All 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. It is thought that human tissue provides shielding and other protection from electromagnetic interference that cannot be replicated in a laboratory setting.2, 6, 11 Many instruction manuals for electronic dental devices discourage use of these devices with patients who have CIEDs,1, 14, 15 but many researchers believe 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,”15 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, 16
Device |
Reported Electromagnetic Interference |
|
In-Vitro (laboratory testing) |
In-Vivo (in people) |
Ultrasonic dental scalers |
|
|
Piezoelectric |
None,15 Minor to Severe6, 11 |
None,1 Minor13
|
Magnetostrictive |
None,15 Minor4 |
Minor10 |
Electronic apex locators |
None,14, 21, 22 Minor2, 6, 11 |
Minor8, 13 to Severe8 |
Electric pulp testers |
None,4, 14 Minor,6, 11, 18 Severe6, 11 |
None,10 Minor13
|
Electrosurgery instruments |
None,4 Minor6, 11, 18 to Severe6, 11, 14, 18 |
N.A. |
Curing lights |
Minor,18 Severe4 |
None10 |
Gutta percha devices |
None,18 Minor2 |
Minor8 |
Ultrasonic cleaning systems |
Severe4 |
Minor10 |
Electric toothbrushes |
None4 |
Minor (rare)10 |
Osseointegration tools |
Minor to Severe6, 11 |
N.A. |
“Minor” refers to non-clinically significant interference (noise, telemetry); “Severe,” to clinically significant outcomes (i.e., pacing disturbances or shock); “N.A.” (Not Applicable), no studies available.
A 2015 in-vivo prospective cohort study10 exposed 32 patients with CIEDs to a magnetostrictive scaler, an ultrasonic cleaning system, a curing light, electric toothbrush, and battery-operated pulp tester. They found minor electromagnetic interference when the scaler and cleaning system were less than 18 inches from CIED leads.10 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.10 This interference with telemetry and device monitoring has been argued to have been the cause of electromagnetic interference in a number of studies.5, 10, 23, 24
There is evidence that piezoelectric scalers (commonly used in Europe) are safer than magnetostriction devices1, 19, 20and may pose no risk to patients with CIEDs.4, 12, 13, 20, 25 A 2000 position paper26 by the American Academy of Periodontology warned “[m]agnetostrictive ultrasonic scalers should not be used by clinicians or on patients with a pacemaker”20 though this warning was later retracted.1, 3, 27 Several in-vitro studies4, 6, 11 showed interference by magnetostrictive scalers though a 2013 in-vivo study found 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.13
Apex locators and osseointegration monitoring tools have been found in in-vitro tests to be a low risk for light electromagnetic interference.2, 11 However, in one in-vivo study, a symptomatic interruption of pacing was induced in patients by two brands of apex locators.8 A 2018 in-vivo study of an apex locator found only minor telemetry interference in 3.3% of patients.13
Although pulp testers were shown to be associated with “severe” electromagnetic interference (stimulation inhibition or inappropriate discharge) in in-vitro studies from 201511 and 2016,6 a number of other in-vitro studies found no interference,4, 10, 14, 22 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.13
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, 14, 22 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,”28 and that head and neck region electrosurgeries using monopolar equipment “pose more of a risk for oversensing and damage to the CIED system.”28
Battery-operated curing lights were shown to induce pacing inhibition in an in-vitro study in 2010,4 but more recent studies from 201510, 22 did not result in 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.10 Both the 2010 and the 2015 studies found little or no risk from electric toothbrushes.4, 10
Gutta percha heat carriers, but not guns, have been shown to produce electromagnetic interference in the form of background noise,2, 8 as well as cause an asymptomatic pause in an in-vivo study published in 2015.8 However, an in-vitro study in 2015 found no interference between gutta-percha devices and implantable cardioverter-defibrillators.22