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’s email in blue boxes, my replies follow 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.

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

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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51 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.

    • Frank says:

      You have your goddamn nerve, violating a patient’s privacy and to do so in the smug, unctuous, manner one expects from a _dentist_, the filthy pirates of medicine.

      • The Dental Warrior says:

        Ahoy, matey! Being a filthy pirate, words like “unctuous” escape me understanding. Arrrr… I bet a bilge rat like yerself has been waitin’ a long time to use it.

  2. Karen says:

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

  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.

    http://abcnews.go.com/Health/GMAHealth/brain-tumors-dental-rays/story?id=16101200

    • 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.

    • Dr. O says:

      Greg, you are absolutely right about the nature of X-Ray exposure. As well as about the practice of shielding the patient wherever the dentist can reasonably do it. Not only do the dentists shield those areas, they use the devices shaping the beam of the X-Ray to limit the exposed areas as much as it is possible. Scientist are working on developing “faster” films, “faster” sensors so the dentists can reduce the dose with the same purpose. The dentists use these technological advancements because they care of their patients.
      Knowing the nature of radiation you would expect that the dentists and their stuff are as far away from the source of the ionizing radiation as possible, this is logical. The patients at the same time must stay where their teeth are, which is sitting next to x-ray machine.
      One thing I think you are missing is what the dentist is. The dentist is a doctor who treats people with dental problems. The dentist is not a patient’s agent at the cleaning station.
      In order to treat the problem you need to get aware of one. So the dentist prescribes the patient the x-rays when (s)he knows that the risk of leaving the dental problem behind is greater than the risk of getting the complications from doing the x-ray survey. Because finding those problems is the dentist’s first, and foremost duty.
      Following the dentist’s advise or not is a choice of the patient. No one’s dignity is in danger.

  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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  14. z says:

    Man, the patient described is the very definition of one of my favorite quotes:

    ” A person against their will is of the same opinion still. ”

    Facts simply aren’t even good enough for some people. I’m not sure you could get 1000 people in a room to agree that it’s Wednesday and that’s irrefutable!

    • z says:

      Sorry.. messed up the quote:

      A person convinced against their will is of the same opinion still

    • The Dental Warrior says:

      True, Z.

      I won’t spend much time trying to convince a patient who is adamant. Either they agree or they don’t. And, if they don’t, we go our separate ways. I’m not willing to risk my license. And, I realize that I’m not going to convince them. The problem is TRUST. If the trust isn’t there, it’s just not going to work. I invite them to find a dentist they trust.

  15. Jim Dude says:

    I keep hearing that you have “facts” on “logic” on your side, when the primary support for your assertion- the comparative risk of dental X-rays – is illogical. You say that a dental X-ray is equivalent exposure to a weekend in the sun or a cross-country flight. This completely ignores the concept of intensity.

    If I lined up one hundred empty bottles and told you I’m going to knock down each one, and your job was to go and stand them up again, never allowing more than 10 to be down at one time, do you think you’d be more likely to fail if I knocked down the 100 over the course of a weekend, 8 hours, etc. or within 1 minute?

    As you should have guessed, the bottles are your DNA, I am the X-ray, and you are the natural DNA repair mechanism. And the 10 bottle limit is the point at which a cancer-causing mutation appears.

    Ethically and logically speaking, from this moment on you should never use your silly and misleading comparative radiation chart again to try to dissuade people from their aversion to frivolous use of X-rays. Or will you stand by your assertion, proving once again that old maxim about humans, that we’re not rational but *rationalizing* creatures?

    • The Dental Warrior says:

      I didn’t say A dental x-ray is the equivalent to a weekend in the sun. I said that a weekend on the golf course was greater than a COMPLETE series of dental x-rays.

      And, it’s not MY “silly chart.” The source of that chart:
      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

      I prefer science to your “silly” bottles metaphor. 🙂

      Here’s the bottom line. It’s my practice. It’s my way or the highway. It’s a free country and there are about 190,000 dentists out there. Perhaps you’ll find one that is willing to treat you without x-ray imaging.

      Jonathan Swift said, “It is useless to attempt to reason a man out of a thing he was never reasoned into.”

  16. Jeff L says:

    Mike,

    Another great thread.

    You handled the situation correctly, with more than enough diplomacy.

    Also really liked and strongly agreed with your response to Dr. Jenkins.

    Glad to know I’m not the only dentist that occasionally gets these folks. I once had a patient scheduled for an FMX and comprehensive exam, he told my front desk how important his time was and that he was “very clean” and “got regular cleanings every year” and was due and could we please take care of his cleaning at the same appt, so we booked him for an hour on my hygienists schedule, after a 30 minute block for radiographs and a perio exam/probe (I would do the exam after). When he gets to the office and fills out his paperwork, he is nice, but after being brought back he REFUSES any X-rays and demands his simple cleaning, “that we promised him”. He allowed my hygienist to look in his mouth and she informed me he had heavy gross calculus, severe inflammation, foul halitosis, etc. I was with another patient so I told my staff to tell him that we would have to get X-rays and do an exam and we would go from there. From the other side of the office I heard him rip off his pt napkin and start yelling at my staff about how “we were all crooks”, as he showed himself to the door.

