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Patients who refuse X-rays

by Dainne D. Glasscoe, RDH, BS

Dear Dianne,

One of the problems I have been experiencing more and more lately is patients who refuse to allow me to take X-rays. The doctor wants us to get new bitewings on every patient once a year, but some patients just won’t allow it.

How should I handle these rejections?
Delaware Hygienist

Dear Delaware,

First, we need to establish that radiographs are a necessary part of good patient care. Since we can see only about one-third of the actual tooth, radiographs provide valuable information that we cannot visualize otherwise.

I remember a patient who consistently refused to allow X-rays. On a particular preventive visit, the doctor asked to see her radiographs. When I told him Mrs. XXX requested that none be taken, he looked at her and said, “Really? What’s that about?” While the patient was responding, he reached into his back pocket, took out a handkerchief, and began tying it around his eyes like a blindfold. He then reached out and said, “Dianne, hand me the mirror,” as if he were going to do the exam blindfolded! The patient started laughing, but she got the point when he told her that treating her without radiographs was like asking him to work with a blindfold. Then she said, “OK, OK, I get the point,” and I took her films.

The point is, it’s our duty to provide competent care, and radiographs are vital to proper diagnoses. Without the necessary films, we compromise our ability to provide competent care.

However, you stated that the rule in your office is “bitewings on every patient once a year.” I take issue with the wisdom of such a mandate. Some patients are caries-free and have been their whole life. Certainly, patients like this do not need radiographs as often as patients who have had moderate or high caries experience. Further, patients with a healthy periodontium do not need radiographs as often as patients with a history of periodontitis. In some cases, there are extenuating circumstances that make exposing radiographs prudent, such as implants, endodontics, and pathology.

The ADA published “Guidelines for Prescribing Dental Radiographs” in 2004 (www.ada.org). Here is a sample of those recommendations:

Recall patient with no clinical caries and not at increased risk for caries:

  • Child with primary or transitional dentition - Posterior bitewing exam at 12- to 24-month intervals if proximal surfaces cannot be examined visually or with a probe
  • Adolescent with permanent dentition - Posterior bitewing exam at 18- to 36-month intervals
  • Adult dentate or partially edentulous - Posterior bitewing exam at 24- to 36-month intervals
  • Recall patient with periodontal disease:
  • Clinical judgment as to the need for and type of radiographic images
  • Patient with other circumstances including, but not limited to, proposed or existing implants, pathology, restorative/endodontic needs, treated periodontal disease, and caries remineralization:
  • Clinical judgment as to the need for and type of radiographic images

We need to use common sense and good judgment in decision-making and planning for radiographs. Too many times, we allow insurance companies to determine when we expose radiographs. Further, we should not expose radiographs just because the patient’s insurance allows it. We need to have a valid reason for taking radiographs that is dictated by our patient’s needs.

As an example, let’s say Joe Blow comes in today for his preventive appointment. His last bitewings were taken three years ago, and he requested no radiographs on his last visit seven months ago. He chews tobacco and has had several carious lesions in the past. Knowing his history of refusing radiographs, a hygienist might feel intimidated about even broaching the subject. I can hear the hygienist voicing the need for radiographs: “Mr. Blow, it has been three years since we took any X-rays on you. Is it OK if we get some today?” Joe, noticing the timidity with which the hygienist asks, boldly proclaims, “Nope, no X-rays!”

The problem is poor communication. Instead of asking his permission to do her job, she should have said, “Mr. Blow, as the doctor has requested, I’m going to take some necessary X-rays today.” For all Joe knows, the doctor personally examined his chart before he came in and instructed the hygienist to take X-rays. If Joe protests, the hygienist should say, “There has been a history of cavities in the past, and tobacco-chewing places you at a higher risk than nonusers. The films are necessary to help us diagnose problems that we can’t see with the naked eye. Would you share with me why you do not want diagnostic X-rays?”

The usual concerns expressed by patients are fear of radiation, cost, and discomfort. A few patients just have an unvarnished obstinance toward anything we want to do. Whatever the reason, be equipped to address the concern.

Fear of radiation - Although X-ray machines vary, the amount of actual radiation is anywhere from .1 to .5 of a 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.

“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.”

Cost - 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.
  • 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 procedure with minimum discomfort.

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

Patients may choose whether or not to proceed with recommended treatment. They 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.”

It is important for the doctor to get involved in discussions about radiographs. The doctor may say, “I understand your concerns about X-rays. But please understand my position that I cannot give you the care you deserve without radiographs. Please be prepared on your next visit for some X-rays.” If, on the next visit, the patient again refuses, then the doctor may decide to dismiss the patient from the practice.

When patients understand how taking radiographs will directly benefit them, there is less likelihood for an objection. The bottom line is that we should use sound judgment and common sense in deciding when patients need X-rays, not some arbitrary standard that says everyone gets them every year or at six-month recare intervals.

The 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. Keep the patient’s best interests in the forefront.
Warm regards, Dianne

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 e-mail dglasscoe@northstate.net. Visit her Web site at www.professionaldentalmgmt.com.

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