I’ll Go to a Dentist I Can Tell What to Do! (x-rays again)

Moray eel at “cleaning station.”  The shrimp probably doesn’t require x-rays.

Ugh!  It doesn’t happen much, but it’s one thing I encounter in my practice of dentistry that is truly maddening.   It’s maddening because my personality is one that relies heavily on logic and facts.

We all get patients who are (for a variety of stated reasons) reluctant to have diagnostic x-rays.  Many will claim it’s the cost.  I come back with offering them for no cost, and then they discover another objection.  Some are literally phobic of radiation.  They’ve been advised by friends and even “authorities” like TV’s Dr. Oz to avoid dental x-rays.  Of course, the advice from these third parties is not typically based in any sort of science or fact.

At age 48, one thing I’ve discovered is that when it comes to positions held on emotional grounds, no amount of science, math, or facts will sway that person.   Despite knowing this via many years of experience in these “debates,” for some reason I continue to try to win people over.  I really should give up.  Einstein said, “The definition of insanity is doing the same thing and expecting different results.”

“It’s just a cleaning!”

In my 24 years of experience as a dentist, I’ve concluded that ultimately it comes down to TRUST.  If a patient trusts third party information more than my explanations as their dentist, there is a problem.  If a patient doesn’t have the bare minimum of trust in me to order diagnostic x-rays, it makes no sense that he or she would trust me to perform surgical / restorative treatment.  If a patient sees my practice as a “cleaning station” for their teeth and nothing more, then we have a problem.

I strongly believe that a patient who doesn’t trust you to take proper diagnostic x-rays is a liability to the practice.  Furthermore, I am stunned at how many dentists will allow patients to remain in their practices without diagnostic x-rays.   Many claim they have the patient sign an x-ray refusal form.  But, according to what I’ve learned, a patient CANNOT CONSENT TO NEGLIGENT TREATMENT.  And, a prophy is treatment.  Scaling and root planing is treatment.

I understand we can treat individual teeth, or problem-related visits, with single PAs or BWs.  But once we take a patient in for periodontal care (including routine hygiene), I believe some sort of full mouth series is warranted.  It can be an FMX or PANO and BWX in some cases.  Without a full mouth series, we don’t have a leg to stand on if a patient makes a legal claim against us.

It’s tougher when 4 out of 5 dentists don’t agree.

Recently I saw a patient who was referred by another dentist up north.  He had a particular issue that I was able to resolve with simple restorative treatment.  At that time he did not object to a single PA radiograph prior to treatment.  This patient decided he would be spending more time here in Florida, so he wanted to have his teeth cleaned.  He explained that he had a “deep cleaning” by a periodontist back home about 6 months ago.

I contacted both his general dentist and periodontist up north.  The GP advised me that this patient had refused x-rays before.  But, he sent me a few select PAs that he had.  A call to the periodontist yielded a surprisingly similar story.  The latest x-rays (which were a mish-mash collection rather than a true FMX) were from 2006!  Nevertheless, both dentists up north emailed me what they had.  Not surprisingly, the old x-rays revealed significant bone loss including molar furcation involvement.

My office manager called the patient to let him know that we’d need a new FMX in order to continue treatment at my office.  He objected and then emailed me over the weekend.  Here is the exchange (patient in italics, my reply in bold):


Hi doctor…..  I received a call from the front desk informing me that I need a full set of x-rays as part of my scheduled teeth cleaning.  As I have said, I had a full set done by the deep cleaning specialist when I had the deep cleaning performed  in Sept.  Apparently the set was not forwarded to Dr. GP’s  office .   I would like to have the cleaning done by your hygenist as scheduled on Mon. without the x-ray addition. I hope this is acceptable. If not, please advise me.  Thanks.

Hello “George”,

We called the periodontist, and she said the only x-rays she had were the ones forwarded to her from Dr. GP.  She sent us what she had.  And, then we also had Dr. GP send what he had.  There were a few recent x-rays of just a few teeth.  The last complete set was dated 2006, according to both offices.   The x-rays sent to me are not actually a full mouth series.  Many views are missing.  And, they’re from 2006, anyway.  The views I received by email are mostly images of the upper back teeth on both sides, and of those, it’s mostly the upper right tooth (same one as we worked on this week).  I personally called to confirm the dates and that they were the only x-rays available. 

Given your periodontal history and the standards of care in the state of Florida, my hands are pretty much tied when it comes to diagnostic x-rays.  Without them, I don’t have a leg to stand on ethically or legally.  It literally puts my license to practice on the line.  A current full mouth series is required, along with a comprehensive exam, in order to perform a cleaning or periodontal maintenance visit.

