Can I as a hyginest refuse to take a patient's x-ray

If the patient is pregnant, can I refuse to take the patient's x-ray or I am mandated to take the x-ray if the doctor tells me to take it. Where does the final liability fall.

ultimately it is the patients decision. You must inform them of all the information and they decide. What type of xrays, digital? Why are you taking them, routine or diagnostic? All of this should be taken into consideration.

Julie in Troy, Michigan said: ultimately it is the patients decision. You must inform them of all the information and they decide. What type of xrays, digital? Why are you taking them, routine or diagnostic? All of this should be taken into consideration.

Thank you. The patient agreed to the x-ray and the doctor told me to take it but I refused as I thought the patient should not be exposed to x-ray.

It is good to be concerned about the patient's health, and it is good to be prepared to refuse to perform procedures you know to be unsafe/unnecessary. The only problem I see is that it is not unsafe to do xrays on a pregnant woman. The current knowledge suggests that the unborn child is not exposed to any significant radiation, esp if under a lead apron. The scatter is so insignificant that we can even stand in the operatory holding a hand-held xray machine (called the Nomad - cordless xray). Further, the safe dose of dental xrays is something like 1200 films a year or many times more with digital sensors. A person is exposed to more atmospheric radiation in a year, or on a continental flight than during an FMS. Ultimately, the risk to the patient is immensely greater if they don't have a necessary dental xray than by the radiation exposure - pregnant or not.

However, patients do have anxiety about the radiation of dental xrays, and it is important to inform them of the general safety of xrays, plus their right to refuse them. A reasonable policy is to forgo annual xrays on pregnant women if and only if she does not have moderate-to-high caries risk or there is some other sign or symptom requiring radiographic assessment. There are many situations where we highly recommend xrays on pregnant women (acute infections, root canal therapy, cavities, etc etc etc), but we postpone their annual bitewings until after the pregnancy if they had xrays within 2 yrs and have to signs/symptoms of concern. Finally, if it has been several years since her last visit (ie the patient doesn't come regularly enough for us to stay on top of her oral health), taking xrays should still be done for the doc to be able to do a proper assessment - otherwise the dental exam is largely blind and bordering on malpractice.

Generally - RDH must defer to the doc with respect to xrays.

'Should dental x-rays be taken during pregnancy?

The accepted cumulative dose of ionizing radiation during pregnancy is 5 rad (.05 Sv). According to the American Academy of Family Physicians, you would need 50,000 dental x-ray examinations to reach the 5-rad cumulative dose to the fetus. The decision to order films during pregnancy is a personal one. Because of the relatively low dose, it is not expected that there will be any harm to the fetus. However, many dentists elect to postpone the radiographic exposures, limiting to those needed to treat the patient during the pregnancy (symptomatic teeth or active decay).'
www.netwellness.org/healthtopics/dentalhygiene/dentalxrays.cfm

No...you do NOT take xrays of a pregnant patient.

30 year vet in Edmonton, Alberta said: No...you do NOT take xrays of a pregnant patient.

This is outdated knowledge based on unsound science. Disregard Edmonton Vet until she can show us a regulation or peer reviewed science to back up her claim. There is no law or regulation against xraying pregnant women.

If there is a pressing health concern that the doctor wants to investigate with an xray, you MUST take an xray. I might fire you if you refused in this situation, and the hygiene college would be right to reprimand you. If she is simply due for annual bitewings, it is OK to pospone xrays based on your office policy, but unwise for you to refuse to take the xrays if the doc and patient agree. Most times we do postpone xrays on a pregnant patient due to their own fears - there have been only a handful of times when xrays were needed immediately in my short career. I think the trend is towards scrapping the whole xray-postponement during pregnancy as science and technology march onward. The outdated regulations requiring lead aprons are slowly being rescinded also - esp in Europe.

Besides, we are hygienists. We can neither prescribe xrays, nor forbid them. Defer to the person with the authority and who is within their right to do so - the dentist!

