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):
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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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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.
Thanks, Mike, now he will show up in my office!! At least you educated him–not.
LOL!
KG
You can’t fix stupid or crazy.
Mike, what is the source on the table of radiation exposure? That one is much better than the one I am using now.
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
I LOVE that radiation table!! Well done with your e-mail responses, sir!!!
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!
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
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!
It’s akin to saying, “If you don’t think you have a heart problem, skip the EKG?”
Well, I’ve had numerous physical throughout my life. Never once have I thought I had heart problems, never once I have requested that my doctor give me a preventative EKG just in case and never once has he or she suggested an EKG when there was nothing to indicate that such a test might be warranted. On that note, I have never had a doctor try and give me a chest x-ray, CAT scan or other such test as part of a routine physical.
I can count on one hand the number of x-rays a doctor has taken over my lifetime, both of which were medically indicated. On the other hand, the number of needless dental x-rays that I’ve had over my lifetime numbers in the hundreds. Not one of those x-rays has revealed anything abnormal.
There are many reasons people dislike dental xrays, and calling them idiots for that opinion is not in any way helpful in trying to convince them of your view. I personally find them uncomfortable, and in my case completely unwarranted over my entire lifetime. I am not convinced that there are sufficient long-term studies with respect to the effect of dental x-ray exposure, airport body scans, normal medically indicated diagnostic x-ray, cellphones, etc. to say that there is no increased risk of cancer as as result of these individually or cumulatively. I have seen the chart posted earlier, and that does not convince me for reasons that are too numerous to get into in this post.
Finally, I believe that the dental community’s instance on unnecessary x-rays (I had to have 21 this morning just to get my teeth cleaned, and because of the industry’s move toward a first visit that is diagnostic only, I spent any hour in the office and did not even get my teeth cleaned — I have to come back for two more visits for that) keeps people needlessly away from the dentist. We are forced to consent to potentially unsafe tests that we do not want (for whatever reason) and that are not medically indicated as a prerequisite to having a simple teeth cleaning. I don’t see the movement toward that as a positive.
First… this blog is directed at an audience of dentists. It is not intended as a sounding board for patients nor as a place for public debate. There are plenty of places on the internet for that. Nonetheless, I’ll indulge this comment with a few in return.
My physician does an EKG on me every year. He has never found any cardiac abnormalities, thankfully. But, as a doctor myself, I know that things change. I am getting older. I’m glad to get that EKG every year.
I haven’t called anyone an idiot.
I’m very happy that many thousands of x-rays I’ve taken have revealed no abnormalities. You should count your blessings that you’ve also been found to be free of pathology.
Yet, in this U.S. of A., if I MISS any pathology (as rare as it may be), I am held legally accountable. It is the STANDARD OF CARE to take DIAGNOSTIC dental x-rays. When the day comes that patients can’t sue us for not finding pathology while acquiescing to their refusal of x-rays, I’d be happy to oblige. In the mean time, I’m expected to adhere to the standard of care, lest I lose my license to practice (and perhaps much more than that).
As for “never finding anything abnormal,” you may find this blog post interesting: Mrs. Smith… This is why we take x-rays.
Some day, I’ll tell the story about how taking a dental x-ray saved the life of one of my patients in the Navy.
“You can’t fix stupid or crazy.”
“In other words…. ‘pissing in the wind.’”
“Pure idiocy.”
“Some people are easier to repell…”
I am shocked that you all are dentists. The posts should have made clear to me from the start that this is not any place for discussion or debate, but now you have too. I did not mean to intrude on your medical discussion and will not post here anymore.
As I part I will mention two things. First, this board has done absolutely nothing to instill in me any confidence that I can have a frank conversation with my dentist about my fears and concerns without being subject to ridicule either to my face or behind my back.
Second, I found it telling that in responding to my post you did not counter my concerns and defend the “standard of care” by explaining how dental x-rays are safe or how the large number of x-rays that are routinely taken are medically necessary. Of all the things that you could have said, you tried to justify the standard by blaming it on lawyers and the risk of a malpractice suit.
