Effects of Living With A Pacemaker

• Mackenzie Crowe

Millions of people live with the help of a pacemaker on a day to day basis. An enormous 600,000 pacemakers are implanted each year and a total of 3 million people worldwide are living with a pacemaker.¹ Like most scenarios, health hazards do not really affect someone until a family member or close friend is diagnosed. We usually do not become curious until someone we truly care about requires some sort of help. That’s just what my family member’s heart needed.

My family member lived with a pacemaker quite a few years before he passed. Along with his age, he had other health complications that lead to arrhythmias, or irregular heartbeats, and his body became too weak to keep up with the demand of pumping blood to all parts of the body; so they implanted a pacemaker. A pacemaker, also known as an implantable cardioverter defibrillator (ICD), is a miniaturized computer that sends electrical stimulation to the heart whenever it senses that the heart is not beating or is beating too slowly.² The pacemaker is about the size of two stacked silver dollars and weighs approximately 17-25 grams.² This device’s main purpose is to help the heart maintain its repetitive rhythm, but it can also store information for a doctor to retrieve which will allow the best possible therapy per individual.² Newer pacemakers can also treat heart failure by resynchronizing the electrical impulses in the heart’s four chambers- therefore improving the heart’s ability to pump blood.²

From the time my family member had one implanted to the time that he passed, he had gone through two pacemakers. Like anything else, pacemakers can malfunction. In my family member’s case, his pacemaker just wasn’t working properly and so they just simply implanted a new one. From then on, everything pertaining to his pacemaker went rather smoothly. When I was young my cousins and I always asked him questions as to why he had it, what it did for him, and sometimes he would even open his shirt and let us feel where the pacemaker was in his chest.

Although I didn’t live with my grandparents I did spend a lot of time at their house and the fact that my family member had a pacemaker rather bothered me. I wanted to know everything about it. I wanted to know what to do if something were to go wrong. I wanted to know if there could be complications that others needed to be aware of. I wanted to know that having a pacemaker wasn’t going to prohibit him from doing normal daily activities. As I spent more time with him and did some research of my own, I learned a lot more about pacemakers. I learned what it’s like to live with someone who has one compared how an individual’s life can change from getting a pacemaker implanted.

This paper aims to help the reader understand exactly what a pacemaker is, and what it does for someone. The reader will also learn about problems associated with having a pacemaker, latest trends and treatments, and trends in nutrition, which will include medication(s). I also hope to see the reader understand how a family can be affected by living with someone who has a pacemaker, and how caring and monitoring a person with a pacemaker can be difficult at times. In a medical aspect, this paper will connect pacemakers and dentistry together. The reader will learn of risks associated to pacemakers in a dental office, dental implications, dental complications, and how to educate a patient of good oral hygiene with the use of pacemaker in place. I have also attempted to identify important questions for the patient and what to do in the instance of an emergency.

Due to the vast amount of pacemakers used throughout the United States, researching and learning about pacemakers will help me be prepared for the evaluation of a patient with this medical history. I know that as a dental hygiene student it is my responsibility to be prepared for patients that present items that could interfere with the dental practice and be ready to make modifications as needed. As a health professional it is also my job to put the health of that patient at the forefront of my care plan when preparing for treatment.

A pacemaker is not to be confused with the heart’s natural pacemaker. This artificial medical device uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beat of the heart.³ Its primary purpose is to keep the heart beating adequately, either because the natural heart is not fast enough, or there is a block in the electrical conduction system. Some pacemakers are combined with a defibrillator in a single device, while others have multiple electrodes stimulating different positions within the heart to help improve irregularity of the lower chambers of the heart.³ Pacemakers are a necessity for many people. Millions of people wouldn’t be able to participate in day to day activities if not for their pacemaker. Pacemakers give a sense of normality to those who would otherwise be struggling to complete an activity that seems so easy to someone whose heart functions fine without assistance.

