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.]


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.


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.

Project Homeless Connect provides ‘disaster relief’ close to home

On May 17, 2013, I participated with other employees in my public health department working at Project Homeless Connect.  This is, at present, a quarterly endeavor to provide a range of medical and social services to the estimated 2,000 homeless individuals of Pierce County, Washington.

However, the people who line up as early as 7 a.m. for a range of needed services are not entirely the homeless. Many have jobs, but lack health and dental insurance. They basically are coming for primary or even emergency care that they cannot access elsewhere.

The Washington State Department of Social and Health Services is one of many organizations participating in Project Homeless Connect.
The Washington State Department of Social and Health Services was one of many organizations participating in Project Homeless Connect, held on May 17, 2013 at Calvary Community Church, in Sumner, Wash.

Project Homeless Connect, in its communications for its volunteer-run event, said it offered the following:

  • Medical and urgent care
  • Urgent dental care
  • Mental health services
  • Social service referrals
  • Vision/glasses
  • Haircuts
  • Child/adult immunizations
  • Veterinary care
  • Legal and financial advice
  • Housing, shelter, employment and education information
  • Tobacco cessation
  • Homeless assistance
  • Veterans services
  • Chemical dependence and assessment

This was no small effort. Months of planning went into pulling off this disaster-relief style engagement that is more associated with hurricanes and tornadoes than with meeting the basic needs of Pierce County, the second most populous (pop. 812,000) in Washington State.

Large, converted vans/trucks lined up providing veterinary services, dental care, and other interventions. Yet, oddly, there was no media present to put the story on the 5 p.m. news or in the daily newspaper the following day. (I checked but found nothing doing Google searches.) Why? Everyone who was homeless in Pierce and most social service and medical service providers likely was aware the event was taking place, for months in advance.

I did see not any elected officials (they may have come, and they may even have volunteered). All of this took place in a county whose hospitals are making profits of $1,000 per patient visit more than the state average and in a county where nonprofit hospitals are earning up to and more than $500 million in profits.

I saw all kinds of people—young, old, white, black, Asian, Latino, Pacific Islander, disabled, able-bodied, veterans, you name it. Volunteers came in all stripes as well. There were military personnel, dental assistant students from Pierce County community colleges (Bates and Pierce ), trained medical providers, church volunteers, hair stylists, and more. The list goes on. What struck me the most was how polite and appreciative the attendees were. Many drove or were driven from remote parts of the county to this somewhat semi-rural area in Pierce, southeast of Tacoma.

One of the providers, Medical Teams International, had one of its full-service converted mobile home vans providing dental care.

Medican Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.
Medical Teams International brought one its converted mobile home vans to Project Homeless Connect on May 17, 2013, in Sumner, Wash.

That program boasts a fleet of 11 mobile dental clinics in Oregon, Washington, and Minnesota that use 38-foot converted motor homes. Each clinic contains has two full medical stations and all necessary equipment, instruments, and supplies. The organization claims it has helped more than 200,000 adults and children with its mobile medical program since 1989.

Medical Teams International defines itself as a christian global health organization “demonstrating the love of Christ to people affected by disaster, conflict, and poverty.” The group works globally, including in Africa, South America, Asia, and North America.

Yet, it was in Pierce, addressing what clearly that organization perceived as akin to disaster and conflict.

In Washington State, 14 percent of all residents are without health insurance, according to the Kaiser Family Foundation. In Pierce County, the percentage is roughly the same.

All of this I find remarkable. Less than five miles from this revolving quarterly circus of human need there was a major shopping center, South Hill Mall, with about every major electronic gadget and consumer good on the market. Truck and car lots were also close by, with products selling from $25,000 and up. The disconnect to me was palpable, particularly the same week the Republican-led U.S. House of Representatives passed its 37th legislative measure to repeal or defund the market-driven health care reform known to its detractors as “Obamacare.”

I recall what one of my University of Washington School of Public Health colleagues—the one I respected more than nearly all others—told me when we talked about our peers who had worked or would work in public health in Africa or in developing nations. My friend asked somewhat ironically, why don’t they work at home. We have plenty of problems here. Given what I saw at Project Homeless Connect in Pierce County in mid-May 2013, I could not agree more.