaning yesterday I knew something was off. Obviously I couldn’t see what she was doing but she seemed very aggressive. It felt like she was going too deep or something. The most pain I’ve ever had with a cleaning and I could tell my mouth was full of blood. My gums were still puffy and sore the next day. This has never happened in the 35 years I’ve gotten cleanings – the pain, blood or puffiness. I mentioned to her she was rather aggressive and she stated I had a lot of buildup.
I appreciate when they go at it and do a good job. But now I’m worried about the what-ifs; could she have caused any permanent damage?
– Rebecca from Illinois

(See Dr. Hall’s answer below.)


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Rebecca,
I’ll try to give you something helpful here, but please understand that, since I can’t examine you, I’m dealing with a certain amount of guesswork.

One statement you made that caught my attention was “The last couple of hygienists admittedly spent only minutes cleaning my teeth, so I don’t doubt I had some buildup.” To me, that sounds like a serious indictment of your previous care. A quality teeth cleaning is mostly about cleaning off the hard deposits (calculus) that attach to your teeth below the gumline. A few minutes isn’t enough time to do that. Doing a thorough job should take a minimum of 40 minutes. While some practices get away with providing only a superficial cleaning that can make the teeth look clean, many quality dental practices give their hygienists an hour to do a cleaning.

If, as you suspect, previous hygienists had not addressed this buildup, it could easily be a painful and possibly bloody job to do a proper cleaning. The presence of these hardened deposits that have been on your teeth for some time would cause your gums to be inflamed. Going down deep under the gums to clean it all off would definitely cause some bleeding.

a drawing of an x-ray of lower teeth, showing progressive levels of gum disease

Image courtesy of Thousand Oaks Family Dentistry, Thousand Oaks, CA

So, getting to your question: Can a hygienist cause permanent damage to your gums? My answer would be yes, indirectly, by failing to fully clean off these deposits. The inflammation that causes can progressively, over a period of years, actually cause destruction of the bony support of your teeth. On the right, I have put a drawing of an x-ray that shows progressive destruction of the bony support of the teeth that occurs if this buildup is allowed to remain on the teeth. If my presumptions are correct, it’s your earlier hygienists that induced some damage to your gums. The more thorough hygienist did you a great favor by cleaning it off. Hopefully she will be around for your next cleaning visit. I would stick with her.

Now it’s possible (though I think unlikely) that your last hygienist was overly aggressive and actually caused bleeding in gums that were otherwise healthy. If so, that involved only soft tissue damage, which would heal without leaving permanent damage.

I hope this is helpful.

– Dr. David Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Why the Peroxide Rinse?

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Hello Dr. Hall,
I had a recent dental cleaning and there were several protocols in place to screen for COVID. One of the things that surprised me was that the hygienist requested that I rinse with peroxide before she cleaned my teeth. I asked if it was related to COVID, and she said yes. She actually said she has been requesting this of patients for over 15 years, even during ‘normal’ times. How effective is this in preventing the spread of viruses? Are all dentists doing this?

Thanks,
Jamie from Colorado

(See Dr. Hall’s answer below.)


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Jamie,
The concern is over aerosols that are generated during a dental appointment. Especially if your hygienist uses an ultrasonic scaler, aerosols are generated that escape into the air of the dental office and can circulate throughout the office. They can remain suspended in the air for several hours. Everyone in the office can then inhale them.

There are several ways of reducing infectious aerosols produced by dental treatment. One way is the use of high-volume suction equipment. When the dentist does procedures, usually the dental assistant will be tasked with holding the high-volume suction close to the field of operation. While that doesn’t provide perfect protection against infectious aerosols, it has been shown to reduce them by about 95%. This method, however, is usually not practical for dental hygiene appointments because there is normally not a dental assistant present.

Recent advertisements to dentists have promoted suction devices with wide openings of a foot or more in width that can be placed near the operatory field. Here is a screen shot of an advertising that I recently received for one of these devices.
A photograph of a dentist working on a patient with a Rhondair suction resting on the patient's chest

This device will capture aerosols into a box with a filter. While a nice idea, my worry would be that the clear shield could get in the way. I noticed the photograph doesn’t have a dental assistant present, and while the dentist, using quality magnification, could maybe work around the shield, I have difficulty picturing how the assistant would.

Another effective option is, rather than reducing the aerosols, to make them less infectious. This is where the pre-operative rinse comes in. In recent years, dental hygiene schools have been teaching hygienists to use a pre-operative rinse before each appointment, but only a small minority of hygienists have actually been doing that. However, with COVID-19, I believe the use of those rinses may be near 100%. In some states, they have actually become mandatory.

There are several anti-microbial rinses that are used. I believe that the peroxide rinse is the most effective because of its quick action to kill oral micro-organisms. The peroxide used is a little more concentrated than you would buy over the counter. What is sold to the public is a 3% peroxide. For dental appointments, while the American Dental Association recommends at least a 1.5% concentration, a number of offices are using rinses with about 4 or 5%. A swish for a few seconds is fairly effective at killing bacteria and viruses. The aerosols then that are generated during your cleaning or other dental treatment will then be much less infectious.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Would I let a rough hygienist clean my teeth?