Some complications with pacemakers during or after implantation (acute) could be bleeding, infection at implantation site, allergic reaction, swelling, or a collapsed lung, all of which are uncommon and can be treated easily and effectively.⁴ Later complications (chronic) can be generator failure and lead failure, both of which are extremely rare.⁵ If patients follow a precise routine of physician care appointments, most complication can be detected before becoming serious. Patients should be aware of symptoms such as weakness, being easily fatigued, lightheadedness, dizziness, and loss of consciousness.⁵ If these symptoms appear after implantation, the patient’s doctor should be notified immediately so that the pacemaker can be checked in correspondence with these symptoms.

Patients with pacemakers should try to adhere to a heart healthy diet after the implantation process in order to have a successful and quick recovery. This type of diet includes low fat and low simple sugars and high fiber contents.⁶ The patient’s diet should also be based on height, weight, current diet pattern, medical history, and level of physical activity. Family members who are in the role of caretaking for post-surgery patients should encourage the patient to try and maintain their current weight or lose weight is the patient is considered overweight by a physician. They should emphasize eating whole foods such as whole cereals, grains, beans, and fresh fruits and vegetables.⁶ Proteins such as eggs, milk, fish high in omega-3 fatty acids, and poultry should also be included.⁶ Fatty foods, fried and salty foods, sweets, or bakery items like cookies and cakes, along with carbonated beverages should be avoided.⁶ The patient should also try to avoid any kind of stress whether is it physical or psychological, and they should take further measures to quit smoking.⁶ If the patient drinks alcoholic beverages, it can be continued but should be done in moderation such as limiting it to one per day or as otherwise discussed with the physician.⁶ Most pacemakers now allow for patients to get engaged in physical activities which is an important aspect in congruence with a healthy diet. Exercise will not only help maintain body weight, but it will also help improve the patient’s cholesterol.⁶ Before beginning any physical activity, exercise should be discussed with the patient’s specialist or dietician. Family members are the best advocate to help keep the patient on track and in line with multiple aspects of their diet, stress levels, smoking, and physical activity.

As of now, no drugs are used along with a pacemaker because treatment consist of upgrading or reprogramming the pacemaker. Sometimes medications are given to the patient when the implantation process begins so that they patient is able to relax but still be aware of their surroundings.⁷ They will still be able to hear and talk to the medical team throughout the process. The patient will also receive anesthetic (numbing) medication at the site of the incision.⁷ Certain patients with atrial flutter/fibrillation or venous problems may be on medications such as Coumadin or patients that have had previous stent replacement may be on Plavix to reduce the chances of blockage.⁸ These medications are not normally prescribed after implantation but if the patient is already taking them before implantation they are normally switched over to a Heparin IV drip for surgery and then slowly moved back over to their medications afterward.⁸

Caring for patients with pacemakers can be difficult if the patient does not value their health as much as they should. It can be hard to take care of someone who would rather let the caretaker do all the work. Patients should be motivated to stay healthy. While most know that this is easier said than done, family members should try to emphasize a healthy diet and how it can really make a difference in their daily living. Elderly patients will need more recuperation time and won’t be able to participate in strenuous activity like a middle aged patient. It is imperative that the caregiver try to get the patient to be self-sufficient so that when the time comes for them to take care of themselves, they will know where to take off from what their caregiver was doing for them.

The implantation of a pacemaker can affect the patient’s ability to undergo various medical procedures. Dental procedures, X-rays, MRI’s, CAT scans, bone density tests, mammograms, and ultrasounds can all affect pacemakers because of the reactions of the energy waves involved in the tests and the electronic component of the pacemaker.⁹ If the pacemaker is not programmed to resists these types of interferences, complications can arise. Dental care, like any specialized treatment, is a necessary and routine healthcare issue. Most dental care visits include x-rays, ultrasonic scaling, drilling, and other procedures that might produce high electromagnetic energy. To avoid malfunctions to the pacemaker and possible harm to the patient, it is extremely important to tell the clinician about the pacemaker in advance.

The oral cavity is a likely source of bacteria that may elicit infections on pacemaker and ICD devices after systemic transmission.¹⁰ According to the American Dental Association, studies show that dental patients with a pacemaker are particularly at risk for developing endocarditis.¹¹ This infection or inflammation of the heart occurs as a result of bacteria that enters the bloodstream from the mouth.¹¹ Under certain conditions, patients with heart problems will be given antibiotic medications before procedures to help prevent bacteria from spreading to the bloodstream.¹¹ This is a proactive approach that protects the patient and the dentist.

