Cardiac Implantable Devices and Electronic Dental Instruments

Electronic dental instruments, like ultrasonic scalers or apex locators, could potentially interfere with some implantable cardiac devices, such as pacemakers or implantable cardioverter-defibrillators.

Cardiovascular implantable electronic devices (CIEDs) use electrical impulses to maintain proper heart rhythm. They are becoming more common as the initial population into which they were introduced ages with an increased life expectancy, and as implantations have increased.^1-6 This means patients, dental professionals and staff are more likely to have CIEDs, which may also increase the possibility of electromagnetic interference from electronic dental equipment.

There is a known history of common electronic devices, even cellphones and tablets,^{7, 8} interfering with CIEDs. In dentistry, there have been conflicting reports regarding whether electronic apex locators, curing lights or ultrasonic devices (e.g., scalers) might interfere with automatic electronic functions of CIEDs.⁹ Electromagnetic interference may cause an interruption in or a change of pacing, or send a positive signal that a shock is needed. Previous in-vitro tests indicated that ultrasonic electronic dental devices caused interference in pacing and other functions.^{2, 4, 5, 10} However, other investigators assert that laboratory tests do not adequately replicate in-vivo conditions, including the proximity of electronic devices used in dental procedures or the shielding of surrounding tissues in the human body.^{2, 4, 5} Additionally, most newer models of CIEDs are considered to have more adequate shielding from electromagnetic interference than older devices.^{2, 4, 9}

In the United States and globally, the number of individuals with CIEDs has increased steadily in recent decades, particularly among adults over 70 years of age.^{11, 12} As a result, more patients with CIEDs are receiving treatment in dental settings, so clinicians should remain aware of the risk of potential interactions between common electronic dental equipment and implanted cardiac devices.^{1-6, 13}

CIEDs include pacemakers, which regulate cardiac pacing with low-energy electrical pulses, and implantable cardioverter-defibrillators, which analyze cardiac rhythm and deliver an impulse when an anomaly is detected.^{2, 3, 7, 13-17} CIEDs consist generally of two main components: a sealed capsule containing the power source, usually implanted inferior to the left clavicle (the subclavian pocket), subcutaneously or subpectorally, with a wire lead that follows the subclavian vein into the heart.^{2, 3, 7, 14-17} Pacemakers have been in use since the 1960s,¹⁴ and early versions could only provide a static pulse; more modern versions can provide ‘on demand’ pacing, which can inhibit or trigger cardiac pulse as needed.^{3, 17}

Early pacemaker models also were not well protected or shielded from electromagnetic interference, but more modern CIEDs have been designed with potential electromagnetic interference in mind,^{2, 5, 18} using sealed casing, filters, rejection circuits, and bipolar modes to limit the risks of such interference.² The fact that older pacemaker models lacked these protective measures may have led to many early reports of the high risks of interference with these devices.^{3-5, 15, 18, 19}

Various types of tested electronic dental devices have shown some potential for causing electromagnetic interference in CIEDs (Table 1). However, there is conflicting evidence, and most of the positive results come from in-vitro studies. Some researchers claim that human tissue provides shielding and other protection from electromagnetic interference that cannot be replicated in a laboratory setting.^{2, 6, 16} Various instruction manuals for electronic dental devices discourage use of these devices with patients who have CIEDs,^{1, 19, 24} but other researchers attest that newer CIEDs are designed to lower the risk of interference from electromagnetic sources.⁶ While some researchers claim that clinical interference from ultrasonic dental devices is “highly improbable,”²⁴ the theoretical possibility remains. A number of studies mention the increasing likelihood of electromagnetic interference if a device comes within 37.5 cm (~15 inches) of the CIED or lead wire.^{3, 7, 25}

A 2015 in-vivo prospective cohort study¹⁵ exposed 32 patients with CIEDs to a magnetostrictive scaler, an ultrasonic cleaning system, a curing light, electric toothbrush, and battery-operated pulp tester. The study found minor electromagnetic interference when the scaler and cleaning system were less than 18 inches from CIED leads.¹⁵ Other asymptomatic minor interactions occurred with other devices at smaller distances but appeared to be interference with the monitoring devices (telemetry) and not the pacing or functioning of the CEID itself.¹⁵ Several studies have cited these interactions with telemetry and device monitoring as evidence of electromagnetic interference associated with dental equipment use.^{5, 15, 28, 29}

There is evidence that piezoelectric scalers (commonly used in Europe) are safer than magnetostrictive devices^{1, 24, 25} and may pose no risk to patients with CIEDs.^{4, 17, 18, 25, 30} Several in-vitro studies^{4, 6, 16} present some evidence of electromagnetic interference by magnetostrictive scalers, whereas a 2013 in-vivo study reported no interference between piezoelectric scalers and 5 different implantable cardioverter-defibrillator types in 12 patients.¹ A 2018 in-vivo study of piezoelectric scalers found only minor interference (noise) in telemetry, and no adverse events in pacemaker function.¹⁸

