Research Article

Knowledge, awareness, and attitude regarding among dental students Anisha A. Mahtani, M. P. Santhosh Kumar*

ABSTRACT

Objective: Barodontalgia is dental pain provoked by atmospheric changes. The prevalence of barodontalgia among Indian pilots is as high as 20.6%. Thus, the aim of the study was to evaluate the knowledge, awareness, and attitude regarding barodontalgia among the dental students of our institution. Methods: A prospective cross-sectional study was conducted during the academic year in January 2019 among the dental students of Saveetha Dental College, Chennai. A total of 200 students were randomly enrolled in the study including postgraduates and undergraduates from 3rd year, final year, and internship. All students in the study voluntarily completed a validated questionnaire consisting of 15 close-ended questions, which was designed to assess their basic knowledge, attitude, and awareness regarding barodontalgia. Data collected were tabulated, statistically analyzed, and results obtained. Results: In the survey conducted, 59% of the students had heard about barodontalgia and 61% of students answered the correct definition of barodontalgia. Only 24.5% knew that the method to prevent barodontalgia would be to perform good restorations, whereas 42% of the participants knew the appropriate treatment methods. 65% of the students have never seen a patient suffering from barodontalgia. The attitude toward learning about barodontalgia was very good as 82% were interested in learning and 80% of the students thought that “barodontalgia” should be included in the dental curriculum. Conclusion: Dental students in this study have moderate levels of knowledge and awareness regarding barodontalgia and showed a positive attitude toward learning barodontalgia. The postgraduates had better knowledge regarding barodontalgia than undergraduate students. Among the postgraduates, the endodontists were more knowledgeable than the other specialty students. KEY WORDS: , Barodontalgia, , Deep-sea divers, Dental pain, Dental restorations, Dental students, Knowledge, Pilots

INTRODUCTION related “direct” barodontalgia and barotitis/barosinusitis- induced “indirect” barodontalgia.[2] Intraoral pain elicited by changes in atmospheric pressure is referred to as barodontalgia. Airline passengers, Barodontalgia, a dental pain caused by a change in pilots, military aircrews, professional, and leisure divers barometric pressure in an otherwise asymptomatic are the group of people affected by barodontalgia. tooth, may be severe enough to cause in-flight vertigo, Dental barotraumas are defined as damages to teeth incapacitation, and premature cessation of flights and dental reconstructions, which can manifest with and altitude-chamber simulations. Barodontalgia usually subsides as the atmospheric pressure returns or without pain, when changes. It is to normal. The common etiologic pathologies for assumed that they occur in connection with defective pain were faulty dental restorations and dental caries dental restorations or pathologies such as apical without pulp involvement, necrotic pulp/periapical [1] periodontitis, infections, secondary caries, and . inflammation, vital pulp pathology, and recent dental The classification of barodontalgia is based on pulp/ treatment.[3] Three hypotheses were proposed for periapical condition and symptoms: Pulp/periapical- barodontalgia: First, expansion of trapped air bubbles under a root filling or against dentin that activates Access this article online nociceptors; second, stimulation of nociceptors in the maxillary sinuses, with pain referred to the teeth; and Website: jprsolutions.info ISSN: 0975-7619 third, stimulation of nerve endings in a chronically

Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dr. M. P. Santhosh Kumar, Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road, Velappanchavadi, Chennai - 600 077, Tamil Nadu India. E-mail: [email protected]