If you refuse current diagnostic x-rays, I’m afraid I cannot see you in my office for periodontal maintenance or cleanings.  I’d be happy to see you on Monday, but we’d have to take new x-rays.  Or we can reschedule if you feel there’s some confusion over an existing current full mouth series and can get that rectified.

Hi Dr…..  Thanks for your email reply.  I must be getting old.  I have a distinct recollection of sitting in the chair while the periodontist  clicked away xraying my mouth prior to starting the deep cleaning. In any event, as you can tell, I have an aversion to xrays.  As a resolution here, I would be happy to sign a written waiver to the effect that I have been advised to have a full set of xrays taken prior to cleaning and have declined.  I think this should cover your concerns.  I have high regard for you and your work and would like to move on from this.    

Hi “George”,

I appreciate the vote of confidence. 

I’m curious about the basis of your aversion to x-rays.  A weekend on the golf course will expose you to more radiation than a complete series of dental x-rays.  So will a cross-country flight in a commercial airliner.  To reach your maximum annual exposure to x-rays, you’d have to have 10,000 dental x-rays.  Here is a reference chart that you may find useful in comparing and understanding x-ray doses.

I’ve highlighted in green, the typical exposure level from annual dental x-rays:  0.008 millisieverts.  Now look at the first source listed in the table, “Natural Background.”  The figure is 2.4 millisieverts.  So, you get 300 times more radiation from just being alive and walking around than you do from dental x-rays in any given year.

Dental x-rays are considered a minimum standard of care issue.  Without x-rays, we’d not discover decay, gum disease (and related bone loss), abcesses / infections, cysts and even tumors.  Just a few months ago, I had a patient who was unaware of a very large cyst in her lower jaw.  It had eaten away about half of the left side of her jawbone.  No symptoms related to it.  A simple bump to her face could have resulted in a fracture or “pathologic fracture,” and it would have been much more difficult to fix at that point.  She ended up being treated in a university setting. 

The amount of bone loss I see in your old x-rays is evidence of significant periodontal disease.  Untreated, it can lead to tooth loss, pain, infection, and even disfigurement.  Without current x-rays, I’d be treating you blindfolded. 

In the end, and at least in the state of Florida, patients cannot consent (even signing a written statement) to negligent treatment.  You can’t sign away on what is considered malpractice.

Again, if you believe there is some confusion at your periodontist up north about current x-rays, I’d be happy to wait (reschedule) until we can get them.  But, otherwise, I’m afraid I can’t continue your treatment without them (or taking our own). 


“I would do anything for teeth…  But, I won’t do that…”

Meatloaf wrote some great lyrics.  I hope he doesn’t mind me borrowing!

One might reasonably wonder why on Earth I’d go to such great lengths to explain the routine use of x-rays to a patient, especially when I KNOW it will fall on deaf ears.  Perhaps I’m a glutton for punishment?  This patient is a well-educated, successful (now retired) businessman (who incidentally spends a LOT of time on the golf course getting radiated).

This huge cyst was unknown and asymptomatic to one of my patients.

Today (Monday), when I returned to the office, my office manager told me “George” called to cancel his appointment.  No surprise.  She then told me that he was quite terse and said, “I’ll find a dentist that I can tell what to do.” 

So, there ya go!  Best of luck to both patient and dentist.  It’s just not worth it to me.  I don’t see any upside and a lot of downside to keeping these patients in my practice. This isn’t my first post about dental x-ray refusal by patients.  Click here to see my previous article, “Mrs. Smith… This is why we take x-rays.” 

Comment away, Dental Warriors!

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21 Responses to I’ll Go to a Dentist I Can Tell What to Do! (x-rays again)

  1. Yar says:

    Looks like you nailed the response that covers your bases, and some people are easier to repell with protocols than with a confrontation. Well done.

  2. Karen says:

    Thanks, Mike, now he will show up in my office!! At least you educated him–not.

  3. You can’t fix stupid or crazy.

  4. Mike, what is the source on the table of radiation exposure? That one is much better than the one I am using now.

    • The Dental Warrior says:

      Source for the table:

      Radiologic and Nuclear Medicine Studies in the United States and Worldwide: Frequency, Radiation Dose, and Comparison with Other Radiation Sources—1950–2007
      November 2009 Radiology, 253, 520-531

  5. Shannon, RDH says:

    I LOVE that radiation table!! Well done with your e-mail responses, sir!!!

