Skipping x-rays: Dental office policy on sporadic x-rays is questioned by reader

Dear Dianne,

I work for a doctor who does not take full-mouth series x-rays, and only takes two bitewings every three years. Is there a website or some kind of written guideline saying how often and what kind of x-rays should be taken?

Western RDH

Dear Western,

Unfortunately, I've been in offices like this where keeping up-to-date radiographs is not a priority. Most of the time, the problem is that the doctor is allowing his or her conservative nature to cloud professional judgment. In some situations, the doctor is so concerned about patient fees that radiographs are neglected.

It is true that some offices abuse radiographs by exposing patients according to some blanket mandate set by management; for example, everybody gets them once per year whether they need them or not. I have observed clinical staff members asking business assistants, "Can Mr. Smith have a panorex this time?" The question refers to whether or not insurance will pay for the radiograph, not necessarily if there is dental necessity. When did we turn over decision-making about the necessity of radiographs to business assistants? We should expose appropriate radiographs according to patient needs and not because of insurance benefits. Taking unnecessary radiographs is just as bad as neglecting to take needed radiographs.

Maybe the doctor you work with is unaware of the written guidelines provided by the American Dental Association posted on their website for anyone to see. A simple Google search of "dental radiography frequency" brings up this link in the first position. (http://www.ada.org/~/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examinations_2012.ashx) The written guideline, titled "Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure," was first published in 1987 and most recently revised in 2012. Every dental professional should be familiar with the contents of this very thorough and well-written document.

Since we know that dental diseases-caries and periodontal diseases-can progress without clinical symptoms, radiographs provide a way to intercept problems before they become extensive and painful. Attempts to identify specific criteria that will accurately predict a high probability of finding interproximal carious lesions have not been successful for individuals due to many variables. Therefore, the ADA Council on Scientific Affairs felt it was necessary to recommend time-based schedules for making radiographs intended primarily for the detection of dental caries. There are exceptions to every rule, and professional judgment should be used to determine the optimum time for radiographic examination within the suggested interval.

Many factors increase a patient's vulnerability to dental disease, and as prudent dental professionals, we are supposed to assess those factors before deciding on the necessity of radiographs. You might be interested to learn that for adult recall patients with few, if any, risk factors, posterior bitewings are recommended every 24-36 months. The ADA document lists the

many factors that we should take into account, such as level of home care, mouth-drying medications, large or deep restorations, implants, and history of periodontal disease, to name a few. The document breaks down radiographic recommendations based on these categories:

• New Patient Being Evaluated for Oral Diseases
• Recall Patient with Clinical Caries or Increased Risk for Caries
• Recall Patient (Edentulous Adult)
• Recall Patient with No Clinical Caries and No Increased Risk for Caries
• Recall Patient with Periodontal Disease
• Patient (New and Recall) for Monitoring Growth and Development
• Patients with Other Circumstances

Concerning full-mouth series radiographs, dental professionals typically feel this is necessary for new patients. The only mention of FMS in the guideline is under the category of new adult or adolescent with permanent dentition: "A full-mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment." The recommendation for children with primary or transitional dentition is "individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images." It also states that for children with open contacts, radiographs may not be needed. For patients with periodontal disease or other circumstances, the operative phrase is "clinical judgment as to the need," meaning we should assess each case individually. Since we cannot see alveolar bone, we need to be diligent and timely concerning radiographs for periodontal patients.

Overall, the ADA "guidelines are intended to serve as a resource for the practitioner and are not intended as standards of care, requirements, or regulations." Dental professionals "must weigh the benefits of taking dental radiographs against the risk of exposing a patient to x-rays, the effects of which accumulate from multiple sources over time."

We also must understand that neglecting to take timely radiographs when dental necessity is evident greatly increases the dentist's liability risk. If a patient decides to file a lawsuit or a board complaint against a dentist and there are no up-to-date or appropriate radiographs, the doctor looks negligent. Some will argue that lacking current radiographs is one aspect of supervised neglect. Without radiographs, small interproximal caries can go undetected and grow into large carious lesions that can involve the pulp. Radiographs enable diagnoses, and the lack of radiographs impedes the doctor's ability to diagnose. In a lawsuit or board complaint, the patient chart-including any and all radiographs-becomes part of the evidence that will either support a negligence/malpractice claim or exonerate the dentist.

Most of the inquiries I receive from hygienists involve patients who refuse to allow radiographs to be taken. My position is this: the patient's refusal of needed radiographs impedes the doctor's ability to diagnose. Dentists and dental hygienists are held to high standards by courts and dental boards, and a "failure to diagnose" case can result from a patient's refusal of needed radiographs. Without x-rays, how can something be diagnosed that cannot be visualized directly? Therefore, when a patient refuses needed radiographs, the safest course of action is to dismiss the patient from the practice. To continue to treat without radiographs is risky and considered by many as practicing below the standard of care.

Whether the situation is an office with deficient radiographic standards or patients who refuse needed radiographs, one principle does not change: patients have more rights than responsibilities, and clinicians have more responsibilities than rights. From a legal standpoint, the playing field is not level between us and our patients. Patients certainly have a right to refuse our recommendations, but doctors also have the right to refuse treatment under circumstances where the patient's refusal of a key diagnostic tool such as radiographs impedes clear and accurate diagnosis.

I appreciate a conservative approach in dentistry, but it is important to ensure that the standards of care are being met. My recommendation for you is to print off the ADA document that I have referenced. If you approach the doctor with clear guidelines and explain that you want to make sure that his patients are receiving care that meets current standards with regard to x-rays, it is likely he will respond favorably. I'd say he's lucky to have you! RDH

All the best,

DIANNE

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an awards winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website at www.wattersonspeaks.com. Dianne may be contacted at (336)472-3515 or by email [email protected].

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