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Dr. Hall,
All of my top teeth (except the molars) have porcelain crowns. I was advised years ago not to have a Cavitron used to clean the crowns. I recently had my teeth cleaned by a new hygienist who became very upset when I asked her not to use the machine. She scaled my crowns with so much force that it was painful and I really worried she would break them. The 4 center teeth do not have a metal lining behind the porcelain and I treat them very carefully. Which is the lesser of two evils – the Cavitron or a brutal hygienist scaling my porcelain crowns with hand instruments? Could there really be that much plaque on a porcelain surface?
– Elizabeth from Massachusetts

Elizabeth,
I’m getting a lot of these Cavitron questions lately. I think that’s because their use is getting more popular with dental hygienists.

The Cavitron by itself won’t hurt your porcelain crowns or other porcelain restorations. See my earlier post on this: Is the Cavitron safe for use with porcelain veneers? We used to give a blanket prohibition against using the Cavitron with porcelain crowns or veneers, but our observation of the care being used by dental hygienists has caused us to soften that. Used properly, there is no risk of damage from the Cavitron to crowns or any other restorations.

What bothers me most about what you told me is that your hygienist became upset when you asked her not to use the Cavitron. I talked to my own hygienist about this Cavitron issue and she said she gets a number of requests from patients to not use the Cavitron in certain places, or other requests, and she honors those requests. This haughty attitude and lack of sensitivity to the patient is not good. It’s kind of like you are in the way of her doing her job. She doesn’t seem to connect that you are paying for her services. Hygienists and dentists get a number of special requests like this from patients, and I believe the proper response is to honor those when possible. Yes, you may have made more work for her, but serving the patient is her job.

To answer your question, yes, the hygienist can do damage even without the Cavitron. Heavy scaling can nick the margins. If I were in your position, I wouldn’t let this hygienist touch my teeth any more, whether she used a Cavitron or a hand scaler or a toothpick. If that meant switching dentists, I would do it, and let the dentist know the reason. From what you’ve told me, I have serious questions about how much she cares about her patients, which for me is the first requirement of quality care. In rough hands, a Cavitron can do significant damage not just to restorations but even sometimes to your teeth.
– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Is the Cavitron safe for use with composite restorations?

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Greetings Dr. Hall:

My query is in relation to the Cavitron Ultrascaler for cleaning. I have a couple of class 5 restorations on my front teeth but am concerned that the metal tip of the Cavitron will damage the composite restoration. I am getting conflicting information online that the Cavitron will damage the composite and will not damage the composite, as long as a low power setting is used. Also, it is safe to use only if a plastic sleeve or carbon composite tip is used? I am confused. Given my particular circumstance, under what conditions is the Cavitron safe to use and not to use? I do thank you, sir, for your input and time on this concern of mine.

Cordially,
– Cara from Pennsylvania

Dear Cara,
The reason you’re getting conflicting answers in your online searches about the effect of a Cavitron on composite restorations is that there isn’t a straight answer to the question.

Yes, a Cavitron can damage porcelain veneers or composite restorations. A class V composite which is right at the gumline could be especially vulnerable. But it depends on the operator whether it actually will or not. I can help explain that with an analogy. I had a barber when I lived in Iowa who, every time I had him cut my hair, he would shave the back of my neck with a straight razor. Now that’s a nasty instrument and used improperly he could have really caused some damage. But he knew how to use it, and because of his skill I was more likely to cut myself with my own safety razor than be cut by him with his straight razor. That’s similar to the Cavitron issue.

I used to include Cavitron on my list of no-nos for people with porcelain veneers and other cosmetic dental work, but I don’t any more. That comes from my personal observation of three different dental hygienists who have used Cavitrons on me with great care and skill. If they’re smooth in their hand motions and light with their touch, they won’t cause a problem. If they’re not, they can damage more than restorations – they can nick and gouge the cementum on your teeth, giving you sensitive areas that attract plaque and calculus.

To give me a little more perspective, I asked my current hygienist, Courtney at Dr. Kelly’s office in Scottsdale, to comment on your question. She said that yes, a Cavitron can damage restorations if it is used improperly. The way she handles it is that she doesn’t use the very tip of the instrument on the restoration, and she is careful not to dwell on any restoration. She added that she has patients who will share with her that they feel uncomfortable with certain procedures and they will tell her they don’t want her using the Cavitron around certain restorations, for example, or they want her to thread the floss through their teeth in a certain way, and she honors those requests. Being her patient, I can say that I feel that the Cavitron is a safe instrument in her hands, and I let her go where she feels she needs to go with it.

What I would recommend, if you have any anxiety about this, is to ask your hygienist what he or she would do around class V composites. Listen to the explanation, and if you detect a level of confidence that reassures you, let them go ahead. If, after the explanation, you have any doubts, then ask them to stay away from those areas and they should respect that request.

Dr. Hall

Question and answer go here.

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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