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 Table of Contents  
SHORT COMMUNICATION
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 76-78

Dental treatment in patients with cardiac pacemakers: Is it a risky affair?


1 Department of Oral and Maxillofacial Pathology, HP Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Periodontics and Implantology, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India
3 Department of Conservative, Government Dental College, Rohtak, Haryana, India

Date of Web Publication16-Jun-2016

Correspondence Address:
Reet Kamal
Department of Oral and Maxillofacial Pathology, HP Government Dental College, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2915.184213

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  Abstract 

Cardiac pacemakers are the implanted devices used to treat patients with damaged heart muscles. These electronic devices are sensitive to strong electromagnetic signals. The dental literature also included articles regarding electromagnetic interferences to pacemakers, due to dental devices such as ultrasonic scalers, electrosurgical unit, ultrasonic bath cleaners, and battery driven light cure composite unit. Although pacemakers of new generation have more protective features than those of past, but still precautionary measures should be taken in dental clinics for the safety of cardiac patients with pacemaker. The aim of this paper is to identify the possible sources from dental clinics which can adversely interfere with the pacemaker activity and to provide some guidelines for safe dental practice in this high-risk group.

Keywords: Electromagnetic interference, implanted cardiac device, pacemaker, ultrasonic scaler


How to cite this article:
Kamal R, Dahiya P, Saini HR. Dental treatment in patients with cardiac pacemakers: Is it a risky affair?. J Dent Res Rev 2016;3:76-8

How to cite this URL:
Kamal R, Dahiya P, Saini HR. Dental treatment in patients with cardiac pacemakers: Is it a risky affair?. J Dent Res Rev [serial online] 2016 [cited 2019 Jan 17];3:76-8. Available from: http://www.jdrr.org/text.asp?2016/3/2/76/184213


  Introduction Top


India is a second most populated country after China and population is still growing at an exponential rate. However, a more alarming fact is the increasing prevalence of cardiovascular diseases. Cardiovascular disease is a broad term consisting of ischemic disease, hypertension, dysrhythmia, valvular heart disease, etc. The use of pacemakers and other implanted devices has become an important treatment modality in the treatment of heart failure patients with poor heart function. These are used to fix electrical abnormalities in people with irregular heart rhythms. The first permanent pacemaker was implanted in 1958 since the pacemaker market is growing at a healthy rate.[1]

On the other hand, with increasing dental health awareness and the establishment of a positive link between cardiovascular diseases and oral health,[2] more and more cardiac patients are seeking dental treatment and patients with cardiac pacemakers are not an exception to this. In 1970's, the patients with cardiac pacemakers were advised to avoid certain environment associated with electromagnetic field, as it might affect the activity of implanted cardiac device. However, with the advancements in biomedical field and the introduction of new pacemaker device, with better pacemaker circuitry and shielding, such interference has been expected less, but still this topic needs revision with more long-term longitudinal research work and more evidence-based facts.

The aim of this paper is to identify the possible sources from dental clinics which can adversely interfere with the pacemaker activity and to provide some guidelines for safe dental practice in this high-risk group.


  Patients wth Pacemakers and Dental Office Top


Nowadays, dental clinics are usually equipped with latest devices such as ultrasonic scalers, apex locators, electrosurgical units, diathermy, pulp tester, battery operated composite curing light, and ultrasonic cleaners. that might affect the cardiac pacemaker activity.

