Stay Sharp: Technical Guidelines and Workplace Strategies for the Clinical Dental Hygienist. (Part 2)

Q: Some of my patients resist getting recommended radiographs. What can I do to encourage them to consent?

A: If you read my article, “Are you Taking Adequate Radiographs?” (November 2021 issue), you know that most practices aren’t taking the necessary images throughout the process of care, especially considering the recommendation of the new global 2018 AAP classifications. Instead, clinicians seem to focus predominately on a dental diagnosis failing to recognize that radiographs are also needed to screen for all potential periodontal conditions.

The simple answer to your question is that you need to create value. Period. If you are getting more “nos” then “yeses,” you’re likely not creating value and, instead, selling services vs. outcomes. The good news: As soon as you change your mind set, your patients will change theirs too.

So how do you create value? By presenting your patients with the rationale behind taking radiographs in the first place. Let’s review:

You take radiographs for both a dental and dental hygiene diagnosis. Using the four vertical bitewings (BW’s), the doctor is looking for cavities, but you are also screening for bone loss. If the bone loss is determined to be due to periodontitis, then you will need to take a FMS to determine severity (Stage), complexity of treatment, progress (Grade), and impact on overall health. If it is determined that the bone loss is due to acquired or developmental deformities (ortho forces, extraction, subgingival restorative, open contacts, etc.) or as the literature refers to as predisposing factors, then you will not need a FMS but will need anterior periapicals (PA’s) in addition to the BWs to screen for a rare type of periodontitis, Grade C, formally known as aggressive periodontitis, occurring around 13 – <30 years of age, which progresses very quickly. As well, a panoramic radiographic is needed every five years to screen for any anomalies, cysts, abscesses, blocked carotid artery, and so on.

If your patient still resists, he or she has the right to do so. However, at every appointment the above message should be reiterated by the clinician. The doctor also has an opportunity to support this message each time he or she comes in to do an exam. If the doctor has been informed that the patient has periodontitis, the first response to the hygienist is to view the FMS. If a FMS was not taken due to patient refusal, the doctor can once again create value by reiterating reasons behind the imaging.

Inevitably, you will start getting to “yes” more often. For those few that consistently say “no” despite your best efforts in creating value, you will as an office have to develop a policy on how to best treat or not treat these patients going forward. Even if they sign a form refusing radiographs, they put your license and your practice in a position of liability. If you were sued, the patient would win simply by showing they didn’t understand the ramifications of refusing radiographs, and since you can not measure understanding, you can’t prove that they understood. So, at some point, you may need to have this conversation with your patient and consider dismissing them if they still say “no.”

The best line I’ve ever read about dealing with this type of patient was in an article by Katheryn Edwards, “What Hygienists Should Say When Patients Refuse Dental Radiographs” (May 2019). Edwards writes, “No patient can give consent for the dentist to be negligent.” I will leave you with that thought and let you decide on your office policy.