Patients who refuse radiographs: Dental hygienists need to proactively assess the need for radiographs

Dear Dianne,

One problem that we are having in my office is the number of patients who refuse to have radiographs. It seems like it is becoming almost a daily occurrence, and I am frustrated and confused about how to handle these situations. The doctor tells us to take bitewings once per year on all patients and either a panorex or full-mouth series every three years. I understand the necessity to have up-to-date X-rays, but what am I supposed to do if the patient will not allow it? It makes me feel very uncomfortable when the patient refuses, as if we are trying to cheat the patient or something. Maybe you can give me some tips on what to say to patients who need X-rays and also what to say when the patient says he doesn’t want them taken.

Needing Help in Florida

Dear Needing,

A patient’s refusal of needed radiographs impedes the doctor’s ability to diagnose. That is really the crux of the matter. If pathology exists and the doctor cannot diagnose it due to lack of radiographs, this could become a “failure to diagnose” case if something untoward happens. Unfortunately, most “failure to diagnose” cases are won by complainants.

Are blanket mandates on taking radiographs appropriate? Not according to the ADA position paper on radiographic frequency found on their website: (ada.org/sections/professionalResources/pdfs/Dental_Radiographic_Examinations_2012.pdf). This excellent document provides guidance to dental professionals as to when radiographs are appropriate. Dental professionals are to expose radiographs according to the needs of the patient. We are to look for risk factors that raise the patient’s risk for oral disease. Some of those risk factors include, but are not limited to:

• Poor oral hygiene
• History of periodontal disease
• Medicines that dry the mouth
• High caries rate
• Large or deep restorations
• Swelling
• Mobility
• Peri-implantitis
• Malposed or impacted teeth
• Pain or dysfunction

Adult patients with few risk factors are not recommended for yearly radiographs. Here is the ADA recommendation:

Adult (Dentate and Partially Edentulous)

“Adult dentate patients, who receive regularly scheduled professional care and are free of signs and symptoms of oral disease, are at a low risk for dental caries. Nevertheless, consideration should be given to the fact that caries risk can vary over time as risk factors change. Advancing age and changes in diet, medical history, and periodontal status may increase the risk for dental caries. Therefore, a radiographic examination consisting of posterior bitewings is recommended at intervals of 24 to 36 months.”

Children with caries or an increased risk for caries require more frequent radiographs than those without risk factors. Therefore, a posterior bitewing examination is recommended at six- to 12-month intervals if proximal surfaces cannot be examined visually or with a probe.

It is recommended that “adults who exhibit clinical dental caries or who have other increased risk factors should be monitored carefully for any new or recurrent lesions that are detectable only by radiographic examination. The frequency of radiographic recall should be determined on the basis of caries risk assessment. Therefore, a posterior bitewing examination is recommended at six- to 18-month intervals.”

I believe it is reasonable to say that we should not be exposing radiographs on patients simply because it is a covered benefit under the patient’s employer-sponsored dental benefits plan. Rather, we should look to each patient’s individual risk factors and then decide if radiographs are needed. If you or I were the patient, that’s what we would want. Nobody wants to be exposed to radiation without a valid reason.

Let’s say “Joe” is on your schedule today. According to his chart notes, he has refused radiographs for the past two years. His home care is less than optimal, and he has a history of caries. The doctor is aware of Joe’s reluctance to have radiographs. After you seat him, you update his medical history and do your tour of the mouth and oral cancer examination. Then you should use these words: “As the doctor has directed, I’m going to take some necessary X-rays of your teeth today.” Notice that you should not ask the patient’s permission to take X-rays that are needed. Joe is still reluctant and says, “No, no X-rays for me.” I believe it is reasonable to ask his reasons why he does not want any X-rays, so you could say this: “Could you share with me the reason you do not want X-rays, because I am quite sure the doctor wants them today.” Then you need to listen to his reason.

It is not your place to argue with this or any patient, but you should record the reason he gives you in the chart narrative. When the doctor comes into the operatory to do the exam, he or she has to get involved. I recommend that the doctor ask the patient directly, “What’s the problem, Joe? Please understand that there’s more of the tooth that I must examine that I cannot see with my bare eyes. X-rays are the only way I can detect some problems in the mouth, and that is why we need them. The state of _______ mandates that I treat all my patients in a competent manner, and I cannot do that without X-rays. For me to treat you without up-to-date X-rays is like asking me to work with a blindfold.” If the patient still refuses, the doctor should dismiss the patient from the practice.

Patients refuse radiographs for various reasons. Here are a few that I have seen personally: (1) fear of radiation, (2) discomfort, (3) inability to pay, (4) religious reasons, and (5) ignorance of the need for radiographs. My recommendation for dealing with patients who say they simply cannot afford radiographs is to offer to take them complimentary. When a doctor makes the decision to retain a patient in the practice and treat that patient without necessary radiographs, the doctor is assuming a huge liability risk. This would be considered practicing below the standard of care. Always remember this: patients have more rights than responsibilities, and dental professionals have more responsibilities than rights. Patients certainly have the right to refuse any treatment recommendation, but doctors also have the right to terminate the patient relationship.

Each patient situation has to be handled based on the circumstances. For example, a patient with a history of cancer in the head or neck region may be fearful of additional radiation that could come from dental radiographs. It is reasonable to make judgment calls based on the situation.

Dental hygienists need to proactively assess the need for radiographs. For example, let’s say your patient seems to be doing well, and it has been 18 months since any radiographs have been taken. When the doctor comes in to do the exam, he may say, “You seem to be doing well today. So, we’ll see you in six months. At that time, we’ll be updating your X-rays.” You can even make sure the doctor knows how long it has been since the last films were taken. For most patients, a directive from the doctor is more impactful than when it comes from a staff member. Dental hygienists are certainly equipped to assess the need for radiographs, but in most situations, doctors are supposed to make the final decision.

All the best,
Dianne

Dianne Glasscoe Watterson, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne's new book, "The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues," is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her website at www.professionaldentalmgmt.com.