Since the 1920s, lead vests and aprons have served as trusted shields against the harmful effects of X-rays for radiologists, technicians, and patients. But new safety guidelines from the American Dental Association (ADA) call for discontinuing their use among patients, both because X-ray technology has evolved significantly over the years, and because there are better ways to reduce patients’ exposure to radiation, such as using digital as opposed to conventional X-ray film.
Other medical organizations have been making similar points for some time. In 2019, the American Associations of Physicists in Medicine concluded that the use of patient lead aprons should be discontinued as they were both unnecessary for safety and had the potential to jeopardize the quality of images. In 2021, the American College of Radiologists also recommended discontinuing lead shielding.
Lead aprons and other lead shields provide “no additional benefit to the patient except for some psychological comfort,” said Mahadevappa Mahesh, a professor of radiology and cardiology at Johns Hopkins University and a chair of the American College of Radiology Commission on Medical Physics. It’s still recommended that doctors and technicians wear lead garments if they’re working in rooms where X-rays are delivered.
But safety practices can linger even after technological advances render them outdated — so it’s reasonable to think that some patients and practitioners may be reluctant to let lead armor go. Mahesh said it will take time to educate dentists and convince them to discontinue use of the shields, as has been the case with other medical professionals.
“This is a legacy practice,” he said. X-ray technicians and radiologists were trained to have patients wear lead shields for their protection, and it takes time to learn to do things differently. “There seem to be pockets of resistance … so I foresee the same type of resistance [among dentists] also.”
Letting go of lead armor
Lead vests and other shields, such as thyroid collars, are meant to protect patients against scattered radiations. But modern X-ray machines are designed to restrict the beam so it only hits the area that needs the imaging, without potentially dangerous secondary rays.
The dose of radiation delivered by the machines is also much smaller than it used to be, so the risk of secondary radiation for the patient is essentially nonexistent. X-rays nowadays are considered safe for patients irrespective of age and health conditions, including pregnancy.
Moreover, lead shields can even be counterproductive, as awkward or incorrect positioning may end up blocking some necessary X-rays, which leads to repeat imaging and exposure to additional unnecessary radiation.
“It’s exciting to see the dental community rally behind the significant evidence that lead aprons don’t provide much protection,” wrote Elsa Pearson Sites, policy director for the Partnered Evidence-based Policy Resource Center with Harvard School of Public Health, via email. In a 2020 op-ed for STAT about discontinuing use of lead vests for patients, she noted that patients could be confused if doctors told them they didn’t need to wear aprons during X-rays, but dentists still continued to provide them.
Yet whether or not dentists and patients will feel comfortable adhering to the guidelines is a different matter. Beyond the habit, there is a certain comfort associated with wearing the aprons — after all, for decades we’ve believed them necessary.
“Moving away from lead aprons is simply a challenging cultural shift. Patients (and providers to some extent) have been conditioned to think that radiation is scary and dangerous, and that X-rays use really high doses of it. So eliminating lead aprons feels reckless and counterintuitive,” said Pearson Sites.
Mahesh stresses that education of practitioners is extremely important in changing current practices. He is working with his students on a comic book about getting rid of patient lead aprons in medical X-rays, and plans to do one for dentists, too.
Patients, too, may need reassurance. “You go to a dental [appointment], get your teeth cleaned, they put on a big apron — most of the time patients don’t know why it is, but they feel comfortable,” said Mahesh.
One question patients may have is why X-ray technicians and doctors continue to wear shielding when in the X-ray room. The reason is that as they work around the patient who is getting X-rays, they are exposed to scattered radiation that is coming off patients on a routine basis, and without the diagnostic benefits of getting the X-ray.
Patients will have a lot of questions for dentists, who may have a hard time convincing them, said Mahesh. In that case, “as a last resort, they should give what the patient wants and put an apron [on them],” he said.