Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : ZC50 - ZC54 Full Version

Aerodontalgia among Airline Pilots of India: A Cross-sectional Survey


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48706.15314
Sabreen Gujral, Shruti Chopra, Shveta Sood, Naresh Sharma, Akshara Singh

1. Postgraduate Student, Department of Paediatric and Preventive Dentistry, MRIIRS, Faridabad, Haryana, India. 2. Postgraduate Student, Department of Paediatric and Preventive Dentistry, MRIIRS, Faridabad, Haryana, India. 3. Professor, Department of Paediatric and Preventive Dentistry, MRIIRS, Faridabad, Haryana, India. 4. Assistant Professor, Department of Paediatric and Preventive Dentistry, MRIIRS, Faridabad, Haryana, India. 5. Reader, Department of Paediatric and Preventive Dentistry, MRIIRS, Faridabad, Haryana, India.

Correspondence Address :
Sabreen Gujral,
Sector 26, Surajkund Road, Faridabad, Haryana, India.
E-mail: sabreengujral@gmail.com

Abstract

Introduction: Barometric pressure-induced dental pain is a clinical entity elicited by atmospheric changes in pressure. Barodontalgia (also known as aerodontalgia) among pilots is of marked interest as it can be a potential flight safety hazard and compromise the personnel’s operational capability and performance. Due to its overlapping signs and symptoms, it may also remain unnoticed and represent itself during a pressure change which may be during ascend or descend of flight.

Aim: To assess presence of barodontalgia and awareness of the phenomenon among commercial pilots based in India.

Materials and Methods: This cross-sectional study was conducted from June to August 2020 using self-reported questionnaire submitted via Google forms (Alphabet, Mountain view, CA, USA) among 410 pilots based in India. It consisted of questions inquiring about the occurrence, localisation, intensity and recurrence of in-flight dental pain. Inferential statistics were performed using Chi-square test, One way analysis of variance (ANOVA) and Independent t-test. The level of statistical significance was set at 0.05.

Results: A total of 370 pilots responded to the questionnaire with a response rate of 90.24%. The incidence was reported among 10.54% (n=39) pilots although 42.7% (n=158) lacked awareness regarding the same. Only a single case of recurrence of pain was reported while none reported any risk to flight safety or accident, secondary to barodontalgia.

Conclusion: The incidence level of barodontalgia among commercial pilots in India is low. However, the lack of awareness is still an unsettling risk and was not found to be of significant difference when compared on the basis of gender and work experience.

Keywords

Aerospace medicine, Atmospheric pressure, Aviation dentistry, Pain

Aviation dentistry is the understanding of the oral and dental health evaluation, prevention and treatment of diseases, conditions or disorders concerning oral and maxillofacial region and its associated structures with its impact on aviators and aircrew members (1). Exposure to an environment of high altitude with abnormal change in pressure gradient can influence the body’s tissues (2). Conditions of oral and maxillofacial region such as barodontalgia, barotrauma and odontocrexis have been reported frequently since the beginning of the 20th century (3).

Barodontalgia is barometric pressure-induced dental or non dental pain elicited due to inability of the pulp to adapt to this change with supplementary factors such as minute void within a restored tooth or faulty tooth restorations (1),(4),(5). The pain can also be evoked after a recent dental treatment and is known as postoperative barodontalgia (6). The incidence of in-flight pain has been reported at altitudes of 2000 to 5000 ft (610 to 1524 m) however during ascent, pain can be attributed to conditions of vital pulp and necrotic pulpal diseases appear during descent. The most commonly affected teeth are the upper and lower first molars (30% of cases). Barodontalgia terminates as the plane lands and returns to ground atmospheric level, but pain originating due to underlying periradicular pathology or facial barotrauma may still linger (4).

The differential pressure is exerted by gas filled cavity in the human body as it is unable to communicate with the exterior environment to equalise it which leads to clinical pain, oedema, or vascular gas embolism and development of headache, numbness, or dental pain (7). Even though the experience of barodontalgia is infrequent it is a recognised potential hazard among pilots leading to in-flight vertigo and unforeseen disability compromising flight safety (8). Dental barotrauma among aircrew can result in a distressing flight experience by precipitating fracture of dental restorations as well as teeth (7).

