Repeated x-ray refusal: Increasing patient compliance during case presentations

Sept. 19, 2016
Every hygienist and assistant has dealt with the patient who continues to decline an x-ray and refuse treatment.

By Amber Auger, RDH, MPH

Every hygienist and assistant has dealt with the patient who continues to defer x-rays and refuse treatment. Most dental teams have clinical protocols in place that enforce a written refusal when the patients choose to be their own dental professional. However, most lawsuits begin with the lack of dental radiographs.(1) A patient cannot agree to negligence, and not having the proper films to diagnose the patient is negligent.(1)

As dental professionals, it is our responsibility to overcome the objections of the patient to protect the health of our patients and protect our licenses.

As a new member of my dental team, I was “warned about” certain patients. The scheduling coordinator would say, “Good luck with her, she never agrees to x-rays. The last time that x-rays were taken on the patient was over two years ago.”

Taking this on as my own personal challenge, I knew I had to present the patient with the facts and teach her why the x-rays were important—not in a generic way, but in a way that specifically educated her about her mouth. I informed the patient that, due to her dental history of crowns and an implant, it was essential that I evaluated each tooth through the use of dental x-rays. Looking the patient in the eye, I boldly told her I was uncomfortable cleaning her teeth without knowing what was under the gums. The patient agreed to the FMX and even thanked me on the way out.

The team was shocked when the patient agreed to the 18 x-rays to complete her full set. The experience she had that day was different. I took clinical photos of each tooth and explained what I saw. I described the “stress lines” and linked it to her grinding and clenching. I informed her that I was concerned about the fractures and how it could progress to extensive treatment if a crown wasn’t performed in the near future.

Explaining this to the patient through the visual aid of clinical photos, x-ray, and 3D models allowed her to understand the risks of not treating the decay that was found on the x-ray. The patient scheduled the appointment for a crown on her fractured molar and a restoration that same day.

Including the specific patient's case when discussing the treatment is essential for case acceptance. For example, when recommending scaling and root planing, include that the patient's high blood pressure puts them at higher risk. Inform the patient that not flossing, not using tartar control toothpaste, and the lack of an electric toothbrush allows calculus to form at a higher rate, increasing the risk of periodontal disease.

Social media has allowed patients to become numb to statistics. Therefore, including their specific case in your treatment recommendations demonstrates that the clinician cares about the specific case.

If the patient continues to refuse x-rays despite improved verbiage and patient-centered case presentation, patient dismissal should be considered. Licensure of both the dentist and hygienist are at risk if the patient files a malpractice lawsuit. In my experience, patients are compliant with x-rays once the clinicians refuse to treat without them. Dismissing patients who refuse to allow the provider to provide the standard of care is not a loss, but a protection of one's career.

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Amber Auger, RDH, MPH, is a hygienist with over six years of experience in multiple clinical settings, including facilities abroad. This experience has allowed her to educate dental hygiene students and coach dental teams on periodontal systems to optimize practice growth. She holds a full-time position at an elite dental office in Boston, and owns her own dental consulting company. Amber obtained master’s in public health from the University of New England and her bachelor’s of dental hygiene from the University of New Haven. Amber specializes in pediatric education, periodontal education, and continues to create progressive systems. She is a key opinion leader for several elite dental companies and a published author. She can be contacted at [email protected].


1. Cathy Jameson. Great Communication Equals Great Production. JC Educational Services. January 2002.