Refusing Dental Radiographs

Sept. 1, 2012
I am a radiology instructor in a local community college. I teach radiology to dental hygiene and dental assisting students.


Dear Dianne:

I am a radiology instructor in a local community college. I teach radiology to dental hygiene and dental assisting students.

I attended one of your lectures recently where you were discussing a patient’s refusal to allow radiographs. In your presentation, you mentioned that if a patient signs a declination form for radiographs, this form may not hold in a court of law. Would you be able to provide me with documentation regarding the refusal of radiographs, the rights of the patient, the rights of the office, and the reason behind the signed document not being legal?

We had a patient yesterday in clinic who has refused radiographs the past several visits. His most recent set is from 2004, I believe. I would like to discuss our radiographic policy with my faculty when everyone returns for the fall semester.

Thank you for your time!

Carolina RDH

Dear Carolina:

When a patient refuses needed radiographs, he or she creates a situation that impedes the doctor’s ability to diagnose. In essence, the patient is forcing the clinician to rely on visual/tactile methods of detection of pathology. Unfortunately, much pathology exists in locations that are not accessible visually or tactilely. Dentists (and dental hygienists) are mandated to practice according to established standards of care by virtue of their licensure. Those standards of care include maintaining up-to-date radiographs.

If pathology exists that the doctor cannot diagnose due to lack of radiographs, the pathology will continue to worsen over time and could result in serious negative — even life-threatening — outcomes for the patient. Consider a scenario where a patient has a tumor in the mandible that, in its early stages, is asymptomatic. Without radiographs, it would not be detected. As the tumor continues to increase in size, symptoms such as pain, tooth mobility, or possibly jaw asymmetry begin to appear. By the time it is discovered, it has already metastasized, and the prognosis for the patient is very poor. The same could be said for an undetected abscess in the maxillary arch that spreads to the patient’s brain resulting in brain death.

In a court of law, these cases become “failure to diagnose” cases. The “failure to diagnose” cases involving oral cancer are among the highest awards today. “Failure to diagnose” cases are almost always won by complainants because of the high standards that are expected of health-care professionals by virtue of their licensure. If a doctor agrees to a patient’s refusal, the doctor assumes a serious liability risk. Again, the patient’s refusal of needed radiographs impedes the doctor’s ability to diagnose.

What if the patient did not like the overhead light and demanded to have it in the OFF position while he is in the chair? Would the clinician be able to provide competent care without the overhead light? Nobody would work in the oral cavity in the dark. Do patients expect to receive competent care? Yes. Are clinicians able to provide competent care while working in the dark? No. Working without necessary radiographs is just like working in the dark.

Of course, office mandates that require “once/year X-rays on everybody” are inappropriate as well. We are to take X-rays only when there is a bona fide need for them. The ADA has provided guidelines on assessing risk and the need for radiographs. This document provides guidance about radiographic frequency, based on the patient’s risk factors.

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 that 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 in 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 that it is 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.

You can have a patient sign an informed refusal form in such cases. However, this is like asking the patient to give his or her permission to allow treatment that is below the standard of care. This assumes the playing field is level between clinicians and patients, but it’s not. Clinicians are held to a higher standard. Remember, clinicians have more responsibilities than rights, and patients have more rights than responsibilities. In business, two people can bargain over business matters. Those same bargaining powers do not exist in the health-care realm. Burton Pollack, DDS, MPH, JD, discusses this concept in his book titled “Law and Risk Management in Dental Practice” (Quintessence Publishing, 2006).

Informed consent/informed refusal forms do not protect any clinician against malpractice claims. The forms are for educational purposes primarily. When a condition is diagnosed and the patient refuses recommended treatment, an informed refusal form is necessary. With the refusal of X-rays, conditions may exist that cannot be diagnosed. That’s a different ball of wax.

In discussing this situation with different legal minds, the best course of action to limit liability risk is to dismiss patients who continually refuse radiographs. In situations where X-rays are warranted and the patient refuses due to financial reasons, I advise the doctor to provide them at no charge if the doctor is unwilling to terminate the patient relationship.

Patients refuse radiographs for many different reasons, including fear of radiation, discomfort, and even religious reasons. It is easy to understand why patients who have endured high levels of radiotherapy for cancer might balk at dental X-rays. Adding to the dilemma of fear is the recent report on dental X-rays as a cause of brain tumors. (Our opinions of the validity of such studies are irrelevant to the decisions our patients make in their own minds when thinking of their personal safety.) Some patients have strong gag reflexes or large tori that make exposing dental X-rays difficult and uncomfortable. These issues must be dealt with on a case-by-case basis, and doctors must balance the risk of liability against the risk of losing the patient.

Sometimes the doctor may feel it is best to terminate the patient relationship when the patient continually refuses radiographs. Other times, the doctor may decide to make an exception and allow fewer than the usual number of radiographs. The answer is not always black or white. It’s difficult to make hard and fast rules regarding how many times to allow a patient to refuse radiographs in light of all the patient situations that exist.

Our challenge is to provide care that is competent and based on patients’ needs. We need our patients’ trust, and building that trust takes time. When our patients trust us, they are more likely to be amenable to our treatment recommendations, including the recommendations for radiographs. RDH

All the best,

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