Management The patient was interviewed, examined, diagnosed and treated at the initial appointment. After local analgesia was administered, the caries was removed and the cavity was prepared for resin composite. The restoration was placed and the occlusion was checked and adjusted. The patient was then reviewed post operatively, in consultation with a visiting specialist endodontist. The patient was asymptomatic. 26 and 27 were not tender to percussion and there was no sensitivity to air blast. Two bitewing radiographs were taken to screen for any further pathology. The patient was instructed not to dive until he was asymptomatic for 24 hours.
Discussion Clinical Considerations Due to the invention of manned flight and personalised selfcontained underwater breathing apparatus (SCUBA), many oral phenomena caused by atmospheric pressure changes have been described as a consequence of these activities. There are many considerations in the clinical diagnosis and management of these phenomena. Boyle’s law dictates that the volume of gas at constant temperature is inversely proportional to the surrounding pressure.2 The change in atmospheric pressure will cause the expansion and contraction of trapped gas contained in the body. Barotrauma is any adverse effects caused by a change in atmospheric pressure. Dental barotraumas can manifest as tooth fracture, restoration fracture and reduced retention of dental restoration. Barodontalgia is an intraoral pain evoked by a change in barometric pressure.1 Robichaud et al concluded that an increase in barometric stress was associated with an increase in dental deterioration.8 In this case, the patient’s interproximal caries had weakened the mesial marginal ridge on the 27. The subsequent barometric pressure change from an environment of high to low pressure upon his ascent would have caused an increase in the volume of the trapped gas in the cavity. The enamel fracture point was reached which resulted in barodontcrexis or “tooth explosion”.9,10 One study indicated that oral pathologies such as dental caries without pulpal involvement account for 29.2% of possible sources of barodontalgia.11 The use of resin composite to restore the tooth was justified as it required less tooth structure to be cut and had greater adhesion.6 Lyons et al showed that other restorative materials had significantly reduced retention as a result of microleakage.12
important an understanding of the effects of barometric pressure changes has on the dentition. Correlating this to patients who subject themselves to the in-flight and underwater environment on a day to day basis, an episode of dental barotrauma or barodontalgia can significantly affect the patient and surrounding personnel. If the patient was mission critical, the impact would be far reaching. In this case, the patient was a recreational diver and was educated. Instructions were given for prevention of future occurrences.
Conclusion This case has highlighted the need for greater awareness of the diagnosis, prevention and management of barometric pressure related dental problems. If this restricts members from performing their duties, there could potentially be serious ramifications for ADF capability. Patients need to be educated and receive regular dental examinations in order to prevent and manage any dental barotraumas. From a military perspective, this is especially true for aircrew, divers and submariners. The impact on general oral health cannot be underestimated. Barodontalgia should be included in the differential diagnoses of head and neck pain.
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Military Considerations In the ADF, members are required to maintain their Individual Readiness (IR) as part of their inherent requirements of service.13 In order to maintain their IR, the ADF requires members to be dentally fit in order that they are able to undertake their operational duties. A member is deemed dentally ready if they are Dental Fitness Classification (DFC) 1 or DFC 2, having been assessed within the previous 12 months.14 DFC is to be classified after every assessment, treatment or consultation.15 The correct diagnosis and management was required for the patient to also comply with Defence policy.
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While the patient was not a professional aircrew, clearance diver or submariner, the patient’s presenting complaint has shown how
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Zadik Y, Drucker S. Diving dentistry: a review of the dental implications of scuba diving. ADJ Sep 2011; 56:265-271 Gradwell & Rainford. Earnsting’s Aviation Medicine. 4th Ed. Butterworth-Heinemann, 2006 ADFP 1.2.2.13 Aviation Medicine for Aircrew. Chp 3 Health Directive 411: Aviation and Diving – Dental Considerations Health Directive 424: Treatment Planning Guidelines for Restorative Dentistry in Australian Defence Force Dental Facilities Roberson TM, Heymann HO, Swift Jr EJ. Sturdevant’s Art and Science of Operative Dentistry. 5th Ed. Ch11, Ch16; pp506508, pp 694-696 Mount GJ, Hume MWR. Preservation and Restoration of Tooth Structure. 2nd Ed. Chap 19; pp 337-346 Robichaud R, McNally ME. Barodontalgia as a differential diagnosis: symptoms and findings. J Can Dent Assoc 2005; 71:39-42 Zadik Y. Dental barotraumas. Int J Prosthodont 2009; 22: 354357 Calder IM, Ramsey JD. Ondontecrexis – the effects of rapid decompression on restored teeth. J Dent 1983; 11:318-323 Zadik, Y. Barodontalgia: what we learned in the past decade? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010 Vol 206; 11-16 Lyons KM, Rodda JC, Hood JA. Barodontalgia: a review, and the influence of simulated diving on microleakage and on the retention of full cast crowns. Mil Med 1999; 164:221-227 Defence Instructions (G) PERS 36-3: Inherent requirements of service in the Australian Defence Force Defence Instructions (G) PERS 36-2: Australian Defence Force policy on Individual Readiness Health Directive 402: The Australian Defence Force Dental Classification System
CADMUS 72
CADMUS 2012