What happens when the patient says, ‘no’

Today I cannot receive one of the most common and beneficial oral health activities, a six-month dental visit with my dental provider, Kaiser Permanente.

Healthy Smile, photo by Rudy Owens.

Healthy smile, photo by Rudy Owens

The reason why? I am refusing to have a panoramic X-ray.

This potentially profitable medical procedure for some dental practices is a recent development in the oral health field that has followed the proliferation of the panoramic technology in the past several decades. However, these are not universally recognized in developed nations as a best health practice for routine dental care compared to bitewing X-rays, which my past dentists used. Neither is without risk. … [More of my guest column in the Sept. 16, 2015, Lund Report health newsletter can be found here.]

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For more information about the European Commission’s guidelines for recommended dental radiography practice and exposure to dental radiography, go to European Guidelines on Radiation Protection in Dental Radiology: The Safe Use of Radiographs in Dental Practice, produced by Victoria University of Manchester (United Kingdom). A more personal perspective on how a dentist may respond to one patient’s concerns about exposure to ionizing radiation can be found in the Daily Kos.

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UPDATE Sept. 20, 2015: One critic of my column printed on the Lund Report web site wrote this statement, apparently to correct the record about what the American Dental Association’s guidelines are:

The ADA’s guidelines from 2012 actually state that for new patients (such as Mr. Owen) a panoramic radiographic exam is recommended so it seems that Kaiser is following the ADA’s recommendation.

“Individualized radiographic exam consisting of Individualized evaluated for dental radiographic exam radiographic exam posterior bitewings with panoramic exam or radiographic exam, diseases and dental consisting of consisting of posterior bitewings and selected periapical based on clinical development selected periapical/ posterior bitewings images. A full mouth intraoral radiographic signs and occlusal views and/ with panoramic exam is preferred when the patient has symptoms. or posterior exam or posterior clinical evidence of generalized dental disease bitewings if bitewings and or a history of extensive dental treatment.”

I found this comment remarkable because the author of it, someone who identified him/herself as Peta Pita (likely an assumed name, and this person misspelled my name too), did not mention the statement that immediately precedes guidelines for all radiography recommendations for people of all ages. So this comment is factually inaccurate.

The ADA foremost states [I put in bold for emphasis]: “These recommendations are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after reviewing the patient’s health history and completing a clinical examination. Even though radiation exposure from dental radiographs is low, once a decision to obtain radiographs is made it is the dentist’s responsibility to follow the ALARA Principle (As Low as Reasonably Achievable) to minimize the patient’s exposure.”

What’s more, the ADA also states for adult patients the following (and this does not include panoramic radiography): “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.”

I enclose a screen snapshot for those who may be unsure how to intepret a recommendation table. This section covers the issue mentioned above, just including recommendations for adults:

Note the statement on top of the table the is overarching guidelines any dental practitioner may wish to follow, if they choose to follow the ADA's recommendations. Note, the ADA does not represent how all countries and other international organizations who promote oral health set guidelines for dental radiography.

Note the statement on top of the table the is the overarching guideline any dental practitioner may wish to follow, if they choose to follow the ADA’s recommendations. Note, the ADA does not represent how all countries and other international organizations who promote oral health set guidelines for dental radiography. Remember, the U.S. health care system is the least efficient and most costly in the world, and a wealth of data highlight the over-use of unecessary medical tests as a major factor leading to this problem. Here is just one example of that: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror.

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2 thoughts on “What happens when the patient says, ‘no’

  1. A very interesting article Rudy. Wonder why they would refuse to use the bitewing X-ray? I haven’t been to a dental check here in Canada, but in Norway (at least 3 years ago) the bitewing X-ray was still the one used.

  2. Inger, it’s a number of issues here:
    1. In the USA we have the least efficient, most expensive healthcare system of all OCED countries, and one reason is excessive testing that does not provide benefits to patients–this is a symptom of a systemic problem of for-profit health care.
    2. The American Dental Association has made ambiguous recommendations that are not backed fully by peer-reviewed science comparing panoramic X-rays vs. examinations without the intervention. I shared one paper on this that I found with dentists and they immediately said the study is flawed, I think, because it challenges the model of testing and “doing more.’
    3. Dentists allege they will be sued if they don’t have X-rays–the argument used all the time to defend expensive, for-profit health care. I’ve heard this line for decades now on any number of problems.
    4. In Oregon, a group called the Board of Dentistry sent out confusing commuinications in 2012 that not only incorrectly interpreted the ADA’s guidelines for adult patients, but then claimed dentists in my state would be allegedly performing less-than-required care without a panoramic X-ray. This guideline has no force in law, has no scientific citation, is not in alignment with even the ADA they supposedly follow. No one has fully challenged this group for promoting a health practice that puts patients at risk of excessive radiation for no medical benefit to patients. But providers claim they “have to” obey this recommendation to bully patients, except those who speak up and then are kicked out of the practice.
    5. Many OCED countries have guidelines that recommend modest use of just bitewings, and many groups who study radiography strongly recommend minimal radiography in all cases. Period.

    It’s a messed up situation. But patients are not organized to challenge the “guys/gals in white coats” when they visit the dental office. This is also about power, and medical professionals will never admit they are wrong or willingly give up power in this dynamic, I think. The doctor is always right is a bias that harms patients and health care when unchecked.

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