Review Article

Aviation dentistry: Past to present

Sidhant Pathak

Department of Pediatric
Dentist, Pathak Dental
Care, Karnal, Haryana,
India
Address for correspondence:
Dr. Sidhant Pathak,
E‑mail: sidpat1@gmail.com
ABSTRACT
Airline industry has gained popularity in recent years and not much known about the dental problems
associated with the high altitude. It is most common in frequent flyers, crew members, pilots etc. Due to the
closed chamber pressure gets accumulated in these organs causing pain, discomfort, and organ dysfunction.
The presence of dental abscesses, periodontitis, deep carious lesions and deep unlined restorations in oral
cavity can stimulate severe pain due to the extreme altitude changes. With proper diagnosis, the various
complications can be avoided. Thus, dentist needs to be well versed with these facts and should provide a
comprehensive treatment.
KEY WORDS: Aviation dentistry, barodontalgia, barotrauma

Introduction body tissues caused by a difference in pressure between a gas

space inside the body and the surrounding fluid.[6] It occurs

D ental care is an integral part of aircrew’s operative fitness

which could be jeopardized by a reduction in air density
and air pressure at higher altitudes.[1]
For the comfort of crew and passengers, aircraft pressure is
maintained at high altitude by means of aircycle machines and
outflow valves in spite of low atmospheric pressure outside.[2]
Aviation dentistry is chiefly concerned with the oral and
dental health status of the aviators with special emphasis on
the prevention of disorders related to change in atmospheric
pressure.[3]
In the human body, various organs viz. facial sinuses, lungs,
stomach, and middle ear contain gases which tend to expand
at low atmospheric pressure. Due to closed chamber pressure
gets accumulated in these organs causing pain, discomfort, and
organ dysfunction.[4]
commonly in scuba divers, air travellers, hyperbaric oxygen
therapy, or after the the explosion due to the shock waves.[7] It
involves various conditions such as external otitic barotrauma,
barotitis media, barosinusitis, barotrauma related headaches,
dental barotrauma, and barodontalgia.[6] During descend from
high altitudes, partial vacuum develops which is manifested
by a retracted tympanic membrane leading to barotitis and
barosinusitis.[8] Barotrauma refers to an acute inflammation
of the sinus and middle ear cavities whereas barosinusitis is
an inflammation of the paranasal air sinuses. The vacuum
created due to air pressure difference causes mucosal edema,
submucosal hematoma leading to dizziness, headache, and
anoxia.[9]
Pain and numbness can also be sequelae due to the pressure
exerted on branches of the fifth cranial nerve.[6]
Barodontalgia

Dental pain occurring due to the changes in barometric pressure

The presence of dental abscesses, periodontitis, deep\ carious
lesions and deep unlined restorations in the oral cavity can
stimulate severe pain due to extreme altitude changes.[5]
Head and Face Barotrauma
Barotrauma refers to the physical damage or trauma to the
is called barodontalgia. It is a symptom and not a pathologic
condition itself. Most often, it is an exacerbation of preexisting
subclinical oral disease.[10] It occurs due to the entrapment of
gases in the closed chamber due to which it is unable to adjust
to the internal pressure. Pain is generally sharp or squeezing in
nature.[3] Pain occurring on ascend is related to vital pulp tissue
and that occurring on descend is related to pulp necrosis or

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DOI:
10.4103/2348-2915.167877 How to cite this article: Pathak S. Aviation dentistry: Past to present. J Dent
Res Rev 2015;2:138-40.

 138 © 2015 Journal of Dental Research and Review | Published by Wolters Kluwer - Medknow