Here is what the ADA says:
'Dental radiographs – Dental radiographs may be needed for dental treatment or a dental emergency that cannot be delayed until after the baby is born. Untreated dental infections can pose a risk to the fetus, and dental treatment may be necessary to maintain the health of the mother and child. Radiation exposure from dental radiographs is extremely low.'

www.ada.org/prof/resources/topics/healthcare_womens.pdf

Here is what the CDA says

'Pregnant patients requiring
essential and/or emergency treatment should receive the minimum number of radiographs
needed for diagnostic purposes.'

www.cda-adc.ca/_files/position_statements/xradiation.pdf

Of course we take the minimum necessary xrays on non-pregnant patients also. We do take xrays on pregnant women as indicated and prescribed by the dentist. End of story.

skrrrrrr in Victoria, British Columbia said: This is outdated knowledge based on unsound science. Disregard Edmonton Vet until she can show us a regulation or peer reviewed science to back up her claim. There is no law or regulation against xraying pregnant women.

If there is a pressing health concern that the doctor wants to investigate with an xray, you MUST take an xray. I might fire you if you refused in this situation, and the hygiene college would be right to reprimand you. If she is simply due for annual bitewings, it is OK to pospone xrays based on your office policy, but unwise for you to refuse to take the xrays if the doc and patient agree. Most times we do postpone xrays on a pregnant patient due to their own fears - there have been only a handful of times when xrays were needed immediately in my short career. I think the trend is towards scrapping the whole xray-postponement during pregnancy as science and technology march onward. The outdated regulations requiring lead aprons are slowly being rescinded also - esp in Europe.

Besides, we are hygienists. We can neither prescribe xrays, nor forbid them. Defer to the person with the authority and who is within their right to do so - the dentist!

Good info but again you are generalizing; in AB we have the right to prescribe them and it is within our right to do so.
I think ultimately it is up to the patient-informed consent.

1RDH in Airdrie, Alberta said: ; in AB we have the right to prescribe them and it is within our right to do so.
I think ultimately it is up to the patient-informed consent.

Interesting. In BC we've had 'independence' and the right to diagnose perio and prescribe perio tx, but not to prescribe or interpret xrays (although we do interp bones level). I guess this goes in tandem with the right to prescirbe Rx meds in AB also?

If the DDS ask you to take an x-ray you take it. If the pt refused then it is up the pt and make sure you write it in the chart. When I do have to take an xray on a pregnant pt I use 2 lead aprons on the pt. I did have one office were I refused to take x-rays. I told the office manager at the time that the x-ray unit was broke and I would have to stand in the room and hold it and take x-rays at the same time. It was an offsite clinic and there was only one lead apron for the pt to wear. Well the office manager at the time didn't tell the head manager this was going on and I was called in the office for refusal of x-rays. The DDS even knew it was broke and we got into it because I told him I was not standing in the room and holding the x-ray arm. It turned into a big mess because they were losing money from the x-rays but they refused to fix it. And I refused to take them. It didn't look good on my part so I had to call the state on them. Deep down I knew these x-rays had to be down but not at the expense of my health.

The follow-up issue is what to do if patients refuse necessary xrays.

In these cases, the best practice seems to be to dismiss them from the practice, including refusing dental hygiene treatment. We cannot meet standard of care without xrays. I had a patient a week ago that hadn't had an xray in 5 years, and kept promising to 'get it next time.' After doing all the patient Ed about it, having her sign an acknowledgement of the need for xrays and the risks of not getting them, I discussed it with the doc. Doc said go ahead with the cleaning, which I did, but I think I will follow up and make sure the patient is expelled if she refuses once more. I think the doc should have backed me up a bit more by talking with the patient.

Perhaps I should have been more adamant, and refused treatment during this recent appt - what do you think?

