Dentistry and
Diving*
Index
Barodontalgia
Muscle and Joint Pain
The
Edentulous
Diver
Dry Socket and
Diving
Root Canal and
Diving
Barodontalgia
Because of Boyle's Law, (as
pressure increases,
volume decreases and vice versa), diving with air-filled spaces in
teeth
cause problems because spaces inside teeth cannot decrease in size and
increase in size in proportion to the depth under the surface. Because
we are already functioning at one ATM of pressure on the surface, a
dive
to 99 feet would increase the pressure inside the cavity to 4 atm
absolute,
a pressure of 58.6 lb/sq. in.
This increase in pressure would
cause pain or barodontalgia
and can severely limit a diver from functioning underwater.
Conditions that can allow air to
enter into the
interior of the tooth can cause barodontalgia, including caries,
defective
margins of restorations, periodontal abscesses, maxillary sinus
congestion,
pulpal lesions and endodontic therapy.
Teeth that have been opened for
endodontic treatment
and temporarily sealed have been known to explode from air trapping and
expansion on surfacing. This is referred to as odontocrexis and is
found
to be more common in deep divers using a heliox mixture. Full porcelain
crowns can also shatter from relatively shallow dives of 65 feet. It is
suspected that trapped air is a very efficient crown remover in teeth
where
the cement bond is failing. Meticulous oral health is advised for
divers
actively engaged in scuba diving and to avoid barodontalgia, all
carious
lesions should be restored, ill-fitting crowns replaced, active
periodontal
lesions treated and all endodontic therapy completed.
Index
Muscle
and Joint Pain
Many divers experience headache and
facial muscle
pain from the continuous jaw clenching that is required to maintain the
mouthpiece of the regulator in proper position. The typical mouthpiece
is made of neoprene or silicon rubber and is held in place by bite tabs
that fit into the dentition of the canines and bicuspids. The average
dive
is 40-60 minutes and requires rather constant pressure on the jaw
muscles,
resulting in fatigue if not pain. Those individuals with "TMJ
syndrome",
(painful temperomandibular joints), find this to be so painful as to
preclude
diving at all.
Extending the bite tabs to cover the
molar areas
balances the weight of the regulator and relieves the stress on the
joint.
There is a commercially available
mouthpiece developed
by an Orthodontist, Dr. Randall Moles, known as "SeaCure" that is heat
moldable and covers the posterior teeth. This is available through dive
shops for about $30.
Index
The
Edentulous and Partially Edentulous Diver
One should avoid wearing full or
partial dental
prostheses while diving as they can be dislodged and aspirated easily,
especially partial dentures. To completely eliminate the possibility of
dislodgment, a custom mouthpiece must be made., using a silicon rubber
mouthpiece ("Comfo-Bite" from U.S.Divers) for the impression. Full arch
impressions are taken with the patient holding the putty in the roof of
the mouth until it is set, then mounted in a hinge articulator and sent
to the lab with the silicon putty impression. This custom made
edentulous
mouthpiece will allow the diver to participate with no chance of
aspiration
of a dental prosthesis.
Dry
Socket and Diving
A "dry socket"
occurs when the
blood clot is lost from an extraction site prematurely, exposing the
underlying
bone and fine nerve endings. The loss of the blood clot also allows
continued
bleeding and retards the healing process. The situation is very painful
but essentially harmless, usually responding to impregnated gauze packs
every 2-3 days over a two week period. Subsequent formation of
new
clot allows for eventual healing to take place, usually in about two
months.
Rinsing with non-alcoholic fluids twice a day for two weeks after
impacted
mandibular third molar removal significantly reduces the incidence of
alveolar
osteitis or dry socket.
Dry socket
occurs in about
5% of tooth extractions, but in 33% of extractions in women on oral
birth
control pills, when the extraction is in the first 3 weeks of the
cycle.
In addition, there are some activities which may increase the
propensity
for dry socket formation... smoking, drinking carbonated beverages in
the
first 24 hours after surgery, spitting or drinking through a straw in
that
same time period. This latter Venturi effect of clot removal might also
come into play with divers sucking air through a snorkel or regulator.
