Hygienist taking dental X-rays of womanWould I like to have some x-rays? I can’t think of why I would say yes to this question unless given a very good reason to allow ionizing radiation go through my body. X-rays are to be prescribed… not offered like a restaurant menu option.

Last month I had my annual dental check up. I choose to go every 12 months because I am at low risk of developing dental caries and gum disease. I eat healthy, very little processed foods or sweet drinks and I almost never snack. Flossing and brushing? You bet: after every meal, religiously. That’s 3 times per day. Every time I brush I use the 2 minute timer (sometime 3 minutes) on my Phillip Sonicare electric toothbrush. My technique is excellent. Even after 12 months, I have little to no plaque or tartar on my teeth and all my probing measurements are 3 millimeters or less, indicating super healthy gums!

Here is how the conversation with the hygienist went at the beginning of last month’s visit. Let’s call her Mary (not her real name for the sake of privacy)

Mary: Would you like to have some x-rays today?

Interesting question. I have never seen Mary before. She doesn’t know that I am dentist. As a matter of fact, I have never seen the same hygienist since I became a patient in this practice. With the way this new visit is starting, I am seriously considering looking for a new dental practice. So I decide not to inform Mary of my professional background and reply:

No. Why do you ask? – Do you know of anyone who would LIKE to have x-rays? I think to myself.

Mary: Well, it’s been 1 year since your last X-rays.

Me: Yes I know. Why do you recommend x-rays today?

Mary: Actually, we recommend x-rays every 6 months.

Me: Really? That seems like a lot. Why so often?

Mary: Well… cavities can develop pretty fast.

Me: What if I told you that I haven’t had a cavity for more than 10 years. Would you still recommend x-rays for me today?

Mary: Yes. One year is a long time and you have many fillings and crowns in your mouth. Without x-rays I can’t tell if you have cavities starting under your fillings or crowns.

With x-rays your dentist can see between teeth and under fillings

Mary is right! With her naked eyes, she can not see between my teeth or under my fillings and I do have many fillings in my mouth. All together, 15 of my teeth have been restored, including 2 crowns and one root canal treatment. Except for one upper incisor fractured in a horse related accident, all of the other teeth were initially filled before I turned 20.

When I entered dental school I had what appeared to be perfect teeth: not a single filling. But the first set of x-rays ever taken of my teeth, at the beginning of my first year in dental school, revealed tooth decay between almost all of my back teeth. I had never heard about floss and although I brushed every day, I didn’t brush after every meal and I certainly never brushed for 2 minutes. I know that because the first time I used a timer, I suspected a malfunction: 2 minutes couldn’t possibly be that LONG!

Dental x-rays must be prescribed according to your risk level.

Young girl having a dental x-raysX-rays are a great diagnostic tool but there are clear rules to follow when prescribing them. Dentists must first examine the patient, then justify and optimize the use of radiation based on the ALARA principle (As Low As Reasonably Achievable). My childhood dentist who never took a single x-ray of my mouth and the dental practice I am about to leave who recommends x-rays every 6 months are extreme examples of poor justification and optimization.

The fact that I have many fillings in my mouth is an indication of possible high risk which could justify Mary’s desire to take x-rays. However, this is a past history that goes back more than 10 years. A history that should have prompted my childhood dentist to take x-rays of my apparently pristine teeth when I was a teen. Had he done that, I may not have a root canal treatment or crowns today. I would have saved a lot of money too.

Decision process for recommending dental x-rays

My current context is low risk: no decay for the past 10 years. All probing depths 3 mm or less, 2 hours or more between snacks and meals, brushing and flossing 3 times per day, using fluoridated toothpaste. In this light, my dentist should have based his prescription for x-rays at my last dental visit  on this context: recommendations based on my individual risk level… not a cookie cutter approach.

In its recommendations paper titled: DENTAL RADIOGRAPHIC EXAMINATIONS: RECOMMENDATIONS FOR PATIENT SELECTION AND LIMITING RADIATION EXPOSURE which was revised in 2012, the American Dental Association clearly outlines the decision process for radiographic recommendations on pages 5 and 6.

Along with the above mentioned recommendation, there is a Risk Assessment Form available online. In my specific case, when combining the two documents, the recommendations for x-ray is every 24 to 36 months… a very different recommendation from what Mary wanted to do.

Know your risk level

Next time you go to your dentist, show up informed. Know your risk level. Radiation is serious business: your dentist must optimize her prescription for x-rays according to your very own risk level and / or circumstances… NEVER a cookie cutter approach. Ask your dentists what risk level (s)he has assigned to you. If it doesn’t match your assessment, ask why. If your risk level is high, ask your dentist what steps you can take to improve your situation and reduce the need for x-rays in the future.

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