July 1, 2000
It`s not exactly "The X-Files," but where do those objections to X-rays come from? Here`s how to persuade resistant patients to pose for pictures.

It`s not exactly "The X-Files," but where do those objections to X-rays come from? Here`s how to persuade resistant patients to pose for pictures.

Dianne Glasscoe, RDH, BS

All hygienists who practice clinical hygiene are eventually faced with the X-ray dilemma. The dilemma is triggered when you say, "Mrs. Jones, it`s time today for your X-ray update." Mrs. Jones then replies, "Let`s just skip that today. I don`t want any X-rays..."

When patients say this, I feel a little queasy inside. I certainly do not want to initiate a confrontation. After all, aren`t we supposed to create goodwill with our patients? How can we do that if we go against their wishes?

However, looking back through Mrs. Jones` chart, I notice her history of caries. It has also been 18 months since her last bitewings, and I know the chances are strong that she will have some recurrent decay lurking somewhere. So how should I handle her objections without seeming aggressive and confrontational?

First of all, why do our patients object to periodic radiographs? The main reasons are:

- Fear of radiation exposure

- Cost

- Discomfort

- Obstinance

Patients may harbor one or all of these objections. However, if you can determine the objection, you can then attempt to dispel the concerns. "Mrs. Jones, could you share with me why you don`t want any X-rays taken?"

Let`s review the four objections above in a little more detail.

* The fear factor -

If patients reveal that they fear 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 of a second for one periapical exposure - an extremely small amount.

I heard a doctor tell a patient once that people get more radiation exposure from their color televisions than from dental X-rays. Although the accuracy of that statement is questionable, this is an analogy a patient can understand. 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 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 patients state that they cannot afford to have X-rays taken, there is little you can do. In the average practice, there will not be many patients in this category. There are 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 when 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:

- For tori, bend the film slightly to accommodate placement around bony protrusions.

- For gagging, use topical anesthetic on 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 to 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.

- For 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 usually guarantees 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.

* Obstinance -

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!

What`s in it for me?

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, try explaining as follows: "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, OMrs. Jones, I?d like to update your X-rays today. Will that be OK?O 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. OMrs. 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.O

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 about the strange turn of events, the doctor could reply that doing dentistry without X-rays is just like doing dentistry with a blindfold!

How frequently should we be taking BW X-rays on our patients? The answer should be dictated by patients? needs.

There is a problem in some offices of patients being X-rayed too frequently. Some practices advocate taking bite-wings 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 fair to the patients who have an extremely low caries index. We typically see many patients who have never had a cavity. There is simply no justification to X-ray such patients at six-month intervals, or even once per year.

Similarly, some patients have some areas of new decay almost every time they come in. Certainly, it is prudent to X-ray these people more often.

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. The average time interval in most offices is 18 to 24 months, but can vary depending on the needs of the patient.

Dianne Glasscoe, RDH, BS, is an adjunct instructor in clinical hygiene at Guilford Technical Community College. She may be contacted by e-mail at dglass coe@north state.net, phone (336) 472-3515, or fax (336) 472-5567.

Severing ties with resistant patients

Many offices have a policy that states if a patient refuses to have the necessary radiographs taken, that patient will be dismissed from the practice. While this 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 patients sign a form stating they willingly refuse X-rays, no patients can give their 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 arises later, the doctor could become entangled in a legal mess. There are recorded cases of patients successfully suing their dentists, even though there was documentation in the patient chart that they were informed of the diagnosis and that the patient refused treatment.

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.

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