X-ray Prescriptive Protocol: “I Don’t Want X-rays; I just want my teeth cleaned!”

Rhonda R. Savage, DDS, CSP

Dental team members are often placed in an awkward position when patients refuse x-rays or question the need for x-rays. Do you have written guidelines for your team? X-ray protocol should be defined by each doctor and the team. Doctors differ in their clinical philosophy; this article is not a definitive guideline but rather a tool for a team meeting. It is important to have a written protocol as it clarifies your team’s responsibilities and your wishes for your patient. In addition, this protocol provides a clearly stated, prescriptive diagnosis for your patients. It removes the question of a team member “diagnosing” what x-rays a patient needs.

In keeping in line with ethical principles, the doctor should always be the one who diagnoses. Without an x-ray protocol, the staff member could be inadvertently diagnosing for the patient.

This protocol will eliminate the need for a doctor to first see each new patient and emergency patient and determine the need for initial x-rays. The doctor’s ability to be efficient will result with the development of an x-ray prescriptive protocol and will also protect the patient’s valuable time.

  1. Full mouth series: A FMX can consist of a set of intraoral films, or consist of bitewing x-rays and a panoramic film.
    1. 1a. If the patient has a “mouthful” of restorations or visible decay, fractured teeth or obvious periodontal disease, an intraoral full mouth set of x-rays is often more diagnostic. Within the FMX set, I recommend vertical bitewing x-rays for patients with obvious periodontal disease.
    2. 1b. If the patient presents with an apparent relatively clean mouth, the beginning full mouth series could consist of a panoramic x-ray and bitewing x-rays. If, upon taking the x-rays, previously treated endodontic teeth are present, I recommend a periapical x-ray of those teeth.

      In addition, if the patient has a symptomatic problem, a periapical could also be taken in the area, which would be considered part of the FMX.

    3. 1c. If a FMX consisted of intraoral films and an additional panoramic film is necessary for diagnosis, consider the option of not charging for the panoramic film. Patients appreciate a “value added” service. Most insurance companies will not reimburse for both; this creates good will with the patient. If your office charges separately for panoramic films added to an intraoral FMX, be certain to let the patient know the fee in advance.
    4. 1d. FMX Frequency: FMX should be taken based upon the patient’s needs. If they have extensive caries or periodontal disease, it may be in the patient’s best interest to have an FMX every 3 years. If they have a very clean, healthy mouth, an FMX may be needed every 5-8 years. Does your team systematically review each patient’s chart daily to determine the last FMX?

    Some offices have one person specifically responsible; usually a front office person. The need for the FMX is noted on the schedule. With regards to frequency: Some offices track this on their practice management software, which is great. But has your office written in the date of the last FMX for your new patients that bring a current set?

  2. New patient x-ray protocol: Do you ever have new patients who refuse x-rays and say, “I just want my teeth cleaned!” How about new patients who refuse an exam and x-rays? In my practice, I refused to see a new patient that refused an exam or didn’t provide current, diagnostic x-rays.

    The new patient who has current x-rays elsewhere: My opinion is that the doctor is setting him or herself up with a difficult patient right from the beginning if you accept this patient into your practice without x-rays. The new patient should know, politely and professionally, that the doctor cannot see the patient in his or her office without x-rays. Also, sometimes duplicated xrays can be of poor quality; new x-rays may be necessary.

    The x-rays can be obtained from the other office, but the patient will need to sign a release form and request the x-rays. The new patient appointment should be set out 1-2 weeks to allow transfer of the x-rays. X-ray transfer can be facilitated and the patient can be seen sooner if the patient can pick up the x-rays.

    Have you ever received a set of duplicated x-rays that you couldn’t read? Now what do you do? The new patient is in your chair and is adamant they will not have new x-rays. I recommend the patient present the x-rays upon check in. Prior to filling out paper work, the staff brings the xrays to the doctor for review. If the x-rays are not diagnostic, the new patient would need to pay for x-rays.

    If the new patient doesn’t bring x-rays and the other office hasn’t sent them, I recommend you do not see the new patient for a new patient exam. To maintain good will, if the new patient has a specific problem, the front office could offer to see the patient and take limited films to help the new patient.

