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ARTICLES

Aerodontalgia Case Series: Dental Complications


Caused by Changes in Air Pressure.*
By K. KISMANTO. Indonesia

Kastubios KISMANTO
Lt.-Colonel/Air Force drg. Kastubios KISMANTO Sp.BM, born in Yoyakarta, Indonesia,
18 September 1966, graduated as Dentist with specialization in Oral Surgery.
Currently, he is Secretary Institute at the Dental and Oral Health institute of the
Air Force Health Department in Jakarta, Indonesia.

RESUME
Quelques cas darodontalgies : complications dentaires dues aux changements de pression atmosphrique.
Nous prsentons trois cas darodontalgies chez des membres de larme de lair indonsienne et leur traitement.
Larodontalgie a t dcrite pour la premire fois pendant la deuxime guerre mondiale lorsque des quipages eurent souffert
de douleurs dentaires au cours de leurs missions. On identifia le phnomne de douleur dentaire au cours du vol comme li
des diffrences de pression atmosphrique. Dans la mesure o latmosphre entourant la terre a une masse et un poids, elle
gnre une pression appele pression atmosphrique. Lorsque lon se trouve haute altitude cette pression diminue. La loi de
Boyle Law tablit que le volume dun gaz est inversement proportionnel sa pression et chaque individu doit saccommoder de
ces diffrences. Larodontalgie est la douleur dentaire cause lorsque le volume dair emprisonn dans lespace clos dune dent
est incapable de se dilater ou de se contracter pour saligner sur la pression atmosphrique ambiante. Larodontalgie survient
plus frquemment sur des dents en mauvaise sant, atteintes dinfections de caries ou de fractures. Un traitement convenable
des maladies dentaires est la meilleure stratgie de prvention.

KEYWORDS: Aerodontalgia, Airforce.


MOTS-CLS : Arodontalgies, Arme de lair.

INTRODUCTION

These air pressure changes can cause medical complications. H.F. Adler referred to this as dysbarism which he
divided into two types:
1. Trapped gas
2. Evolved gas

The air surrounding the Earth is called atmosphere and


extends from the earth surface to 3000 km skyward1.
The air encircling the earth have a mass and weight so
that will generate pressure so that is called air pressure.
The higher altitudes have less mass of air so this will
result in a lower air pressure. As a result, the edge of
atmosphere or beyond the highest altitude of the
atmosphere is space or empty space.

This article will discuss dysbarism caused by trapped


gas.
According to the definition, dysbarism is caused by
trapped gas in the body which cannot adjust to the
changing air pressure of the outside environment. This

Certainly, pressure changes around human body will


affect its physiology. The type and size of alteration in
humans body physiology will be determined by the
amount of air pressure changes with larger adjustments required for significant pressure changes. If the
body is unable to accommodate this changes then the
individual may experience physiological changes or
pain due to the pressure differences.
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Correspondence:
Lieutenant Colonel drg. KISMANTO. Sp.BM
Dental and Oral Health institute
Air Force Health Department
Lembaga Kesehatan Gigi & Mulut TNI AU
JL. Puntodewo, No. 1, Komp. Dirgantara II
Halim Perdanakusumah, Makasar,
Jakarta Utara, 13610, Indonesia
kastubios@yahoo.com

Individuals serving in aviation will experience altitude


changes regularly when aircrafts ascend and descend.

International Review of the Armed Forces Medical Services

* Presented at the 41st ICMM World Congress on Military Medicine,


Bali, Indonesia, 17-22 May 2015.

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can occur in difference body cavities such as: cavum


tympani, sinus paranasalis, teeth with cavities, tractus
digestivus and tractus respiratorius. In air transportation, Boyles law is prevailing, which state that inversely
proportional gas volume with its pressure. Hence as the
air pressure around body increases or decreases, the
differences of air pressure between the trapped air
inside the body cavity and the external environment
causes pressure within the body cavity.

tooth which results in a localized infection encompassing the tissue around the roots of a tooth. That localized infection can create an air space that is influenced
by changes in air pressure.
In many places in the world, public awareness of dental
health is still relatively low; therefore, they do not seek
treatment for existing dental problems6. The physiological changes of air travel alters the oral environment
resulting in asymptomatic dental problems becoming
symptomatic with pain.

AERODONTALGIA
Aerodontalgia is a painful feeling in the teeth resulting
from atmospheric pressure changes such as that experienced at high-altitudes. The more general diagnosis
of barondontalgia applies to any condition that is a
result of air pressure differences which would include
air crew and sea divers. (insert reference)
Aerodontalgia incidence was 0.7 - 9.5%8. This pain was
first identified during military conflicts where military
aviation was utilized. This finding resulted in research
regarding barodontalgia. It was discovered that predisposing factors such as dental caries, defective restorations, and fractured teeth often initiated a pulpal response of pain with the changes in air pressure.

