What Hygienists Should Say When Patients Refuse Dental Radiographs

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When a dental hygienist struggles to talk a patient into receiving the basic standard of care, the frustrating experience can leave an indelible on a career. Eyes roll across the country during morning huddles when the hygienist spots a familiar patient name with the words “Overdue for x-rays” on the schedule!

Exploring and practicing communication skills through verbal scripting strategies can make discussions about radiographs less exhausting. The entire team, including the doctor, will need to be on board to create successful radiograph denial strategies. You probably won’t ever eliminate this challenge, but you can reduce it by taking the following steps.

Clarify the Doctor’s Clinical Philosophy

Every practice experiences refusal from patients to take images from time to time. The practice should have a clinical philosophy in place that helps determine the protocol for taking radiographs. The ADA, in collaboration with the FDA, developed recommendations for dental radiographic examinations to serve as an adjunct to the dentist’s professional judgment regarding treatment protocols. The doctor should plan to share his or her philosophy about radiographic exams during a team meeting.

Identify the Benefits of Radiographs

Radiographs can help the dental practitioner evaluate and definitively diagnose many oral diseases and conditions. Often, a radiograph is necessary to identify problems that are asymptomatic or undetected clinically. In addition, radiographs help find decay, evaluate root structure, check the health of the bone, help diagnose periodontal disease, and see the status of developing teeth.

Your practice should make a bulleted list of these benefits so that everyone “speaks the same language” to patients. Sometimes a patient’s refusal is actually a request to understand why you are recommending radiographs.

Ask the Patient Why They are Hesitant

It is important to understand the reason a patient has refused radiographs. Stating a set x-ray interval for all patients as a part of an “office policy” will not address the individual challenges patients express. It will also likely create further resistance by the patient.

Once you have determined the specific challenge, you can address it confidently. Generally, refusals fall into one of three categories: cost, discomfort, and radiation exposure.

Base Your Scripting on the Patient’s Challenge

Select scripting based on the specific reason for the refusal. You will be more successful if you acknowledge the reason for the resistance and work with the patient in a way that allows them to feel in control of their health-care decisions. After all, don’t we all want to feel in control?

The patient will feel more in control when they have an opportunity to discuss their concerns. This is easily accomplished with, “May I ask why you don’t want to have (films/x-rays/images/pano) taken today?” Maintain eye contact and listen carefully, repeating back their concerns to acknowledge that you heard and understood.

Example Scripting

Responding to cost resistance:

“I understand that cost is a concern for you. Other patients have found that it is much less expensive to pay for the diagnostic ability x-rays give us to catch possible problems when they are small and less expensive to repair.”

“Knowing that cost is a concern, I would highly recommend we take x-rays to save you money down the road. The beauty of (x-rays, films, pano) is that it gives us the ability to find and treat conditions very early on – ultimately saving you money down the road.”

“I understand your concerns about x-rays. Please understand my position that I cannot give you the care you deserve without radiographs. Please be prepared on your next visit for x-rays, and we will take the minimum number necessary.”

Offer to take the radiographs and bill the patient so they can pay on a later date if that fits your collection guidelines.


“I understand you have experienced (discomfort, a strong gag reflex) in the past and I’m sure that is making you less likely to want to go through that again! Let’s work together on this. I will have someone help by pushing the x-ray button, and we can use a smaller sensor to make it go faster. Let’s get as far as we can together.”

Radiation exposure:

“I certainly understand your perspective. Thank you for sharing. We have had such advancements in imaging technology that the truth is that dental x-rays are quite safe. The amount of radiation is extremely small due to the fast-speed film (or digital technology) we use. These pictures provide us with valuable information about things we can’t see under the gums, under fillings, and in between your teeth.”

“I understand your concerns. Our concern for you is that we only see a third of the tooth without x-rays and cannot successfully diagnose issues that may not cause symptoms. Would you consider fewer films, (BWX, set of 8, etc.) that will keep us both comfortable – you with less radiation and us with the ability to still do a thorough job for you?”

“I understand your concerns regarding radiation. Let me put these x-rays into perspective for you. A unit called a “rem” measures radiation. A rem is a large unit, much like a mile is a large unit of length, so we usually use a millirem (mrem) instead, much as you would measure in inches instead of miles for most purposes. (It takes 1000 mrem to equal one rem.) Advances in x-ray equipment allow us to get a good x-ray image using much less radiation than was previously required. A typical dental x-ray image exposes you to only about 2 or 3 mrem. The National Council on Radiation Protection (NCRP) says that the average resident of the U.S. receives about 360 mrem every year from background sources. This comes from outer space, radioactive materials in the earth, and small amounts of radioactive material in most foods we consume.”

Legal risks

Improper diagnosis due to a lack of dental radiographs leaves the practice in a state of liability. Even if you have a patient sign a form stating he or she willingly refuses radiographs, no patient can give consent for the dentist to be negligent. A patient simply cannot waive their right to receive adequate care by signing a refusal for x-rays. If continued resistance occurs, the doctor needs to determine at what point they will dismiss the patient from the practice.

The bottom line is that language shapes perception. You have the power to frame the conversation in a manner that opens further dialogue and elevates oral health awareness among your patient base.

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Katharyn Edwards, RDH, has been a practicing dental hygienist in the Seattle area since 1988. She is a working hygienist and practice manager three days a week in private practice. She balances her clinical career with a consulting role for Burkhart Dental. Kathy has been a consultant for Burkhart Dental since 2008. Kathy’s 21 years in dentistry, preceded by a 10-year accounting career, allows her to bring passion to both patient-centered care and sound business strategies for dental practices. Kathy was a founding member and director for the SouthShore Dental Hygiene Study Club for ten years, which now serves as a model for other dental hygiene study clubs nationwide. She has spoken on dental and business topics in the United States and internationally in Beijing, China. You can also find her kayaking, boating and jet skiing on the Puget Sound with her life love, Justin, and their two grown daughters.