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Patient refuses X-ray

by Dianne D. Glasscoe

Dear Dianne:

Every now and then, a patient refuses to let me take X-rays. This always makes me feel uncomfortable, because the feeling I get is that the patient thinks he or she knows more than I know.

Our policy on bitewings is once a year, and if the patient is caries-prone, we take them every six months. The doctor tells us to take a full-mouth series every three years and a panoramic X-ray every five years.

What should I say to someone who refuses X-rays?
Needing Help in Nebraska

Dear Needing:

Most dental clinicians are faced with the X-ray dilemma at some point, and it is uncomfortable when a patient refuses or challenges the radiographic examination.

What are the primary objections to radiographs?
o fear of radiation exposure
o cost
o discomfort
o obstinacy

Your patient may harbor one or all of these objections. However, if you can determine why your patient objects to having radiographs taken, you can then attempt to dispel their concerns. "Mrs. Jones, could you share with me why you don't want any X-rays taken?"

• The fear factor - If the patient relates that he or she fears the radiation from dental X-rays, it is our job to try to dispel those fears. Although X-ray machines vary, the amount of actual radiation is anywhere from .1 to .5 second for one periapical exposure - an extremely small amount. Digital radiography is even lower than that.

I heard a doctor tell a patient once that people get more radiation exposure from their color televisions than from dental X-rays. Although this is an analogy a patient can understand, the accuracy of that statement is questionable. The point the doctor was trying to make was that we receive radiation from many different environmental sources, not just dental X-rays.

We could respond, "Mrs. Jones, the truth is that dental X-rays are quite safe. The amount of radiation is extremely small due to the fast-speed film (or digital technology) we use. These pictures provide us with valuable information about things we can't see under the gums, under fillings, and in between your teeth."

• The money factor - If the patient relates to you that he or she cannot afford to have X-rays taken, you have two choices:

• Offer to take the films and let the patient pay later
• Or make an agreement with the patient that the X-rays will be taken on the next recare visit so the patient can come prepared to pay for them

Be sure to document thoroughly any conversation regarding future X-rays in the patient chart. There are probably instances when the real cause for objection of X-rays is fear, but the patient just uses finances as an excuse.

• Discomfort - Some patients genuinely disdain X-rays because of discomfort. Tori (large or small), a strong gag reflex, or a small mouth with a shallow floor are all factors we must deal with in taking intraoral radiographs. Each case calls for special efforts from us to make the experience easier. Here are a few tips I have learned over the years:

• Tori - Bend the film slightly to accommodate placement around bony protrusions.

• Gagging - Use topical anesthetic to anesthetize the floor of the mouth and palatal areas. Another trick is to smear a small amount of salt on the sides of the tongue to help quell the gag reflex. Some clinicians report that having the patient rinse with a mouthwash, such as Scope or Listerine, can eliminate gagging long enough to expose radiographs.

• Small mouth - Use smaller size film or even pedo size.

• When all else fails, a panoramic film is better than no film at all.

• Although the use of rigid film holders increases the likelihood of a quality film, film holders are contraindicated for patients with any of the previously mentioned problems.

It is easy to understand why some patients dread having X-rays taken. We should do everything possible to carry out the X-ray procedure with a minimum of discomfort.

• Obstinacy - Some patients will object to radiographs no matter what you say or do. These people usually display an unvarnished contrariness to anything dental and are only interested in one thing - getting out as quickly and cheaply as possible. All who practice clinical dentistry will have a few patients like this. Thank goodness, these patients are in the minority!

Legal risks

Many offices have a policy that states that, if a patient refuses to have the necessary radiographs taken, the patient will be dismissed from the practice. While this practice may seem rather inflexible and even a bit harsh, from a legal standpoint it may be the wisest policy. It should be understood that even if you have a patient sign a form stating he or she willingly refuses X-rays, no patient can give his or her consent for the dentist to be negligent. If a radiograph is not taken when it is needed for proper diagnosis, and a serious dental problem later arises, the doctor could become entangled in a legal mess.

Patients have the choice of whether or not to proceed with recommended treatment. Patients can refuse any diagnostic test or treatment, including resuscitation, cancer treatment, or dental X-rays. However, doctors cannot provide care for patients based on an incomplete diagnosis without becoming subject to liability for failure to diagnose or treat existing conditions. This is a serious matter for the doctor. Good documentation in the patient record is an absolute necessity.

When the doctor decides that a patient should be dismissed from the practice for refusing radiographs, some risk management courses recommend that the dismissal letter contain the phrase that failure to treat could result in "permanent, irreversible damage to your dental health."

When patients understand how taking radiographs will result in some benefit directly to them, there is less likelihood for an objection. For the regular recare patient, you can state: "Mrs. Jones, in order to check the areas I cannot see in between your teeth and under fillings, I am going to take some necessary X-rays."

For those procedures that you feel are necessary, it is best not to ask the patient's permission. Do not say, "Mrs. Jones, I'd like to update your X-rays today. Will that be OK?" Questions like this show hesitancy on your part and make it easy for the patient to refuse.

It is recommended that any films be taken near the beginning of the recare appointment. This enables the hygienist to check for areas of calculus and possible decay before the doctor comes in for the examination. "Mrs. Jones, as the doctor has requested, I'm going to take some necessary X-rays. Let's do that first so the films can be developed and ready when the doctor comes in."