Finally (and I know this is a third thing where I previously just said two), your EGK analogy or whatever you might want to call it is completely off point. A yearly EKG, even at your age, whatever that might be, is not the standard of care. And I am sure that your doctor would still perform the rest of your yearly physical or diagnose and treat you for whatever symptoms you might have even if you refused the EKG unless perhaps your symptoms dictated that an EKG was medically necessary.
In contrast, the entire dental community now requires x-rays as a prerequisite to a simple teeth cleaning without any individualized assessment (i.e., age, dental history and symptoms or lack thereof) of whether x-rays are medically necessary. If you really wanted to do something positive for the profession, then maybe instead of making fun of your patients and their concerns on this board, you should spend your time advocating for a change in the standard of care from something that is driven by lawyers (if that’s even true, which is highly debatable though as you’ve made clear not here) to something that is driven by the actual needs of the patients.
You’re the one that brought up EKG as an example. You suggested, incorrectly, that it should not be done preventively. You are simply wrong about that. I don’t refuse the tests my doctor orders, as I base my decisions on SCIENCE and REASON. And, I don’t consider my relationship with my doctor adversarial, as you apparently do. I actually trust my doctor. Crazy, I know!
You obviously have your opinions, and we’re not here to change them. Likewise, I no longer try to convince those rare patients that refuse x-rays in my practice. I invite them to find another dentist. So, yeah… I’ve given up on pissing in the wind, this reply notwithstanding. I’ve had countless “frank” conversations with patients about x-rays. Very much like you, some of them shake their heads and continue their refusal. No amount of actual science will sway them. It’s simply not worth it. It’s really not. The insist on asserting their right to refuse x-rays. Accordingly, I assert my right to not see them as patients.
If the modicum of trust needed to get diagnostic x-rays is absent, it begs the question as to why the patient would trust me to do ANY treatment. When mutual trust is absent, continuing care is simply a bad idea.
My comment about “pure idiocy” was directed at NBC’s Dr. Snyderman. I stand by that remark. She’s an idiot. So is “Dr. Oz.” Their dental advice is consistently and provably incorrect… and even dangerous. They should not be giving out dental advice, just as I am not qualified to advise patients on cardio-thorasic surgery.
The standard of care IS largely due to LEGAL issues. You may want to reconsider who is “to blame” for x-rays being the standard of care. The bottom line is that if we conduct a dental examination and fail to diagnose something, we are legally liable. Surely you’re familiar with the term “defensive medicine.” Examination without diagnostic x-rays is considered NEGLIGENT. Like it or lump it. That’s the way it is. I choose my battles. You are free to choose yours.
If I could be guaranteed to be free from liability when a patient refuses x-rays, I’d have no issues with patients who refuse them. I won’t hold my breath waiting for that day to come.
Finally, you get more natural background radiation from daily living in a year than you do from a complete set of dental x-rays. Dental x-rays are safer than walking around, when it comes to radiation.
Good luck in your quest to find a dentist you can trust.
I reread my posts, and I never once stated that an EKG should not be done preventively. You are mischaracterizing my posts. What I made clear both times was that, for that example, I do not believe an EKG should be given blindly but would be a good diagnostic tool if it was indicated by symptoms, age, medical history, etc. That’s the same way I feel about dental x-rays, but dentists only employ a one size fits all approach to x-rays.
I do not view my relationship with my doctor as adversarial, but I do like to be involved in my own medical care decisions. I do not object to medically necessary tests and would follow my doctor’s recommendation, but I do object to those that are given for other non-medical reasons (i.e. defensive medicine). As a patient I am forced to try and differentiate between the two. No doctor is going to tell me when he/she is ordering a test that is not medically necessary and is just a CYA. If the test carried no risks, I might just do it. But with something like x-rays, I have to think twice.