Apex locators and osseointegration monitoring tools have been found in in-vitro tests to be a low risk for light electromagnetic interference.^{2, 16} However, in one in-vivo study, a symptomatic interruption of pacing was induced in patients by two brands of apex locators.¹³ A 2018 in-vivo study of an apex locator found only minor telemetry interference in 3.3% of patients.¹⁸

Although pulp testers were shown to be associated with “severe” electromagnetic interference (stimulation inhibition or inappropriate discharge) in in-vitro studies from 2015 and 2016,⁶ a number of other in-vitro studies found no interference,^{4, 15, 19, 27} nor was interference found in a 2015 in-vivo study.¹⁰ A 2018 in-vivo study found minor interference in telemetry in 7.5% of patients.¹⁸

Electrosurgical units are used to remove and cauterize tissue, and are available as monopolar (which requires an electrical current to pass through the patient’s body) and bipolar (in which the current is completed between two electrodes at the device tip) devices. In-vitro studies have consistently shown clinically significant electromagnetic interference to CIEDs from monopolar electrosurgery, including pacing interruptions and electrical shock.^{6, 19, 27} The Heart Rhythm Society/American Society of Anesthesiologists published a consensus statement on management of CIED patients, which states that “[m]onopolar electrosurgery is the most common source of [electromagnetic interference] and CIED interaction in the operating room,”³¹ and that head and neck region electrosurgeries using monopolar equipment “pose more of a risk for oversensing and damage to the CIED system.”³¹

Battery-operated curing lights were shown to induce pacing inhibition in a 2010 in-vitro study,⁴ but more recent studies from 2015^15, 27 did not report any electromagnetic interference from curing lights. Ultrasonic cleaning systems were shown to produce significant electromagnetic interference in the 2010 study,⁴ and while minor interference with telemetry was encountered in the 2015 in-vivo study, pacing or sense functions were not affected.¹⁵ Both the 2010 and the 2015 studies found little or no risk from electric toothbrushes.^{4, 15}

Gutta-percha heat carriers, but not gutta-percha guns, have been shown to produce electromagnetic interference in the form of background noise,^{2, 13} as well as cause an asymptomatic pause, as demonstrated in a 2015 in-vivo study.¹³ However, a 2015 in-vitro study found no interference between gutta-percha devices and implantable cardioverter-defibrillators.²⁷

Although the available evidence is limited (and in some cases conflicting), consideration should be given to the possible effects ultrasonic or electronic devices could have on dental patients or staff who have implantable cardiac devices. Some manufacturers offer recommendations on use of their devices in the vicinity of such implants, and reports of interference from a dental device are generally within 37.5 cm (~15 inches) to the device or the leads. As noted in a 2022 guideline from the British Heart Rhythm Society, at a distance of at least 15 centimeters (approx. six inches), interference from ultrasonic scalers, apex locators and other dental devices is not considered likely to present any clinical risk to individuals with CIEDs.³² The same guideline also advises clinicians that “[p]eople with implantable devices should be carefully observed during dental procedures.”³²

According to a 2020 systematic review, most dental instruments are safe and compatible for use in routine dental practice while maintaining an appropriate distance away from the CIEDs.⁹ Dentists also may consult with the treating cardiologist to determine if ultrasonic or electronic devices can be safely used when providing dental treatment to a patient with a CIED. If ultrasonic or electronic dental devices (or other such equipment) are used, it may help reduce risk to avoid waving the device and avoid placing electrical cords on or over the patient’s pectoral region, and to turn off this equipment when not in use.