Ultrasonic scalers

Ultrasonic scalers are designed to facilitate scaling and root planing. These are divided into two types: Magnetostrictive and piezoelectricity scalers. In magnetostrictive units, an alternating current produces magnetic field that causes the tip to vibrate. It operates between 18,000 and 45,000 cps.[3] Whereas, in piezoelectric units the movements of tip occurs by the dimensional changes in crystals housed within the handpiece, as the electric current passed over the surface of the crystals and it operates in the 25,000–50,000 range.[3],[4]

Contradictory findings have been obtained during investigations into the effect of the ultrasonic scaler on the pacemaker. Griffiths in hisin vivo study [5] and Adams et al.[6] in theirin vitro study found interference with the pacemaker activity with the use of ultrasonic scalers. Whereas, Simon et al. and Luker in their studies did not find any interference with the use ultrasonic scaler.[7],[8] A study investigating the magnetostrictive scaler stated that interference can be caused if the pacemaker pacing lead comes within 37.5 cm of the scaler.[9]

Roedig et al. evaluated the interference of single chamber pacemaker, dual chamber pacemaker, dual chamber implantable cardioverter-defibrillator (ICD) and biventricular ICD by different dental devices. They found that the use of ultrasonic scaler (Cavitron) interfere with the pacing activity of dual chamber pacemaker at 17 and 23 cm from the generator, the single chamber pacemaker at 15 cm and both ICD's at 7 cm from the generator or leads. However, all studies are in agreement that the piezoelectric ultrasonic scalers tested did not affect pacemakers.[10]

The American Academy of Periodontology (2000) recommended that the dentists should avoid the use of magnetostrictive ultrasonic scalers in patients with cardiac pacemakers as it might produce deleterious effects on patient's cardiac health.[3]

Ultrasonic bath cleaner

Miller et al. reported that atrial and ventricular pacing were inhibited by electromagnetic interference produced by ultrasonic bath cleaner up to 30 cm.[9] Roedig also documented similar finding that the use of ultrasonic cleaning system caused interference with both single and dual chamber pacemaker at 9–12 cm and 15–23 cm, respectively.[10]

In 2007in vitro study, Brand et al. found that the most dental equipment, except for ultrasonic bath cleaners, did not interfere with the normal functioning of ICDs.[11]

Electrosurgical units

Interference with pacemaker activity by electrosurgical units has been consistently reported, which is suggestive of deleterious effects of these electrosurgical units on pacemakers.[9],[12] But, Roedig et al. findings were in contract with these previous studies.[10]

Electric pulp tester, apex locator, light cure units, high-speed handpieces, dental X-ray machines

Most of the studies could not report any deleterious effect of these dental equipment on pacemaker activity. Wilson et al. did not report any interference between electric pulp tester and apex locator use and pacemaker activity.[13] whereas, Roedig et al. found severe interference with the use of battery driven composite curing light.[10] Hence, from the inconsistent results of these studies it has been clear that more or less, all dental equipment can affect the normal functioning of cardiac pacemakers and can bring life-threatening conditions. Dental professionals have to more alert whereas conducting any procedure.

Precautionary measures in dental office

Patients with cardiac pacemakers are not only at higher risk for bleeding and infection in dental office but also prone to electromagnetic interference generated by dental devices. Hence, following precautions should be considered by dental professionals while treating patients with cardiac pacemakers:

  1. All patients who have any type of implantable cardiac devices should provide the details of manufacturer's identification card like manufacturer of the device, model number, serial number, date of implantation, and mode of operation. to their oral health provider [14]
  2. Dental professionals should encourage sterilized working environment and should only use genuine electrical and electronic dental devices, as local made (un-standardized) dental equipment can generate electromagnetic interferences
  3. The patient should be enrolled in a detailed medical history, consisting of specifications of cardiac pacemaker, any previous complication due to pacemaker, time since the patient is on pacemaker, medication, etc.
  4. Before any therapeutic service dentist should consult patient's cardiologist and if needed, cardiologist should be informed about the dental procedure
  5. For oral prophylaxis, the dentist should consider the use of hand scalers although piezoelectric scalers are documented to be safe. Patients should be motivated to use manual toothbrushes. Patients, who are using battery driven powered toothbrushes, are advised to maintain a distance of at least 6 inches between battery charger unit and the implanted device and a distance >1 inch between the toothbrush and implanted device
  6. Care should be taken not to place electrical cords over patient's chest
  7. Unshielded pacemakers should be covered with a lead apron
  8. Epinephrine and other vasoconstrictors should be used with caution in clients with pacemakers
  9. Dentists should be aware of symptoms of pacemaker malfunction such as difficulty in breathing, lightheadedness, dizziness, change in pulse rate, prolonged hiccoughing, swelling in chest and arm, and chest pain. In such conditions, cardiologist should be consulted immediately.