The degree of Aerodontolgia can be influenced by the


following environmental changes and result in more
dental pain:
1. Temperature
Higher altitude results in colder temperatures which
results in a trigger factor, to isothermal layer placed
where constant relatively temperature is -55 Celsius
degree7.
2. Air Pressure
Air/gas exploitation causes pressure in dental pulp and
pain symptoms will occur7.

The altitude of 5.000 ft 15.000 ft, is the most common


range at a constant altitude in which barodontalgia
occurs, but the pain is variable depending on the individual and tooth related complications. The pain will
usually cease at ground level.

3. G. Force
Both G positive or G negative may affect pre-existing
dental conditions. When G positive, blood fluid collects
to the end of body part, so that the top of body part,
including teeth will experience a deficiency of blood
circulation. Inversely if G negative, blood collecting to
the top of body part may include teeth. Deficient blood
circulation caused by G force may trigger pre-existing
dental conditions resulting in pain7.

Aerodontalgia occurs when decayed teeth or defective


treatment exists, for example:
1. Caries or damage tooth
Caries or decayed teeth with a narrow orifice creates an
enclosed space subject to air pressure differences.
Research result that toothache while flying at an altitude not a pathological disorder in itself, but is a continuation of tooth decay that has gone before1. Real
tooth pain can appear as a result from barometer pressure changes. Dental treatment not completed on
caries teeth, fractured teeth, or teeth with incomplete
root canal treatment are the most common clinical
situations that result in pain experienced at high altitudes. In those cases, etiologies of pain are divided into
2 types. The first type of pain is caused by a vital pulp
reaction of a caries tooth as a result of increased atmospheric pressure. The second type is pain caused by a
non-vital pulp reaction where the surrounding tissue or
a pre-existing infection is affected by the atmospheric
pressure causing patient pain.

4. Air emboli
If an air emboli occurs around the apical area of a tooth
which encompasses the pulpal or nerve tissue, this pressure change may cause tooth pain as air planes ascends
or descends. This typically occurs when a plane ascends,
because of the exploitation effect more spontaneous
than emphasis effect1.

CASE SERIES
The following three cases reports describe cases of
aerodontalgia experienced by Suswatud and
Suskesbangans students after their experiences in a
hyperbaric chamber. A hyperbaric chamber is a room
that is pressurized three times higher than normal air
pressure and delivers pure oxygen. It used to simulate
air travel and treat a variety of conditions including
serious infections and decompression sickness. In these
cases, two of the students experience pain in their
teeth resulting from atmospheric pressure changes,
while a third student has his pre-existing tooth pain
relieved with altitude (pressure) change.

2. Defective tooth restoration


A defective tooth restoration can result in an enclosed
space or cavity between the tooth and the restoration.
Previous restorations placed to treat extensive caries
can create this situation resulting in Aerodontalgia
experienced weeks after dental treatment.
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Case I
29 year-old male experiences toothache in lower left
posterior tooth when reaching an altitude of 5000 ft.

3. Periapical abscess
The periapical abscess is an infection of the pulp of the

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derived from 26 teeth with caries in the distal part.


Both cases are not taken immediately treatment
because in normal position no complaints of pain.
Immediately after the completion of education in case
I made repeated treatments with filling the root canal,
whereas in the second case made dental fillings with
root canal treatment.

Dental history of having restoration replaced on lower


left posterior tooth two years prior. Since the second restoration, patients tooth was asymptomatic with no other
dental conditions such as an abscess, tooth fracture, or
temporal-mandibular pain.
1st Case: Dental x-ray image radiolucency exist under tooth
filling. Occurs because the treatment is not perfect
Gas swelling that happened will suppressed apically
because lack of drainage so that the pain will occur.

Case III
35 year-old male with a history of tooth pain in maxillary right third molar experiences opposite effects of
previous cases of aerodontalgia with the pressure
changes in the hyperbaric chamber relieving his dental
pain. Pain disappears while ascending to altitude of
8000 ft - 25000 ft and while descending to normal altitude. At the time of coming up with first position that
tooth pain start to arise. Patient reports dental history
of having pain in maxillary right posterior tooth two
days prior to hyperbaric oxygen chamber training
which was treated with analgesics. Pain persisted until
the pressure changes of the hyperbaric chamber alleviated the tooth pain. No other dental complications
noted
3rd Case: Dental x-ray image radiolucency distal teeth 18.
tooth decay is not known, resulted in the air space.
Pain feeling disappear when patient at the altitude.
Pressure changes can caused drainage in tooth cavities.