1. Maiorana C, Grossi GB, Garramone RA, Manfredini R, Santoro F. Do ultrasonic dental scalers interfere with implantable cardioverter defibrillators? An in vivo investigation. J Dent 2013;41(11):955-9.
2. Dadalti MT, da Cunha AJ, de Araujo MC, de Moraes LG, Risso Pde A. Electromagnetic interference of endodontic equipments with cardiovascular implantable electronic device. J Dent 2016;46:68-72.
3. Pisano P, Jr., Mazzola JG, Tassiopoulos A, Romanos GE. Electrosurgery and ultrasonics on patients with implantable cardiac devices: Evidence of side effects in the dental practice. Quintessence Int 2016;47(2):151-60.
4. 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(5):521-6.
5. Misiri J, Kusumoto F, Goldschlager N. Electromagnetic interference and implanted cardiac devices: the medical environment (Part II). Clinical Cardiology 2012;35(6):321-28.
6. Miranda-Rius J, Lahor-Soler E, Brunet-Llobet L, Sabate de la Cruz X. Risk of electromagnetic interference induced by dental equipment on cardiac implantable electrical devices. Eur J Oral Sci 2016;124(6):559-65.
7. Tom J. Management of patients with cardiovascular implantable electronic devices in dental, oral, and maxillofacial surgery. Anesthesia Progress 2016;63(2):95-104.
8. Nadeem F, Tran CT, Torbey E, et al. Interference by modern smartphones and accessories with cardiac pacemakers and defibrillators. Curr Cardiol Rep 2022;24(4):347-53.
9. Niu Y, Chen Y, Li W, Xie R, Deng X. Electromagnetic interference effect of dental equipment on cardiac implantable electrical devices: A systematic review. Pacing Clin Electrophysiol 2020;43(12):1588-98.
10. 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(1):33-6.
11. Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009--a World Society of Arrhythmia's project. Pacing Clin Electrophysiol 2011;34(8):1013-27.
12. Greenspon AJ, Patel JD, Lau E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol 2011;58(10):1001-6.
13. Moraes AP, Silva EJ, Lamas CC, Portugal PH, Neves AA. Influence of electronic apex locators and a gutta-percha heating device on implanted cardiac devices: an in vivo study. Int Endod J 2016;49(6):526-32.
14. Baddour LM, Epstein AE, Erickson CC, et al. A summary of the update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. J Am Dent Assoc 2011;142(2):159-65.
15. Elayi CS, Lusher S, Meeks Nyquist JL, et al. Interference between dental electrical devices and pacemakers or defibrillators: results from a prospective clinical study. J Am Dent Assoc 2015;146(2):121-8.
16. Lahor-Soler E, Miranda-Rius J, Brunet-Llobet L, Sabate de la Cruz X. Capacity of dental equipment to interfere with cardiac implantable electrical devices. Eur J Oral Sci 2015;123(3):194-201.
17. Stoopler ET, Sia YW, Kuperstein AS. Does ultrasonic dental equipment affect cardiovascular implantable electronic devices? J Can Dent Assoc 2011;77:b113.
18. Conde-Mir I, Miranda-Rius J, Trucco E, et al. In-vivo compatibility between pacemakers and dental equipment. Eur J Oral Sci 2018;126(4):307-15.
19. Sriman N, Prabhakar V, Bhuvaneswaran JS, Subha N. Interference of apex locator, pulp tester and diathermy on pacemaker function. J Conserv Dent 2015;18(1):15-9.
20. U.S. Food and Drug Administration. Magnets in cell phones and smart watches may affect pacemakers and other implanted medical devices. Washignton, D.C.: U.S. Food and Drug Administration; 2021.
21. Lacour P, Parwani AS, Schuessler F, et al. Are contemporary smartwatches and mobile phones safe for patients with cardiovascular implantable electronic devices? JACC Clin Electrophysiol 2020;6(9):1158-66.
22. Asher EB, Panda N, Tran CT, Wu M. Smart wearable device accessories may interfere with implantable cardiac devices. HeartRhythm Case Rep 2021;7(3):167-69.
23. Shea JB, Aguilar M, Sauer WH, Tedrow U. Unintentional magnet reversion of an implanted cardiac defibrillator by an electronic cigarette. HeartRhythm Case Rep 2020;6(3):121-23.
24. Gomez G, Jara F, Sanchez B, Roig M, Duran-Sindreu F. Effects of piezoelectric units on pacemaker function: an in vitro study. J Endod 2013;39(10):1296-9.
25. Trenter SC, Walmsley AD. Ultrasonic dental scaler: associated hazards. J Clin Periodontol 2003;30(2):95-101.
26. Idzahi K, de Cock CC, Shemesh H, Brand HS. Interference of electronic apex locators with implantable cardioverter defibrillators. J Endod 2014;40(2):277-80.
27. Maheshwari KR, Nikdel K, Guillaume G, et al. Evaluating the effects of different dental devices on implantable cardioverter defibrillators. Journal of Endodontics 2015;41(5):692-95.
28. Crossley GH, Poole JE. More about pacemakers. J Am Dent Assoc 2010;141(9):1053; author reply, 53-4.
29. Patel D, Glick M, Lessard E, Zaim S. Absence of in vivo effects of dental instruments on pacemaker function. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2005;99(4):430.
30. Kamal R, Dahiya P, Saini H. Dental treatment in patients with cardiac pacemakers: Is it a risky affair? Journal of Dental Research and Review 2016;3(2):76-78.
31. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management. Heart Rhythm 2011;8(7):1114-54.
32. Thomas H, Plummer C, Wright IJ, Foley P, Turley AJ. Guidelines for the peri-operative management of people with cardiac implantable electronic devices: Guidelines from the British Heart Rhythm Society. Anaesthesia 2022;77(7):808-17.

Professional Resources

• ADA Library Services
• ADA Store: The ADA Practical Guide to Patients with Medical Conditions (Item #P031)

Patient Resources

• ADA MouthHealthy.org: A-Z Topics: Pacemakers
  
  

• American Heart Association Devices that May Interfere with ICDs and Pacemakers
• Journal of the Canadian Dental Association: Does ultrasonic dental equipment affect cardiovascular implantable electronic devices?