Do Lead Aprons Still Have a Place in the Dental Office?
In September, I read a position statement from the ADA regarding the discontinuation of lead apron use. I scanned the article, thought it far-fetched, and went on my way. A couple weeks later, I was preparing to take X-rays on my patient, a radiology tech. As I reached for the lead apron, she stopped me, saying, “I don’t want it.” I turned back towards her, only mildly confused. She continued, “I’m an X-ray tech, and we no longer use lead aprons because they cause more harm than good.” Remembering the statement from the ADA, I replied enthusiastically that I was just learning how lead aprons might be a thing of the past. She told me that at least two hospital systems in our area had completely done away with lead aprons - even for pregnant women. While walking the dogs with my husband that night, I asked if he could find out if they were still using them at the hospital where he works. His response was flippant: “Won’t the answer obviously be ‘yes?’” I rolled my eyes as I told him that the answer was actually very likely to be “no.” The next day, he brought home the brochure from his hospital explaining why lead aprons are no longer used. So, all hospital systems in my area and countless world-renowned medical facilities, organizations, and publications recommend we break up with lead aprons. Of course, dentistry is always one of the last to any party. However, my father instilled in me a strong sense of punctuality. Consider this my attempt to get to the party fashionably instead of embarrassingly late.
The first X-ray was observed on November 8, 1895, in the laboratory of German physicist Wilhelm Roentgen. Mysterious crystals, the glow from which could not be hindered by the various materials Roentgen used to attempt blocking them. A discovery that, at the time, was so far off the radar that the London Standard wrote, with regards to the revelation, “The Presse assures its readers that there is no joke or humbug in the matter. It is a serious discovery by a serious German Professor.” Seven weeks passed from when Roentgen discovered the first X-ray to when he came out of hiding in his laboratory and shared his discovery with the world. It did not take long for the world to catch on, and by mid-January 1896, “X-ray mania” was in full swing.
At the time, a single X-ray required seventy-five times the current recommended annual radiation dose. It wasn’t long before signs of damage began to emerge. The same year, physicist Elihu Thomson suspected that X-rays weren’t entirely benign and intentionally exposed his pinky finger to the beam of an X-ray tube over several days to prove it. When his finger swelled and became stiff and painful, he took to alerting others of the potential dangers of X-rays. Today’s dentists would have cautioned Thomson that if something hurts, he should stop doing it. Reports of sunburn and hair loss, among other things, soon surfaced. Unfortunately, humans will be humans, and that discovery led to the development of radiation therapy for hair removal. 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 shortly after the first German Radiology Congress in 1905. This included heavy lead aprons, thick gloves, and radiation-proof enclosures for the X-ray tubes, which previously hung freely and exposed, allowing harmful radiation to be emitted in all directions. This protective equipment was intended for the workers who came in contact with X-rays: the medical providers and the technicians who worked on the machines.
We began shielding the reproductive organs of patients before exposing them to X-rays in the 1950s after research proved that the radiation was responsible for altered DNA in fruit flies. In 1950, the International Commission of RadiologicalProtection “strongly recommended that every effort be made to reduce exposures to all types of ionizing radiations to the lowest possible level.” In 1966, the same commission introduced us to the concept we now know as ALARA - As Low As Reasonably Achievable.
And that brings us to today, where we still operate under the same assumptions as in the 1950s. Coincidentally, this closely matches the narrative of Delta Dental, where we set the costs for dental care and haven’t seen much progress since. The low reimbursement rates, despite skyrocketing expenditures, are costing dentists their livelihoods; the continued use of lead aprons when everything else about radiography has advanced in the last 70-plus years might be at the expense of our patients’ safety.
Today, there are a growing number of organizations advocating for the end of the lead apron, including the American Association of Physicists in Medicine, National Council of Radiation Protection and Measurements, International Commission on Radiological Protection, American College of Radiology, Society for Pediatric Radiology, American Academy of Oral and Maxillofacial Radiology, and the American Dental Association, just to name a few.
Why would so many organizations and institutions 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. A 2007 publication of the International Commission on Radiological Protection (ICRP) revealed that “no human studies provide direct evidence of a radiation-associated excess of heritable disease.” We have known since the 1970s that radiation at doses necessary for diagnostic imaging does 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 seventies.
Also of note is the fact that radiation exposure to anatomy located outside of the Field of View stems almost exclusively from the internal scatter radiation generated in 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? All the data shows that doses under 100 mGy pose little to no risk to a developing fetus. As a point of reference, even if the fetus were in the primary beam, the fetal dose is less than 4 mGy. According to the American Academy of Oral and Maxillofacial Radiology, “In all modalities of dentomaxillofacial imaging, including CBCT, the fetus is well outside the field of imaging and radiation dose is less than 0.01 mGy.”
