Tips on what to do when the patient refuses to consent to X-rays

Tips on what to do when the patient refuses to consent to X-rays

This blog is about the importance of taking x-rays to diagnose decay and some strategies to communicate with the patient when the patient is hesitant to take X-rays.

What do you do when the patient refuses to take X-rays?

We know X-rays are important for dentists and hygienists to see all the surfaces of the teeth.

It helps us see in between the teeth.

It helps us see below the bone and other areas where we otherwise couldn’t easily diagnose decay.

And there’s concern with us treating patients without X-rays.

There could be decay that’s missed and we all want what’s best for our patients and for
decay not to be missed..

Here’s some perspectives for you to consider when communicating with the patients and you always learn something from everyone.

Some things you want to use, some things you don’t, but there may be some things here
that you can consider.

What to do when a patient refuses an x-ray

Luckily it’s rare that a patient refuses x-rays, but it does happen.

When it does, the first question to ask them is: what is your reason for being hesitant about taking the x-rays?

You might hear that: it’s a concern about the cost of the x-ray. You might hear an answer that it’s a concern about the radiation.

1 st concern: radiation

For example, concerning radiation exposure. A patient who was an ENT was concerned about radiation exposure for his son to take a dental xray..

So sometimes you have an educated patient who just isn’t familiar with what the dentist is doing in terms of x-rays and the impact it has on our treatment when we don’t have x-rays.

Usually it helps to explain the low exposure of digital radiography.

You can also tell the patient digital radiography reduces the amount of radiation exposure up to 80% compared to traditional film. The radiation exposure from standard digital X-rays is minimal.

One bite wing x-ray, which is what we use to check for cavities in between the teeth, is approximately 0.001 millisieverts of radiation.

To put this into perspective, a three-and-a-half-hour plane ride is estimated to expose an individual to 0.01 millisieverts of radiation or about 10 times the amount of radiation as a bite wing x-ray.

A standard medical chest x-ray is 0.1 millisieverts or about a hundred times the exposure of
a bite wing.

The amount of radiation for digital dental X-rays is very low and is even low in comparison to
the radiation we are exposed to flying in an airplane. Hopefully this information will help
reduce the patients’ anxiety.

2 nd concern: cost

Secondly, if cost is the issue, there may be a time when you choose to do the x-ray for free, especially if the X-ray is part of other procedures and the x-ray is going to be necessary to complete the diagnosis and do the treatment.

Of course, we wouldn’t necessarily charge for every x-ray for a root canal, but the cost of an X-ray is usually a much lower percentage of the total cost compared to the treatment itself.

So if there’s truly an issue paying for the x-ray, then there may be some issues about the cost of the total treatment in general, and I think we try to resolve those financial concerns in one way or another to help things move forward.

What are the practical consequences of not having an x-ray?

The other thing to tell the patient is the practical consequences of not having an x-ray.

If you see decay on the occlusal of a tooth and try to treat it without the X-ray, you may leave decay on the other surfaces of the teeth in between the adjacent teeth on the mesial and the distal, and then later you may have to redo this filling later.

So usually when explaining the importance of the x-ray, that would help resolve the issue. And of course, the goal is to get the patient to consent to the x-rays you need.

You could create a form that the patient can sign that says the patient is aware of the risks of not taking X-rays and is not holding the doctor or hygienist liable for any undiagnosed conditions.

It could have words to say something like, “I have voluntarily elected not to have diagnostic X-rays taken to help with the diagnosis and treatment planning of my dental condition.

This is being done against the recommendation of my dentist, I do not hold my dentist liable for any failure to diagnose or any misdiagnosis due to lack of the recommended x-rays.

I assume full responsibility for any conditions related to my dental health that may not have been diagnosed or misdiagnosed due to a lack of radiographs.”

So this can be one way to document that you’ve explained to the patient the risks and that the patient understands and agrees to move forward without the x-rays.

We don’t use this form a lot, but it could be a tool for the hygienist who wants to take the Xray and the patient is hesitant.

The hygienist could use a document like this to share with the patient, and it gives the patient a chance to think about the importance of the x-rays even before the doctor comes in to explain things further.

It gives more time for the hygienist to share information with the patient and for the patient
to process that information and could save some time communicating with the doctor later.

So that’s another benefit of the form.

And just in general as a dentist, it’s better to have a great view of the patient. You want to have a Panorex and bite wings before treating the patient.

You want to know who you’re treating and what’s going on. And sometimes even having just a bite wing without a pan, sometimes it’s going to make it hard to see everything.

We know that the dentist and the patient are at a disadvantage without X-rays and it makes it harder for everyone. But even though we need the x-rays to really diagnose and treat the patient, and we know it gives the patient the best patient care, there could be some exceptions when you do treatment without an x-ray.

Exceptions where no x-ray is doable

For example, if the patient is missing all of their posterior teeth and maybe they only have
lower anterior teeth and all of these teeth are asymptomatic, maybe it’s an older patient
and they just do not want to take an X-ray and they’re reluctant.

Well, if you feel comfortable, you can diagnose the decay on asymptomatic lower anterior
teeth visually. You may do the treatment without the x-ray that day. And then as you build
rapport and trust with the patient, hopefully maybe at the following visit we can get consent
for more x-rays to check the bone and the lower teeth, and recheck the vitality of the lower

Another instance, maybe if the patient’s pregnant and we just don’t want to create any extra worry for the expectant mom about radiation, maybe it appears to be a low risk patient and we see a small occlusal cavity.

You should always explain to the patient that without an x-ray, we may miss some mesial or distal decay, but if they see an occlusal cavity that they want to treat, that might be an instance to treat a tooth without an X-ray.

And then we can update the x-ray after the pregnancy and let them know if further work may be needed on that tooth.

Certainly if it’s an anterior tooth, but even a posterior tooth, we may consider this, especially if there are no adjacent teeth to the resorted posterior tooth. And there also may be instances to take an X-ray on a pregnant patient after consulting with their doctor.

But certainly if the mom is hesitant to take an X-ray, you should to try to work with them during the pregnancy. So in general: there are advantages to having a Panorex and bite wings for the patient in order to offer the best comprehensive care that we can. 

But you want to try to meet the patient where they are and sometimes do a procedure to help meet the patient in the middle and build trust, and hopefully we’re able to do more care in the future.

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