    I guess I can thank my staff that I never actually had to see or talk to him. Patients like that will give you an ulcer if you let them.

    In my dental software collection of example images, I have several intraoral photos I took of a virgin premolar, which to the untrained eye looks perfectly healthy and caries free. An experienced dentist will pick up on the sublet differences in shade through the enamel translucency at the marginal ridge. I then have a BW radiograph of this tooth showing a very large inter proximal lesion. Then several photos I took as I prepped the tooth, showing the extent of decay as it was exposed and removed. This series of photos and X-rays will convince anyone but the truly emotional types who have made up their mind that dentists are not to be trusted and “if their teeth don’t hurt, they are fine”.

    • The Dental Warrior says:

      Thanks for your comments, Jeff. I find photos helpful some of the time. But, those (fortunately rare) patients who are simply not going to have x-rays will never be convinced. They are right. We are wrong. They don’t trust us. That’s the bottom line. I don’t want to treat a patient who sees me as an adversary.

  17. J says:

    I hope I’m not one of those difficult patients, but I did ask my new dentist not to do X-rays! Before you roll your eyes, I’d like to explain my situation and ask for your comment.

    My previous dentist specifically told me not to get X-rays for 3 years. I then moved out of state and had to find a new dentist, so I brought my X-rays and previous dentist’s notes. On those records, I saw that my previous dentist had cited CAMBRA in making the 3-year recommendation. I did some quick research and found a 2007 paper (http://www.nmhr.org/retreat/2011/21-p115-ad2.pdf) and a 2011 paper that cited the 2007 paper (http://www.rdhmag.com/etc/medialib/new-lib/rdh/site-images/volume-31/issue-10/1110RDH095-109.pdf). Both indicated that an adult with low caries risk should get bitewings every 24-36 months. Furthermore, I read that most dental education programs have adopted CAMBRA for teaching dental students (probably including my previous dentist, who was at a university).

    I told my new dentist about this, but my new dentist did not seem to be familiar with CAMBRA. My new dentist insisted that every patient in the practice had to get X-rays done every year. At the most, she would allow me to do them every other year, in which case I would have to sign a waiver absolving her from liability. In the end, I defaulted to her judgment and got FMX and bitewing X-rays done during my first visit. I still have not decided whether I will sign that waiver for next year.

    I’d like to hear your thoughts about this situation, because I feel that it is different from the patients discussed above. Unlike those patients, I have low risk for caries and my reasons for not getting X-rays were based on scientific research and recommendations from another dentist that I trusted. But, how do I reconcile the fact that my new dentist does not subscribe to the same guidelines? I don’t feel it is my place to “educate” my new dentist or tell them how to practice, but I wonder if they are missing out on good information.

    • The Dental Warrior says:

      Hello “J.” My blog is primarily intended for discussions among dental professionals rather than a consumer / patient audience. But, your comment was rational and not accusatory (like some I’ve had to delete).

      The bottom line is that you should feel comfortable speaking with your dentist about it (just as you have here). Though, it seems that you may be confusing “CAMBRA” and “ALARA.” CAMBRA is more about overall caries risk assessment and is being pushed by a company that sells products to dentists (Cari-Free). ALARA is a radiation safety principle that specifically addresses x-ray frequency (and doesn’t require the purchase of products).

      This article was about patients that flat-out refuse x-rays. Interestingly, the majority of them have very poor oral health (making them HIGH risk). Comically, many of them engage in other risky behaviors, such as smoking. But, they have fixated on not getting ANY x-rays. Most dentists are glad to have a genuine discussion with patients like yourself.

  18. Michael Nugent says:

    Just had a patient walk out. He refused X-rays. He “did not want them!!”. Then he says “Doc, this is just a money making racket.”. I told him well then lets do the X-rays at no charge so my hygienist and I can see your teeth properly. Then it was RADIATION concern. Patient then again raises his voice and says “I don’t want X-rays”. I said NO PROBLEM…you are the boss. Unfortunately, that means we can not see you today. Patient walked out of my office. I’m in a good mood, I think I am going buy lunch for my team today!

    • The Dental Warrior says:

      Yep. Yep. Yep. Sounds familiar. The REAL objection is that these folks feel like they should have “total control.” It’s a CONTROL issue. The problem with that, is that their “control” disappears as soon as a problem occurs as the RESULT of their previous “control.” Suddenly, it’s the dentist’s fault. And, then come the legal issues. It’s sad that it has to be that way in this litigious culture. But, we have to practice defensively every hour of every day.