Pilots and other aircrew members must be subjected to routine dental examinations (9). The examining dentist must be qualified to recognise, assess and be prepared to provide treatment as well as preventive measures to avoid the incidence of pain (10). In the current times, a more conservative protocol must be followed in comparison to the conventional one where in it was recommended to extract all pulpless teeth and roots in aircrew members (11). Flyers must be advised to avoid exposure to pressure changes until completion of all necessary conservative, endodontic and prosthetic procedures. Prevention of intraoperative flare up can be done by scheduling appointments to complete root canal treatment (RCT) prior to exposure to change in cabin pressurisation (9).

Lack of awareness and regulation for dental examination and treatment along with disagreement about grounding period by aircrew members present a limitation. Thus, with the increasing number of air travellers it is essential for the dental clinicians to raise awareness about flyers toothache and other in-flight conditions (10). The objectives of the present study were to assess the frequency of barodontalgia among commercial pilots based in India and obtain an insight of the characteristics of the pain experienced.

Material and Methods

This cross-sectional research study evaluated commercial airline pilots of India from June to August 2020. The study received approval (Ethical no. MRDC/IEC/2020/05A) from Ethical Committee of Faculty of Dental Sciences, Manav Rachna International Institute of Research Sciences, Faridabad, Haryana, India.

Sample size calculation: Sample size was calculated using G*Power data analysis using formula (4pq/l2) where l is the permissible error (5%), ‘p’ is the prevalence rate (20.6%) (12) and ‘q’ is (1-p). As the study, population i.e., aircraft pilots in India is approximately 10,000 thus, sample size of 260 was calculated to be sufficient considering the previous published prevalence of 20.6% (12).

Inclusion criteria: Pilots based in India were only included in this study.

Exclusion criteria: Subjects below 25 years and above 65 years and pilots who were non residents of India were excluded from the study.

Questionnaire

The self-administered questionnaire was designed to inquire information regarding demographics of the pilots like age, sex and their profession related characteristics such as flying hours. Data regarding incidence and characteristics of in-flight pain such as frequency, localisation, intensity and it’s recurrence in subsequent flight was obtained. The survey also questioned whether pain was during ascend or descend of flight, its termination, if the pilot visited the dentist and the treatment provided for the same. Pilots were also questioned if they were aware of the term barodontalgia. Thus, a total of 14 questions were framed as multiple choice and liner scale. The questionnaire was anonymous to maintain the privacy and confidentiality of information reported in the present research. The questionnaire used by research published by Rai B et al., was adapted for present day status (12). The questionnaire was checked for validity using content validity and questions with content validity ratio of 0.7 were included in the study. Reliability was assessed through pilot study inclusive of 30 participants who were administered the questionnaire and a Cronbach’s alpha value of 0.738 was obtained. The results of the pilot study have not been included in the study.

Non probability snowball sampling technique was used for data collection. Contact details were obtained through administrative heads of various social media groups of aviation community. The questionnaire was emailed and participants were requested to complete the survey within a period of one week. The survey was submitted using Google Forms (Alphabet, Mountain view, CA, USA) by 410 commercial pilots from governmental and private sectors of India. Data was entered into Microsoft excel spreadsheet and then checked for any missing entries. Responses by 40 pilots were excluded as 13 questionnaires were received incomplete and 27 pilots did not respond.

Statistical Analysis

Data was entered into Microsoft excel spreadsheet and was analysed using Statistical Package for Social Sciences (SPSS) version 21. Categorical variables were summarised as frequencies and continuous variables were summarised as mean and standard deviation. Graphs were prepared on Microsoft excel. Inferential statistics were performed using Chi-square test, ANOVA and independent t-test. Chi-square test was used to compare categorical data. Independent t-test was used to compare two independent means. ANOVA test was used to compare more than two independent means. The level of statistical significance was set at 0.05.

Results

The survey was accessible from June to August 2020. A total of 370 commercial airline pilots responded to the questionnaire. The age of the pilots investigated ranged between 25 to 65 years, with maximum respondents aged between 41-55 years (53.5%, n=198). Male subjects were 290 (78.4%) and female subjects were 80 (21.6%). Notably, the maximal respondents had flying experience of more than 20 years (53.5%, n=198) and were flying more than 500 hours annually (Table/Fig 1).

Barodontalgia was reported by 39 Indian pilots (10.54%, p=0.0001). On intergroup comparison, frequency of barodontalgia was 10.4% (n=14), 12% (n=12) and 6.1% (n=13) seen in age groups 25-40 years, 41-55 years and 56-65 years, respectively (Table/Fig 2). The pain was reported during ascent by 46.2% (n=18) subjects while 33.3% (n=13) reported it during descent. However, only 35 pilots were able to localise the in-flight pain with 79.5% (n=31) reporting it to be originating posteriorly (Table/Fig 3).

