“Mrs. Smith… This is why we take x-rays.”

“X-rays are like a box of chocolates.  You never know what you’re going to get.”

X-rays are a perennial battle we wage with a certain segment of our patients.  Can I get an “amen?” It’s really quite odd when you dissect the issue.  I don’t believe physicians get the same resistance we get when they ORDER x-rays.  But, it seems the consensus out there is that x-rays are some sort of scam perpetrated by dentists to make extra money.  Of course, that’s simply preposterous.  If we wanted to make money illicitly, we wouldn’t waste time on penny-ante stuff like x-rays.  It would be a lot easier to do it other ways that would be far more lucrative.  Sometimes I think my head will explode when a patient refuses x-rays.  Education simply doesn’t work very well when it’s up against EMOTION.  Nevertheless, we Dental Warriors plod onwards.  :)

Today’s Patient

Today I had a new patient come in complaining that over the weekend she felt some pain and a swollen lymph node.  To be clear, she did not refuse x-rays.  She was fully in agreement about taking x-rays.  Very nice lady.  But, the title of this blog post will make sense later.

She pointed to the lower left side and mentioned that it feels better now that she’s at my office.  (Kinda like that car making the noise that quits when you take it to the mechanic. :) )  She also mentioned that at times it radiated to the upper left side. Clinically, I found a couple of broken down teeth – one in the upper left posterior quadrant and another in the upper right posterior quadrant.  But, neither seemed to be a source of discomfort.

I also noted clinically that in the area of #18, the tissue resembled what you would see a month or two after an extraction.  Healed, but not totally healed.  I asked the patient, and she said the tooth was extracted “a long time ago.”

My assistant took a couple of PAs of the areas on her left side (source of pain).  We took an upper and lower film just to cover our bases.

Upper left side.  Broken down #13. Garden variety stuff. Asymptomatic.

Lower left side missing all the molars. But…. rut-roh! What’s going on there?

Me no likey what I see in the lower PA.  I order a panoramic film.

Whiskey Tango Foxtrot!

I don’t like THAT at all!

The cystic lesion extends from #18 area to the neck of the condlye!

I referred this patient to the oral surgeon.  She has an appointment tomorrow.  Likely benign – something like a dentigerous cyst or keratocyst.  Nevertheless, it needs to be addressed.  She’d be a prime candidate for a pathologic fracture.

“Take a look at this, Mrs. Smith.  This is why x-rays are important.”

X-rays like these can be an excellent “educational” tool to use with those patients who are doubtful of their value.  “We don’t find lesions like this very often. But, we’re sure glad we took these films when we do find them.”

In the end, if I cannot convince a patient to have proper diagnostic x-rays, I’m not willing to assume the liability and bid him / her a fair “Alpha Mike Foxtrot.” (That’s Navy-speak for “see-ya!”)

PS…  Follow-up to this case. Incisional biopsy was done by oral surgeon. Diagnosis: Keratocyst. Due to the extensive size of the lesion, she was referred to a university for surgical treatment.

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13 Responses to “Mrs. Smith… This is why we take x-rays.”

  1. Robert Gioia says:

    VERY NICE – but xrays cause cancer LOL!!

  2. Re-tweeting now. Awe inspiring reason to be committed to a standard of care that protects your patients. Very nice …

  3. I do what my dentist tells me to do. 1, he’s a personal friend: 2, he’s a skilled craftsman!! I think a rare combination. And he is an awesome baritone to boot and could have easily been a famous oratorio singer!

  4. Amazing! People are funny about x-rays sometimes. I don’t ask them to sign a refusal (should I?), I’ll ask to check the problem area only, usually not a big deal. If it is a big deal I start to consider them PITA pts. and treat minimally. ‘Educating ‘ them till I’m blue in the face is pointless.

    • The Dental Warrior says:

      Hi Alvaro,

      I’m not an attorney. But, a patient cannot sign away his or her rights. Patients cannot consent to negligence. So, IMO such a refusal form will be worthless if you end up in court. Again… not an attorney… ask your own malpractice company what they think.

      But, to me it goes deeper than that. Refusal of basic diagnostics such as x-rays indicates a lack of trust. And, a patient who doesn’t even trust me about x-rays is not a patient I want to treat at all. It’s just not worth it to me. It’s not worth the risk. And, it’s definitely not worth the very small gain.

      If a patient absolutely refuses x-rays, then we simply will have to part ways.

  5. The Dental Warrior says:

    Follow-up to this case. Incisional biopsy was done by oral surgeon. Diagnosis: Keratocyst. Due to the extensive size of the lesion, she was referred to a university for surgical treatment.

  6. Pingback: ABC News – The Wisdom of Removing Wisdom Teeth | The Dental Warrior

  7. Pingback: I’ll Go to a Dentist I Can Tell What to Do! (x-rays again) | The Dental Warrior

  8. Very good piece on the cyst and need for X-rays.
    We are rebuilding our v old website and would like to use your piece and acknowledge where it came from. May we do that please?

    Many thanks

    ps What was the diagnosis and outcome?

    • The Dental Warrior says:

      Thanks for comments and your interest, James. For a number of reasons, I cannot allow use of my images / photos.

      You might consider a source for stock photos like this: Dental X-ray Images for sale. I have no financial interest in this. Just trying to help. :)

      The diagnosis was keratocyst. She was referred to a university for treatment due to the extent of the lesion. I have not seen her since.

  9. Kate says:

    I just wanted to let you know that I think about this case every time I order a pano as part of a periodic comp exam for a patient of record.

    “Sometimes it good just to check the whole jaw out” “There are things that we can see with this film that are hard to see any other way”

    Good catch.

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