Received on: 16-02-2019; Revised on: 07-03-2019; Accepted on: 10-04-2019

1358 Drug Invention Today | Vol 12 • Issue 7 • 2019 Anisha A. Mahtani and M. P. Santhosh Kumar inflamed pulp. As atmospheric pressure decreases RESULTS during ascent, trapped gases may expand and enter dentin tubules, thereby stimulating nociceptors in Out of the 200 participants, 66 were males and 134 the pulp or causing the movement of pulp chamber were females between the age group of 18–25 years. contents through the apex of the tooth, also causing 59% of students were aware of barodontalgia pain.[4] [Figure 1]. 61% of students answered the correct definition of barodontalgia [Figure 2]. About half Dental barotrauma is observed among military of the participants were aware of the methods for personnel than in civilian air passengers or flyers. The diagnosing barodontalgia [Figure 3]. prevalence of caries increases in microgravity. Many cases on the breaking of dental restorations, tooth Sixty-eight percent of participants answered fractures, sharp, or diffused pain have been reported. correctly that aviators and deep sea divers are Pain that is observed is caused by the pressure which is the groups of people most commonly affected exerted on various nerves and their branches. In flyers by barodontalgia [Figure 4]. Only 22% of the who fly at high altitudes, decrease in levels students were aware of the causes of barodontalgia, can have a deleterious effect on teeth, fillings, gums, which is due to faulty restorations and deep caries and the mouth. A common complaint is xerostomia. [Figure 5]. Only 24.5% of the participants knew the Due to a decrease in saliva content, there is an increase modes of prevention of barodontalgia [Figure 6]. in the risk of periodontal diseases.[5] 42% of the students chose the right treatment plan for barodontalgia, being removing the void spaces There is an increase in the incidence and prevalence of by carefully replacing the offending restoration, barodontalgia, and it varies in different populations.[6,7] or repeating endodontic treatment or removing the Dentists in their practice may encounter patients who tooth [Figure 7]. are prone to barodontalgia such as pilots, airline passengers, military personnel, scuba divers, and One-third of them were not aware of the causes people receiving hyperbaric oxygen . Hence, of orofacial pain due to atmospheric pressure they must have adequate knowledge and awareness changes, whereas 20.5% of the students chose regarding the causes, prevention, and treatment of correctly and pulpal necrosis [Figure 8]. barodontalgia. According to the literature, the level Nearly 34.5% of the participants chose Boyle’s law of awareness about barodontalgia among dentists as the law that defines barodontalgia [Figure 9]. varies.[8] Thus, the aim of the study was to evaluate Nearly 39.5 % of students replied that helium the knowledge, awareness, and attitude regarding gets trapped between the tooth and the restoration barodontalgia among the dental students of our [Figure 10] and 55.5% of the participants answered institution. that endodontists are the specialists who treat barodontalgia [Figure 11].

METHODS Only 35% of participants have seen a patient with A prospective cross-sectional study was conducted barodontalgia either in a college or in a hospital during the academic year in January 2019 among the [Figure 12]. One-third of the students have learned dental students of Saveetha Dental College, Chennai. about barodontalgia from the internet. Only 14% Two hundred students were randomly enrolled in the said they learned about it from a lecture and 13% study including postgraduates and undergraduates from 3rd year, final year, and internship. A written informed consent was obtained from all the students. All students in the study voluntarily completed a questionnaire consisting of 15 close-ended questions, and they were asked not to discuss between them or refer to any sources of information for answering the questions.

The questionnaire was selected from previous research on a relevant topic and few amendments in the questionnaire were made with the help of the professionals. This validated questionnaire was designed to assess their basic knowledge, attitude, and awareness regarding barodontalgia. Data collected were tabulated, statistically analyzed, and results obtained. Figure 1: Awareness of barodontalgia

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Figure 2: Definition of barodontalgia

Figure 3: Diagnosis of barodontalgia

Figure 4: Groups of people affected by barodontalgia from a textbook. 39.5% of students have not learned Overall, approximately 44% of students had about barodontalgia [Figure 13]. About 80% of the sufficient knowledge about barodontalgia. In this participants showed a positive attitude toward learning study, the postgraduates had better knowledge barodontalgia [Figure 14] and including barodontalgia regarding barodontalgia than the undergraduate in the dental teaching curriculum [Figure 15]. students. Among the postgraduates, the endodontists

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Figure 5: Causes of barodontalgia

Figure 6: Prevention of barodontalgia

Figure 7: Treatment of barodontalgia

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Figure 8: Causes for pain respectively during ascent and descent

About 59% of students were aware of the term barodontalgia and 61% of students answered the correct definition of barodontalgia, which shows that they have a basic awareness about barodontalgia. Our results are in accordance with the study by AlMadi[8] in which 61% of dentists knew the correct definition of barodontalgia. In the study by AlMadi, less than 28% of dentists were aware of the groups of people affected by barodontalgia,[8] whereas in our study 68% of dental students were aware of the groups affected by it.