Hi skrrrrrr,
I worked in an office that had patients who had not had x-rays in 10 or more years. I was always trying to educate them on necessity for complete diagnosis and standard of care and got to the point of insisting on them signing refusal forms every time they refused. My doc would never back me up and when it got to the point on some of them that I was having to hold the teeth in place to scale for fear they'd fall out I said I could no longer practice with such low standards for patient health. Mind you I worked there 7 years. I got to the point also that I was afraid of consequences possibly to my license because I knew we should be dismissing them and holding ourselves to a higher accountability. It's difficult to refuse treatment if the doc isn't onboard.
By the way, I had an interview yesterday and thought of you. They wanted me to have treatment diagnosed and charted before the dr came in for the exam. I told him it's beyond the scope of our license and his comment "well, I know but everybody does it". I said "I don't". Needless to say, I didn't get it.

skrrrrrr in Victoria, British Columbia said: The follow-up issue is what to do if patients refuse necessary xrays.

In these cases, the best practice seems to be to dismiss them from the practice, including refusing dental hygiene treatment. We cannot meet standard of care without xrays. I had a patient a week ago that hadn't had an xray in 5 years, and kept promising to 'get it next time.' After doing all the patient Ed about it, having her sign an acknowledgement of the need for xrays and the risks of not getting them, I discussed it with the doc. Doc said go ahead with the cleaning, which I did, but I think I will follow up and make sure the patient is expelled if she refuses once more. I think the doc should have backed me up a bit more by talking with the patient.

Perhaps I should have been more adamant, and refused treatment during this recent appt - what do you think?

It is up to the doc, most dont want to lose goodwill. If a patient signs a waiver, I would think they would be released of
misdiagnoses in a law suit. Also, could take intra/oral pics.
Does it make the hygienist feel better though...nope.

Suzanne in Terre Haute, Indiana said:
By the way, I had an interview yesterday and thought of you. They wanted me to have treatment diagnosed and charted before the dr came in for the exam. I told him it's beyond the scope of our license and his comment "well, I know but everybody does it". I said "I don't". Needless to say, I didn't get it.

haha, Touché Suzanne ;) But then how is what you do different than Dental Assisting with the scaling module?

nojobs in Toronto, Ontario said: It is up to the doc, most dont want to lose goodwill. If a patient signs a waiver, I would think they would be released of
misdiagnoses in a law suit. Also, could take intra/oral pics.
Does it make the hygienist feel better though...nope.

I attended a seminar that focused on patients signing refusal forms for x-rays and perio tx. A pt sued and won because she didn't fully understand the long term consequences of her refusals due to her education level. She had only completed 8th grade and she argued that staff had allowed her to neglect her health. Something about approved negligence. The dr said he should have told her he couldn't approve or supervise her dental care knowing that she was ultimately agreeing to eventual loss of her dentition and possible other health issues because she was also a diabetic patient. She also said he agreed knowing he would make more money in the long run when she needed crowns instead of fillings. He said he should have dismissed her as a patient. But we went back to the office and nothing changed.

skrrrrrr in Victoria, British Columbia said: haha, Touché Suzanne ;) But then how is what you do different than Dental Assisting with the scaling module?

Assistants in IN cannot use hand scalers or an ultrasonic scaler. Just last June (08) they became eligibe to do coronal polishing and administer fl2 tx. I have heard there is legislation underway for them to be regulated to remove both hard and soft deposits above the gumline but I don't know how far along in the process it is. Hygienists are licensed to scale supra and subgingival calculus, root planing and curretage with or without anesthetic. I got on several websites for DA schools today out of curiosity and none of the curriculum had a scaling module. I wonder if they do allow it in the future how much theory they will have to learn and if they will have to be licensed as we are or if they will take a weekend course and get a certificate? Should be interesting.

30 year vet in Edmonton, Alberta said: No...you do NOT take xrays of a pregnant patient.

YES you do if required. Bacteria from infections enter the bloodstream, get in between the wall of the uterous & placenta & dislodge the placenta. The amount of radiation is insignificant to this senerio. informed consent is required though. If the patient is in for an emergency exam or is PAIN....the key word, you do what is required. LA is a different story, as there is no scientific proof that it crosses the placenta but there is know proof that it doesn't.