Case II
29 year old female complains of pain in maxillary left
molar within altitude range of 8000 to 25000 ft, After
altitude was normalized, tooth pain was alleviated.
Extensive dental history with several extractions and
restorations in tooth number 12, 21, 22, 26, 36 and 35.
Tooth restoration in 26 was restored by non-dentist. No
history of dental abscess, tooth fractures or temporalmandibular pain.
2nd Case: Dental x-ray image radiolucency distal teeth 26.
tooth decay is not known, resulted in the air space.
Gas swelling that happened will suppressed apically
because lack of drainage so that the pain will occur.

IMPLEMENTATION
With case I and II, the tooth pain caused by pressure
changes was treated by replacing the defective dental restorations. Before completing restorations, hermetically
root canal treatment is important. Complete obturation or
filling of root canal space is needed to prevent any open
spaces that could be affected by air pressure changes. For
case III, tooth #1 was diagnosed with gross caries and nonrestorable so the treatment choice was extraction.
For these cases, the diagnosis is aerodontalgia or barodontalgia which is dental pain experienced in teeth
resulting from pressure differences in entrapped gas
within the tooth.
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DISCUSSION
Based on experiences since World War II and prior
research, aerodontalgia which is tooth pain caused by
difference in air pressure is not a separate pathology but
is a condition that occurs when a pre-existing dental
pathology exists.

Case I, aerodontalgia derived from dental fillings that


not treated root canals previously. Case II aerodontagia

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The influence of barometric pressure causes changes


that results in either gas expansion or contraction in
the human body. While in-flight, air pressure increases
inside the body cavities which can cause an expansion.
If either an anatomical or physiological barrier exists
that prevents equalization of the gas pressure, then a
pressure will be created that can cause pain within the
body.
Pathologic gas expansion in Aerodontalgia is related
with Boyles law, which states that volume of a gas is
directly proportional to the pressure on it, when temperature is constant (P1 x V1 = P2 x V2). As a result, the
pressure changes in a tooth affect the nerve tissue
known as the pulp within the tooth and that results in
the pain sensation experienced by the patient5. The
ability to adapt to pressure changes in high-altitude is
different with for each individual. It can depend on
overall health and physical condition, previous highaltitude experience, and individual response to velocity
and pressure changes. Rudges reports that decompression sickness happens at an altitude of 8.000 ft, Allans
at 14.000 ft, Rayman and Mc. Naugtans 11.000 ft, and
Voges at 14.000 ft4.
Aerodontalgia usually occurs at altitudes between
5.00015.000 ft after the aircraft reaches a constant
altitude. This pain may become more severe with an
increase in altitude but will usually dissipate at ground
level.
In the first case, the x-ray revealed that a radiolucency
existed under the dental restoration. That non-filled
space resulted in trapped gas which exerted a pressure
on the pulpal and apical nerve tissue resulting in patient
pain. A similar situation also existed in the second case.
The treatment in both of these cases was removal of
defective restoration, root canal therapy, and placement
of new restorations. The root canal treatment will seal
the pulpal space and prevent any trapped gas associated
with symptoms of aerodontalgia.
The third case was characterized by tooth pain that
occurred during increasing elevation or air pressure
while in the hyperbaric chamber. Dental x-ray image
demonstrated a radiolucency on distal portion tooth
#18 signifying gross dental caries. In situations of gross
dental caries, gas may be trapped within the decayed
portion of the tooth. The increase in air pressure during
flight will result in pressure changes within a carious
tooth and can result in symptoms of aerodontalgia.
Once normal air pressure is reestablished, those pressure differences in the carious tooth normalize so the
patient will no longer experience pain.