Figure 9: Law defining barodontalgia Students were most knowledgeable about the definition of barodontalgia (61%), knowledge of were more knowledgeable than the other specialty the groups affected by it (68%), treatment provider students. (55.5%), diagnosis of barodontalgia (53%), the treatment necessary (42%), site of accumulation DISCUSSION of helium gas (39.5%), law defining barodontalgia (34.5%), and least knowledgeable about prevention Barodontalgia can pose a serious safety risk to divers, of barodontalgia (24.5%), causes of barodontalgia pilots, and airline passengers.[9] It has a significant (22%), and causes of pain due to atmospheric pressure worldwide prevalence, and it varies in different changes (20.5%). Since rarely any publication was regions. According to a study, 34% of military pilots done on this subject, it was difficult to compare our and divers from Saudi Arabia and Kuwait experienced data with other studies. Our data showed on an average barodontalgia at one point in time during their career.[10] there was a moderate level of knowledge regarding Prevalence rates were 17.3% among divers,[11] 10.49% barodontalgia (44%) among dental students. among Jordanian military pilots,[12] 8% in aviation,[13] Meticulous history taking, clinical, and radiological 7.3% among French armed ,[14] and 6.5% in examination are the mainstay of diagnosis. History French civilians,[15] military pilots and aircrew and it [16] of recent dental treatments, on-ground preceding was 2.63% in a Spanish population. symptoms, pain onset⁄cessation (on ascent or descent) and nature of the pain are invaluable data. The dentist The prevalence of barodontalgia among Indian pilots must look for faulty restorations (including dislodged was as high as 20.6%.[17] The variations in prevalence restorations over a vital pulp) and secondary (residual) might be due to differences in the regulations in oral caries lesions, to perform a vitality test and necessary health evaluation before flying or diving.[18] As the periapical radiographs, and to rule out sinusitis or incidence of barodontalgia is high in India, dental pain originating from the temporomandibular joint students should be aware of this phenomenon. It is, or masticatory muscles.[19] In our study, 53% of therefore, recommended that dental students should students were aware of the methods of diagnosing encounter more information through their study in barodontalgia. dental colleges. This study was done to assess the knowledge and awareness of dental students of our According to the law of Boyle-Mariotte, the pressure institution toward barodontalgia. of an ideal gas is inversely proportional to the volume,

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Figure 10: Site of accumulation of helium gas

Figure 11: Dental specialists involved in treating barodontalgia

and sinuses. The same law applies if a person climbs to high altitudes (in flight); in this case, outside pressure decreases, permitting the volume of gases to increase.[20] In our study, 34.5% of students knew about the Boyle’s law which explains the mechanism leading to barodontalgia.

In scuba tanks, oxygen’s natural diluent gas, nitrogen, is replaced by helium, resulting in a gas of lower viscosity. This gas enters the tissues, including teeth, and can sometimes get trapped in closed spaces, such Figure 12: Identification of a patient with barodontalgia as the pulp chamber and root canal. There are two mechanisms by which gases can get trapped in spaces: provided that the and the amount of gas If there is a space between a tooth and its restoration, are constant. Specifically, as a person descends deeper gas may be forced into it during an increase in and deeper below the water surface, pressure exerted pressure; and dissolved gas may diffuse from on by the water increases and reduced the tissues into spaces as pressure decreases. Consistent volume of gases in enclosed spaces such as teeth with Boyle’s Law, trapped gas will expand, and the

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Figure 13: Sources of information about barodontalgia

due to the expansion of the gas that is trapped beneath the restorations. Pressure differences can occur in the human body when a gas-filled cavity is unable to communicate with the exterior, and the pressure cannot be equalized. Clinically, the resulting pressure difference that occurs between the gas-filled cavity and the exterior environment can lead to pain, edema, or vascular gas embolism.[21] According to our study, 39.5% of students were aware that the helium gas gets trapped in the space between the dental restoration and tooth.

