Barodontalgia

1. Barodontalgia An Overview for Medical Aviators CAPT Mike Brenyo DC USN BS DMD MS FACP

2. Disclosures • I have no actual nor potential conflicts of interest in relation to this presentation. • My views, as expressed, in no way shape or form, reflect the views • of the US Navy, or its beloved Dental Corps, • nor the newly established DOD Defense Health Agency(DHA). • This presentation is my own personal & professional opinions. • Some, if not most; of the visuals are indebted to the internet for usage • and are in the public domain for for academic and not pecuniary interest.

3. Enabling Learning Objectives • Recognize Barodontalgia and its presentation. • Understand its relevance in aviation settings. • Determine in-flight triage and post mission management • Provide Differential Diagnosis (dental or a sinus problem?) • Know its prevention recommendations. • Determine Treatment or Referral for a patient presenting with Barodontalgia

4. Street Cred • Catholic School Upbringing; Eagle Scout (1976) • Son of career Naval Officer & Endodontist (Dad is 85) • Microbiology Major - BS (1980) Univ. of Notre Dame • DMD from Univ. of Pittsburgh (1984) • Prosthodontics Certificate; Bethesda/Walter Reed) (1997) • MS in Oral Biology(1997) ; The George Washington University • Board Certified Prosthodontist;(2001) • Retired-retained on Active Duty (since 2014) CAPT DC USN • 34 years practice exposure to Armed Forces Personnel. • 15 years OUT of CONUS living in 4 of my 11 duty stations. • 4 years Air Station Duty, 3 years aboard USS Enterprise CVN-65 • Graduate; USMC OCS/ PLC, Quantico. (1979) Aviation Contract • Private Pilot Obtained in 1991. Have not flown solo/PIC in decades • Sinusitis sufferer and still experience terrible ear pain in commercial aircraft !!!

5. Why this Topic? • Vol-n-told • Relevant • 3. Waxing • nostalgic

6. Barodontalgia • Introduction • Definition • Etiology • Classification • Diagnosis • Management

7. “We are what we repeatedly do. Excellence, then, is not an act,but a habit” - Aristotle

8. Introduction • BLUF: • Incidence is low (3 per 100 flight years) • Pain is excruciating • Confirmed Barodontalgia is experienced in previously • restored defective teeth • Untreated dental caries may cause pain at altitude • Air trapped in teeth expands in ascent (Can also cause pain on descent) !!! • Altitude of occurrence varies with individuals( AGRO pilots NEVER get it ! ) • Rarely caused by root abscess with a small pocket of trapped gas

9. Definitions of Barodontalgia • Pain in the soft tissue resulting from a disequilibrium in the air-filled spaces around a tooth caused by ascent or descent into places with differential barometric pressure. • Oral (dental or nondental) pain caused by a change in barometric pressure in an otherwise asymptomatic organ. • A “symptom” of a preexisting sub-clinical oral disease. • Not the cause

10. What it is: • Barometric-induced toothache- usually seen in pilots/divers. • And of course, passengers along for the ride ! • Symptom/exacerbation (flare-up) of a preexisting sub-clinical oral disease. Healthy teeth DO NOT experience Barodontalgia ! • Potentially incapacitating event and serious risk to flight mission • Can be severe enough to cause inflight vertigo and premature flight cessation

11. What it is NOT: • Odontecrexis - deterioration of restorations and tooth fracture. Usually occurs without pain. • Facial barotrauma (3) - barometric-related trauma to facial cavities: * These are pressure changed-induced (new) pathologic conditions.. Barotitismedia (middle ear barotrauma) tympanic membrane External otitic barotrama - ext. ear canal mucosa “Earplugs” Barosinusitis – paranasal sinuses, pressure differences *[NOTE] Referred pain from these can be manifest as a toothache. Therefore. INCLUDE in Differential Diagnosis • .

12. Prevalence • 0.7-2% in USAF altitude chambers (1940s) • It ranked 5th as complaint and 3d as cause of chamber simulation termination. • with pressurized cabins, only slight reduction • Usually above 3,000 ft. with 11% of aircrew affected. • Seen at 5,000-35,000 ft. BUT More common 9,000-27,000 ft. • 3-37% of barodontalgia is NON-Dental facial Barotrauma

13. Divers get this too …! Pilots only get this in a water landing !

14. Don’t forget that intraoral and extraoral masks can potentially cause TMJ Issues (referred pain)

15. Etiology

16. And…… Carious lesions, hyperemic and necrotic pulp & periapical spaces, periodontal abscesses, cysts, impacted teeth, defective restorations…..

17. Dentinal Hypersensitivity: is NOT Barodontalgia. Cold air from ambient(?) or OXYGEN Masks can cause exquisite pain (happens but rarely)

18. Predisposing/preexisting conditions(SOURCES) • Dental Disease: THE COMMON STUFF: • Dental caries, defective restorations, pulpitis, pulp necrosis, periapical periodontitis, periodontal pockets, impacted teeth mucous retention cysts. • *See Merck Manual Chapters 57-59 • Failed or defective Dental restorations (emphysema) • Recent Dental Work

19. CAVEAT • No consensus exists on pathogenesis of pulp related barodontalgia • BUT a HEALTHY Tooth is unaffected by barometric change !!! • Etiology: barodontalgia is NOT a pathological condition in itself. It is a symptom that reflects a flare-up of preexisting sub clinical oral disease.

20. Classification • direct/indirect (from somewhere/something else) • Pulpal & Periapical conditions & symptoms • FDI – Internationally Accepted

24. Diagnosis

26. Diagnosis Myths • Identifying the pain during a pressure change is a diagnosticindicator for the clinician. Treatment involves removing the void space by carefully replacing the offending restoration, repeating the endodontic treatment or removing the tooth

27. “Obstacles are those frightful things you see when you take your eyes off your goal” - Henry Ford

28. Ownership of Problems “Where is the Monkey?”

29. PREVENTION • GOOD ORAL HEALTH (key feature) • Periodic Dental Examination • Pulpal testing of extensive restorations, • periodontal probing • (Thorough intra and extra oral investigation) • 24-72 hours Grounding is an effective means to prevent postoperative barodontalgia ! • ( Which IS the vast majority of the cases of reported events !!!) • Proper prior flight planning should • include sufficient time interval • before next planned flight.

30. PREVENTION • Direct pulp capping is : CONTRAINDICATED • Panoral radiograph Q 3-5 yrs *(military) • 24 hours flight restriction following a • procedure with anesthetic /or within 7 days post Oral Surgical Procedures (extraction) • Grounding for: certain medications, intraoral bleeding, oroantral communication, emphysema, facial swelling. .

31. Treatment (FDI Guidelines) • Treatment Options elaborated in Guidelines • Can range from palliative to definitive • Access to care ( It’s more difficult in flight)

32. Management

33. CONCLUSION: • Barodontalgia is related to atmospheric pressure differences when subjected to in a flight environment. Importantly; a dentist must know origin and causes as well as treatment of preventive and curative measures. Regular dental visits for Oral Health maintence and prevention.

34. Recommendations • And parting shots…..from the Bully-pulpit !! • Ante-mortem dental records for positive identification. • Pano-oral radiograph every 3 years. DNA and fingerprints may not be suitable for mass casualty.

35. “Man must fly above the earth to the top of the atmosphere and beyond for only then he will fully understand the world in which he lives.” - Socrates

36. First Solo Do you remember your first time ? Carol-Vorderman-successfully-completes-her-first-solo-flight

37. “Everyone smiles in the same language.”

38. THE END brenyodontist@yahoo.com VoIP (412) 548-2123 Bibliography available upon request

39. What do we do next?