Smile High

Media item: article

Date published: 12 January 2016

This page records the media item. The original article is the property of its publisher and is not reproduced here.

The archive preserves the headline and the date; the article is not reconstructed. What follows is general information on the subject the title points at, and one that is genuinely useful and almost never written about: teeth, air travel and pressure.

Barodontalgia: toothache caused by changes in pressure

Barodontalgia is tooth pain triggered by a change in ambient pressure — in an aircraft, while diving, or in a hyperbaric chamber. It is a recognised phenomenon, well documented in aviation and diving medicine.

The key point: pressure does not cause the problem. It reveals it.

A healthy tooth does not hurt at altitude. Barodontalgia occurs where there is already pathology — usually an inflamed or necrotic pulp, deep or recurrent decay, a defective restoration with air trapped beneath it, a periapical lesion, a recent restoration that has not settled, or sinus disease referring pain to upper teeth. What are the causes of toothache and what are their symptoms? runs through the list.

Gas trapped in a small void expands as ambient pressure falls. In an aircraft cabin, pressurised to the equivalent of a couple of thousand metres, that expansion is enough to produce pain in a tooth with a void under a restoration or an inflamed pulp — see Tooth Pain and Ache and Why do I need a filling?

Pain on ascent and pain on descent point to different things, which is why the timing is worth reporting to a dentist accurately.

The practical consequence: a tooth that hurts on a flight needs examining afterwards, even if the pain stopped on landing. It is a signal, not a quirk. I have a toothache — what could be the cause? and How can I relieve a toothache? cover the interim.

Barotrauma of the sinuses

Far more common than barodontalgia, and frequently mistaken for toothache.

The roots of the upper back teeth sit immediately below the maxillary sinus, sometimes separated by less than a millimetre of bone. Sinus congestion produces pain in several upper teeth at once, worse on bending forward, often with a blocked nose.

Toothache from a single tooth is usually one tooth. Diffuse pain across several upper teeth, with a cold, is usually sinus. Distinguishing them requires examination and often a radiograph, and getting it wrong leads to root canal treatment on a healthy tooth. Common signs and symptoms of a toothache is the fuller comparison.

Dental fitness for aircrew and divers

This is regulated territory in some contexts.

Divers, aircrew and people working in hyperbaric conditions are, in various settings, required to be dentally fit — because a dental problem at depth or altitude is a problem in a place where it cannot be treated, and because a loose restoration or a poorly fitting appliance can interfere with holding a regulator mouthpiece.

For divers specifically: ill-fitting dentures and recent extractions are genuine concerns; the socket after an extraction needs time to heal before diving (I've just had oral surgery — what can I expect during recovery?), and clenching on a mouthpiece for extended periods is a recognised cause of jaw joint and muscle pain in divers — see What are the most common symptoms of TMD?

A dental examination before a long trip, an expedition, or a dive course is not fussiness. It is the same logic as servicing a vehicle before a long drive — how often should I go to the dentist?

Dental problems while travelling

The practical part.

Before you go

• Have an examination if you are overdue, particularly before a long or remote trip. A tooth that is borderline at home becomes an emergency in a place where you do not speak the language and cannot assess the practitioner. What is considered a dental emergency?
• Deal with anything symptomatic. Do not travel on a tooth that is already sore.
• Take a small dental kit: temporary filling material from a pharmacy, dental floss, paracetamol and ibuprofen, and a spare of any appliance you rely on. What do I do if a temporary filling comes out? and My denture is broken — what should I do? cover the two most common travel failures.
• Check your travel insurance. Most policies cover emergency dental for pain relief only, with a low limit, and exclude anything they consider pre-existing or elective. The Australian Dental Association makes the same point about the other direction: complications from elective dental treatment obtained overseas "are not always covered by travel insurance and the treatments may not be covered by Australian health funds". Read the dental clause specifically.
• If you wear a retainer or an aligner series, take it and keep it with you — not in checked luggage. Teeth move. See Will my teeth need retainers after I've had braces? and How to protect your aligners and your smile.