    Have a tickler file or a note in your calendar to systematically follow up with a new patient if you have not received their x-rays; call the new patient 72-48 hours in advance of their appointment regarding their x-rays.

  3. The existing patient who refuses x-rays: Keep in mind that you cannot protect yourself as a doctor by having a patient sign a form, refusing x-rays. Later, they can still say, “I didn’t know what I was signing!” Treating a patient without x-rays is considered a form of “supervised neglect.”

    In my office, a patient could refuse x-rays or defer taking them, for up to 1-2 years, depending on the patient’s condition. At this point, I’d sit down with them privately in the operatory. I’d say,

    “Sam, I really enjoy you as a patient. But you need to know that I’m really concerned because we haven’t taken x-rays in xxxxx months. I can’t provide you with the care that you deserve without x-rays. It’s like asking me to take off my glasses, put one hand behind my back and still give you quality care. X-rays are 50% of my ability to let you what’s happening in your mouth. We can keep your x-rays to a minimum and if necessary, take more as needed. We’re ok for today; but if we can’t take x-rays at your next appointment, I’m sorry, but you’ll need to find another health care provider. Will it be ok with you that we take x-rays next time?”

    What about the patient who refuses x-rays, each time claiming “she’s trying to get pregnant?” I would say, “Sarah, I understand your concern. But it’s so important for you to have x-rays. X-rays are 50% of the ability to diagnose and let you know about your health needs. We’re ok for today, but prior to your next cleaning appointment, you’ll need to call us on the first day of your period and we’ll get you in for your necessary films. So, over the next 6 months, you’ll need to call us and we’ll make certain you will be able to have your films, provided it’s during our normal work day.”

  4. Children and FMX: I recommend that you consider taking a panoramic film around the age of 4-5 years to verify development of permanent teeth. Another panoramic film is ideally taken again at the age of 8-9 years, looking for ectopically erupting canines. In both of these age categories, early orthodontic referral may be important. I also recommend a panoramic film at the age of 15-16 to check for third molar development.
  5. Periodontal disease and referral: Most periodontists need a current FMX with vertical BW’s, taken within the last 2 years when you refer. Vertical bitewings are more diagnostic for bone loss than horizontal bitewings.
  6. The emergency patient: Well trained assistants and hygienists can do testing: percussion, bite testing, palpation, hot and cold testing and most importantly, asking questions about the patient’s symptoms. Through prescriptive x-ray protocol, she has the doctor’s permission to take periapical(s) and bitewings in the areas of concern. I requested a bitewing for caries diagnosis and periapicals in the area(s) of concern.
  7. Frequency of x-rays: The ADA’s position is that the need for x-rays varies for each patient. Here is an excerpt from the ADA guidelines:

    “How often X-rays (radiographs) should be taken depends on the patient’s individual health needs. It is important to recognize that just as each patient is different form the next, so should the scheduling of X-ray exams be individualized for each patient. Your dentist will review your history, examine your mouth and then decide whether you need radiographs and what type. If you are a new patient, the dentist may recommend radiographs to determine the present status of the hidden areas of your mouth and to help analyze changes that may occur later. If you have had recent radiographs at your previous dentist, your new dentist may ask you to have the radiographs forwarded.“

    Source: http://www.ada.org/public/topics/xrays_faq.asp

In conclusion, I consider the team members to be an extension of the doctor. Clearly written prescriptive x-ray protocol allows efficient processing of patients, saving the patient and the doctor time. The doctor determines the basic minimum x-rays needed for each situation.

Upon the doctor’s diagnosis, there may be a need for more x-rays in addition to the initial screening xrays. At the hygiene appointment, discuss the patient’s needs for their upcoming necessary x-rays. Write these needs in the chart and on the schedule.

If your recall/reactivation program is strong and you pre-schedule your hygiene patients for their follow up recare visit, you should be seeing 85% of your patient base. Measure your FMX ratio to your patient base. As an example, if you have 2000 patients of record and on average, a FMX is taken every 5 years; you would ideally be taking 400 FMX a year. Your goal is to be 85% effective, which would be 340 FMX annually.

Sit down at your next team meeting and use this as a guideline for your discussion. Ask yourselves: How well are we doing in meeting our patient’s radiographic needs?