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Tooth Pain: Under Water And In The Sky

by Paweł Łabno and Andrea Paula Moraru – IADS Congress – Sharm el Sheikh Egypt

(zdjęcia za zgodą Patrick’a Musimu – rekordzisty świata w nurkowaniu swobodnym – The Ultimate Dive 209 m)

(Patrick zmarł w czasie treningu w swoim prywatnym basenie w 2011 r.)

When I started to search for a good and interesting subject for a paper work, I was looking for something related to the most common dental problems according to the U.S. Army. Possible topics were caries, periapical abscesses, post-operative complications and sport correlations.

I always believed that careless and mediocre approach of a dentist can become a serious safety risk to his patients. In the globalized times, the world is smaller than anytime in history of mankind. People got used to travel around the globe in a few hours, and flying a plane doesn’t surprise us anymore. Life has become easier than ever and the ways of spending our free time are more sophisticated. We are struggling to find more extreme sports and reach higher limits. As my dear friend Andrea Paula Moraru was presenting our work at the IADS Congress in Egypt 2008, I was climbing the Mont Blanc – the highest mountain in Europe. 50 years ago, I’d be the only person on the road to the top, but today it’s crowded as the beach in Saint Tropez.

When you reach to the end of this article I’d like you to know how to answer your patient to these questions:

  • Is it possible for a tooth to explode from inside to outside?
  • Can it implode in the opposite direction?
  • What is the reason that my tooth hurts me so badly when I’m flying a plane or diving in the ocean?

Let’s begin with saying that environmental pressure variations have been shown to cause dental pain in divers, submariners, pilots, airline passengers, balloonists, mountain climbers and aviators.

The Pressure

The pressure at any level in the atmosphere may be interpreted as the total weight of the air above a unit area at any elevation. At higher elevations, there are fewer air molecules above a given surface than a similar surface at lower levels.

Henry’s Law

At a constant temperature, the amount of a given gas dissolved in a given type and volume of liquid is directly proportional to the partial pressure of that gas in equilibrium with that liq- uid. This is why more nitrous dissolves during a descent of the diver when the pressure is rising.

Dalton’s Law

The total pressure exerted by a gaseous mix- ture is equal to the sum of the partial pressures of each individual component in a gas mixture.

Boyle’s-Mariotte’s Law

For a fixed amount of gas kept at a fixed temperature, P and V are inversely proportional- while one increases the other decreases.

Imagine a situation of a technical rescue diver who is unable to act during sudden mission be- cause of a tooth pain. Think about a plane test pilot, who already checked all controls, buttons, switchers of his million dollar baby and while performing his maneuvers his face becomes red, a blood is moving into the head and pulp inflammation causes so much pain that he has no other choice than return to base. What about a mountain climber who had to pay a huge amount of money for permission to reach Himalayas and after many days of struggle has to surrender and watch his friends going further because his headaches are so strong that they cause problems with keeping the balance. You should know that although all the problems we will be talking about are connected to pressure changes, the mechanisms of problems showing up underwater and in the sky are different. Moreover free divers and technical divers suffer due to different reasons. And the problem of barodontalgia happens more often underwater because of higher altitude/pressure correlation. Now we’re going to explain a few terms:

  • Barotrauma/Aerotrauma is a physical dam- age to body tissues caused by a difference in pressure between an air space inside the body and the surrounding gas or liquid Damage occurs in the tissues around the body’s air spaces because gases are compressible and the tissues are not. During increases of ambient pressure, the internal air space provides the surrounding tissues with little support to resist the higher external pressure. During decreases in ambient pressure, the higher pressure of the gas inside the air spaces causes damage to the surrounding tissues if that gas becomes trapped.
  • Tooth Explosion – rising pressure in the tooth chamber caused by trapped gas can crack in parts surrounding walls. For example cotton wool covered by temporary filling between root canal treatment visits or caries lesion.
  • Tooth Implosion – higher pressure of the environment can cause the crack of the tooth from the outside to the center like collapsing of a black hole.
  • Barodontalgia/Aerodontalgia is a toothache by barotrauma/aerotrauma.

Barodontalgia as a term was used in 1940 originally describing the pain developed by pilots in unpressurized cockpits. After the World War II the incidence of reported barodontalgia has decreased because of new dental materials, new dental procedures and cabin pressurization however in the XXI century standards of living, make extreme sports got many followers and the human body is put into uncommon conditions. We as a dentist have to keep that in mind because our work will have to stand up to much greater forces than were predicted by a us and producers. Many different complaints start to show up from an altitude of 3000m (0,75 atm) and in the diver at 10m /1,0 atm. Adler classified symptoms of barodontalgia as being caused by either trapped gases or envolved gases. When an air bubble inside a human body is unable to travel outside to equalize the pressure /tooth restoration/, excessive gas pressure or volume may result in mechanical tissue disruption. The problem became so significant that military medicine had to stimulate continued research.

More research studies are required but many cases are needed which narrows the number of scientific facilities to military or oceanography labs.

Reexposure to altitude in a chamber can be used to confirm a doubtful diagnosis or to determine the effectiveness of therapy. It is especially needed in technical, rescue divers or pilots. Posterior teeth are more frequently involved than anterior teeth and maxillary teeth are affected more often than mandibular teeth. Teeth filled with amalgam and are more likely to be involved than unrestored teeth and recently restored are particularly susceptible. Strohaver has recommended that after deep restorations flying and diving should be postponed to 48-72 hours to allow time for the dental pulp to quiet down and stabilize.

During a crown preparation dentin permeabil- ity increases but it shouldn’t cause a problem if the restoration is well sealed and there is no mi- croleakage however if it occurs, it may indicate a deficient margin or disruption of the cement.

At the sea level there may be no symptoms but several meters below the surface barodontalgia may present clinically before crown debonging. Full ceramic prosthetic fillings can crack in parts even at the 20m depth. After tooth extraction a blood makes a clot that prevents bone from getting infected. Patients should avoid diving for 2-8 weeks. Venturi effect of clot removal might also come into play with divers sucking air through a snorkel or regulator.

What we do have to look for: Deep Caries, Pulp Inflammation, Dead Pulp, Dentin Permeability, Heavy Restorations Without Lining Cements Under Preparations, Infected Root Canals, Inappropriate Root Canal Treatment, Dentin Permeability, Periapical Lesions, Periodontal Abscesses, Maxillary Sinus Congestion, Recent Tooth Extraction, CaOH2 Lining /Resorption/, Temporary Feelings /especially divers using heliox: helium + O2, Cements Used To Fix Casted Restorations, Inflammations In The Oral Cavity Region, Not Yet Fully Healed Oral Wounds, Temporomandibular Joint Overweight, Insufficiently Light Cured Composites.

  • Symptoms: tooth explosion, tooth implosion, pain: head, muscles, joints, tearing porcelain crown in parts, full prosthetic fillings damage / aspiration/, deconcetrating pain, vertigo effect /pilots,divers/, post extraction complications related to bone inflammation.
  • Treatment: closing dentine tubules, reconstructing marginal line of crown cement, using new generation of composite light curing lamps with regulated intensity.

The preventive treatment is very important. Both complete clinical and radiological examinations must be achieved. Regular dental examination are essential for the crew.