Risk using electronic instruments in dentistry on patients with pacemaker or implanted cardioverter defibrillator

Individuals with an increased risk of life threatening cardiac arrythmia may get an implantable pacemaker or automatic defibrillator. The implants can maintain a regular cardiac rhythm or regulate abnormal heart rhythms, especially those that could be dangerous and cause a cardiac arrest. Electromagnetic interference from electronic apparatus or instruments may affect the function of the implants. Within dentistry, many electronic instruments are used i.e., to remove dental plaque and tartar, or to measure the length of the root canal.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: Report no: ut202406 Registration no: SBU 2023/1110 https://www.sbu.se/ut202406

Question

What systematic reviews have been published regarding the risk with electronic instruments in dentistry for patients with pacemaker or implantable cardioverter defibrillator?

Method

A systematic literature search was performed using the following databases: Medline, Scopus and INAHTA: s database for HTA -reports.
Two authors independently assessed the abstracts of all identified studies.
Risk of bias in relevant systematic reviews was assessed using an assessment tool based on AMSTAR.

Identified literature

One relevant systematic review with low to moderate risk of bias was identified [1]. The results and conclusions are presented in Table 1. In one relevant systematic review, the risk of bias was high, therefore the results and conclusions are not reported [2].

Table 1 Systematic reviews with low/moderate risk of bias.
Included studies Population, Intervention, Control Outcome and Resultsa
Niu et al, 2020 [1]
Electromagnetic interference effect of dental equipment on cardiac implantable electric devices: A systematic review
6 clinical studies Population:
104 patients with PM in six studies:Baseline PM setting was used in 5 studies and 1 study reduced the unipolar sensitivity value to 0.5 mV2 studies repeated the intervention/exposure after setting PM to maximum sensitivity. 57 patients with ICD in 4 studies.The setting for bradyarrythmia and tachyarrythmica sensing and therapy was not changed in 3 of the studies while disabled in 1 study. 

Intervention:
EAL:
5 different types. 4 studies in patients with PM and 2 studies with ICD 

EPT:
5 different types in 4 studies. 4 studies in patients with PM and 3 studies with ICD 

Ultrasonic instruments:
Ultrasonic dental scaler was tested in 3 studies in patients with PM and 2 studies with ICD. 

Other dental instruments tested:
Electric toothbrush (1 study), electric operated curing lights (2 studies), gutta-perca heating devices (1 study), air scaler (1 study), electrosurgery unit (1 study), and caries detection device (1 study). Ultrasonic cleaning system (bath) was tested in 1 study.		 Overall synthesis regarding electromagnetic interference in vivo:
The six in vivo studies included in the review reported no EMI from dental equipment in patients with PM or ICD, or minor background noises that did not alter their function at preset sensitivity settings.One study detected more severe EMI with altered PM or CID function when the sensitivity of the implant device was lowered and at the setting of a unipolar sensing configuration. 

Results from specified instruments:
EAL:
No interference was observed using two EAL types on patients with PM, whereas an ECG noise was observed using three other EAL types.No interference on ICD was observed using four tested EAL types. However, in a few patients with an ECG noise with the preset PM sensitivity, lowering of the PM sensitivity setting affected the function and caused disruption in the heart’s natural rhythm, a pause. 

EPT:
None of the tested EPTs affected the function of PM or ICDs.One type of EPT induced ECG noise in 7.5% of the patients with PM, whereas 4 other EPT types did not.No EMI observed from 4 tested EPTs in patients with ICD. 

Ultrasonic dental scalers:
None of the tested scalers affected the function of PM or ICDs.Minor EMI events with ECG noise/intracardiac channel noise/telemetry loss were observed in patients with PM and ICD using three different types of ultrasonic scalers. With a fourth type no EMI was observed in patients with ICD.
Authors' conclusion:
“Future in vivo studies with large sample sizes and consistent experimental conditions may help to achieve a more conclusive result.”

References

  1. 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. Available from: https://doi.org/10.1111/pace.14051.
  2. AlRahabi MK, Ghabbani HM. Influence and safety of electronic apex locators in patients with cardiovascular implantable electronic devices: a systematic review. Libyan J Med. 2019;14(1):1547071. Available from: https://doi.org/10.1080/19932820.2018.1547071.