I’d be remiss not to mention the advances in digital radiography that have allowed a vast reduction in the amount of radiation necessary to produce a diagnostic image. But we’re all pretty well versed on that subject, including most patients, so I won’t dwell on it here.
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 a few arguments against lead aprons that I’ve heard before and that have never fully compelled me, such as the infection control argument, the trapped scatter argument, and the unnecessary retakes argument. And sure, these arguments are valid. But it wasn’t until I read the “automatic exposure control” argument that I was entirely on board.
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 obviously a fantastic thing. Unless there is a structure (such as part of a lead apron) in the path of the beam, that 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 undiagnostic image due to the increased radiation, and you’ll have to retake it anyway, leading to even more radiation.
Why are we still using lead aprons? That’s a good question. A 2017 survey of radiology technicians by the Advanced Health Education Center (AHEC) asked what they would do if the facility they worked for introduced a policy of no patient shielding. 86% of respondents stated they would “continue to shield patients even if their facility changed the policy.” One percent went to far as to say they would quit their jobs. Patients are accustomed to being draped with the heavy lead prior to X-ray examination. Most of our patients don’t know any other way. Are these good reasons to continue the status quo despite evidence that we are hurting our patients?
The American Academy of Oral and Maxillofacial Radiology recommends that “patient gonadal and fetal shielding during diagnostic intraoral, panoramic, cephalometric, and CBCT imaging should be discontinued as routine practice.” Of course, there will be pushback from our patients and even some colleagues. William R. Hendee, Ph.D., a highly reputed radiology professor and dean, was quoted as saying, regarding public perception of radiation risk, “If the sources of reason and wisdom in the community are silent, only irrational and foolish voices will be heard…enough examples of these effects exist today in our society to suggest that reasonable voices have been silent long enough.” Oh, and by the way, this was published in 1991.
Preempting any concerns from the patient should prove to make this transition less awkward for everybody. Start with an email and/or text blast. Keep it simple but informative. Keep fliers in the waiting room and patient operatories. When a patient presents for X-rays, explain to them that the facility has made the educated decision to do away with lead aprons because evidence shows that they provide little to no benefit while increasing patient risk. Answer any questions they have; address their concerns. The first six months to a year are always the most difficult with any change in the dental office, but we have to give our patients the benefit of the doubt. We have to believe in their ability to make informed decisions. As with all things, there are special circumstances to consider. Pregnant and apprehensive patients should be counseled on the adverse effects of lead aprons but allowed to use them if they still choose.
As a middle-aged dental hygienist, it never occurred to me that lead aprons could become obsolete in my lifetime, and yet here we are. I know many will be skeptical and hesitant. But soon, our patients will question us for using lead aprons because everyone around us has stopped and with good reason. Think about it. Who do you suppose our patients trust more - their dentist or their physician? It’s unfortunate and unfounded, but let’s not give them more fuel for their fire.
Anonymous. “AAPM Position Statements, Policies and Procedures - Details.” AAPM.Org, American Academy of Physicists in Medicine, 2 Apr. 2019, www.aapm.org/org/policies/details.asp?type=PP&id=2552.
Anonymous. “What Would You Do? Stop Shielding Your Patients?” Https://Www.Aheconline.Blog.Com, Advanced Health Education Center, 15 Jan. 2018, aheconline.blog/2018/01/15/what-would-you-do-stop-shielding-your-patients/.
Benavides, Erika, et al. “Patient Shielding During Dentomaxillofacial Radiography.” The Journal of the American Dental Association, vol. 154, no. 9, 2023, doi:10.1016/j.adaj.2023.06.015.
Boice, John, et al. “Evolution of Radiation Protection for Medical Workers.” The British Journal of Radiology, vol. 93, no. 1112, 2020, doi:10.1259/bjr.20200282.
Conca, James. “Why You Should Ditch That Lead Apron in the X-Ray Room.” Forbes, Forbes Magazine, 14 Apr. 2022, www.forbes.com/sites/jamesconca/2020/01/28/ditch-that-lead-apron-in-the-x-ray-room/?sh=781a77873bd5.
Marsh, Rebecca M., and Michael Silosky. “Patient Shielding in Diagnostic Imaging: Discontinuing a Legacy Practice.” American Journal of Roentgenology, vol. 212, no. 4, Apr. 2019, doi:10.2214/ajr.18.20508.
Schusser, Manuel. “Light and Shadow - How We Learned to Rein in the Risks of X-Rays.” Siemens Healthineers MedMuseum, 1 Sept. 2021, www.medmuseum.siemens-healthineers.com/en/stories-from-the-museum/radiation-protection.
Zenger, Ingo. “‘Röntgen Must Have Gone Mad.’” Siemens Healthineers MedMuseum, 8 Nov. 2022, www.medmuseum.siemens-healthineers.com/en/stories-from-the-museum/roentgen-gone-mad. Accessed 04 Dec. 2023.
Comments
Post a Comment