    • The Dental Warrior says:

      Thanks, Shannon. My email replies made my point, I suppose. But, it also goes to show you that irrefutable, rational FACTS will not sway someone whose position is based purely on emotions. In other words… “pissing in the wind.”

      Oh well… c’est la guerre! :)

  6. michael says:

    Be ready dental warriors. My hygienist just told me she say on the national news Xrays cause brain cancer!!!!

    quick google search shows it is hot off the presses. Got to go do a class II but I am going to watch and read the national crap and see what they are saying so I can tell my patietns the truth.


    • The Dental Warrior says:

      I just watched the Today Show segment, and I lost all respect for Dr. Nancy Snyderman (their medical correspondent). My jaw dropped when she said, “If your teeth are healthy then don’t get the x-rays.” Ummm… how does the patient know they’re healthy? It’s akin to saying, “If you don’t think you have a heart problem, skip the EKG.”

      Pure idiocy!

  7. Lolabees says:

    I once had a patient who came in with 6 ROTTEN teeth for a limited exam. He refused an FMX, but allowed me to take PA’s. It worked okay because it was essentially an FMX for him. When he didn’t like my treatment plan, he sent me a 4 page typed letter in the mail titled “Hale’s Revised Treatment Plan” (changed his name, of course) He explained to me why he thought he should have 1 surface resins (instead of extraction of hopeless teeth that actually would have needed root canal, crown lengthening, post + core crown!!!) You know how he knew this? He liked the fees on his discount plan (at the time I was working at a dental mill) for those procedures. He told me this in his letter.

    I replied to him with a very thoughtful and kind letter explaining that I respect his opinion but that I can’t treat him. I followed all the rules for a dismissal letter. That was the best thing I could have ever done. Not only did he send me a 5-page hate letter calling me a used car salesman, but he also filed a complaint with the board accusing me of patient abandonment, bad ethical practices, etc. He even quoted the ADA Code of Ethics all over his complaint. Obviously they dropped the case, but I had all that aggravation from 1 guy I had met 1 time. He was a nut job. It’s best to nip it in the bud. Like we always say, “if you know so much about dentistry, why are you coming to me? Why don’t you do it yourself?”

  8. Rah Men says:

    I understand your points, but would counter with a few key things to consider. First, the radiation of dental x-rays is placed in a very sensitive area, around the thyroid, brain, head& neck. While the radiation amount is quite low, it is not zero. For patients who come in every 6 months, that’s 2x/year exposure. Also, children may be much more sensitive to the negative effects of radiation in those areas than adults. You shouldn’t be nonchalant over such radiation exposure, even if the total dose in millisieverts is low.
    Second and most importantly, the x-ray should not be a substitute for the exam. If you have a patient, especially a child, who has a small cavity, but completely normal x-ray 6 months ago, and you can visualize or probe nearly all surfaces of their teeth, what point is there in getting another x-ray? To say that *every* patient needs an x-ray, regardless of the overall clinical picture, is ridiculous and inappropriate. The dental x-ray should not be a reflexive order before you see the patient or use your clinical skills and review recent results.

    • The Dental Warrior says:

      I don’t know any dentist that reflexively orders x-rays every 6 months. And, I’ve never advocated x-rays being a substitute for visual and tactile examination. Nor does any other dentist.

  9. Greg says:

    I am a degreed Electrical Engineer with extensive experience in radiation. No amount of ionizing radiation is safe. Period. Why does the dentist or assistant ask the patient to wear a lead vest? Why do they hide behind a wall during the x-ray? Because although the amount of radiation in a single dose is small, the damage to DNA and cellular structures in the human body is cumulative. Repeated x-rays add to your yearly exposure, which should be limited whenever possible.

    What is wrong is dentists siting “studies” and “facts” that ignore the inherent danger of x-rays. Furthermore, many dentists are now siting “state law” that supposedly says x-rays are required. This is false, and if true would be a violation of natural law and human rights. Forcing any person to undergo undesired exposure to radiation is a violation of human dignity.

    • Cult45 says:

      Greg, the lead apron is used to limit the exposure to the patient as much as possible. The dentist or assistant leaves the room because they are taking images on patients every day….duh! As you yourself stated: “although the amount of radiation is small, the damage to DNA and cellular structures in the human body is cumulative. Repeated x-rays add to your yearly exposure, which should be limited whenever possible.”
      A certain amount of xray imaging is necessary to properly diagnose and treat many dental conditions. No one is “forcing” anyone to undergo unwanted radiation, they are certainly free to leave as they please. However, it can often prove difficult to find a provider who will agree to practice below the standard of care.

