• Yes, if there is the potential for electromagnetic interference (EMI) from dental/dental hygiene equipment that could affect operation of a CIED and/or if there are questions or uncertainties regarding comorbidities (including underlying arrhythmia). However, most dental/dental hygiene procedures do not involve strong electromagnetic signals and thus are unlikely to interfere with CIEDs (particularly newer models).

Is medical consult advised? 

• Yes, consultation with patient/client’s cardiologist or the cardiology unit responsible for follow-up of the CIED is recommended when planning therapeutic services, including for timing post-insertion if the CIED has been recently implanted. If dental/dental hygiene equipment in the office has the potential to cause EMI that interferes with the operation of a patient/client’s CIED, the consult should clarify the type of implanted cardiac device as well as whether it is unipolar or bipolar (with unipolar devices providing fewer safeguards against EMI). As well, consultation may be warranted to determine the severity and stability of the patient/client’s medical condition(s), as well as to determine appropriate timing for dental hygiene treatment. Additionally, consultation should be sought if there are signs/symptoms of possible infection related to recent CIED insertion.

• Yes, if there is the potential for electromagnetic interference (EMI) from dental/dental hygiene equipment that could affect operation of a CIED and/or if there are questions or uncertainties regarding concomitant morbidities (including underlying arrhythmia). However, most dental/dental hygiene procedures do not involve strong electromagnetic signals and thus are unlikely to interfere with CIEDs (particularly newer models).

Is medical consult advised?

• See above. Also, consultation may be necessary to confirm there are no indications for antibiotic prophylaxis (see below).

Is medical clearance required?

• Yes, if there is the potential for equipment-related electromagnetic interference of the implanted cardiac device. Also, clearance may be required for comorbid conditions or the underlying disease entity that led to implantation of the cardiac device (e.g., myocardial infarction)
  

Is antibiotic prophylaxis required?

• No, not generally (for the prevention of infective endocarditis) for cardiovascular implantable devices, including cardiac pacemakers (intravascular or epicardial) and ICDs. Furthermore, antimicrobial prophylaxis is not recommended for dental/dental hygiene invasive procedures to prevent CIED infection. However, consultation with the patient/client’s primary care physician or cardiologist may be indicated to confirm that there are no other indications (such as certain cardiac conditions) that may warrant antibiotic prophylaxis for the prevention of infective endocarditis or related adverse outcomes.

Is postponing treatment advised?

• Potentially, if the CIED was recently placed (e.g., for 1 to 6 weeks post-implantation, depending on the type of device, to allow for surgical wound healing, avoidance of lead dislodgement, reasonable post-implantation comfort, and adequate arm mobility). Also, the dental hygienist should avoid the use of equipment that poses risk of EMI in a patient/client with a CIED.