For the periodontal recare patient, state: "Mrs. Jones, in order to check the bone around your teeth and to make sure things are remaining stable, I am going to take some necessary X-rays."

For the new patient who needs a full-mouth series, state: "Mrs. Jones, in order for us to properly treat you, some X-rays are needed. These pictures provide us with valuable information and help us see things we cannot see otherwise."

For the patient who adamantly refuses to have any radiographs taken, maybe the doctor should put on a blindfold and then pick up the drill. When the patient asks the doctor what he or she is doing, the doctor would reply that doing dentistry without X-rays is just like doing dentistry with a blindfold!

Radiographic frequency

How frequently should we be taking bitewing X-rays on our patients? The answer to that question should be dictated by the needs of the patient.

There is a problem in some offices of patients being X-rayed too frequently. Some practices advocate taking bitewings on every recare patient every six months. These same practices wonder why they have patient retention problems. There are few (if any) doctors, hygienists, or other staff members who would submit to having dental X-rays every six months. This six-month rule is not grounded on sound radiology principles and is not fair to the patients who have a low-caries index. Because of good home care and fluoride, we typically see many patients who have never had a cavity. There is simply no justification to X-ray such patients on a six-month interval, or even once per year.

Similarly, there are patients who have some area of new decay almost every time they come in. Certainly, it is prudent to X-ray these people more often than those who are not caries prone.

The bottom line is that we should use sound judgment and common sense in deciding when patients need X-rays and not abide by some arbitrary standard that says everyone gets them every year or six-month recare interval. The average time interval in most offices is 18 to 24 months, but can vary depending on the needs of the patient.

So, next time your patient either questions or refuses X-rays, don't take it personally. The patient may have some legitimate concerns, and it is up to you to address whatever issues come to light.
Warm regards, Dianne


The following guidelines have been endorsed by the American Dental Association and have been published by the U.S. Department of Health and Human Services:1

The recommendations are subject to clinical judgment and may not apply to every patient. They are to be used by the clinician only after reviewing the patient's health history and completing a clinical examination. These guidelines do not need to be altered because of pregnancy.

Child with primary dentition

• New patient - All new patients to assess dental diseases: Posterior bitewing examination if proximal surfaces of primary teeth cannot be visualized or probed. To assess growth and development: Posterior bitewings or panoramic.

• Recall patient - Clinical caries or high-risk factors for caries: Posterior bitewing examination at six-month intervals or until no carious lesions are evident. No clinical caries and no high-risk factors for caries: Posterior bitewing examination at 12- to 14-month intervals if proximal surfaces of primary teeth cannot be visualized or probed. Periodontal disease or a history of periodontal treatment: Individualized radiographic examination consisting of selected periapical and/or bitewing radiographs for areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically. Growth and development assessment: Usually not indicated.

Child with transitional dentition

• New patient - Individualized radiographic examination consisting of periapical/occlusal views and examination and posterior bitewings.

• Recall patient - With clinical caries or high-risk factors for caries: Posterior bitewing examination at six-month intervals or until no carious lesions are evident. No clinical caries and no high-risk factors for caries: Posterior bitewing examination at 12- to 24-month intervals. Periodontal disease or a history of periodontal treatment: Individualized radiographic examination consisting of selected periapical and/or bitewing radiographs for areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically. Growth and development assessment: Individualized radiographic examination consisting of a periapical, occlusal, or panoramic examination.

Adolescent

• New patient - Individualized radiographic examination consisting of posterior bitewings and selected periapicals. A full-mouth intraoral radiographic examination is appropriate when the patient presents with clinical evidence of generalized dental disease or a history of extensive dental treatment.

• Recall patient - Clinical caries or high-risk factors for caries: Posterior bitewing examination at six- to 12-month intervals or until no carious lesions are evident. No clinical caries and no high-risk factors for caries: Posterior bitewing examination at 18- to 36-month intervals. Periodontal disease or a history of periodontal treatment: Individualized radiographic examination consisting of selected periapical and/or bitewing radiographs for areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically. Growth and development assessment: Periapical or panoramic examination to assess developing third molars.

Dentulous adults

• New patient - Individualized radiographic examination consisting of posterior bitewings and selected periapicals. A full-mouth intraoral radiographic examination is appropriate when the patient presents with clinical evidence of generalized dental disease or a history of extensive dental treatment.

• Recall patient - Clinical caries or high-risk factors for caries: Posterior bitewing examination at 12- to 18-month intervals. No clinical caries and no high-risk factors for caries: Posterior bitewing examination at 24- to 36-month intervals. Periodontal disease or a history of periodontal treatment: Individualized radiographic examination consisting of selected periapical and/or bitewing radiographs for areas where periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically. Growth and development assessment: Usually not indicated.

Edentulous adults

• New patient - Full-mouth intraoral radiographic examination or panoramic examination.

• Recall Patient - Not applicable.

1 The Selection of Patients for X-ray Examinations: Dental Radiographic Examinations, Rockville, MD: US Department of Health and Human Services. (HHS publication (FDA) 88-837)


Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email dglasscoe@northstate.net. Visit her Web site at www.pro fessionaldentalmgmt.com.

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