facial barotrauma. Pain occurring on both ascend and descend
is related to the periapical disease.[10]
The explanation for the pathogenesis of barodontalgia was given
by Strohaver in 1972 where he advocated the differentiation
into direct and indirect types. In the direct barodontalgia, the
reduced atmospheric pressure leads to direct effect on a tooth on
the affected tooth, whereas, in the indirect type, pain occurs due
to the stimulation of the superior alveolar nerves at the time of
maxillary barosinusitis. In the direct type, the pain is moderate
to severe, which develops during take‑off and is well localized
and the patient can identify the involved tooth. In the indirect
type, pain is dull, poorly defined involving the posterior teeth
and develops during landing.[11]
Disease of pulp is the probable cause for the pain in barodontalgia
but Hodges reported that dental pain can also occur in healthy
teeth during the altered atmospheric pressure.[12]
Barodontalgia may also occur due to the expansion of trapped
bubbles under a restoration causing activation of pain receptors.
Referred pain to teeth can occur due to the stimulation of
nociceptors in the maxillary sinus.[13]
Odontocrexis
This condition is also known as barometric tooth explosion.
Preexisting leaked restorations or recurrent caries lesions
underneath restoration can cause tooth explosion when exposed
to high altitude environment. Common cause of damage was
the accidental expansion of gas which was trapped beneath
the restorations.[14] Calder and Ramsey reported that the tooth
damage was experienced due to poor quality restorations and
unrestored teeth with or without caries.[15]
Dislodgement of crowns was due to the fractures in PFM
restorations or due to the pressure changes in microtubules of
dental cements.[16]
Dental Treatment
Lack of agreement regarding the dental treatment and grounding
period of aircrews for dental reasons poses a major drawback.
Prosthetic considerations
Lyons et al. advocated that crowns cemented with resin cement
did not have reduced retention whereas those cemented with
glass‑ionomer cement or zinc phosphate cement had reduced
retention with the tooth under environmental pressure
changes.[17]
The most common reason for this may be porosities which are
incorporated during the manipulation of zinc phosphate cement
and glass‑ionomer cement. These microporosities expand
and contract upon the pressure changes leading to weakened
cement.[18] Microleakage may also be one of the factors for low
strength detected in zinc phosphate and glass‑ionomer cements.[19]
Journal of Dental Research and Review ● Jul-Sep 2015 ● Vol. 2 ● Issue 3 139 
Pathak: Aviation dentistry
Complete maxillary dentures reduce its retention at low
barometric pressure at high altitude.[20] For edentulous fliers
retention can be increased by osteointegrated dental implants.[6]
Restorative dentistry
Differential thermal contraction is seen in amalgam restoration
at low temperature of a high altitude environment in comparison
to tooth hard tissue. Harvey advocated that cold temperature is
the prominent factor underlying dental fracture.[21] According to
Sognnaes, grinding of teeth was a causative factor for restorative
failure.[10]
Periodontal considerations
There is a high‑risk of caries and periodontal diseases due to
the decreased salivary flow and dryness of mouth. Dryness of
the mouth can be due to the breathing of dry compressed gases
in the aircraft.[22]
Endodontic considerations
Rossi contraindicated the direct pulp capping in aircrew patients
and advocated endodontic treatment in suspected cases of
invasion to the pulp chamber in order to prevent the sub‑acute
pulpitis or silent pulp necrosis and their potential barometric
pressure related consequences.[23] Root canals infection if not
treated may cause the leakage of the intracanal infected content
to the periradicular tissues and subcutaneous emphysema.
Oral surgery
After the extraction of maxillary teeth, dental surgeons should
always rule out the existence of an oroantral communication
as it can lead to sinusitis when exposed to a pressure changing
environment.[24]
Prevention
Caries excavations and restorations should be completed before
air travel. Leaky restorations should be replaced. During the
restoration of a carious tooth, a thorough examination of the
floor of the cavity should be done to rule out any penetration
into the pulp chamber. In such cases a protective cavity
liner should be applied (e.g., glass‑ionomer cement). During
multi‑visit endodontic treatment, the temporary restoration
must be placed properly. When oroantral communication is
diagnosed; referral to an oral surgeon for its closure is indicated.
Cuspal coverage crowns could also be a preventive measure.
Resin cements are preferred for cementation, as they give better
retention. During flight, chewing gum or candy will increase the
salivation and prevent dryness in the mouth.[7]
Conclusion
Due to tremendous increase in air travellers viz. pilots, aircrew
personnel, air passengers, flight attendants and leisure pilots
 Pathak: Aviation dentistry

special precautions must be taken during endodontic, restorative,
prosthodontic and oral maxillofacial surgical treatments for the
aircrew patients to prevent any kind of in‑flight incapabilities
leading to serious issues. Aviation dentistry is an emerging
science, which has been much neglected. The dental clinicians
should take an initiative to raise awareness levels and sensitize
the air travellers about this issue. The need of the hour is to
promote the diagnostic tools and treatment guidelines to the
aviation industry to ensure wellness of air travellers. Aviators
and dentists should embrace all available opportunities for
incorporating oral and dental health into aviators’ physical
standards, to promote their wellness.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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