• Prior to using ultrasonic or electronic equipment that poses potential EMI risk, the dental hygienist should ask each patient/client if a cardiac pacemaker or implantable cardioverter defibrillator is present. Similarly, dental hygienists or other healthcare workers with CIEDs should be aware of their own implanted devices and exercise caution in using equipment¹ or consumer electronic devices that pose potential EMI risk.
• Electromagnetic interference from some dental devices may temporarily interfere with the function of certain CIEDs, posing risk of inhibition of cardiac pacing, asynchronous pacing, or inappropriate shocks, mostly with older model pacemakers and ICDs. Prior to 2000, the literature on EMI was conflicting and controversial (much being based on in vitro [laboratory], rather than in vivo [in people], observations). More recent human studies, in conjunction with previous data, suggest, however, that most dental devices (i.e., ultrasonic scaling devices; ultrasonic bath cleaners; and battery-operated curing lights, amalgamators, electrical pulp testers and apex locators, handpieces, electric toothbrushes, microwave ovens, and X-ray units) do not cause significant interference with the pacing and sensing of newer model pacemakers and ICDs.² 
• Particular caution should be exercised with older ferromagnetic/magnetostrictive³ ultrasonic scalers, which may cause single beat inhibition with unipolar pacemakers⁴. In addition, particular caution in the use of electrosurgery units is still recommended.⁵ 
• Electrical cords should not be placed over the chest⁶ of a patient/client with a CIED. EMI risk may be additionally reduced by not waving the dental device or its cords over the patient’s pectoral region, as well as by turning off the equipment when not in use.
• Dental chairs with magnetic headrests may need to be avoided for patients/clients with CIEDs.
• Patients/clients are usually issued a CIED manufacturer’s identification card by their cardiologist, which provides information on model, mode of operation, serial number, manufacturer, and date of implantation, as well as medical contacts. This information, which should be carried by the patient/client and recorded by the oral health professional, will assist in determining whether dental hygiene treatment should proceed. The manufacturers of cardiac devices and/or dental equipment may be contacted for advice regarding the possibility of EMI and precautionary measures.
• Clinical relevance of EMI depends on various factors, including the type of dental equipment used, the application distance, and the type, model, and manufacturer of the CIED.
• “Safe” procedures/equipment generally include dental radiographs, cone beam CT⁷, dental hand pieces, composite curing lights, sonic scalers, and piezoelectric scalers. Newer ultrasonic scalers are unlikely to have any adverse effects on patients/clients with newer bipolar (as distinct from unipolar) implanted cardiac devices. As well, transcutaneous electrical nerve stimulators (TENS) are unlikely to interfere with an implanted cardiac device provided the equipment is not placed directly over the implant site. 
• Dental/dental hygiene equipment that poses no EMI risk should be substituted for instruments that pose potential risk. For example, because ferromagnetic/magnetostrictive instruments may affect unipolar pacemakers, the dental hygienist can instead use sonic or piezoelectric instruments as an adjunct to manual debridement.
• Contrary to former thinking, lead apron coverage does not provide additional protection from EMI; such coverage provides protection from ionizing radiation only. 
• Improvements in the design, manufacture, and protective shielding of CIEDs means that adverse clinical outcomes are very unlikely in the dental hygiene or dental setting. Most dental/dental hygiene procedures do not involve strong electromagnetic signals. However, caution should be exercised when operating equipment that can potentially generate EMI.
• Consumer electronic devices that may create magnetic interference, including cell phones and smart watches, should be kept 15.2 cm (six inches) or more away from the implanted device, because such personal devices may inhibit normal functioning of the CIED.⁸ 
• In the event of a CIED malfunctioning during a dental hygiene/dental appointment, all sources of potential electromagnetic interference (such as ultrasonic units) should be turned off, and emergency medical services (EMS) protocol may need to be activated should function not be quickly restored. In most circumstances, the implanted cardiac device will return to normal function when interference ceases. All suspected interference incidents should be reported to the patient/client’s cardiologist.  
• While electric and battery-powered toothbrushes are generally considered safe, a precaution was issued by a leading cardiac implant manufacturer relating to the use of sonic toothbrushes with a battery charger. The manufacturer recommended that patients/clients maintain a distance of at least 6 inches (i.e., 15.2 cm) between the battery charger unit and the implanted device, as well as a distance greater than 1 inch (i.e., 2.5 cm) between the toothbrush and the implanted device.
• The dental hygienist should recognize that the presence of an implanted cardiac device signals a cardiovascular condition that may require treatment modifications⁹. Baseline vital signs (including blood pressure) and ongoing monitoring are prudent in the office setting.
• Stress reduction protocols¹⁰ should be considered for all patients/clients with CIEDs (particularly those with ICDs) to reduce the risk of cardiovascular effects caused by stress during dental hygiene or dental treatment. Administration of exogenous epinephrine and other vasoconstrictors (e.g., in local anaesthetics) should be limited to minimize risk of arrhythmias and other adverse events.
• In the event of a cardiovascular emergency requiring the use of an automated external defibrillator (AED) for a patient/client with an ICD or CRT, the AED pads should be placed as far away from the implanted device as possible (ideally 13 cm at a minimum). The patient/client should also be advised to undergo an evaluation of the implanted device by his/her cardiologist to ensure that damage has not occurred.

• None specific to CIEDs; however, there may be oral side effects from concurrent medications such as anti-hypertensives or anti-arrhythmics.