Of the incidences reported, 48.7% (n=19) had persistent pain after landing and 89.7% (n=35) visited their dentist for the same. Most of the investigated pilots who had encountered pain, RCT was performed 68.6% (n=24) whereas restoration was done for 11.4% (n=4) pilots and extraction for 10.6% (n=7) (Table/Fig 4). Only one pilot had complained of recurrence of pain while 97.4% pilots reported that the episode of pain did not occur again. The survey also highlighted that 45.4% (n=168) pilots underwent routine dental examination and 26.5% (n=98) only visited their dentist in case of an emergency (p=0.022) (Table/Fig 3). Awareness regarding the phenomenon was notably reported by 30.4% (n=88) male pilots and 23.8% (n=19) female pilots while 104 pilots lacked awareness about the same (Table/Fig 5).

Discussion

Air travel is the quickest means of transport, flying at a speed of 800 kms/hr. According to The International Civil Aviation Organisation (ICAO) preliminary compilation of 2018, 4.3 million passengers are carried on scheduled air services (13). Aircrew members fly an average of 500 hours/annum to provide comfortable services to the passengers. At higher altitude, due to hypobaric environment, pilots and other aircrew members, suffer from deleterious effects on their teeth, gums and bones. This inhospitable environment and cabin pressure changes are also responsible for inducing xerostomia, a causative factor for dental diseases (2). Such oral manifestations can also be seen with frequent flyers however, the intensity may vary. Significant difference in manifestations of such diseases is also noticed between aircraft personnel of commercial flights and military pilots due to variation in exposure time and intensity of pressure change (7).

Dental surgeons have deduced barodontalgia as an emergency. In the present study, 10.54% (n=39) commercial Indian pilots from government and private sectors of India have reported that they have experienced in-flight dental pain as opposed to 20.6% Indian origin pilots who reported in 2010 (12). By using similar study design 10 years later the present study reveals that the frequency of barodontalgia has been reduced. This decrease in barodontalgia can presumably be attributed to better oral hygiene maintenance due to regular dental examination. In this context, results from this study report that 45.4% (n=168) of pilots visit their dentist for routine dental examinations. Moreover, improved technology maintaining cabin differential pressure also contributes in lowering the rate of barodontalgia (14). The current incidence of barodontalgia in pilots based in India is lower than pilots of commercial airlines of Pakistan (29.03%) but higher than commercial pilots of France (6.5%) (15),(16). Military pilots of Kuwait and Saudi Arabia and pilots of Turkish Air Force have reported an incidence of barodontalgic pain of 49.6% and 12%, respectively (17),(18). In contrast, Israeli Air Force reported a prevalence of 8.2% in 2007 and a frequency of 0.26% was reported in the German Air Force Crew by Kollmann W (19),(20). However, Pakistani military pilots have reported 0% of barodontalgia (15). This discrepancy can be ascribed to the difference in study design, study sample and cultural and ethnic backgrounds. The contrasting difference between commercial and military counterparts can be attributed to the assumption that military pilots are more likely to be subjected to extreme situations (15).

In the present study, data regarding in-flight pain and its characteristics were obtained. None of the participants of this study complained of existence of pain prior to the flight. Ritchey B and Orban B, propounded higher prevalence of barodontalgia due to rapid ascent, this is in correlation with the present study where in 46.2% pilots (n=18) reported pain during flight ascent (21). The higher incidences recorded during ascent explains that pain was associated to the underlying vital pulp pathology and hence 11.4% (n=4) and 68.6% (n=24) subjects of the study reported that they were provided restoration and root canal treatment, respectively with a possible diagnosis of acute pulpitis, caries or faulty restorations (20). Based on available evidences, no association between intensity of pain experienced by the pilots and gender was noticed. The mean in-flight pain reported by the male pilots was 5.3 and female pilots was 5.5. In Kollmann’s high altitude chamber simulation series, 29% of incidences were due to exposed vital pulp and 14% due to pulpitis or periapical periodontitis. Most common incidental cause of barodontalgia was deep caries without pulp exposure in Kollmann’s series likewise for 11.4% (n=4) of subjects participating in the present study, restoration of offending tooth was done, root canal treatment was provided to 68.6% (n=24) of the pilots with in-flight pain while 10.6% (n=7) underwent extraction (20).