  Conclusion Top


It has been now clear from the results of numerous studies that dental equipment such as ultrasonic scalers, ultrasonic bath cleaners, light cure unit, and electrosurgical unit can create electromagnetic interferences and can adversely affect the normal functioning of pacemakers.

Dentist should realize these interferences and should take precautionary measures to reduce their deleterious effects. The literature regarding this topic is still scarce and needs more long-termin vivo studies to determine the real effects of dental treatments or dental equipment on the pacemaker functioning.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Imich W, Parsonnet V, Myers GH. Pacing. In: Giuliani ER, Gersh BJ, McGoon MD, Hayes DL, Schaff HV. editors. Mayo Clinic practice of cardiology. 3rd ed. st. Louis: Mosby;1995. p. 909-10.  Back to cited text no. 1
    
2.
Najafipour H, Malek Mohammadi T, Rahim F, Haghdoost AA, Shadkam M, Afshari M. Association of oral health and cardiovascular disease risk factors “results from a community based study on 5900 adult subjects”. ISRN Cardiol 2013;9:1-6.  Back to cited text no. 2
    
3.
Drisko CL, Cochran DL, Blieden T, Bouwsma OJ, Cohen RE, Damoulis P, et al. Position paper: Sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol 2000;71:1792-801.  Back to cited text no. 3
    
4.
Trenter SC, Walmsley AD. Ultrasonic dental scaler associated hazards. J Clin Periodontol 2003;30:95-101.  Back to cited text no. 4
    
5.
Griffiths PV. The management of the pacemaker wearer during dental hygiene treatment. Dent Hyg 1978;52:573-6.  Back to cited text no. 5
    
6.
Adams D, Fulford N, Beechy J, MacCarthy J, Stephens M. The cardiac pacemaker and ultrasonic scalers. Br Dent J 1982;152:171-3.  Back to cited text no. 6
    
7.
Simon AB, Linde B, Bonnette GH, Schlentz RJ. The individual with a pacemaker in the dental environment. J Am Dent Assoc 1975;91:1224-9.  Back to cited text no. 7
    
8.
Luker J. The pacemaker patient in the dental surgery. J Dent 1982;10:326-32.  Back to cited text no. 8
    
9.
Miller CS, Leonelli FM, Latham E. Selective interference with pacemaker activity by electrical dental devices. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:33-6.  Back to cited text no. 9
    
10.
Roedig JJ, Shah J, Elayi CS, Miller CS. Interference of cardiac pacemaker and implantable cardioverter-defibrillator activity during electronic dental device use. J Am Dent Assoc 2010;141:521-6.  Back to cited text no. 10
    
11.
Brand HS, Entjes ML, Nieuw Amerongen AV, van der Hoeff EV, Schrama TA. Interference of electrical dental equipment with implantable cardioverter-defibrillators. Br Dent J 2007;203:577-9.  Back to cited text no. 11
    
12.
McCormack J. Electrosurgical equipment and pacemekers: A possible hazard. Br Dent J 1975;139:221.  Back to cited text no. 12
    
13.
Wilson BL, Broberg C, Baumgartner JC, Harris C, Kron J. Safety of electronic apex locators and pulp testers in patients with implanted cardiac pacemakers or cardioverter/defibrillators. J Endod 2006;32:847-52.  Back to cited text no. 13
    
14.
Yeo TP, Berg NC. Counseling patients with implanted cardiac devices. Nurse Pract 2004;29:58;61-5.  Back to cited text no. 14
    




 

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