What happens when the patient says, ‘no’

After refusing to have a panoramic X-ray, Kaiser refuses to schedule a dental visit

OPINION- 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.

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.

Four bitewing X-rays, normal in many U.S. dental exams, generates about .005 millisieverts of radiation, according to the American College of Radiology. That equals what one gets on a normal day from the sun and other sources. The panoramic dental X-ray gives twice that dose, if the machine is working correctly and maintained properly. Though some say these are both small doses, these are cumulative, and there is never “safe exposure” to ionizing radiation.

This concern weighed on my mind when I said, “No.”

Now I am being excluded from a best practice, the dental exam, by a major health provider that reports serving 240,000 dental members in Oregon and Washington.

When I first visited my dentist at Kaiser’s Eastmoreland dental office on Feb. 20, as a new patient, I told the dentist I would not allow the procedure. The dentist I saw told me I would get the panoramic X-ray or find another provider—all while I sat in the chair during my exam. That day, however, the machine was not working. I said I would try to find an old set I had from my wisdom tooth procedure, when the images were necessary for oral surgery, not an exam.

When I tried to get my second annual visit, I wrote the clinic on Aug. 23 that I did not find the old images and still refused to have a panoramic X-ray because of my health and public health concerns about procedures that are not needed for basic exams. I said I wanted an oral exam, allowed under my plan. I also shared published research on the limitations of these procedures as a best practice for dental care.

When I spoke on the phone on Aug. 31, with my assigned dentist, I was told Oregon dentists were required by the Oregon Board of Dentistry to do panoramic X-rays. I have yet to find information on the board’s web site or in state statutes for dental practices to do them. The dentist also claimed the practice was endorsed by the American Dental Association. (The ADA did publish this position on its web site in April 2012: “The ADA’s long-standing position is that dentists should order dental X-rays for patients only when necessary for diagnosis and treatment.”)

The dentist then told me I could not be seen.

I then talked to the Eastmoreland clinic manager on Sept. 4. She also told me on the phone I would be denied my next visit. The manager told me I would not receive a copy of a policy justifying this denial of care. On Sept. 11, I received a final letter from another clinic dentist, also without any policy justification denying me care. The letter states “the dentist does still need to have this film to complete your exam.” Some generic brochures were included from the ADA on X-rays, without any information on the risks and benefits of panoramic X-rays, or even their radiation dosage.

Between August 23 and Sept. 14, I called Kaiser’s dental benefits office five times to have this decision confirmed as a policy. I have not received a call back or anything in writing confirming that Kaiser has such a policy. So it is impossible for me to know if the actions reflect company policy or are arbitrary decisions of a clinic or its providers.

Regardless these actions are at odds with international standards for exposing anyone to radiation in a clinical setting.

According to guidelines by the International Atomic Energy Agency for patients and medical practitioners exposed to radiation, providers “should avoid using a ‘routine’ protocol for X-rays of patients and always examine the patient before choosing any X-ray procedures.”

A study published in the April 2012 issue of the journal Cancer on the link between dental radiation exposure and brain tumors meningioma prompted the American Cancer Society to release a statement that month calling for more studies on the relation between between dental X-rays and these tumors. The ACS statement notes, “Until that research is done, the best advice we can give people is to get dental X-rays when they are necessary and only when they are necessary.”

As a patient, I strongly believe patients have the right to determine if any medical procedure will promote their health. Panoramic X-rays are not a universally endorsed medical practice in any developed country for routine adult dental care, including the United States. Dentists I saw in Alaska, Washington and Missouri over the last 10 years never used them. They all used bitewings, but conservatively and only when necessary.

The European Commission as far back as 2004 issued guidelines to promote the best use of dental radiography for millions of Europeans annually, recommending that “bitewing radiographs taken for caries diagnosis should be used in the first instance.”

The commission further stated, “For a new adult dentate patient, the choice of radiography should be based upon history, clinical examination and an individualized [sic] prescription.” The commission also recommended, “Informed consent should be obtained from patients prior to radiography in accordance with national requirements.”

As a public health professional who spent two years working in Pierce County, Washington, promoting community-based oral health and community water fluoridation, I have great appreciation of oral health to overall health for everyone at all stages of life. I especially value oral health professionals.

When patients have a good oral health foundation—fluoridated drinking water, regular dental care, healthy diet, no tobacco use—costly and possibly unhealthy extra interventions may not be needed, particularly for a first dental diagnosis. My own goal is to minimize radiation exposure, except when necessary, in respectful collaboration with a health provider.

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Rudolf Owens has an MA in journalism, from the University of North Carolina, and an MPH, from the University of Washington. He worked for nearly two years promoting community-based oral health and community water fluoridation in Pierce County, Washington prior to returning to his former home of Portland in 2014.

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Comments

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.”

http://www.ada.org/~/media/ADA/Member%20Center/FIles/Dental_Radiographic...

Also Kaiser Dental opens itself to legal risks by treating Mr. Owen without radiographs. If a radiograph is not taken but needed to do a proper diagnosis and then later some dental problem arises, the dentist and Kaiser is held liable. Even if Mr. Owen were to sign a form stating that he refuses X-rays, this is not enough to release Kaiser from liability. Many practices have the policy to dismiss patients from the practice if they refuse radiography exams. Doctors can’t provide care for patients based on an incomplete diagnosis without being held liable at a later time. Maybe in a different, less litigious society letting patients decide things like this might be possible but in our current society it seems Kaiser is just doing the smart thing.

Peta Pita