Ready to give up the lead vest?

At a dental appointment last month, I spotted a lead vest hanging unassumingly on the wall of the exam room as soon as I walked in. "Still there, but now obsolete," I thought.

I'd just learned about new guidelines from the American Dental Association (ADA) saying lead vests and thyroid collars that cover the neck are no longer needed during dental x-rays. But they'd been a fixture of my dental experiences — including many cavities, four root canals, a tooth extraction, and two crowns — for my entire life. What changed, and could I feel safe without the vest?

Why were lead vests used in past years?

Lead vests and thyroid collars have been worn by countless Americans during dental x-rays over the years. They've been in use for far longer than my lifetime — about 100 years. The heavy apron-like shields are placed over sensitive areas, including the chest and neck, before the x-rays are taken.

"I haven't worn a lead apron in the last 10 or 15 years — unless a dentist insists I put it on — because I know it isn't needed," says Dr. Bernard Friedland, an associate professor of oral medicine, infection, and immunity at Harvard School of Dental Medicine.

What has changed about dental x-rays?

When lead vests and thyroid collars were first recommended, x-ray technology was much less precise. But the technology has evolved significantly over the last few decades in ways that dramatically improve patient safety:

• Digital x-rays enable far smaller radiation doses, reducing radiation exposure and the risks associated with higher doses, such as cancer. "The doses used in dental radiology are negligibly small now. If you go to the dentist today for a full series of mouth x-rays that are taken with a digital sensor, the total exposure time is just over five seconds," explains Dr. Friedland, an expert in oral radiology. "A hundred or so years ago, that exposure time would have been many minutes."
• The small size of today's x-ray beam significantly reduces radiation "scatter" and restricts the beam size to only the area needing to be imaged. This protects patients from radiation exposure to other parts of the body.

A less-recognized strike against using lead vests and thyroid collars is their ability to get in the way. They may block the primary x-ray beam, preventing dentists from capturing needed images. This quirk can lead to repeat imaging and unnecessary exposure to additional radiation. This is more likely to occur with panoramic x-rays.

The gear may also spread germs, Dr. Friedland notes. Although disinfected, it's not sterilized between uses. "There's a risk of spreading bacteria and viruses," he says. "To me, that's also an issue and another reason I don't want to use one on myself."

Who no longer needs the shields?

No one does — even children, who presumably have a long life of dental x-rays in front of them. The new recommendations apply to all patients regardless of age, health status, or pregnancy, the ADA says.

The recommendation to discontinue lead vests has been a long time in the making. In fact, the ADA isn't the first professional organization to propose it. The American Association of Physicists in Medicine did so in 2019, followed by the American College of Radiology in 2021 and the American Academy of Oral and Maxillofacial Radiology in 2023.

Are some people confused or concerned about the no-lead-vest policy?

Yes. The new guidelines are bound to draw confusion and fear, Dr. Friedland says. Some people may even insist on continuing to wear a lead vest during x-rays.

"A big problem is that people's perception of risk is very skewed," he says. "Some people, you'll never convince."

People are likely to feel more comfortable if the practice is uniformly adopted by dentists. However, the ability to implement this change may hinge partly on public response. And it could take a while to fully adopt.

"I think the public is going to have more say on this than dentists," Dr. Friedland says. "It might take a generation to make this change, maybe longer."

Still concerned about the new recommendations?

If you have lingering concerns about the new recommendations, talk to your dentist.

And ask if dental x-rays are necessary to proceed with your diagnosis or treatment plan. Sometimes it's possible to take fewer x-rays — such as bitewing x-rays of the upper and lower back teeth only — or to use certain types of imaging less frequently. Even with far safer x-ray conditions, dentists should be able to justify that the information from images is integral to diagnose problems or improve care, Dr. Friedland says.

It's worth noting that the dose of radiation, while far lower than in the past, varies with the type of imaging and which parts of the jaw are being imaged. For example, the digital dental x-rays mentioned above involve less radiation than conventional dental x-rays. Either panoramic dental x-rays, or 3-D dental x-rays taken with a CBCT system that rotates around the head, typically involve more radiation than conventional dental x-rays.

Whenever possible, dentists should use images taken during previous dental exams, according to the ADA. "If I don't need an x-ray, I don't get one," says Dr. Friedland. "I'm not cavalier about it. I also use technical parameters that keep the x-ray dose as low as reasonably possible."