  19. T says:

    I am not a dentist, but would appreciate some input. I am 45 years old ( and have never had a cavity). As a child I had annual cleanings and x-rays as recommended by the dentist ( I don’t recall how often that was). As an adult (lets say from 21- 45), I have had twice annual cleanings and annual x-rays. I have always followed the advice of my dentist or medical professional, but now the advice is conflicting.

    Last year I was diagnosed with a brain tumor known as an Acoustic Neuroma or a Vestibular Schwannoma. They are not cancerous, but still serious. They commonly cause loss of hearing and vertigo to the point of negatively affecting one’s quality of life. Fortunately so far I have only experienced partial loss of hearing in one ear. Of course I have done quite a bit of research, and consulted with numerous experts (Stanford, House Ear Clinic etc.). They don’t know what causers these tumors other than possibly cell phone use and dental x-rays. I have asked the numerous medical professionals I have consulted with regarding their personal use of cell phones and dental x-rays. They almost all stated that they do not place their cell phone next to their head, and do not have dental x-rays. I no longer use cell phones except to text, and I would like to limit the number of dental x-rays I receive in the future.

    I reluctantly discussed my situation with my dentist (knowing in advance the response would probably be something similar to what is in this blog). I think that from the expression on my Dentist’s face, he had never heard of a Vestibular Schwannoma. He agreed to forego the x-ray for my most recent cleaning, and agreed to only require an x-ray every 2 years. Considering that I have very healthy teeth and gums, I think I should be able to go longer than every 2 years.

    I know the value of dental x-rays, and that we are exposed to radiation every day from the environment, but in my situation, I would rather risk a cavity, and pay to have it repaired (out of pocket if necessary) rather than risk further damage to my brain or end up needing brain surgery (which I have so far managed to avoid).

    I have made an appointment for my next cleaning with a different dentist, but am dreading having this conversation again.

    professional input requested

    thank you

    • The Dental Warrior says:

      Sorry to hear of your situation. And, I want to mention that I am not here to render any opinions without seeing a patient in person, nor is my blog intended as a resource for patients. A medical professional suggesting to not (ever) have dental x-rays by stating that he / she doesn’t is being irresponsible and reckless. Personally I would approach that “medical professional” in my chair as I would anyone else… refuse to treat them. I described exactly that scenario in this comment above. Let them find a dentist willing to risk liability for undiagnosed issues and for treating without diagnostic x-rays. The interval for diagnostic dental x-rays can certainly be tailored to fit each patient’s needs and dental disease risk factors. But, I believe one would be hard-pressed to find a dentist willing to treat without ANY diagnostic x-rays.

      I understand you feel you would like to limit your exposure. The dentist, unfortunately, has to consider his or her entire future livelihood when faced with the potential for litigation. A patient cannot consent to negligent treatment. The dentist is on the hook, even with a “signed waiver.”

      Best wishes for your uneventful recovery!

  20. T says:

    I am not saying I will never have another X-ray. Just not anytime soon, as dealing with a brain tumor is extremely stressful and I really don’t need a dentist giving me grief about xrays. I would still like to have my teeth cleaned twice a year. But brain health trumpts teeth hands down any day of the year and I will take the advice of a radiologist from Stanford over a dentist. The medical world changes their opinion on what is considered safe fairly frequently. Remember not too long ago blood letting was considered healthy. Just because there is no definitive proof at this point in time that xrays are not safe does not mean that it won’t be discovered that they DO cause brain tumors at some point in the future. Bottom line patients don’t know who to trust and dentists who refer to their patients fears as pure idiocy certainly don’t help. it really is too bad that our society has become so litigious that some dentists may refuse ( like the one I recently dumped) to take into consideration what is best for the individual patient.

    • The Dental Warrior says:

      The dentist isn’t giving you “grief.” The dentist is following what is considered the standard of care. Treating teeth without diagnostic x-rays isn’t what is best for any patient. It’s considered malpractice, regardless of what the Stanford radiologist (who knows nothing about the practice of dentistry) says. I agree your medical condition is the priority. I hope it resolves quickly and uneventfully for you. 🙂

  21. T says:

    Can you refer me to one of those dentist who are willing to risk being sued? A dentist with the moral fortitude to do what is best for the patient really seems like the type of dentist to have.

  22. Soon to be doctor R says:

    Hello, current D2 at NYUCD. Just wanted to say this was a great thread which provided me with a much needed and entertaining break from studying Gen Path. There were some real gems to be had here, glad I got to see that. Looking forward to frequenting this site.