  10. Michael Radcliffe DMD says:

    Great job on the x-ray response. I am new to the dental warrior and look forward to more of your posts.

  11. Ian Jenkins says:

    I’m a physician who treats only hospitalized patients. The large majority have serious, life threatening illnesses–heart, lung, kidney, infectious, or malignant disease. They all require complex, multifaceted care including potentially dangerous medications–insulins, blood thinners, chemotherapy, opiates, etc. And for each and every one of them, my team and I craft an individualized plan of care based on their goals and beliefs. Don’t want blood? Won’t inject insulin? Can’t take pills twice a day? Refuse to take a statin or vaccine for some reason? Leaving when sick? Refusing potentially life saving surgery? I deal with it daily. And know what? Once I document my recommendations and their response, I’m good. I’ve been sued once (unsuccessfully, and for following the standard of care), met plenty of lawyers, and I teach a course with an annual law and ethics panel to students, and people who disobey documented recommendations have no legal leg to stand on. A woman had a cyst in her jaw, a one in a million case? What’s your point–that we should do screening skeletal surveys of every bone? My god. Think about it. What if you refused a vaccine, mammogram or colonoscopy and your doctor kicked you out of their practice? None ever would, because that’s stupid, but you’d be outraged. And you know what? All my dentists tell me different things about different fillings and frequency of x-rays; like my fellow doctors, they’re just people, and they’re often wrong. If a person should get kicked out of a dental practice because skipping xrays might result in a cavity, surely people who refuse a PSA should face the same right? Except we now know PSAs don’t work, result in lots of anxiety and damaging treatments, and wasted billions, but doctors do them anyway including in the elderly and those with brief life expectancies. I double check anything a doctor tells me and thus would do the same with dentists, including my dentist two days ago who didn’t know about the meningioma study and told me the “law” and the ADA requires dental xrays annually–except neither of those things are true. I fall into the every 2-3 year category, which he didn’t know, so excuse me for not assuming he’s an infallible god.

    I’m just shocked at how perturbed all the dentists are over the tiniest quibble that someone doesn’t want additional radiation pointed at their brain and thyroid, small amount or not. It’s not your brain! Spend a day in an actual high risk setting with my sick, resource poor, frequently mentally ill / drug using / jailed patients and their organ and life threatening problems, and you’ll get over your dental xrays in 10 seconds.

    PS: best way to avoid a lawsuit is not to piss off a patient, so what did my dentist do? Inform me AFTER I drove there (rather than at the last visit) I HAD to have xrays or he’d reduce his liability (aka increase it) by refusing to care for me. It’d be more cost effective for me to work a shift to pay off dental costs than to spend weeks suing someone over change, and the only reason I’d ever consider it was his being dogmatic and wrong at the same time.

    • The Dental Warrior says:

      I appreciate your comments. But, your medical examples are not really comparable. You’re talking about patients refusing TREATMENT. They refuse to take their meds. Refusing surgery. We are dealing with patients insisting on treatment without a proper DIAGNOSIS. Dental x-rays are not a treatment modality. ANY dental treatment without a proper DIAGNOSIS is malpractice, plain and simple. No x-rays (for proper diagnosis) is below the standard of care in dentistry. A more appropriate medical example would be if you were to treat a tumor without proper imaging (CT, MRI, x-ray, etc) or without a biopsy. “I just want you to cut that lump out, Doc. I don’t want the CT or MRI or a biopsy.” Would you do a lumpectomy on the patient who refused mammography?

      I once had a retired surgeon (MD) insisting that I didn’t need an x-ray of his grossly-decayed tooth before treating it. “Just fill it.” Ummm… yeah.. no. We need an x-ray before we can touch that tooth. After some back and forth, he gruffly consented to the x-ray. The x-ray revealed decay to the pulp of the tooth. That meant either doing root canal treatment (and then restoring it) or extracting the tooth. I informed him of the diagnosis and treatment options. He berated me with, “You’re making mountains out of molehills! I just want you to fill it.” I then explained that would be like shaking up a soda and then putting a cap on it. “Filling” it would turn it into a raging toothache. When I continued to insist on the proper treatment, he ripped his bib off and walked out saying, “I’ll pay for the x-ray and go somewhere else.” I smiled and told him that today’s EXAM and x-ray were on me and to have a nice day. There is no doubt, that if I had treated your medical colleague according to his demands, he would have absolutely BLAMED ME for the sequellae of the negligent treatment.

      One of the top reasons for dental litigation is undiagnosed periodontal disease. X-rays are critical to screening and diagnosing periodontal disease. And, when those patients find out from another dentist that they are going to lose their teeth, they are going to look back and point the finger. Patients can’t consent to negligence.

