Barodontalgia

Case Report

84th Annual AsMA Scientific MeetingMichael H. Hodapp, DDS, MAGD

Disclosure Information84th Annual AsMA Scientific MeetingMichael H. Hodapp, DDS, MAGD

I have no financial relationships to disclose.

I will not discuss off-label use and/or investigational use in my presentation

Barodontalgia

CC: “During our July Vacation when my husband and I were drove up into the mountains, I got a terrible pain in my lower right tooth and it stayed with me the whole week. Then it went away when we came back down.”

Barodontalgia

– Pain in the lower right jaw

» Patient points to tooth #29 (45)

– Pain occurred at about 7000 feet (2100 meters)

– The pain was strong at first (about an 8-9 on a 1-10 scale) and then gradually decreased to about a 4, but was there the whole vacation.

» Described as a dull and throbbing pain with hot and cold sensitivity.

» The pain intensified in the morning and lasted the whole day.

» The pain stopped immediately after descending, however, the hot and cold sensitivity remain and do not linger.

– Patient denies any sinusitis or issues with her ears and denies the use of any sinus related medications.

Subjective findings

Barodontalgia

- #29 (45): Abfractive lesion

- #30 (46): Porcelain Crown

- #31 (47): Heavy wear, vertical buccal cracks and horizontal occlusal cracks on tooth

Objective findings- visual assessment

BarodontalgiaObjective Findings

- Radiographic assessment

#29 (45) Amalgam approximating pulp

#31 (47) Questionable loss of lamina dura on distal root

BarodontalgiaRadiographic findings

Barodontalgia

• Palpation test.

– No sensitivity to palpation on entire right side.

• Percussion test

– Tooth #29 (45): mild to moderate tenderness.

– Tooth #30 (46): no tenderness.

– Tooth #31 (47): mild tenderness to percussion.

• Probing test

– No probing depths >3mm around 29-31 (45-47).

• Tooth sleuth bite test

– Teeth 29-31 (45-47): No painful response.

• Thermal testing

– Teeth 29 and 31 (45 and 47): hypersensitive to the cold test but did not linger.

– Tooth #30 had very little response to the cold test.

Objective findings

Barodontalgia

• Tooth #29 (45)

- Patients perspective: Patient thinks it is tooth #29 that elicited the pain.

- Visual assessment: Tooth #29: Large DO amalgam. Facial abfractive lesion.

- Radiographic assessment: Large coronal radiopacity approximating pulp. No apical radiolucencies. Lamina dura appears intact.

- Test Results: Probing, palpation and bite test; NSF

- Percussion test - mild to moderate tenderness.

- Thermal test - Hypersensitive/did not linger

• Tooth #30 (46)

– Visual assessment: Porcelain veneer crown.

– Radiographic assessment: Porcelain veneer crown. No apical radiolucencies.

- Test Results: Probing, palpation and bite test; NSF

- Percussion test – no tenderness to percussion.

- Thermal test – Very little response to cold.

• Tooth #31 (47)

– Visual assessment: One large and two small amalgam fillings with heavy occlusal wear. Crack running through distal marginal ridge, across occlusal surface, and connecting to vertical crack in buccal groove .

– Radiographic assessment: Questionable if lamina dura is intact on distal root.

- Test Results: Probing, palpation and bite test; NSF

- Percussion test – mild tenderness.

- Thermal test - Hypersensitive/did not linger

Assessment of Teeth

Barodontalgia

– If pain occurs during ascent:

» Tooth is usually alive.

• Dull throbbing pain:

• Reversible pulpitis,

• Periodontal abscess,

• Barosinusitis

• Sudden sharp penetrating pain:

• Irreversible pulpitis, recent treatment

– If pain occurs during descent:

» Tooth is usually dead.

• Severe persistent pain:

• Pulpless tooth with periapical abscess.

• May persist after flight

• Note: can occur with ascent.

• Dull throbbing pain:

• Periapical pathosis

• May persist after flight

• Barosinusitis (upper posterior teeth)

• Usually persists after landing

• Barotitis-media (lower posterior teeth)

• May persist after landing

Diagnostic Assessment- Patient description: “Dull throbbing pain during ascent”

Barodontalgia

- Occurred during ascent: alive (teeth are vital)

- Dull throbbing pain:

- Reversible pulpitis

- Suspect teeth

- #29 filling approximating pulp

- #30 Porcelain veneer crown

- #31 Heavy wear and cracks

- Periodontal abscess

- All probing’s 3mm or less

- No visible radiographic signs of periodontal disease

- Barosinusitis

- Sinuses clear

- Health history does not indicate ear or sinus issues

Assessment

Barodontalgia

- Inform the patient

- Start conservative/treat the obvious

- Tooth #31 (47) Cracked Tooth.

- Treatment selected may not cure the cause.

- May require additional treatment.

- #29 (45) still suspect.

- #30 (46) may also be cause

- Treat the obvious:

- Tooth #31 (47); heavy occlusal wear with cracks on occlusal and buccal surfaces.

- Start conservative

- Remove fillings #31 (47) and transilluminate.

- Mini consult with patient.

- Treat according to findings.

- Reevaluate

Plan

BarodontalgiaClinical findings

BarodontalgiaObjective findings (day of treatment)

BarodontalgiaTreatment

- Place crown

- Follow-up appointment to evaluate

Barodontalgia

• Patient flew in November without incident however…

• Patient states that cold sensitivity is mostly gone, but still has a little achiness occasionally on this tooth.

– Again, patient points to tooth #29 (45).

• Tooth #29 (45)

- Visual assessment: Large DO amalgam. Facial abfractive lesion.

- Radiographic assessment: Large coronal radiopacity approximating pulp. No apical radiolucencies. Lamina dura appears intact.

- Test Results: Probing, palpation and bite test; NSF

- Percussion test – mild tenderness.

- Thermal test – responded and did not linger

• Tooth #30 (46)

– Visual assessment: Porcelain veneer crown.

– Radiographic assessment: Porcelain veneer crown. No apical radiolucencies.

- Test Results: Probing, palpation and bite test; NSF

- Percussion test – No sensitivity to percussion test.

- Thermal test – Very little response to cold.

• Tooth #31 (47)

– Visual assessment: Porcelain veneer crown

– Radiographic assessment: intact lamina dura

– Test Results: Probing, palpation and bite test; NSF

- Percussion test – No sensitivity to percussion.

- Thermal test – Little response to cold.

Evaluation

Barodontalgia

• Tooth #29 (45)

- Visual assessment: Large DO amalgam. Facial abfractive lesion.

- Percussion test - mild to moderate tenderness.

- Occlusion check - reveals traumatic occlusion

• Plan

– Adjust lateral interferences bond class V facial and reevaluate.

• Treatment

– Adjusted lateral interferences bonded class V facial.

Assessment

Barodontalgia

• Final Assessment:

– Patient states that everything is great, and that she hasn’t even thought about her teeth since the last time she was in.

Assessment

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