• CIEDs are used to improve the function of an electrically malfunctioning heart, thus improving quality of life for eligible persons suffering from heart failure, ventricular dyssynchrony, or electrical instability¹¹ of the myocardium following a myocardial infarction or as a result of other cardiac abnormalities. They typically consist of a battery-powered¹² generator implanted subcutaneously (most commonly near the clavicle in adults, but in children they may also be implanted in the abdomen), with electrode leads (wires) that connect to various areas of the heart via the venous circulation. Advances in technology of CIEDs means that today’s cardiac resynchronization therapy devices¹³ and ICDs¹⁴ are small computers or microprocessors, which often provide combination features.
• In a demand pacemaker, the leads monitor heart rate and deliver a pacing impulse only when the rhythm of the heart falls into a predetermined abnormal range. In the less common fixed-rate pacemaker, continuous pacing of the heart rate occurs regardless of the heart’s inherent rhythm. In an implantable cardioverter defibrillator, a precisely calibrated cardioversion/defibrillation shock can be delivered upon detection of an abnormal heart rate (i.e., ventricular tachycardia or fibrillation) to stop abnormal electrical activity and restore normal heart rate.
• Cardiac implantable electronic devices are becoming increasingly common given an aging population and growing adoption of technology. More than 3 million persons globally, including more than 500,000 in North America, have implanted cardiac pacemakers. 70% to 80% of permanent pacemakers (PPMs)¹⁵ are implanted in persons aged 65 years or older.
• Pacemakers and ICDs may be sensitive to strong electromagnetic signals that can temporarily interfere with their function. ICDs on the market today are bipolar¹⁶, having enhanced protection and filtering against EMI. Pacemakers may be either bipolar or unipolar¹⁷, with unipolar devices typically providing less protection and filtering against EMI.
• Signs/symptoms of pacemaker malfunction include: unusual activity or discomfort from the implanted device; difficulty breathing; light-headedness; dizziness; alterations in pulse rate; swelling in extremities (particularly in the ankles and feet); chest pain; prolonged hiccoughing; and muscle twitching.
• Signs/symptoms of infection related to CIED insertion include pain, swelling, erythema (redness), and pus at the site of device insertion, as well as elevated temperature (38°C or higher).

• Tom J. Management of Patients With Cardiovascular Implantable Electronic Devices in Dental, Oral, and Maxillofacial Surgery. Anesth Prog. 2016;63(2):95-104. doi:10.2344/0003-3006-63.2.95
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896049/  
• Bradshaw PJ, Stobie P, Knuiman MW, et al. Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population. Open Heart 2014;1:e000177. doi:10.1136/openhrt-2014-000177
  https://openheart.bmj.com/content/1/1/e000177  
• Johnson T. Power Instrumentation Considerations. Dimensions of Dental Hygiene. April 2014;12(4):20–24.
  https://dimensionsofdentalhygiene.com/article/power-instrumentation-considerations/  
• Stoopler ET, Sia YW and Kuperstein AS. J Can Dent Assoc 2011;77:b113.
  http://www.jcda.ca/article/b113  
• Shah AH, Khalil HS, and Kola MZ. Dental management of a patient fitted with subcutaneous Implantable Cardioverter Defibrillator device and concomitant warfarin treatment. Saudi Dent J. 2015 Jul 27(3):165–170.
  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501466/ 
• College of Dental Hygienists of Manitoba
  https://cdhm.info/practice-resources/ (Interpretation Guideline for Cardiac Implanted Electrical Devices (CIEDs) and Ultrasonic Instrumentation)
• College of Dental Hygienists of British Columbia
  http://www.cdhbc.com/Practice-Resources/Interpretation-Guidelines/Implanted-Cardiac-Devices.aspx  
• Ottawa Heart Institute
  https://www.ottawaheart.ca/pacemaker-implantation-patient-guide/discharge-follow-care 
  https://www.ottawaheart.ca/implantable-cardioverter-defibrillator-patient-guide/discharge-follow-care-after-your-icd-procedure  
• American Dental Association
  https://www.ada.org/en/member-center/oral-health-topics/cardiac-implanted-devices-and-electronic-dental-instruments 
  http://circ.ahajournals.org/content/121/3/458.full.pdf (Update on Cardiovascular Implantable Electronic Device Infections and Their Management: A Scientific Statement From the American Heart Association)
• American Heart Association
  https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000969 (AHA Scientific Statement, May 18, 2021: Prevention of Viridans Group Streptococcal Infective Endocarditis)
  http://www.heart.org/HEARTORG/Conditions/Arrhythmia/PreventionTreatmentofArrhythmia/Devices-that-may-Interfere-with-Pacemakers_UCM_302013_Article.jsp#.V4VXk6sondl 
• Dentistry IQ
  https://www.dentistryiq.com/dental-hygiene/article/16365621/magnets-in-dental-chairs  
• U.S. Food and Drug Administration
  https://www.fda.gov/radiation-emitting-products/cell-phones/magnets-cell-phones-and-smart-watches-may-affect-pacemakers-and-other-implanted-medical-devices  
• Mayo Clinic
  https://www.mayoclinic.org/tests-procedures/pacemaker/about/pac-20384689 
• WebMD
  https://www.webmd.com/heart-disease/heart-failure/biventricular-pacing#:~:text=Pacemakers%20usually%20last%20five%20to,about%20two%20to%20four%20years  
• National Health Service
  https://www.nhs.uk/conditions/pacemaker-implantation/recovery/  
• Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5^th edition). St. Louis: Elsevier; 2020.
• Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9^th edition). St. Louis: Elsevier; 2018.
• Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3^rd edition). Baltimore: Wolters Kluwer Health, 2015.  
• Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015.