Earlier this week my hygenist told me that I would receive more radiation walking to the car after my appointment than I would from the full series of dental x-rays she was about to give me. I chose not to believe that even though she seemed earnest and I don’t think she would lie to me. The conclusion I drew was that she’s heard too much second or third hand information trying to justify dental x-rays rather than doing her own research. That didn’t affect whether I thought she’d do a fine job cleaning my teeth. Trust is not an all or nothing proposition.
As for your assertion that you base your decisions on SCIENCE (I will leave my opinions on your reason out of this), I have seen little to no science in this discussion. It seems clear to me that you are not relying on any peer reviewed studies (or even less rigorous ones) to back up your claims that dental x-rays are safe, because you haven’t cited to a single one. If you are aware of any, I am genuinely interested.
The only “science” appears to be that chart and your claim that it shows that we get 300 times more natural background radiation each year than we do from dental x-rays (although, according to my hygenist, you are grossly understating the amount of background radiation we get each year
).
I am not trying to be disrespectful here, but the conclusions that you draw from that chart show a profound lack of understanding of basic physics. Radiation is a spectrum with x-rays falling toward the more dangerous end as a type of ionizing radiation. What one must take into account in looking at the yearly dose of background radiation is that it comes from many different places along the spectrum, in many different strengths and over a very long period of time. It also reaches the body in many different places (e.g., some exposure like sun to the skin, some like radon to the lungs, etc.). Dental x-rays (or any diagnostic x-ray for that matter) come from a specific point in the spectrum, are in a much more concentrated dosage and are purposefully designed to expose a specific point in the body. Comparing the exposure levels on the chart, at least as far as trying trying to draw conclusions as to the relative cancer risks based on that alone, is an apples to oranges comparison. As a dentist you should appreciate that distinction and see that the conclusions that you are trying to draw from that data are just not scientifically reliable.
I understand that your feelings on this subject are strong, and obviously I am not going to change them, but I also don’t see anything to back them up other than that you’re a dentist and I should trust you on all things dental. Your patents who have refused x-rays have obviously not been able to articulate a sound basis for their decisions, but there is a basis for a different point of view. I hope you at least remember that in your future patient encounters.
Did you notice the SOURCE of the radiation chart??? I’m guessing no.
I lack a basic understanding of Physics??? LOL! You know that adage about assuming, right?
Again… I cited the source of 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
Do you think they lack a basic understanding of Physics?
Patients who don’t want x-rays are entitled to their decision. But, I will not put my career (and my worldly possessions) on the line to assuage their fears. That’s just the way it is. Fortunately, those encounters are very rare. I will listen to patients’ concerns. But, if they will not listen to facts and science, I cannot help them. It’s my practice. It’s my ass on the line. I have way too much invested and too much at risk. When the day comes that I’m guaranteed not to be held liable, I’ll change my mind.
Good luck! And, that will be the end of this exchange.
PS… My doctor ROUTINELY orders an EKG for my annual physical (and for every patient in his practice). No symptoms. No history of heart disease. Not related to age (I’m not that old.)
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?”
Thanks for you comments, Lolabees. You dodged a bullet with that guy. Good for you!
I can see your point of them being a good idea & you wanting them on your end, but the thing I take issue with is is the idea of *compelling* someone to get them. There should be an x-ray refusal form so that you’re not liable, yes, but at the same time how are patients who are forced into something (regardless of how ridiculous it may be to you), if they’re not a believer in it, going to trust you? Some people want vaccines, others don’t; some pediatricians give them, others don’t. We’re talking about a *cleaning* here. If a cleaning is all someone wants, I’m not sure I understand why there should be a law forcing them to have another procedure… (?).
Hi Stacey,
An x-ray refusal form signed by a patient is absolutely worthless. Malpractice is malpractice. A patient cannot consent to substandard treatment. Treatment without x-rays is below the standard of care. Period. So, even if a patient signed such a “release,” the dentist WILL be liable for anything missed. Such is the world we live in.