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Dental Problems - Procedures

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I am off travelling and have done a lot of diving but my girlfriend has a fake tooth which is attached to the teeth either side with metal / glue. Although this is very well fixed she is worried about the pressure - any advice?

A - Firstly, I would suggest a quick dental check up for hidden vials of potassium cyanide or other suicide pills hidden within the fake tooth. Next, blindfold your girlfriend, take her down into the basement, tie her to a chair and administer intensive interrogation with the aid of a feather duster, a riding crop and a sordid imagination. If she still won’t talk, I think we’re okay to go diving. A tooth like this is going to be solid and therefore not susceptible to pressure effects. As long as the glue holds tight there’s nowt to worry about.


There are occasional tales of exploding teeth and ballooning gums that make the scientific dive literature, but I think more as exceptional cases than as common problems. The term ‘aerodontalgia’ has been coined for this, mainly to confuse the layman – it literally means ‘air tooth pain’. You can get gas spaces forming around the roots of infected teeth or where old fillings cause little gaps to appear between the tooth and gum. During a descent the contracting gas spaces can suck in blood or make the gum swell, causing pain, or in the worst case scenario, a particularly fragile tooth can collapse. Naturally, the gas expands again on ascent, again causing pain, or the occasional ‘blow out’, where the tooth literally explodes. Some older divers with lots of fillings can actually gauge their depth quite reliably on the basis of how much pain they’re in. But before anyone with fillings panics, cases like this are unusual. A dental check once a year should show up any problems. Pain in the teeth on a dive can sometimes be referred from a sinus squeeze, but if it persists a trip to the ‘drawer-tooth’ is probably a good idea.

Q - I know you are a doctor and not a dentist but I hope you can help. If you can inform me of any diving-dentists I'd be very grateful.

The situation is this. I've had to undergo the removal of a front tooth which has been the bane of my life since the age of 14 when my brother first kicked me in the mouth and broke it. I now have to wear a palette with a false tooth for 6 months before they can bridge the gap. My worry is this. Although it's quite a good fit I can still move the palette up and down away from the roof of my mouth. Will this cause me any problems by creating air pockets when I descend which I may have problems equalising? Can I manipulate the palette in my mouth to overcome this or should I remove it before I dive? I don't want to create problems for myself but it would ruin my smile when I get back on the dive boat!

I can't be the only person who has had to confront this situation and it may sound stupid to even ask but it so changes the way I appear to myself let alone my fellow divers. Okay - it's vanity. However I'd rather take it out and enjoy my diving than give myself problems.

A - “When my brother FIRST kicked me in the mouth”?! Sounds like a tough upbringing in your household. My sympathies.

I think you should remove the palette before you dive. The reason is not air pockets, which won’t happen by the way, but mainly obstruction. The palettes slide in and out I believe, and there could be a situation where it could get caught up or even prevent quick accurate placement of your buddies occy if you had an out of air situation. It would be mad to be struggling to first place your teeth in line before biting on a reg in an emergency. When the bridge is in, all will be back to normal again. So don’t worry about your smile when you get back on the dive boat. That’s not the first thing blokes look at anyway.

Q - I'm due to go to Malta in March, but my 13-year-old daughter has beentold by her orthadontist that she will be having braces fitted on 15 February. Will this prevent her taking her Open Water course and diving? Would the brace prevent her from breathing through the regulator mouthpiece?

A - Braces come in all shapes and sizes but generally aren't a problem for divers. The (obvious) principle is that your daughter should be able to hold the reg in her mouth and form an adequate seal around the mouthpiece.There are tabs on the mouthpiece of the regulator, just like a snorkel, and there are occasional reports of these snagging on braces.

You can get mouldable mouthpieces which would solve this if it becomes a problem. Ifshe can open her mouth to eat then breathing through it should be fine.

There are some elaborate orthodontic constructions that reduce the bite diameter but I doubt whether these would you allow you to get the mouthpiece in at all.

Q - I'm hoping you could help me with a diving question.

I am having a new orthodontic treatment called Invisalign. If you haven't heard of it, it basically does the job of braces by using very thin plastic aligners that look kind of like gum shields only a lot more fitted.