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include crown-tooth fracture, tooth erosion, acute abscess periapical, odontogenic infections and barophysic
phenomena, also imperfect tooth restoration3.
Main etiologies of aerodontalgia are also related to
non-hermetic endodontic treatment and subsequent
pulpitis which is caused by bacterial contamination
secondary to a defective tooth restoration. One of the
most painful responses that often occurs while in-flight
or in a decompression chamber is due to defective amalgam restorations which are undercondensed or incompletely filled within the preparation. In cases of aerodontalgia, replacement of defective restoration will
often alleviate symptoms of tooth pain immediately.
Large tooth restorations in close proximity to the pulp
can induce tissues changes so that symptoms may occur
weeks after its insertion and may mimic aerodontalgia
during flight. In these situations, no treatment should
be completed because the hypersensitive pulp or reversible pulpitis due to the large restoration will often normalize. If the symptoms continue after a few weeks
and the tooth is diagnosed with an irreversible pulpitis,
then root canal treatment should be completed.
Carious or decayed teeth where the pulp has been compromised will often by symptomatic with altitude
changes. In those cases, the etiologies of the pain can be
divided into two categories. First category is pain caused
by vital pulp reaction of decayed tooth as a result from
atmospheric pressure. Second category is pain caused by
non-vital pulp reaction or pulpal necrosis as a result of
atmospheric pressure changes.
Dental treatment will be unique for each clinical case
with root canal therapy preferred versus extraction.
Rarely etiology of pain while in-flight is periapical abscess around root of teeth which related with infection,
so that occur small gases. Those gases trapped and will
expand with more increase height and its cause painful
feeling in the teeth. That pain usually ceases at ground
level. Although at ground level those teeth seems like a
normal teeth and patient compliance is not exist, but the
abscess should be examination with dental X-ray. There
was one case happened while pressure changes with
decompression chamber, which periapical abscess broken out at high altitude and make infectious spreading
so that the patient should be hospitalized.

Treatment for the third case is extraction, because the


tooth is a 3rd molar (wisdom) tooth that does not function in mastication or occlude with the opposing tooth.
This tooth is also difficult to treat due to its location.

Immediately dental treatment caused by high altitude is


unpretentious, which is with reverting to the altitude
before tooth pain is exist. If tooth pains exist while plane
is ascend or on the top of altitude, so going to the
ground level will be make its pain healed. But if the pains
occur while plane descend, so going to ascend will make
its pain disappear. All of the aviator who has tooth pain
while in-flight should be immediately treated by dentist,
for some examinations and most necessary therapy.

Predisposing factors of aerodontalgia include tooth


decay, irreversible pulpitis, pulpal necrosis, and partial or
defective previous root canal treatment. Other etiologies

If on examination tooth disparity is not exist, so that


possibility is a disease which its symptoms like aerodontalgia that called aerosinusitis.

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CONCLUSION

REFERENCES

Correct handling at disparity of tooth will avoid the existing


of aerodontalgia. Perfect restoration of the damaged tooth
is needed, moreover if endodontic treatment is necessary
before. Tooth that contra-indicated for treatment should
be extracted.

1. ADLER HF. 1964 Aeromedical Reviews Dysbarism. USAF


School of Aerospace, Medicine Aerospace Medical
Division, Brooks Air Force Bace, Texas.
2. Air Force Pamphlet, 1968 Effect of Altitude on Ears,
Sinuses and Teeth Department of The Air Force;
Washington, 161-16.

SUMMARY
We present three cases of aerodontalgia in Indonesian airforce
personnel and their treatment. Aerodontalgia was first described in World War II when air crew experienced tooth related
pain during military missions. They identified the phenomena
of tooth related pain during flight that is caused by differences
in air pressure. Air encircling earth has mass and weight, so
that will generate a pressure which is called air pressure. As you
proceed to higher altitudes, the outside pressure decreases.
Boyle Law states that gas volume is inversely proportional with
its pressure, hence as the air pressure increases or decreases,
the individual needs to physically accommodate these differences. Aerodontalgia is tooth related pain that is caused
when the air pressure in the enclosed space of a tooth is unable to expand or contract to adjust to the outside air pressure.
Aerodontalgia more frequently occurs when dental health is
compromised due to a complications such as infection, caries,
or tooth fracture. The correct treatment of dental disease is the
best strategy in avoiding Aerodontalgia.

3. Anonim, 1995, Dasar-Dasar Ilmu Kesehatan Penerbangan,


Direktorat Kesehatan TNI AU, Jakarta.
4. FABIAN B.G 1998 Case Report: Inflight Decompression
sickness Affecting the Temporomandibular Joint,
Aviation, Space and Environmental Vol. 69. No. 5.
5. LARSEN A.S, BUCHWALD C, VESTERHAUGE S 2003 Sinus
Barotrauma-Late Dignosisi and treatment with ComputerAided Endoscopi Surgery, Aviation, Space and
Environmental Vol. 74. No. 2.
6. SRIYONO W.N, 2009 Pencegahan Penyakit Gigi dan Mulut
Guna Meningkatkan Kualitas hidup, UGM Yogyakarta
7. SUKOCO D, 2008 Aspek Aerofisiologi
Penerbangan, Perkespra Pusat, Jakarta.

dalam

8. ZADIK Y, 2009 Aviation Dentistry: Current Concepts and


Practice, British Dental Journal 206 (11-16).

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