Dental treatment for patients with cardiac implantable electronic devices

Originally appeared in the November/December 2015 issue of Dispatch

In a previous professional practice article  the College discussed the dental management of patients who have had a recent myocardial infarction (MI) or undergone cardiovascular surgical procedures.

Following an MI or as the result of other cardiac abnormalities, there may be electrical instability of the myocardium. This might be managed by certain medications, but some patients may present with a cardiac implantable electronic device (CIED), such as a pacemaker or cardioverter-defibrillator. Dentists may wish to know if there are any precautions necessary before undertaking dental treatment for these patients.

Cardiac implantable electronic devices consist of a battery-powered generator implanted subcutaneously, with electrodes that pass to various areas in the heart. As the previous article outlined, a comprehensive medical history and review of systems where indicated may reveal further details regarding the patient’s medical condition and medications. In addition, there are specific considerations in the dental management of patients with CIEDs.

There have been concerns regarding potential electromagnetic interference (EMI) between these implantable devices and many other common products, such as some dental equipment like electrosurgery units, TENS units, ultrasonic bath cleaners, ultrasonic scalers, electronic apex locators, electric pulp testers, dental chairs with magnetic headrests and battery-operated curing lights. Inhibition of pacing, asynchronous pacing or inappropriate shocks are possible adverse responses of implantable devices to EMI.

The available literature on the topic of EMI has been somewhat conflicting and controversial. The conclusions and/or clinical significance often depends on such factors as: the type and manufacturer of the implanted electronic device, the type of dental equipment used, the application distance, whether studies were conducted in vitro or in vivo, study sample size, how interference was measured, and whether or not the interference resulted in a clinically significant event.

The American Dental Association has said that “dentists who use ultrasonic devices, like ultrasonic scalers or instrument cleaning systems, should be aware that they could interfere with some implantable cardiac devices, such as pacemakers or implantable defibrillators.” Although certain imaging techniques, such as MRI, may be a concern for patients with an implanted cardiac device, standard dental radiographs and cone beam CT scans do not pose a risk.

There have been many improvements in the design, manufacture and protective shielding of implanted devices so an adverse clinical outcome is unlikely. Nevertheless, caution should be exercised when operating dental equipment that has the potential to generate electromagnetic interference.

Patients are typically issued an identification card which provides information such as the type of device (model/serial number), the manufacturer and date of placement. The manufacturers of the cardiac device and/or dental equipment may be contacted for advice regarding the possibility of EMI and for any precautions that should be considered. If there is any uncertainty, it may be prudent to avoid the use of certain types of dental equipment if possible.

Current guidelines from the American Heart Association on the prevention of infective endocarditis advise that antibiotic prophylaxis is generally not required for these types of devices. Medical consultation with the patient’s physician, cardiologist or other specialist may be necessary to confirm that there are in fact no other indications for antibiotic prophylaxis, as well as to determine the severity and stability of the patient’s medical condition(s), appropriate timing for dental treatment (particularly in cases where the CIED was recently placed), and if there are any concerns about possible EMI.

Given that such patients are being treated for cardiovascular disease, baseline vital signs, ongoing monitoring, and a stress reduction protocol to include limiting exogenous epinephrine would be prudent.

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