¹ Some manufacturers offer recommendations on use of their devices in the vicinity of CIEDs, and reports of interference are from a dental device usually within 37.5 cm (~15 inches) to the CIED or leads.
² This likely reflects the bipolarity (shielding) of more modern ICDs and pacemakers, as well as changes in dental device design. As a group, CIEDs implanted in the 1990s or before were more susceptible to EMI than are devices that have been implanted within the past 15 to 20 years.
³ Magnetostrictive ultrasonic instruments are not generally contraindicated for use on patients/clients with a bipolar pacemaker or an ICD.
⁴ Single beat inhibition is not considered clinically significant by some pacemaker manufacturers. However, at least one manufacturer recommends caution when using ultrasonic scalers, and discontinuing use if the patient/client with an implanted cardiac device feels lightheaded or experiences an irregular heartbeat.
⁵ Electrosurgery cautery units (monopolar more so than bipolar types) have demonstrated EMI in medical settings.
⁶ The abdomen should additionally be avoided if the CIED was implanted intraabdominally.
⁷ CT = computerized axial tomography
⁸ Recent studies have found that personal electronic devices such as wearable smart devices, cellphones, and electronic cigarettes that contain high strength magnets can produce magnetic fields strong enough to affect CIED performance, including switching the mode of a pacemaker or disabling of the cardioverter-defibrillator function. High field strength magnets may cause certain CIEDs to switch to “magnet mode” and suspend normal operations until the magnet is moved away from the CIED.
⁹ For example, a patient/client with an ICD may be on concomitant anticoagulant therapy.
¹⁰ Stress reduction protocols include the establishment of a good rapport with the patient/client; suitable appointment time (e.g., in the morning) and duration (i.e., short as possible with termination if patient/client develops signs/symptoms of fatigue or procedure intolerance); comfortable chair position; and sedation if necessary.
¹¹ Such electrical instability can lead to life-threatening ventricular tachycardia and/or fibrillation.
¹² Pacemaker batteries typically last 5 to 15 years, with surgery (usually quicker and easier than the original implant surgery) being required to replace the battery. Biventricular pacemakers combined with an ICD do not tend to last as long — 2 to 4 years.
¹³ CRTs are pacemakers that re-synchronize the heart’s contractions caused by arrhythmias, essentially “re-tuning” electrical conduction in the heart. They are most commonly used to manage bradycardia (slow heart rate).
¹⁴ ICDs are used to treat potentially life-threatening tachyarrhythmia (abnormally high heart rate). In newer generation ICD combination units, if an initial low energy electrical pulse does not restore normal rhythm, defibrillation of the heart will then occur by the sending of higher energy electrical pulses.
¹⁵ In addition to PPMs, there are also temporary pacing devices that are used when permanent cardiac pacing is not immediately indicated, available, or the risk of inserting a permanent pacemaker outweighs potential benefit. Temporary cardiac pacing is most commonly used for patients/clients with symptomatic bradycardias (slow heart rate), most commonly due to atrioventricular (AV) node block.
¹⁶ The terms “bipolar” and “unipolar” have superseded the older terms “shielded” and “unshielded” when referring to electronic filter and insulator safeguards incorporated into implanted cardiac devices.
¹⁷ In a unipolar pacemaker, the leads stimulate only one chamber of the heart. In a bipolar pacemaker, one lead is usually inserted into the right atrium, and the second lead is positioned with the right ventricle.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.