Suzanne in Terre Haute, Indiana said: Assistants in IN cannot use hand scalers or an ultrasonic scaler. Just last June (08) they became eligibe to do coronal polishing and administer fl2 tx. I have heard there is legislation underway for them to be regulated to remove both hard and soft deposits above the gumline but I don't know how far along in the process it is. Hygienists are licensed to scale supra and subgingival calculus, root planing and curretage with or without anesthetic. I got on several websites for DA schools today out of curiosity and none of the curriculum had a scaling module. I wonder if they do allow it in the future how much theory they will have to learn and if they will have to be licensed as we are or if they will take a weekend course and get a certificate? Should be interesting.

I was being tongue in cheek, of course. The scaling module is usually a CE course, but so far is only used in a couple states and provinces. Of course it doesn't cover the plethora of knowledge and advanced perio techniques that us RDHs get.

I am a bit unsure what you mean by 'diagnosing.' Do you mean you do not attempt to chart existing restorations, missing teeth, visible lesions on teeth (other than decay)? This is clearly within our scope in my province, and we had to do it on all patients in DH school (the school with 2 CDHA presidents as instructors, and some who sit on the board of examiners and board of eductors for all of Canada).

Diagnosing is telling the pt tooth #3 has a DO. You can chart it but you can't say the pt has it till the DDS said it first. I think dismissing the pt because of refusal of xrays is so OM. Some people have a fear of radiation, amalgam, and fluoride. The proper way to handle it is to tell the pt the benefits of x-rays and why we need them, have the pt sign an xray refusal letter, and document it in the chart. You should still ask at every appt. Most pt's will if they end up with problem. I had pt's bring their own water because of their phobia of water in the dental office. 20/20 had something on there about the water in the dental offices. Are you suppose dismiss those pt's too? Or what about those pt's who take x-rays but refuse to do tx because of cost. I guess they get dismissed too.

skrrrr aren't you suppose to be working? Prime example of OM on the computer instead of working. I guess being married to the boss has it's perks!!!!!!!!!!!!!!!!!!!1

hyg sucks in Richmond, Virginia said: skrrrr aren't you suppose to be working? Prime example of OM on the computer instead of working. I guess being married to the boss has it's perks!!!!!!!!!!!!!!!!!!!1

Today is the day of Remembrance for our fallen soldiers, so most Canadians are off of work. The difference is I don't get paid today, but all our staff does get paid full wages for this day off, which is a great perk for them.

hyg sucks in Richmond, Virginia said: Diagnosing is telling the pt tooth #3 has a DO. You can chart it but you can't say the pt has it till the DDS said it first. I think dismissing the pt because of refusal of xrays is so OM. Some people have a fear of radiation, amalgam, and fluoride. The proper way to handle it is to tell the pt the benefits of x-rays and why we need them, have the pt sign an xray refusal letter, and document it in the chart. You should still ask at every appt. Most pt's will if they end up with problem. I had pt's bring their own water because of their phobia of water in the dental office. 20/20 had something on there about the water in the dental offices. Are you suppose dismiss those pt's too? Or what about those pt's who take x-rays but refuse to do tx because of cost. I guess they get dismissed too.

There is significant discussion about this among dentists. It may be considered malpractice, and a letter of consent to decline xrays may not be enough to protect the doctor from a malpractice suit or discipline from the regulatory board. A doctor must dismiss a worker who refuses to maintain standard of care.

No Hyg should be diagnosing decayed surfaces and Rx Tx, I wanted to just see what Suzanne is talking about - sounded like recording existing fillings is off-limits in her view?

skrrrrrr in Victoria, British Columbia said: This is outdated knowledge based on unsound science. Disregard Edmonton Vet until she can show us a regulation or peer reviewed science to back up her claim. There is no law or regulation against xraying pregnant women.

If there is a pressing health concern that the doctor wants to investigate with an xray, you MUST take an xray. I might fire you if you refused in this situation, and the hygiene college would be right to reprimand you. If she is simply due for annual bitewings, it is OK to pospone xrays based on your office policy, but unwise for you to refuse to take the xrays if the doc and patient agree. Most times we do postpone xrays on a pregnant patient due to their own fears - there have been only a handful of times when xrays were needed immediately in my short career. I think the trend is towards scrapping the whole xray-postponement during pregnancy as science and technology march onward. The outdated regulations requiring lead aprons are slowly being rescinded also - esp in Europe.

