X-rays and office mandates

Aug. 1, 2010
Last year the practice where I worked for 10 years was sold. The new owner has made some changes along the way, some good and some bad.

by Dianne Glasscoe-Watterson, RDH, BS, MBA
[email protected]

Dear Dianne,

Last year the practice where I worked for 10 years was sold. The new owner has made some changes along the way, some good and some bad. One of the good changes he made was to install a washer/dryer so our clinic attire can be laundered at the office. However, one of the negative changes was to mandate a new X-ray policy for our patients. Our doctor wants me to take X-rays on everyone at least once a year. I do not feel like he made this change out of concern for our patients, but rather as an easy buck. His justification is that he doesn’t want to miss anything.

I am very conflicted and uncomfortable with this new mandate. On two occasions when I did not take X-rays on patients who clearly did not need them, the doctor took me to his office and gave me a verbal lashing. The last time, he warned me that I could face dismissal if it happened again. I don’t want to lose my job, because hygiene jobs are scarce in my area. But I also do not feel good about exposing patients to radiation they do not need. I have to live with myself, and it makes me feel terrible every time I push the exposure button on patients who do not — in my opinion — need X-rays. Can you give me any advice on how to handle this bad situation?

Need to Work

Dear Need,

It sounds like the problem is a difference of opinion between you and the doctor about when patients actually need radiographs. My question is, what criteria you are using to determine need? Certainly, your education has given you the skills to assess the particular risk factors that exist with your patients and make decisions regarding appropriate care. However, clinicians often differ on treatment recommendations, depending on their philosophy of care.

I remember a particular situation where a retiring doctor sold his practice to a young doctor. Appalled at the lack of up-to-date radiographs, the new owner instructed the hygienist to start taking more radiographs. Evidently the former owner did not know the liability risk inherent with not having current radiographs. The hygienist was accustomed to the former owner’s laidback style and felt conflicted over the new owner’s desire to bring the practice up to recommended standards. However, over time, she was able to understand the new owner’s reasoning and adjusted her routine accordingly. When a new owner takes over a practice, staff members sometimes go through an uncomfortable adjustment period of learning and adapting to the new owner’s practice philosophy.

First, let me state that is it inappropriate to take radiographs solely because a patient’s third party benefits cover that procedure. All too often, I have overheard hygienists asking business assistants when a patient can have X-rays, as if it is the purview of the third party payer — who has never looked inside the patient’s mouth — to decide if radiographs are appropriate. If the patient needs radiographs, they should be taken without regard to third party payment. To practice otherwise is unethical.

The ADA has written a guide to assist clinicians as to radiographic frequency. The entire guide can be seen at http://www.ada.org/sections/scienceAndResearch/pdfs/topics_radiography_examinations.pdf. If you read the document, you may be surprised by some of the guidelines. For example, on page 4 it states, “Radiographic screening for the purpose of detecting disease before clinical examination should not be performed.” Yet how many times do hygienists take X-rays before even looking in the patient’s mouth?

Consider an adult patient who has excellent oral hygiene, flosses daily, eats a healthy diet low in sugar, has no periodontal involvement or recession, and comes in for preventive care every six months. Does this patient need X-rays once a year? Not according to the ADA guideline. In fact, the guideline states patients with no clinical caries and low risk for caries or periodontal disease should have posterior bitewings every 24 to 36 months.

Certain risk factors increase the need for more frequent radiographs. Those factors include:

  • High level of caries experience or demineralization
  • History of recurrent caries
  • High titers of cariogenic bacteria
  • Existing restoration(s) of poor quality
  • Poor oral hygiene
  • Inadequate fluoride exposure
  • Prolonged nursing (bottle or breast)
  • Frequent high sucrose content in diet
  • Poor family dental health
  • Developmental or acquired enamel defects
  • Developmental or acquired disability
  • Xerostomia
  • Genetic abnormality of teeth
  • Many multisurface restorations
  • Chemo/radiation therapy
  • Eating disorders
  • Drug/alcohol abuse
  • Irregular dental care

If a patient exhibits certain risk factors, such as the items listed above, radiographs need to be taken more often than for individuals without risk factors. The ADA guidelines help us understand that patients present with many different issues. We must take those issues into account for each individual and determine which procedures are appropriate and necessary, including radiographs. It should be noted that risk is not static. Over time risk factors change, particularly if a patient is placed on medications that cause xerostomia or goes through any number of life-changing events.

I remember visiting a practice where hygienists were instructed to take bite-wing radiographs every six months. Patients were complaining, and hygienists were at a loss when asked to justify why X-rays were being taken so often other than to say, “The doctor wants them.” The business assistant told me that several families had requested that their records be sent to other offices. When I asked the doctor if he had X-rays taken every six months of his own teeth, he replied, “No, I don’t need them that often.” Hmm, that’s interesting. Was his patient population different from the average dental practice? No. What factors necessitated the inordinate number of X-rays? Were the X-rays being taken in an attempt to be thorough? The end did not justify the means. This doctor’s mandate was hurting his practice.

Obviously, your doctor believes it is important to have current radiographs. However, using radiographs as a profit center in the practice is never appropriate. Patients are not stupid. Practices that expose their patients unnecessarily to radiation will find patient retention to be problematic. We should treat our patients as we would wish to be treated if we were in their position. I would not want my health-care providers performing unnecessary procedures on me, even if those procedures are covered by third party benefits. It’s just not ethical.

I recommend making copies of the ADA radiographic frequency guidelines for you and your employer. Then sit down and discuss those guidelines. Maybe you can reach the middle ground that is necessary for both of you to feel that patients are being served appropriately.

Best wishes,

About the Author

Dianne Glasscoe Watterson, RDH, BS, MBA, 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 Watterson for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at www.professionaldentalmgmt.com.

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