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.
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.
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).
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!