Besides, we are hygienists. We can neither prescribe xrays, nor forbid them. Defer to the person with the authority and who is within their right to do so - the dentist!

If your R.D.H. is a good employee, and refuses to do this, you would fire her? Why not make the Dr. and the Pt. happy and you two take this responsibility and have the Dr. take the x-ray....then if their is a problem with the PG pt. it is the Dr.'s shoulders of litigation....as the R.D.H. would write in her notes:" Dr.....took and X-ray of tooth....". This would help all three: Dr., pt. and R.D.H. With the way things are going in the Hygiene field, and many more pt's "willing to sue a practice" , this I feel is the best scenario....R.D.H.'s have enough to worry about just finding employment.....

exp in Massachusetts said: If your R.D.H. is a good employee, and refuses to do this, you would fire her? Why not make the Dr. and the Pt. happy and you two take this responsibility and have the Dr. take the x-ray....then if their is a problem with the PG pt. it is the Dr.'s shoulders of litigation....as the R.D.H. would write in her notes:" Dr.....took and X-ray of tooth....". This would help all three: Dr., pt. and R.D.H. With the way things are going in the Hygiene field, and many more pt's "willing to sue a practice" , this I feel is the best scenario....R.D.H.'s have enough to worry about just finding employment.....

Do Docs know how to take a good xray? I have never seen a doc take an xray to date. I would not want the docs I know taking an xray on me because the DAs and HYG are more skilled at this and far less likely to make errors/do retakes.

I think in the OP's case, it is time that the doc sat down with the RDH and show the scientific evidence and the regulations, and give her a 2nd chance. There needs to be a discussion about it, and to listen to what the RDH has to say about the situation. If she ignores this and continues to refuse to do her job duties, then what kind of employer would I be if I didn't fire her? If she was refusing to probe patients at every recall visit, she would get fired. If she was leaving subG calc and refused to change, she would be fired. In the xray situation it is worse than just refusing to do her job, though - it is misleading to the patient by implying it is unsafe to take xrays on a pregnant woman, which undermines the patient's confidence in the practice and understanding of the safety of xrays.

skrrrrrr in Victoria, British Columbia said: Do Docs know how to take a good xray? I have never seen a doc take an xray to date. I would not want the docs I know taking an xray on me because the DAs and HYG are more skilled at this and far less likely to make errors/do retakes.

I think in the OP's case, it is time that the doc sat down with the RDH and show the scientific evidence and the regulations, and give her a 2nd chance. There needs to be a discussion about it, and to listen to what the RDH has to say about the situation. If she ignores this and continues to refuse to do her job duties, then what kind of employer would I be if I didn't fire her? If she was refusing to probe patients at every recall visit, she would get fired. If she was leaving subG calc and refused to change, she would be fired. In the xray situation it is worse than just refusing to do her job, though - it is misleading to the patient by implying it is unsafe to take xrays on a pregnant woman, which undermines the patient's confidence in the practice and understanding of the safety of xrays.

Skrrr, Many Dr.'s "do know how to take a good x-ray", they had to learn in school and many here in the states take there own if needed. What would your wife do if the R.D.H. and the D.A. were out sick....would you be taking the x-ray for her? Many, PG pt's and R.D.H.'s , I think , still feel that x-rays can wait til the baby is born....and I feel that if the Dr. insists on the film, he/she should take it if it is absolutely necessary to THEM. If you were a woman and PG you might think differently, but you are a man so....

.. so you're more likely to believe in make-believe, not science?

skrrrrrr in Victoria, British Columbia said: .. so you're more likely to believe in make-believe, not science?

Dr.'s in BC ....you don't trust them to take x-rays? Does your wife know how to take them....I'm sure she does and well , I'm sure....so you didn't answer the question: if by chance the D.A. and R.D.H. were out sick and the Dr. was the only one to take the x-ray...then what happens? Do you take them? (Do you still have your license....)? Again, I reitterate, you are not a woman and so if it were you....wouldn't you rather wait if it could til after you had your baby?