If something happens abroad

• A knocked-out permanent tooth is the same emergency anywhere, and it is worth knowing precisely what the variable is, because the version in general circulation is wrong. The International Association of Dental Traumatology's 2020 guidelines make it extra-oral DRY time that matters, not total elapsed time. Handle the tooth by the crown, and replant it immediately at the scene if you can — the IADT's instruction is to encourage whoever is present to do exactly that. If you cannot, get it into a storage medium quickly, because dehydration of the root surface "starts to happen in a matter of a few minutes". The IADT's order of preference is milk, then HBSS (a purpose-made tooth-preserving solution), then saliva — spat into a glass — then saline; water is "a poor medium" but "better than leaving the tooth to air-dry". After 30 minutes of extra-alveolar dry time most periodontal ligament cells are non-viable, and beyond 60 minutes they are likely to be non-viable regardless of the medium — but the guideline is emphatic that this is not a reason to give up: "the decision to replant a permanent tooth is almost always the correct decision even if the extra-oral dry time is more than 60 minutes", because replantation preserves bone height and width and keeps later options open. And check first that it is a permanent tooth: primary teeth should not be replanted. Then find a dentist urgently. (What should I do when a tooth is knocked out?)
• Facial swelling with difficulty swallowing or breathing is a medical emergency. Go to a hospital. The RACGP's own airway checklist for these presentations asks whether there is swelling below the level of the mandible and in the upper neck; whether the mouth opens more than 2 cm between the front teeth; whether the person can speak in sentences, control their saliva and swallow; whether stridor is present; and whether the tongue is pushed up against the soft palate. Its standing instruction if any of those are present is unambiguous: keep the person sitting up, do not lie them flat. See Dental Emergencies Explained and Emergency Dentistry.
• And if you are given antibiotics abroad and nothing else, that is not treatment. The RACGP states it flatly: "Antibiotic treatment without dental treatment to remove the cause always fails." Antibiotics may buy time to get somewhere the tooth can actually be drained or removed; they do not fix it.
• For a lost filling or crown, temporary filling material from a pharmacy will usually hold until you get home. Keep the crown if it comes off in one piece — it can often be recemented (Dental Crowns).
• Get records of anything done to you, in writing, including what materials were used. Whoever manages it afterwards will need them, and the ADA identifies this as a specific hazard of overseas treatment: "records and complete details of treatment obtained overseas are unlikely to be available to those providing subsequent treatment in Australia" — Second Opinions and Corrective Dentistry.
• A practitioner overseas is outside AHPRA's jurisdiction, and the Australian complaint pathways do not apply to them.

And on 'while I'm there' treatment

Dental tourism is heavily marketed to Australians. The Australian Dental Association's position is that Australian residents "should only seek elective dental care in Australia", on the grounds that overseas elective treatment "carries the risk of adverse oral and general health outcomes with long term problems which may be difficult to resolve on return to Australia". That is a professional policy position rather than an evidence base — the policy contains no complication rates, and it is worth reading as such.

The practical issues it identifies are the ones that actually bite: treatment completed in a week usually means crowns rather than veneers, and therefore much more tooth removed permanently; indemnity insurance, which Australian practitioners must hold, "may not be the case in overseas clinics"; complications appear after you are home; and remedial work in Australia on failed full-arch overseas treatment is expensive and sometimes not possible. The ADA's most useful single sentence is the structural one: "Optimal ongoing oral health cannot be achieved in a single episode or short course of treatment and requires regular maintenance." This is covered in detail at 'Like a set of piano keys': Why Australians are opting for veneers, and in Dental tourism: what risks are involved?, Dental tourism — the pitfalls and Overseas dental work could cost you more in the long term.

One more, since it comes up on long flights

Cabin air is very dry, and dehydration reduces saliva flow. Saliva is the mouth's main defence — it buffers acid and delivers minerals back to the tooth surface. See My mouth is always dry.

So on a long flight: drink water, avoid grazing continuously on snacks, avoid sipping soft drink or juice across hours (are sugar free soft drinks better for my teeth?, is soda water bad for your teeth?), and clean your teeth when you can. Frequency of acid exposure matters — the Australian Dental Association's policy on sugar puts it as "the form, frequency, timing and total amount of sugar intake are significant in the initiation of the caries process", with particular emphasis on snacking on sugary drinks and sugar-rich foods of limited nutritional value. A fourteen-hour flight of constant nibbling is a textbook pattern for it — how does your diet affect your teeth?