  23. John says:

    A patient cannot consent to neglect. No radiographs when they are indicated equals I’m not treating you. Plain and simple. If you want to find a dentist who practices below the standard of care, then be my guest….wish patients would wake up. We’re not selling stereo equipment, we’re delivering healthcare….the customer isn’t always right

  24. Pat says:

    Ionizing radiation is accumulative and from one person to the next you are throwing the dice on long term consequences thus the desire to minimize diagnostic x-ray band exposure. Having worked around high energy power supplies designed to polarize CRT’s I am well aware of the x-radiation hazard and understand the concern dental patients have. Getting prescribed dental x-ray’s appears to increase the risk for a commonly diagnosed Brain Tumor a new study discovered (web med 04/10/2012) 40%-to 90% increase according to the Web Med report. So the dental “industry” is in denial it appears and may be subject to “class action” litigation. The effects of Ionizing Radiation are well documented..there is no ignorance sanctuary on this.

    • The Dental Warrior says:

      That study wasn’t only flawed, it was abysmally flawed. To see why it was grossly flawed, see: http://thedentalwarrior.com/2012/04/10/oy-veh-here-we-go-again-x-rays/

      Spoiler alert: Multiple anecdotes do NOT make data.

      The benefits of diagnostic dental x-rays VASTLY outweigh the near zero risks.

      Until the day comes that we are declared IMMUNE to malpractice lawsuits with patients who refuse x-rays, it is our DILIGENT prerogative to refuse to treat those patients. So, good luck finding a dentist who will treat you without x-rays. 🙂

  25. DJB says:

    Hey Dr. Warrior,

    This post comes from another field where we have the exact same issue with our patients. I am a newer-grad optometrist who practices full-scope medical optometry. For those who are not familiar with the difference between optometrists, older generation OD’s may not have training/certification to be able to diagnose/treat medical eye conditions such as glaucoma or macular degeneration. Younger optometrists have training from year one of optometry school to practice full scope primary eye care.

    Practicing this type of eye care requires that we meet not only our patient’s needs for corrective eyewear such as glasses or contact lenses but also that we perform in-depth health evaluations on an annual basis. For these type of exams require we examine the health of the outside as well as inside of patients’ eyes. There are two methods to an internal health evaluation: (really both together are optimal) the dreaded dilation and/or a camera that takes wide-field shots inside of the eyes. Although our patients may not like the symptoms and/or cost of these procedures, they are necessary for us to spot problems. Internal health evaluation is a minimum standard of care in the eye care world.

    Sometimes we are met with resistance from our patients when it comes to a health evaluation of their eyes. They will tell us that they “just want a glasses prescription” or “I see fine, please don’t perform that test on me.” Just like dental x-rays, if we are unable to examine the inside of the eyes, we are unable to determine what the health of the eye is. Many conditions have zero symptoms and can be treated – but only if they are found. Eye care providers can be held liable for missing eye conditions that are not discovered, even if it is because a patient declines testing. What legal training tells us is that the professional should know best based off of their academic training, standards of care, and clinical experience.

    Reading posts like yours helps empower me and my team to ORDER this test on every patient annually. If patients refuse we must figure out what the hurdle is (financial, belief that “everything is okay,etc), and make arrangements to address that specific issue. Also reading your post helps me realize that there is a subset of the population that goes around to different professionals and refuses recommendations. Why? Maybe because they believe they know better. I really don’t know a solid answer to that question. Similar to the way you practice, I am not willing to take on these patients and their liability. We take an oath to be a medical providers and I intend to do so for the entirety of my clinical career. Whether my patients are excited about it or not, my recommendation and style of practice will revolve around taking care of them in the best way that I know how.

    • The Dental Warrior says:

      Hi DJB. Thanks for your comment. I’ve had to delete a bunch of comments from laypersons here attacking me (or my colleagues / profession) as being motivated by greed (laughable, as x-ray fees are a pittance)… or just being big meanies who don’t understand our patients. I like the quote from Jonathan Swift: “It is useless to attempt to reason a man out of a thing he was never reasoned into.” It is difficult to use reason when faced with an emotionally-based or irrational fear.

  26. Allison RDH says:

    Thank you for posting this! As an RDH, I just spent a long afternoon trying to convince my patient she needed X-rays. When explaining to her how both legally and ethically it is the only way to diagnose decay and treatment , she practically yelled at me that she was a lawyer and she didn’t have to have X-rays taken. It infuriated me and my doctor gave in to her telling her that she must have them on her next visit. Nothing makes me more angry than patients who think because they have a certain occupation, they can go into an office and demand you do what they say. I went on the internet looking for something to make me feel better and I found your blog 🙂

    • The Dental Warrior says:

      LOL! Oh, man… That would have opened the door for me!

      “Lawyers are EXACTLY the reason I MUST have x-rays. If that doesn’t work for you, there’s the door. Maybe you can find a fellow attorney to provide your dental care… since lawyers know more about it than dentists, after all. Have a nice day.”

      Thanks for visiting my blog, Allison! Have a great day!

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