Comprehensive information about diving and undersea medicine for the non-medical diver, the non-diving physician and the specialist.
Dental Barotrauma, Candida Infection and 'Choices'
by Laurence Stein, DDS
*This patient experienced a severe barodontalgia with complications of Candida albicans infection of the mouth.† Because of the pain, she became dehydrated, infected and debilitated.† There was concern that she might have systemic problems such as HIV infection or diabetes but these were ruled out by her local MD.
Perhaps the most important part of
article is that the patient, knowing she was sick, elected to
diving.† This may well have saved her life.† Imagine what
if she pushed herself or her spouse pushed her to dive.†
lack of nutrition, pain, bacterial and fungal infection, this
is a dive
that could have become tragic.† One simple problem has a way
into a tragedy.
"After living with rather pitiful teeth, in May of 2000 I decided to have an upgrade-crowns and veneers from a respected aesthetic dentist. After several consultations, my teeth were prepped and the tiny porcelain works of art made for 20 of my teeth. Since my husband and I were leaving for a month of diving at the end of June, the Dr. and I opted for a mega-appointment during which all 20 of my new veneers and crowns would be cemented on. Sore but smiling, my husband and I left 3 days later for a month of diving.
My first dive was a shock. In about 20 feet of water, I noticed a pain in my jaw. By 30 feet, it was awful; a stabbing pain under a molar that felt like a nail being driven through my jaw. After about 10 minutes, it seemed to subside; and we continued the dive. However, ascent only made things worse. By the time we got out, I was in excruciating pain and soon on the phone to my dentist and to DAN. I had read about dental barotrauma but never expected I'd be a test case.
DAN put me in touch with diving dentist Larry Stein of Miami. In a series of three-way faxes we decided that I seemed to be suffering from irreversible pulpitis under my new crown-a tooth whose pulp had become so irritated that it had swollen and injured the nerve. Diving, of course, exacerbated the condition. I had a choice: stop diving, or have an emergency pulpectomy done on the island (a procedure in which the nerve of the tooth is extracted, essentially the first step of a root canal).
I opted to stay out of the water and see how my tooth felt. But the tooth continued to feel sore. I had trouble eating, and felt cranky from being in constant discomfort. After a week, I decided to have a local dentist perform the pulpectomy, and sought the services of a highly regarded dentist who knows divers' ailments. He quickly (and painlessly) extracted the nerve, put a temporary patch on the crown, and suggested I try a conservative dive to see how I felt.
So after eight days of being out of the water, we went in. I dove a textbook conservative dive, with a very slow descent and ascent. No problems. The next day, we tried another dive, and alas, the results were not so benign. I wrote in my log, "tooth pain again after surfacing. A very painful night, too." The pain was back, and I was out of the water until the dentist could see me five days later.
He then checked the tooth, found a little residual bleeding and nerve fragment, replaced the temporary filling and included some soothing oil of clove. Again, I tried diving a day later. The offending tooth didn't hurt, but the mouthpiece of my regulator irritated my sore mouth. After a few more days of very light diving, I realized I was wearing out. My log reflects it. "Ulcerated mouth, regulator hurts." My mouth was so sore that I had stopped eating much, living primarily on Ensure. Sleep was fitful; there was so much soreness in my mouth that I could hardly concentrate, much less relax. I felt crummy and stayed out of the water.
By the weekend, I had developed a horrible infection in my mouth. My tongue and cheeks were covered in what looked like whitish fur. My mouth and lips were swollen and I could barely choke down anything. I subsisted on water and 2 cans of Ensure per day. I had lost a lot of weight, about 15 pounds (and I'm athletic in build, not overweight to start). Looking at my log, one can tell something was wrong. My usual lengthy descriptions are telegraphic and my handwriting erratic. Out of 23 days on the vacation, I had done 12 dives. It was clearly time to go home and get serious. I was completely miserable: couldn't eat, couldn't talk, in constant pain. All I wanted was to be put out of my misery.
When I got home, I learned that I had developed a candida infection in my mouth (called thrush when it occurs in children)-essentially a yeast infection. It's pretty unusual for a healthy adult to succumb to candidiasis, as it is a sign of a compromised immune system. My physician was concerned and ordered blood tests to check for diabetes (since I was neither a cancer nor HIV patient, diabetes was her concern).
Interestingly, my blood work was just fine. I was simply so run-down from weeks of pain, poor nutrition, and stress that my body just caved in temporarily. I had lost a total of 17 pounds, was dehydrated, sleep deprived, and hurt. For someone who is athletic, a divemaster and active diver, and normally healthy, it was a shock to be so sick-and from a toothache!
