Time to Ditch the Lead Apron? The Evidence Says Yes.

Note from Amanda: This post first appeared on my previous blog on December 11, 2023, and has been updated for clarity and context.

The American Dental Association recommends against using lead aprons for dental X-rays. They said as much in a September 2022 position statement. I read that statement, thought it far-fetched, and went on my way.

Until I had a radiology technician as a patient due for her annual bitewings.

"I don't want it," she said as I reached for the lead apron.

I turned around, head cocked.

”We don't use them anymore. They cause more harm than good."

I mentioned it to my husband at dinner that night. He brought home a brochure from the hospital where he works the next day. The brochure explained why they are no longer using lead aprons. World-renowned medical facilities, organizations, and publications recommend we break up with lead aprons. Change is difficult anywhere, but with patients already dubious about taking dental X-rays, offices are hesitant to ditch the lead and cause a fuss.

Let's see if we can't remove some of the hesitancy, shall we?

I’ll start at the beginning.

German physicist Wilhelm Roentgen observed the first X-ray on November 8, 1895. By mid-January 1896, "X-ray mania" was in full swing.

At the time, producing a single film required seventy-five times the current recommended annual radiation dose. Signs of damage began to emerge, and reports of sunburn and hair loss surfaced. That discovery led to the development of radiation therapy for hair removal because humans will be humans. We're nothing if not predictable and vain.

Despite our inherent vanity, reason won out, and radiation protection became an increasingly popular subject of research. Protective equipment emerged in 1905, including heavy lead aprons, thick gloves, and radiation-proof enclosures for X-ray tubes. However, this protective equipment wasn't for the patients exposed to the X-rays; it was intended for the workers who came in contact with radiation: the medical providers and the technicians who worked on the machines.

It wasn't until the 1950s that we began shielding the reproductive organs of patients before exposing them to X-rays—after research proved that the radiation was responsible for altered DNA in fruit flies.

Which brings us to today, where we still operate under the same assumptions as in the 1950s. But continuing to use lead aprons in a modern radiographic landscape isn't just outdated—it may increase the risk to our patients.

Today, there are a growing number of organizations advocating against lead apron use.

• American Academy of Oral and Maxillofacial Radiology
• American Association of Physicists in Medicine
• American College of Radiology
• American Dental Association
• International Commission on Radiological Protection
• National Council of Radiation Protection and Measurements
• Society for Pediatric Radiology

Why would so many organizations recommend doing away with lead aprons?

Remember those fruit flies we talked about earlier? Well, first off, they're fruit flies. They are about 500 times smaller than the average human. And they were being dosed with extremely high amounts of radiation, even by human standards. Yet, no hereditary effects have ever been observed in humans, regardless of the dose size.

We have known since the 1970s that diagnostic radiation doses do not cause tissue changes or damage, nor does it affect fertility. The only reason we've been using shields since then is to prevent gene mutations in future generations. Which, of course, we now know isn't a risk, even at the radiation levels necessary to produce a diagnostic image in the 1970s.

Also, radiation exposure to anatomy outside the field of view stems almost exclusively from the internal scatter radiation generated inside the human body. Lead aprons do not prevent or protect against this internal scatter radiation, making them fairly useless.

OK, but what about pregnant women? We still shouldn't take X-rays on them, right? Or at least use two lead aprons over the fetus?

According to the data, there is little to no risk to a developing fetus with doses under 100mGy. The dose of radiation the fetus receives is only four mGy—and that's if we're pointing the primary beam directly at the fetus. Why would we do that? I don't know. We shouldn't. Let's not.

Instead, the amount of radiation the fetus is exposed to when mom is having a dental X-ray is less than 0.01. By the way, that's for all dentomaxillofacial imaging methods including CBCT, according to the American Academy of Oral and Maxillofacial Radiology.

Maybe they aren't necessary anymore, but lead aprons make our patients feel safe. Shouldn't we just keep using them? I mean, they aren't hurting anything, right?

Wrong.

There are several powerful arguments against lead aprons.

• The Infection Control Argument revolves around their potential for microbial contamination, difficulty in cleaning, shared use, and the risk of cross-contamination.
• The Trapped Scatter Argument says that the scatter radiation generated inside our bodies has the potential to get trapped between our bodies and the lead apron instead of being allowed to escape and dissipate.
• The Unnecessary Retakes Argument is based on the thyroid collar's tendency to get in the way and block crucial anatomy from view—necessitating a retake, and more exposure to radiation.
• The Automatic Exposure Control Argument is my personal favorite argument against lead aprons. It's nerdy and compelling.

Automatic exposure control was introduced in the 1950s, and by the early 1970s, it was standard on all new X-ray machines. It does just what it sounds like; it automatically controls the amount of exposure (radiation) to produce a diagnostic image regardless of patient size, density of structures, etc. And it does this all while using the smallest amount of radiation possible. Which is great.

Unless there is a structure (such as part of a lead apron) in the beam's path, the beam is having difficulty penetrating. Because in that instance, the machine will increase radiation exposure, even though you and I both know that it will never penetrate that lead.

Even if the lead isn't obscuring anatomy, you'll likely have an image that is too dark to be diagnostic due to the increased radiation. You'll have to retake it anyway, leading to even more radiation.

Wow, that IS compelling! So why are we still using lead aprons?

Excellent question! But honestly? There isn’t a great answer. Except in California, New York, and Texas, where state law still requires lead aprons.

Everywhere else, it mostly comes down to old habits, a lack of understanding, and a healthy dose of fear—mainly of patient pushback.

Are these good reasons to continue the status quo despite evidence that we could be hurting our patients?

Of course not! What's next?

Start with an email and/or text blast. Keep it simple but informative. Keep fliers in the waiting room and operatories. When a patient presents for X-rays, explain that the facility has made the educated decision to no longer use lead aprons because evidence shows that they provide little to no benefit while increasing patient risk. Answer any questions they have; address their concerns.

Keep a lead apron on the premises for pregnant and apprehensive patients. But take the opportunity to educate them and allow them to make an informed decision.

I never thought lead aprons would become obsolete in my lifetime—but here we are. Our patients trust us to keep them safe. And that includes knowing when to let go of old customs that no longer serve us.

"If the sources of reason and wisdom in the community are silent, only irrational and foolish voices will be heard" —William R. Hendee, PhD

Let's not be silent. Let's be wise. Let's stay on top of evolving technology and research because, as ancient Greek philosopher Heraclitus once said, "the only constant in life is change." We need to advocate for our patients because we have the information they don't have to advocate for themselves.

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