Loculated air pockets do not seem to be an important factor, as is the
case with an incomplete root canal
With the
information above,
one would suppose that a diver could return to the sport anytime
between
two and eight weeks - depending upon the rate of healing, lack of
infection
and absence of pain as determined by his/her oral surgeon.
Index
Root
Canal and Diving
by Larry Stein,
DDS
A root canal
treatment involves
the removal of the nerve tissue from within the offending
tooth.
Many patients think that roots are being removed which is not
true.
If you have
an infected tooth
or the dentist finds pus (infected material) inside the nerve
chamber
and canals, he may perform the procedure in stages--usually 2
visits.
In the last few years it has become customary to try to finish a
root canal in 1 visit, time permitting, if the tooth is NOT
infected.
Not infected does not mean you don't have pain.
Most root
canal procedures
don't hurt--during the procedure or afterwards. HOWEVER,
there
are a few cases that create the fearful reaction of patients when
they hear that they need this treatment.
Following the
root canal,
most root canal specialists (Endodontists) will place a cotton
pellet
and a temporary filling into the pulp chamber. This is done
whether the canal is treated in one or more visits. The tooth
should
then have a post, core and a cap as a final restoration.
Minimally,
the canal and chamber must be closed airtight with either a permanent
cement,
or a permanent filling. No cotton should be left in the chamber
and
no airspace should remain.
A cement
filling or a permanent
filling should only be considered temporary. If no cotton is placed and
a TEMPORARY filling is used, it will leak. Leakage from the mouth into
the root canal space is one of the leading causes for root canal
failure.
A temporary crown place over a core or post and core should cause no
problem
but in the week or two after the crown preparation, while you are
waiting
for the permanent crown, sometimes the temporary crown comes off.
Don't lose it--put it back on and get back to your dentist.
There is one
exception to
the diving with a temporary cap rule. If your restorative dentist
has prepared the tooth for a cementable, metal post and core which will
be placed at the time the crown is cemented, then THERE WILL BE AN AIR
SPACE WITHIN THE TOOTH. In this case it is possible for the tooth
to implode. So ask the endodontist to place a core or your
restorative
dentist to place a core at the time of crown preparation. No air
space, no problem.
Some teeth in
need of root
canal therapy are fractured. The fracture cannot be seen on an
X-ray.
The fractured portion of the tooth can constitute a potential site for
compressed gas to accumulate. Root canal teeth are also more
brittle
than vital teeth and can be broken more easily--that is the reason for
the cap recommendation.
Finally, you
should expect
1-2 visits to the specialist and 2 visits to the restorative
dentist.
If the root canal procedure is multi-visit then wait until it is
completed
and has a solid core inside. Your pool classes
shouldn't be a
problem but
any open water dive could be. Stay away from the deep end of the
pool if the root canal is not complete.
Addendum:
The actual root canals are filled with
a material
called gutta percha. It is a rubbery like substance which flows under
heat
and pressure. It is compressed into the canals just to the
narrowest
part of the nerve canal(s). Filling a canal short may leave room
for debris, dead tissue and bacteria to accumulate. This may lead
to a future retreatment. It is also a potential area for
compressed
gases from the bloodstream to accumulate. Since there is no
active
blood supply to the area short of a complete fill, the accumulated
gases will expand on ascent and cause
pain.
In fairness to dentists who perform
root canal
treatments, it can be difficult to see the actual end of the
canal.
Some specialists now have operating microscopes and fiber optic devices
they can thread into the canals and actually see the end of the root
from
within. This is now becomming the "Standard of Care". I
would
suggest a specialist with fiber optic instruments and
microscopes--especially
if the tooth is a molar. Recent research has shown that nearly
30%
of molars may have an extra canal that escapes detection
visually.
That untreated canal can be a cause for future failure of the tooth.
Larry Stein, DDS
Consultant
to Diving Medicine Online
Index
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*Some material adapted from William
E. Stein D.D.S.
Aitkin, Minnesota.
