I went in for a routine dental cleaning. It was never provided.

I’ve spent my career on multiple sides of health care, independent practice, hospital-owned systems, and health insurance, which has made me acutely aware of how incentives and operational norms can quietly shape care. Still, what happened during this visit surprised me.

After I was brought back to the exam room, I was told bitewing X-rays would be taken before the cleaning. I explained that I had undergone full-mouth dental radiographs within the prior several weeks at the same dental practice and preferred to defer additional imaging at this visit.

My reasoning was straightforward: I was asymptomatic, low risk, meticulous about oral hygiene, had no dental caries for more than 20 years, and was trying to avoid unnecessary cumulative radiation exposure.

What followed caught me off guard.

I was told the cleaning could not proceed without X-rays. When I pushed back, politely and clinically, the hygienist said that proceeding without them could put her license at risk.

That was the moment the visit changed. Not because of disagreement, but because of framing.

I asked to speak with the supervising dentist, my dentist. After some discussion, it was acknowledged that evidence-based guidance, including recommendations from the American Dental Association, does not require radiographs as a condition for routine dental cleanings. X-rays are recommendations, based on individual risk and clinical judgment, not time-based mandates.

Despite that acknowledgement, I was told the practice requires imaging on a fixed two-year cadence, even though I was still within that window. Since I declined X-rays and asked to speak with the dentist, I was then told there was no longer time to complete my cleaning that day. I was offered the option to return less than a month later for X-rays, followed by a cleaning.

At its core, this was not a dispute about dentistry or radiation exposure. It was about something familiar to anyone who works in health care: what happens when evidence-based guidance collides with rigid policy, operational norms, and predictable systems, and the patient says no.

Informed refusal is not refusal of care

Informed consent is foundational to health care ethics. Less often discussed, but equally important, is informed refusal, the patient’s right to decline an intervention after understanding its risks and benefits.

Declining a non-mandatory diagnostic test should not, by itself, foreclose access to routine care. Yet in practice, refusal often triggers something else entirely: a system response.

What I experienced was conditional care. More plainly, it was denial of care. The message, intended or not, was clear: Compliance was required to proceed.

This dynamic is not unique to dentistry. Across health care, “recommended” quietly becomes “required,” not because the evidence changed, but because workflows harden around it. In my case, the evidence is clear: Multiple reviews show no outcome benefit to routine imaging in low-risk, asymptomatic adults.

How systems, not individuals, shape these moments

It’s tempting to assign blame to individuals in these encounters, but that misses the point. Most clinicians are acting in good faith inside systems that reward standardization and predictability.

In dentistry, diagnostic imaging is separately billable and often reimbursed on predictable schedules. Cleanings alone tend to carry thinner margins. Imaging also provides documentation that feels protective in a liability-conscious environment. From an operational standpoint, fixed policies reduce variability and keep schedules moving.

None of this is nefarious. But it does create strong incentives for imaging to become routine, even in low-risk, asymptomatic patients, despite guidance that explicitly discourages one-size-fits-all use.

Over time, the distinction between “clinically indicated” and “operationally preferred” blurs. Front-line staff are left enforcing policies they may not have helped design. Patients experience those policies as mandates. Trust erodes quietly.

Why the licensure framing matters

What troubled me most was not the preference for X-rays, but the invocation of licensure risk to enforce compliance.

Telling a patient that a clinician’s license is at stake if care proceeds after informed refusal introduces pressure that undermines shared decision-making. It shifts the conversation away from individualized risk assessment and toward institutional self-protection. Patient-centered care is lost.

Even when unintended, that framing can feel coercive. It places the burden of absolute compliance on the patient while holding routine care hostage, not because patient choices are unsafe, but because the system is uncomfortable accommodating reasonable deviation.

That is a fragile place for trust to live.

Preventive care should not be transactional

Preventive care works best when it is collaborative, flexible, and grounded in individualized risk, not when it becomes transactional.

When patients feel that routine services are contingent on acquiescing to non-mandatory interventions, they may disengage. Some delay care. Others hold to their convictions and forgo care entirely. A few quietly comply while feeling unheard. None of those outcomes serve the long-term goals of prevention.

The irony is that evidence-based guidance already gives clinicians the latitude to individualize care. The problem is not the absence of standards; it is the difficulty of practicing them inside systems optimized for throughput and predictability.

A broader lesson for health care

Dentistry, in this case, is not the villain. It’s a microcosm of modern health care.

Across health care, we see the same tension: guidelines designed to support clinical judgment colliding with policies designed to reduce variability. When the latter win by default, patient-centered care becomes conditional.

The answer is not to abandon standardization, nor to vilify clinicians operating within it. The answer is to be honest about where incentives and convenience have overtaken nuance, and to recommit to the distinction between recommendations and requirements.

If we want patients to trust evidence-based medicine, we have to practice it even when it complicates workflow. Especially when a patient says no.

Aaron S. Rosenberg is a patient advocate.