Barodontalgia was reported to occur during flying at altitudes of 600–1500 M and during diving at depths of 10–25 M. During commercial flights, Figure 14: Attitude towards learning about barodontalgia aircraft personnel is exposed to only minor pressure differences, but exposure lasts for a relatively long period of time. In contrast, military and aerobatic pilots are subjected to rapid pressure changes and strong acceleration forces.[22] Here, the main triggers identified are inadequate restorations, secondary caries, inadequate root canal fillings, postoperative lesions, or apical or periodontal damage.[23] In our study, only 22% of participants were aware of the causes of barodontalgia; 20.5% of the students knew that pulpitis and pulpal necrosis causes pain due to atmospheric pressure changes and these results are alarming.

Certain measures can be taken to prevent barodontalgia. When an upper posterior tooth is extracted, the dentist should rule out the existence Figure 15: Attitude towards inclusion of barodontalgia in of oroantral communication. If there is involvement, dental curriculum it can lead to sinusitis and can be adverse if it is exposed to a pressure changing environment. Hence, resulting stress may cause tooth fracture. This process oroantral communication should be ruled out. is known as odontecrexis, a Greek word meaning Patients should not drive or fly in nonpressurized tooth explosion. The damage is caused accidentally cabins within 24 h of a dental treatment requiring

1364 Drug Invention Today | Vol 12 • Issue 7 • 2019 Anisha A. Mahtani and M. P. Santhosh Kumar anesthetic or 7 days following surgical treatment. providing good exposure on this subject to the dental When dealing with patients involved in diving or students. Nowadays, it is common for the dentists aviation, clinicians should pay close attention to areas to encounter divers, airline passengers, and pilots in of dentin exposure, caries, fractured cusps, fillings, their routine dental practice and barodontalgia is a and periapical pathology. If a patient arrives in the prevalent condition worldwide.[26] Sound knowledge office complaining of symptoms of barodontalgia, the about barodontalgia may help in diagnosing, and examiner should establish whether there is a history treating this condition in such patients. Furthermore, of recent flying or diving. The examination should barodontalgia must be considered in the differential include an estimate of the age of restorations in the diagnosis of orofacial pain.[27] probable area, screening for caries and poor-quality restorations, a percussion test on suspected teeth, an Nearly 39.5% of students have not learned about evaluation of the response to electrical stimulation or barodontalgia. About 80% of the participants showed heat and cold, and radiographic examinations.[24] a positive attitude toward learning barodontalgia and including barodontalgia in the dental teaching One clinical benefit of barodontalgia is that it curriculum. Hence, the topic “barodontalgia” must be may help the dentist locate early caries, leaking routinely integrated in the dental curriculum and both restorations, and periodontal abnormalities. The the undergraduate and postgraduate students must placement of a zinc oxide eugenol (ZOE) base was be encouraged to learn about the concepts in found to prevent barodontalgia when reversible diagnosis, prevention, and treatment of barodontalgia. pulpitis was known to be the underlying cause, which This will increase the knowledge levels of students is attributed to the well-known sedative effects of and help them to be prepared with handling cases of ZOE. In reference to surgical measures for people barodontalgia in their dental practice.[28] under pressure, a premature resection of the apex of the dental root, or prophylactic removal of the wisdom CONCLUSION teeth could prevent barodontalgia. In the instances where surgical measures have taken place, at least Dental students in this study have moderate levels of 72 h must have elapsed before the patient is exposed knowledge and awareness regarding barodontalgia to pressure. Hence, the diagnostic exclusion of dental and showed a positive attitude toward learning pathologies and avoidance of retentive reconstruction barodontalgia. The postgraduates had better knowledge materials are important factors for the prevention of regarding barodontalgia than undergraduate students. barodontalgias and dental barotraumas. The key to Among the postgraduates, the endodontists were more avoid barodontalgia is good oral health. Dentists must knowledgeable than the other specialty students. The pay close attention to areas of dentin exposure, caries, topic “Barodontalgia” must be routinely integrated fractured cusps, the integrity of restorations and into the dental teaching curriculum. Barodontalgia is periapical pathology in those at risk.[25] According to an important condition which affects the quality of life our study, only 24.5% of students knew the prevention of the patient. Continuing dental educations programs strategies of barodontalgia. Hence, during teaching, on barodontalgia must be conducted on a regular basis much emphasis should be given regarding the causes to keep the students updated with the current concepts and prevention of barodontalgia. and practice of barodontalgia. In this study, the postgraduates had better knowledge REFERENCES regarding barodontalgia than the undergraduate 1. Zadik Y. Barodontalgia: What have we learned in the past students. This could be related to advancement in the decade? Oral Surg Oral Med Oral Pathol Oral Radiol Endod year, or exposure to cases (patients with barodontalgia), 2010;109:e65-9. increased maturity with age and having prepared 2. Gaur TK, Shrivastava TV. Barodontalgia: A clinical entity. for licensing exams. Among the postgraduates, the J Oral Health Commun Dent 2012;6:18-20. 3. Zanotta C, Dagassan-Berndt D, Nussberger P, Waltimo T, endodontists were more knowledgeable than the other Filippi A. Barodontalgias, dental and orofacial barotraumas: specialty students. This could be attributed to the A survey in Swiss divers and caisson workers. Swiss Dent J exposure of postgraduates about this topic and cases, 2014;124:510-9. especially the endodontists as they are involved in 4. Rajpal PS, Sachdev G, Waghmare M, Pagare SS. Dental barotrauma and barodontalgia. JMSCR 2014;2:3477-83. treating this condition. 5. Kieser J, Holborow D. The prevention and management of oral barotrauma. N Z Dent J 1997;93:114-6. In our study, only 35% of participants have seen a 6. Zadik Y, Zapnick L, Barenboim E, Einy S, Goldstein L. patient with barodontalgia either in a college or in a Incidence and etiology of barodontalgia in the Israeli air . private hospital, which explains for the lack of adequate In: The Joint Meeting of the Continental European, Israeli, and knowledge about barodontalgia. When a patient Scandinavian Divisions of the IADR. Istanbul Turkey; 2004. 7. Sipahi C, Kar MS, Durmaz C, Dikicier E, Bengi U. Prevalence with barodontalgia visits dental college or hospital, of barodontalgia in Turkish air force flight crew. Gulhane Med case discussions and forums must be arranged, thus J 2007;49:1-4.