Conflicting results have emerged in response to barodontalgia from data obtained from hypobaric simulators and in-flight data due to inconsistency in exposure time and cabin pressurisation thus, participants having minimum of 100 hours of flying time in a year were considered for the study. None of the investigated pilots reported flight safety risk/premature landing due to the oral pain experienced in-flight as opposed by 13.5% of French commercial and military pilots surveyed by Laval-Meunier F et al., (16).

The recurrence rate of in-flight pain documented by Indian pilots was 2.6% (n=1) juxtaposed to the previous studies by Rai B et al., in which recurrence rate was 10.2% and Al-Hajri W and AL-Madi E in 2006 in which recurrence rate of 16.4% was reported (12),(17). Subsequently, no case of premature landing due to in-flight pain or reoccurence of pain had been reported by Pakistani pilots (15).

A 42.7% Indian pilots participating in the present study were unacquainted with the phenomenon of barodontalgia. Thus, its essential to raise awareness among pilots as well as dental surgeons. Dental students in Chennai, India displayed low percentage of 41% participants who were aware of the phenomena, while awareness level of 22.2% has been reported among dental students in Saudi Arabia (10),(22). Thus, with thorough knowledge, periodic examinations including vitality tests in extensively restored teeth, retreatment of faulty restorations and diagnostic radiography such incidences can be prevented. In cases, with pulpal pathology meticulous root canal treatment is advised, but recent systematic reviews show promising outcomes with less invasive therapies such as coronal pulpotomy (23). The root canal treated teeth must be restored with full coverage crowns for functional as well as aesthetic purposes. This also increases the long term survival of the tooth as opposed to direct restorations (24).

Pain due to necrosis of pulp usually appears during descent and was seen in 33.3% (n=13) pilots and 10.6% (n=7) among the total underwent extractions due to the intensity of the pain. Extractions of impacted third molars is also recommended owning to their symptoms which can be sudden in onset and recurrent infections. Most of the subjects (79.5%, n=31) were able to localise their pain to posterior teeth region and this is in association to the higher prevalence of caries in occlusal fissures of first and second molars (25).

Pilots and aircrew must be obligated to resume to duty once the procedure has been completed. Moreover, multi visit RCT must be preferred over single visit as it has a lesser frequency of swelling and analgesic use (26). The incidence of barodontalgia in different regions of the world has been summarised in (Table/Fig 6) (5),(12),(15),(16),(17),(18),(19),(20),(27).

Patients are advised not to fly in nonpressurised cabins within 24 hours of a dental treatment requiring anaesthetic. Following surgical treatment a mandatory seven days of rest period must also be taken (8). A compulsory annual examination must be recommended for all pilots and aircrew members by aviation dental specialist to record any deterioration in dental health. It is also advised that pilots and crew must be provided the due precautions and instructions for management of in-flight occurrence of dental pain. The patients examined to be at risk should be Temporary Medical Unfit (TMU) for flying as a flight safety hazard. In the present day, it is recommended that dental health must be incorporated for aviator’s physical standards. It has also been highlighted that barodontalgia has been neglected in dental education and research in the recent years, despite demonstrated essential role of atmospheric pressure generation and oral pain.

Limitation(s)

The study is limited to self-reported data and no clinical correlation was conducted however more research into understanding of history, diagnosis, treatment challenges and preventive programmes in the form of increased awareness among pilots is proposed.

Conclusion

It is evident from the available data that incidence of barodontalgia was reported 10.54% of the sample population which is relatively low as compared to reports from other countries. It was found to be of minor nature and did not disrupt the health of the pilot or the flight routine. However, dental barotrauma still remains a field of concern for flyers and its awareness among dental surgeons as well as pilots have been found out to be low.

Acknowledgement

The author wish to express deep sense of gratitude and professional thanks to Capt. Kulvinder Singh, DGM Air India and Dr. Gp Capt. MPS Marwah, Aviation Medicine Specialist and Col Dr. Navreet Singh, cardiologist for their keen interest and inspiring guidance to bring this research paper into fruition. The author would also like to acknowledge the pivotal role of her family for their constant encouragement.

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DOI and Others

10.7860/JCDR/2021/48706.15314

Date of Submission: Jan 27, 2021
Date of Peer Review: Apr 21, 2021
Date of Acceptance: May 19, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
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• iThenticate Software: Jun 04, 2021 (8%)

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