Certain dental procedures often involve the use of electrical equipment that may come into close proximity to an implanted pacemaker. There is a possibility that exposure to some of this equipment may temporarily affect the function of the pacemaker. Some potential interactions that might take place are: inhibition of pacing: pacing not provided when needed, asynchronous pacing: pacing provided at a fixed rate whether needed or not, and inappropriate shocks: shock therapy provided when not needed.¹² Some manufacturers contraindicate product use in patients with pacemakers, but there are also other things that can be done to avoid complications.¹² The clinician should seat patients away from power sources or adjust equipment to the lowest possible setting and should also avoid draping cables over the implantation site.¹² If the patient begins to feel lightheaded, have increased heart rate, experiences a shock, or hears beeping from their device they should move away from the source of interference or the clinician should power down the device.¹² This will allow for the pacemaker to return to normal.

According to the Boston Scientific Analysis of Dental Equipment, drills and cleaning equipment, dental x-rays, and apex locators all showed no signs of interference.¹² Ultrasonic scalers can cause disturbances but are very unlikely unless notified by the manufacturer.¹² To be on the safe side, the majority of dentists would not use an ultrasonic scaler to perform a scale in a patient fitted with a pacemaker or an implantable cardiac defibrillator (ICD).¹³ Other dental office equipment that may cause interferences are dental chairs with magnetic headrests and electrocautery.¹² Both are temporary affects although if patient’s pacemaker is programmed not to respond to magnetic headrests then patients may sit in these chairs.¹² Patients considered to be at risk from external interference can have a magnet placed over the pacemaker to switch the pacemaker to fixed-rate mode making it immune to external signals.¹⁴ Use of mini magnets in prosthetic dental procedures is safe for patients with implanted pacemakers.¹⁵

Clinicians should be prepared to make accommodations for patients that have pacemakers. The use of hand instruments will be critical if a patient shows signs of being sensitive to electrical devices. It is the job of the clinician to be able to adapt to that patients’ needs rather than making the patient adapt to the office; this includes helping the patient make changes at home as well.

Some patients with pacemakers may need assistance when it comes to good home care. The patient will most likely need accommodations to be made shortly after surgical implantation. It may be hard for the upper chest and dominant hand to move a toothbrush around the oral cavity. Clinicians should be aware of this need and should be ready to make suggestions based on the individual. Some ideas that may be beneficial are having another person brush for the patient for the first few days after the surgery. If the patients then feels better suited to take over they could begin brushing once a day along with a mouth rinse and slowly move up to brushing twice a day and flossing when they feel fit to do so. This may be easier for the patient and at the same time they are still accomplishing good oral health care.

Before beginning treatment in a dental office the patient should make sure that their clinician knows of their personal health status with their pacemaker included and that their clinician is prepared if an emergency would arise. It’s best to have a clinician certified in CPR and that is knowledgeable on how to use an automated external defibrillator (AED) if necessary. CPR chest compressions can be done as usual on a patient with an implanted pacemaker.¹⁶ Implantable pacemakers are also designed to withstand the shock of an external defibrillator but the pads should not be placed over the device or the pacemaker can sustain damage.¹⁶ If the patient has an implanted medical device, an alternative AED pad position is advised, such as the anterior-posterior position.¹⁷ It is best to place the pads as far from the source of the pulse as possible and to use the lowest power clinically acceptable to try and deliver a shock that will not damage the device but will restart the patient’s heart.¹⁶

Pacemakers are a vital source of life for many Americans. They enable people to keep living a normal lifestyle. Although there will always be aspects that patients can do to sustain better care for themselves, having a pacemaker is really quite easy. Monitoring the device is important and routine doctor visits are necessary for upkeep and general health. My family member was able to go on living his life as he normally would’ve because he had the help of his pacemaker. Without that, I may not have had as much time with him as I was able to have, and for that I am truly grateful. Modern technology is continually growing and the pacemaker system is developing with it. I hope that this paper gives you a general knowledge about pacemakers, health importance at home and with family members, and their connection to the dental office.

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