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8. AlMadi EM. Knowledge about barodontalgia among dentist in 18. Shetty KP, Satish SV, Rao K, Bhargavi PA. Barodontalgia – A Saudi Arabia. Egypt Dent J 2010;56:2331-9. review. Endodontology 2013;25:156-60. 9. Rauch JW. Barodontalgia – dental pain related to ambient 19. Zadik Y. Barodontalgia. J Endod 2009;35:481-5. pressure change. Gen Dent 1985;33:313-5. 20. Stoetzer M, Kuehlhorn C, Ruecker M, Ziebolz D, Gellrich NC, 10. AlHajri W, AlMadi E. Prevalence of barodontalgia among von See C. Pathophysiology of barodontalgia: A case report and pilots and divers in Saudi Arabia and Kuwait. Saudi Dent J review of the literature. Case Rep Dent 2012;2012:453415. 2006;18 134-40. 21. Jagger RG, Jackson SJ, Jagger DC. In at the deep end – an 11. Zadik Y, Drucker S. Diving dentistry: A review of the dental insight into and related dental problems for the implications of scuba diving. Aust Dent J 2011;56:265-71. GDP. Br Dent J 1997;183:380-2. 12. Al Khawalde M, Abu Al Ghanam M, Khazaaleh N, Al 22. Lyons KM, Rodda JC, Hood JA. Barodontalgia: A review, and Khawaldeh H, Habashneh RF. The prevalence of barodontalgia the influence of simulated diving on microleakage and on the among Jordanian military pilots. J R Med Serv 2016;102:1-7. retention of full cast crowns. Mil Med 1999;164:221-7. 13. Lakshmi, Sakthi DS. Aviation dentistry. J Clin Diagn Res 23. Zadik Y. Barodontalgia due to odontogenic inflammation in the 2014;8:288-90. jawbone. Aviat Space Environ Med 2006;77:864-6. 14. Gunepin M, Derache F, Blatteau JE, Nakdimon I, Zadik Y. 24. Kini PV, Jathanna VR, Jathanna RV, Shetty K. Barodontalgia: Incidence and features of barodontalgia among military divers. Etiology, features and prevention. HRPUB 2015;3:35-8. Aerosp Med Hum Perform 2016;87:137-40. 25. Hamilton-Farrell M, Bhattacharyya A. Barotrauma. Injury 15. Laval-Meunier F, Bertran PE, Arrivé E, Paris JF, Monteil M, 2004;35:359-70. Nguyen S. Frequency of barodontalgia among military or 26. Zadik Y. Dental barotrauma. Int J Prosthodont 2009;22:354-7. civilian pilots and aircrew members. Aviat Space Environ Med 27. Zadik Y. Aviation dentistry: Current concepts and practice. Br 2013;84:1055-60. Dent J 2009;206:11-6. 16. Gonzalez Santiago Mdel M, Martinez-Sahuquillo Marquez 28. Anuradha P, Grover S. Aviation dentistry: The neglected field A, Bullón-Fernández P. Incidence of barodontalgias and their by dentists in India. A review article. J Indian Assoc Public relation to oral/dental condition in personnel with responsibility Health Dent 2010;8:36. in military flight. Med Oral 2004;9:98-105, 92-8. 17. Rai B, Kaur J, Catalina M, Anand SC. Prevalence of barodontalgia in Indian origin pilots: A survey. Int J Stomatol Source of support: Nil; Conflict of interest: None Declared Occlusion Med 2010;3:115-7.