Search strategies

Medline via OvidSP 7 November 2023

Title: Dental care and pacemaker
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp = Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf; .pt = Publication type; .ja = Journal abbreviation; .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase a. Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity- and precision-maximizing version (2008 revision); Ovid format. The Cochrane Collaboration; 2008. Available from: https://training.cochrane.org/handbook/current/chapter-04-technical-supplement-searching-and-selecting-studies#section-3-6-1.  with modifications: the following terms are added: clinical trial, phase iii.pt. ; randomised.ab. ; ("Phase 3" or "phase3" or "phase III" or P3 or "PIII").ti,ab,kw.
Search terms Items found
Population:
1.; (exp Pacemaker, Artificial/ or pacemaker.ti,ab,bt,kw. or (cardi* adj3 device*).ti,ab,bt,kw. or (electronic adj3 device*).ti,ab,bt,kw. or PM.ti,ab,bt,kw. or ((implanted or implantable) adj3 (electrodes or defibrillator or defibliratiors)).ti,ab,bt,kw. or exp Electrodes, Implanted/ or exp Defibrillators, Implantable/) 193 460
Intervention:
2. (exp Dentistry/ or exp Dental Care/ or exp Dental Equipment/ or (dent* adj3 (Scanner* or laser or ultrasonic or suction or "optical microscope")).ti,ab,bt,kw. or ("apex locators" or "gutta percha").ti,ab,bt,kw. or "root canal".ti,ab,bt,kw. or endodont*.ti,ab,bt,kw. or Electrotom.ti,ab,bt,kw.) 451 030
Study types: systematic reviews and meta-analysis / randomized controlled trialsaa
3. ((Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys*" or metaanalys*).ti,bt,ab.) not (editorial/ or letter/ or case reports/)) 455 513
Combined sets:
4. 1 AND 2 710
5. 3 AND 4 22
Final result
6. 4 710

Scopus via scopus.com 7 November 2023

Title: Dental care and pacemaker
TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields W/n = Within. Proximity operator retrieving terms within n words from each other.; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words.; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range; DOCTYPE = Publication type; "re" = review; "le" = letter; "ed" = editorial; "ch”"= book chapter;"cp" = conference proceedings; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population:
1. (pacemaker OR (cardi* W/3 device*) OR (electronic W/3 device*) OR PM OR (implant* W/3 electrodes) OR (implant* W/3 defibrillator*) 440 968
Intervention:
2. (Dentistry OR Dental OR endodont* OR (dent* W/3 Scanner*) OR (dent* W/3 laser) OR (dent* W/3 ultrasonic) OR (dent* W/3 suction) OR (dent* W/3 “optical microscope”) OR “apex locators” OR “gutta percha” OR “root canal” OR electrotom) 666 493
Study types: systematic reviews and meta-analysis / randomized controlled trials
3. TITLE-ABS-KEY ( ( systematic  W/2  review )  OR  "meta analy*"  OR  metaanaly* ) AND (EXCLUDE (DOCTYPE, “le”) OR EXCLUDE (DOCTYPE, “ed”) OR EXCLUDE (DOCTYPE, “ch”) OR EXCLUDE (DOCTYPE, “cp”)) 667 808
Combined sets:
4. 1 AND 2 1543
5. 3 AND 4 37
Final result
6. 4 1543

Citation Search: Scopus via Elsevier (citation search) 8 December 2023

Title: Dental care and pacemaker
Search terms Items found
Cited articles
1. DOI(10.1111/eos.12534) 6
2. DOI(10.1016/j.adaj.2014.11.016) 10
3. DOI(10.1016/s0022-3913(05)80385-3) 10
4. DOI(10.1016/j.jdent.2013.08.006) 12
5. DOI(10.1111/iej.12487) 5
6. DOI(10.36660/ijcs.20200312) 1
7. DOI(10.1016/j.joen.2006.03.005) 35
8. DOI(10.1080/19932820.2018.1547071) 6
9. DOI(10.1111/pace.14051) 3
Citing articles
10. #1-9/or View cited by 68
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