Related pages: Emergency Dentistry, Fighting decay, Getting to the root of the issue, General Dentistry, and the rest of the media record.

Common questions

My child's tooth was knocked out on holiday. What should I have done?

It depends first on whether it was a baby tooth or an adult one: a primary tooth should not be replanted. For a permanent tooth, the variable is extra-oral dry time, not the time since the accident — which is why the widely repeated "twenty minutes" framing is unhelpful. Handle it by the crown, put it straight back in the socket if you can, and otherwise into milk (or a tooth-preserving solution, saliva or saline) within minutes, because the root surface starts drying almost immediately. Even where the tooth has been dry for over an hour, the IADT's position is that replanting is almost always still the correct decision, because it preserves the bone and keeps later options open. Then get to a dentist.

The tooth hurt for two days after the flight and then stopped. Is it fine now?

Not necessarily, and this is the single most useful thing on this page. The RACGP's account of how a dental abscess develops explains why: "Pulpitis results in pain that is poorly localised. When pulp necrosis finally occurs, there is no pain." Pain stopping can mean the inflammation settled — or it can mean the nerve inside the tooth has died, which is silent and which does not repair itself. The next stage is not silent: "when an acute periapical abscess develops, a severe well-localised pain develops", and the RACGP notes that at that earlier point "the dental abscess is easily treated by extraction or root filling", whereas later it is not. It also observes that by the time patients present with an abscess, "all patients have had intermittent episodes of pain as a warning that something is wrong." A tooth that aches at altitude and then goes quiet has given you the warning. Get it examined and radiographed. See Tooth Pain and Ache and How is a tooth abscess treated?

How bad can an untreated dental infection actually get?

Bad enough to be a hospital problem at scale. The AIHW counts roughly 88,600 potentially preventable hospital admissions for dental conditions in Australia in 2023–24, a rate of about 3 per 1,000 population; the published systematic review puts dental-related admissions at 10 per cent of all potentially preventable hospitalisations and 22 per cent of those due to acute conditions. The clinical end of it is documented in an audit of 672 patients treated for severe odontogenic infection at the Royal Adelaide Hospital between 2006 and 2014: 64 per cent were assessed as being at high risk of airway obstruction, the average age was in the thirties with a range from 18 to 95, patients went to theatre within a few hours for removal of the causative teeth and incision and drainage of the involved spaces, average time in intensive care was 38.5 hours and length of stay was 1.9 days for low-risk and 5.1 days for high-risk patients. One piece of terminology worth correcting while we are here: Ludwig's angina — "angina meaning 'choking'" — strictly describes infection involving the whole neck bilaterally from the mandible down, and the RACGP notes the term "is commonly misinterpreted to apply to any localised neck infection". Most facial swelling is not that. It still needs seeing the same day. See Can a dental abscess affect your general health? and Emergency Dentistry.

Should I have my wisdom teeth out before a long trip, just in case?

Not on the strength of the trip alone. The clearest guidance on this remains NICE technology appraisal TA1, published in March 2000 — which is United Kingdom NHS guidance with no legal or funding status in Australia, and is a quarter of a century old, so treat it as a reasoned position rather than current Australian policy. Its recommendation was that "the practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS", and that surgical removal "should be limited to patients with evidence of pathology". The pathology it accepted is a specific list: unrestorable decay, non-treatable pulpal or periapical disease, cellulitis, abscess and osteomyelitis, resorption of the tooth or its neighbour, fracture of the tooth, disease of the follicle including cyst or tumour, and a tooth obstructing jaw surgery or sitting in the field of a tumour resection. On the complaint most people actually have, it drew a line worth knowing: "a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery." So the question to put to a dentist before you fly is not "should these come out" but "is there anything on that list in my mouth right now" — which is a radiograph and an examination, not a guess. Third molars usually erupt between the ages of 18 and 24. See Wisdom Teeth.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment. Directions are on Location; enquiries go through Contact Us.

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This page records a published article and its date. The archive does not preserve its content, and the information above is general information rather than a summary of it. It is not a diagnosis, a treatment plan or fitness-to-fly or fitness-to-dive advice; those assessments are made by the relevant medical examiner. Third-party published content is not reproduced.

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