Questionnaire • Radiographs Demographics: • All of the above Age – 18–20 21–23 >24 6. How will you prevent barodontalgia? Year of study – III BDS IV BDS INTERN I MDS • Extract all decayed teeth II MDS IIIMDS • Root Canal Treatment for all decayed teeth Sex – Male Female • Perform good restorations on decayed teeth 1. Have you heard of the term barodontalgia? • All of the above • Yes • I don’t know • No 7. How will you treat barodontalgia? 2. How would you define barodontalgia? • Repeating the restoration • Dental pain due to change in atmospheric • Extraction of offending tooth pressure • Root canal treatment of offending tooth • Dental pain due to change in temperature • Remove the void space by carefully replacing the • Dental pain due to trauma offending restoration, or repeating endodontic • Dental pain due to change in climate treatment or removing the tooth • I don’t know • I don’t know 3. People affected by barodontalgia are? 8. What does pain during ascent and descent indicate, • Medical health professionals respectively? • Aviators and deep sea divers • Pulpal necrosis and pulpitis • Teachers and students • Pulpitis and pulpal necrosis • Singers and Public speakers • Facial barotrauma and sinusitis 4. Causes of barodontalgia? • Sinusitis and Facial barotrauma • Sinusitis • I don’t know • Faulty restorations and Deep caries 9. Which law does barodontalgia follow? • Ear infections and Headaches • Wolff’s law • All of the above • Boyle’s law • I don’t know • Stefan’s law 5. How will you diagnose barodontalgia? • I don’t know • Case history 10. Where do gases such as helium get trapped? • Intraoral examination • Space in the pulpal cavity • Extraoral examination • Space between the tooth and the restoration

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• Sinuses 13. Where did you learn about barodontalgia? • Pterygomaxillary Space • I haven’t learned about it 11. Which dental specialists treat barodontalgia? • On the Internet • In a lecture in class • Prosthodontists • In a textbook • Endodontists 14. Are you interested in learning more about • Oral surgeons barodontalgia? • Periodontists • Yes 12. Have you come across a patient who complained of • No tooth pain during flights? 15. Do you think it should be included in the dental • Yes, in college curriculum? • Yes, in a hospital • Yes • No • No

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