Thankfully, the medicines worked and I recovered quickly. Perhaps more thankfully, though, I made some good choices. I didn't push myself to dive when I felt bad. I sought medical help and listened to advice. I called it quits when I had to. Dr. Stein pointed out that I probably saved myself from a diving disaster by not diving when I was suffering. And I am lucky to be married to someone who didn't push me but was more concerned with my welfare than with our dive vacation. I wonder, though, if I would have been so conservative had I been on an exotic live aboard. I probably would have pushed myself to dive no matter how awful I felt.
I'm grateful to all concerned for helping me through this crazy trauma. We are planning our next dive trip, and I have not scheduled any big dental appointments before the trip!"
Dr. Laurence Stein’s assessment
While this article is related to barotraumas of teeth, it is more importantly, an example of making choices. Making the right choices can possibly save a life. Accidents, including dive accidents, very frequently have a "chain" of circumstances and decisions which can ultimately lead to potential disaster. This really a story about avoiding this chain of circumstances and ultimately avoiding a potentially disastrous conclusion.
If you dive long enough you will witness or be party to an accident. More importantly, it is very hard to stop what you are doing wrong once the sequence begins. Peer pressure to continue to dive and prove that you are not affected by situations that you really would rather avoid can be very strong--especially among male divers. I suspect almost anyone who pays good money to travel, book gear and dives, etc., wants to get their money's worth. Even if it means diving in conditions that are less than ideal. It is really tough to consciously decide to abort a dive or never attempt it in the first place. When I have aborted a dive I've been razzed by my friends--it's embarrassing but you must stick to you decision. When something doesn't feel right then stop, assess the situation and stop the dive if something is wrong. If you don't feel well, don't dive.
Several months ago DAN was contacted by the patient described in the narrative above, a woman on an island who experienced tooth pain during a scuba dive. Her vacation was planned for a stay of about a month. DAN contacted me and her dentist also contacted me. In consultation, we (the two dentists) decided that it would not be wise to continue scuba diving. The patient had recently finished some dental work and it seemed like one of her teeth was experiencing an irreversible pulpitis. In plain English, the nerve in one of her teeth was swollen; the circulation was compromised to the point that the nerve was going to die. The tooth may have had an underlying pathologic problem PRIOR to treatment that could not be detected or the treatment set into motion as series of events that led to pathology. When you have 20 teeth treated at the same time there is a percentage chance that at least one or two teeth will have problems--either immediately or some time in the future.
The painful scuba dive was the
broke the camel's back." Her tooth became sore. This limited
intake to the point that she was drinking two Ensure cans a
else. Her tooth became so
sore that she stopped eating and drinking. She was finally forced to do the unthinkable-see a strange doctor in a foreign country. Luckily for her, he was well trained, and provided appropriate treatment. This is where the lure of beingaway and feeling somewhat better clouded her judgment. She tried a dive, successfully.
Her spirits boosted, she tried another the following day-only this time the pain was back and her mouth was sore. Finally, miserable, her mouth ulcerated, unable to eat and in constant pain she decided to return home early.
It turns out that was the best decision of her life and could well have prevented a real disaster. Her low food consumption, constant pain, dehydration had rendered her immune system incapable of fighting off a fungus infection called Candida Albicans. It is a yeast infection. It can occur in the mouth, at the corners of the mouth, in the throat, in the sinuses, and other parts of the body that have a mucous membrane.
Two types are commonly seen -- erythematous and pseudomembraneous. The first type results in ulcers of the mouth, which are very sore and make eating very difficult. For those of you who suffer from canker sores in the mouth imagine what an entire mouthful of these would feel like! The second variety causes white patches, which can be rubbed off and is one of the signs of a Candida infection. In young children the condition is called Thrush. The infection is considered an "opportunist" only causing infection when a body is not healthy.
It can be found in persons taking antibiotics, which alter the normal bacterial flora, which help keep an opportunist infection like Candida in check. It is also found in diabetics, immuno-compromised people such as cancer patients on chemotherapy, radiation treatment, and leukemia patients and in the last few years it has been added to the list of conditions associated with HIV infection.
Upon her arrival back home she was worked up by her M.D. She tested negative for diabetes and had no risk factors for HIV. The scuba dive and recent dental treatment turned out to be the proximate cause of her illness and all this was started by a tooth that was beginning to die following dental treatment. Root canal treatment fixed the tooth. If you think that ignoring your dental health prior to diving is no big deal--think again.
What I find most interesting in
was the patient's willingness to forgo a dive vacation to kill
decision may well have saved her life. Imagine what might have
if she had made a dive to 100 ft.
and stayed within normal sport tables. She was exhausted, stressed, in pain, malnourished, dehydrated and infected. The possibility of a very serious episode was multiplied by each one of these links in a chain. She had the good sense to break the chain and it very possibly saved her life.
Laurence Stein DDS