My query is whether I am allowed to dive with these in my mouth? They do not cause me excessive pain or discomfort. My only worry is that perhaps if some air got caught in-between my teeth and the aligners it might cause a problem. Would you be able to advise me?

If you are unable to help perhaps you have a contact that might be able to offer some assistance?

A - At last someone has invented something to stop the shame and embarrassment of our nation's children. And adults for that matter. I can't see a problem here at all. If it lies outside your teeth, away form the nerves, then even if air got in, it should be able to get out as well as you ascend. The only potential disaster is if air gets in and under at depth, and then you block it in by biting on your reg mouthpiece too closely. Air would expand on ascent and, I suppose could cause pain. But if you got this, then ease off the bite on your reg, and all should be fine.

From the other side of the coin, do ask your dentist fitting it if there would be issues of having a rubber mouthpiece close to it for 2 hours a day. If there is a risk of dislodging it or breaking it, then maybe get it fitted after your dive hols, as from my experience, there's nothing cheap in the world of teeth, and you don't want to see a couple of grand settling on a sandy bed in the blue.

Q - I'm due to have a wisdom tooth out (bottom right) on the 18th September. However, I am going diving on 3rd October.

I have been having trouble equalising due to the tooth interfering with my ear, so thought by having it out I might be able to equalise more easily, however is this date too close to diving and should I postpone the extraction?

Please help.

A - I'm not really convinced that a wisdom tooth, inflammation around it and all, will really affect your ability to equalise. Certainly pain from the tooth can be referred to the ear, but a tooth so far back in the mouth is nowhere any of the relevant tubes.

But if its causing enough aggro to want you to remove it then it's best you go ahead.

Now, the all important timing.

3 weeks should be ok from the op to a dive. However I have seen tooth extractions go merrily awry. Post op infection, constant bleeding, all that nonsense. So I think the safe thing to do is not book the trip until a week before. If you are fine 2 weeks after the op then you will be fine to dive. But any inflammation and infection will prevent you from biting on your reg mouthpiece, a dangerous problem even in the mildest current.

Q - If I have had a root canal work or fillings in the past what are the considerations for diving?

A - Ouch. You think seeing the dentist can be a bad experience, just wait until you have a tooth blow out on an ascent.

Like most things that cause you pain underwater, it's all about air spaces. We all know that the middle ear and sinuses will traumatise and squeeze if they are not properly equalised or cannot release the air within upon ascent. Well, there is a third potential air space not a lot of divers know about and its right there biting onto your mouthpiece. Normal teeth are a solid mass of dentine, enamel, nerve fibres and pulp and so don't compress on descent or ascent. But what can go wrong is when these healthy teeth become diseased and begin to get a hole or two in the middle of them. These holes are either due to being forgetful with the toothpaste for a few years or when you have succumbed to your wallet and been to a bad dentist. A poorly fitted filling is perhaps the commonest tooth problem that will bring a tear to ascending divers eyes. What can happen is that the pressurised air breathed at depth can make its way into a tooth cavity underwater. If that air gets trapped in the tooth, it will expand on ascent, press on any nerve in that tooth and cause the sort of pain that can only be described as being hit by Tyson in a debate about a fender bending! What causes air to be trapped, as normally the hole will just release gas through the same entrance as it went in, are things like the filling dislodging during a dive or even biting down on a different part of the mouthpiece later on in the dive. The same goes for badly fitted crowns as well. If you get a tooth squeeze there's not a whole lot you can do except take the pain, figure out how you are going to take revenge on the dentist later that week and reach for the whisky on surfacing. Sometimes moving your mouthpiece to a different bite may work or sucking on the tooth may remove any detritus that blocks the now air filled hole. Now, root canal work is different and I speak from experience. This is a long, literally boring and expensive procedure and should deaden the nerve in the tooth. If there were a potentially fillable air space then you wouldn't feel anything as the nerve has been killed. Bad dentistry could still lead to a space, which could blow a tooth, but it would have to be really bad dentistry and on surfacing forget the painkillers just call a lawyer!

So there you have it, teeth and diving, but the key here is that you wont know you have a problem until it happens, and if it does get the tooth fixed before going in again. Just look after them in the first place.

(other dive medical questions)



   


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