My wife would be PO'd if a staffer decided to stand there and refuse to do a necessary xray. I'm not so sure she could get a good Post PA on her own, esp with our digital xrays. I don't think she's taken more than a handful since dental school 9 yrs ago - and in school they were usually taken by DAs.

I take dozens of xrays every week, being careful to keep the head aimed away from my gonads, and following the regs and CDA advisories. I also make sure the staff don't take more than 4000 xrays on my own teeth in one year, because that is the max allowable yearly limit ;) I would imagine taking only 1000 or so would be more than safe for a pregnant woman, even my wife, though so many xrays would never actually be done.

It is still up to the patient to consent, of course.

if the DA and all the RDHs are away from work, the office is effectively closed. If there is an emerg patient on closed days, I take the xray, or we bring in a DA. Doc can choose to do whatever she wants - she doesn't pull teeth nor place implants either (We have associate doc for that).

I'll just add that my wife and I think very highly of hygeinists. Never run into difficulty with them, and she has given them plenty of lattitude to practice as they wish. Generally, there has been nothing but amicable relations between the doc and the RDHs in her 9 years.

skrrrrrr in Victoria, British Columbia said: This is outdated knowledge based on unsound science. Disregard Edmonton Vet until she can show us a regulation or peer reviewed science to back up her claim. There is no law or regulation against xraying pregnant women.

If there is a pressing health concern that the doctor wants to investigate with an xray, you MUST take an xray. I might fire you if you refused in this situation, and the hygiene college would be right to reprimand you. If she is simply due for annual bitewings, it is OK to pospone xrays based on your office policy, but unwise for you to refuse to take the xrays if the doc and patient agree. Most times we do postpone xrays on a pregnant patient due to their own fears - there have been only a handful of times when xrays were needed immediately in my short career. I think the trend is towards scrapping the whole xray-postponement during pregnancy as science and technology march onward. The outdated regulations requiring lead aprons are slowly being rescinded also - esp in Europe.

Besides, we are hygienists. We can neither prescribe xrays, nor forbid them. Defer to the person with the authority and who is within their right to do so - the dentist!

Skkrrrr....I realize you post VERY frequently on all of these threads........

We do not take xrays--BWS routinely on our pregnant patients. Obviously, if there is an EMERGENCY or AN INFECTION and absolutely NECESSARY DENTISTRY HAS TO BE DONE FOR THE PATIENT in an acute situation, we will take a PA, but ROUTINELY, we DO NOT take xrays on our pregnant patients and if you were to ask all the dentists who work in our office the question, they would all say NO, we don't take routine xrays on pregnant patients. Regular cleanings during pregnancy is our routine in our office and IF any acute situation presented itself, we would advise the DDS and possibly do a PA if necessary.

Skrrr, Your wife should take a course or you, can show her how to get the best angle for "all PA/bw's". Many Dr.'s take there own films/digital x-rays....what else does she feel that she can't do, and NEEDS an R.D.H. or D.A. for? It may be the case someday, so what will she do? Again, you are not a female...if you were a woman, I feel you would feel different about having an x-ray taken while PG. (The comment on your privates.....not necessary)...

skrrrrrr in Victoria, British Columbia said: There is significant discussion about this among dentists. It may be considered malpractice, and a letter of consent to decline xrays may not be enough to protect the doctor from a malpractice suit or discipline from the regulatory board. A doctor must dismiss a worker who refuses to maintain standard of care.

No Hyg should be diagnosing decayed surfaces and Rx Tx, I wanted to just see what Suzanne is talking about - sounded like recording existing fillings is off-limits in her view?

I do chart existing restorations on new patients, along with missing teeth. I may even tell the pt dr will probably rec a bridge or a partial, or maybe a crown. But I'm leaving the diagnosis to him/her. That's as far as I'll go. Then afterward, I'm happy to explain the procedure or why it's rec.