      The reality is that it’s JUST NOT WORTH THE RISK. We don’t have to treat everyone. We can’t please everyone. Fortunately, with good patient rapport, x-ray refusal is very rare in my practice. And, the few patients that remain adamant about not having them… well… life is too short. I prefer to practice MY way while keep stress to a minimum. If after rational discussion, the patient still refuses… I invite them to find a dentist that will acquiesce to their demands. There are 25 dentists on my street, alone. I’m not “the one,” and I’m OK with that.

      Incidentally, the cyst in the woman’s jaw is hardly “one in a million,” as you smugly asserted. I’ve seen several similar (cystic) cases in my career so far. The first one I found was only 2 years into my career. And, I’ve hardly seen a million patients. I’ve also found several cases of cancer.

      I do agree that the best way to avoid litigation is good relationships and good communication. However, none of that will save your ass when the patient changes his / her mind about you years later when they discover a problem “YOU MISSED.” They will forget ALL about your discussion about their refusal for x-rays once an attorney bends their ear.

  12. Happy New Year, Mike. I agree with your response to Dr. Jenkins concerning proper diagnosis. He does make a few good points, but I feel as if the true core issue is being lost in the broader scope of the debate. The odd thing is that I don’t really know if I’m sure what the true core issue is. Your replies always seem well thought out, so I’d like to get more clarification from you if I could.

    I, like you, am always baffled when a patient balks at x-rays (or any recommended suggestion). Research has pretty much laid to rest the notion that true harm will result from judicious use of diagnostic radiographs. Heck, it would seem that even prolific use of non-discriminate films could not cause issues. I know the risks are not “zero”, and this is where the argument goes astray amongst professionals. Engineers, physicians, and other professionals each have a different perspective based on the real worlds they work in, including us.

    Radiographs are safe when properly done, their cost is relatively inexpensive, and the information they provide is invaluable in proper patient care. Period. I just can’t get
    past the mindset and bickering back and forth between different professional groups, public perception, and ultimately our inherited “us vs. them” dilemma.

    Is it truly about safety? Is it truly about cost? Is it that we are too egotistical and inflexible? Do we as doctors, just like some of our patients, hate to be told what to do?
    I personally don’t feel there should be such a big deal made over this issue, but why has it been such a hot button for so many years? Sorry for my long rambling post, but the more I think on this, the more goofy it gets. I guess I’d just like your objective feedback.
    Thanks, Mike, for your consideration.

    • The Dental Warrior says:

      Hi Brian,

      I don’t think it boils down to just one thing for all people. So, I don’t think it’s just about “safety.” I don’t think it’s just about cost. For SOME it may be those things. But, I’ve had objections based on cost. Then when I offer to do them for FREE, they stutter and stammer about some OTHER reason they don’t want x-rays. So, even when cost is cited as the reason, it’s often a bluff.

      If “safety” is the reason for the objection, it’s easily addressed from a SCIENTIFIC and LOGICAL standpoint. Yet, it will often fall on deaf ears. Why? Because American culture is one that trusts TV personalities more than their own doctors.

      And, there is that word: TRUST. I think, ultimately, it boils down to a lack of trust. And, there is also the issue of CONTROL. Some people are VERY uncomfortable if they are not in CONTROL. I saw that with special operations guys in the military. You’d think they’re super-tough guys, right? They ARE! But, when some of them were in the dental chair, they turned into quivering messes. Why? Because they are used to being IN CONTROL. They don’t like being at someone’s “mercy.”

      And, egos get in the way, too. But, for me, it’s not ego… not MY ego. It’s simply about covering my ass. I’ve been at this long enough to have learned that those patients that go all-out in telling you they will sign anything, waive anything, and “would NEVER sue”…. are THE FIRST ONES THAT WILL (sue you or file a board complaint). If there are negative outcomes down the line because you acquiesced to their sub-standard demands, they will quickly forget about having sung your praises and promising to be accountable for their own actions. Nope. They WILL come after you and make your life miserable. Mind you, I’ve not had a preponderance of such experiences. They say true wisdom comes from learning from the mistakes of others. :)

      If I KNEW that I would be 100% immune to lawsuits and complaints with a signed release (for no x-rays), I could not care less. But, until THAT day comes, it’s either my way (the standard of care) or the highway.

      So, to ME… it’s just not worth it. I don’t have a compelling need to have everyone “like” me. I don’t need to be everyone’s dentist. It is quite liberating to get to that point.

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