1 Balwant Rai Space Dentistry [email protected]Aeronautical and Space Dentistry New Proposed concepts of oral and maxillofacial treatment and Management: Aeronautical and Space Dentistry Balwant Rai Space Dentistry

2 Outer space Aeronautic ExtraterrestrialIntroduction Outer space Aeronautic Extraterrestrial Rai et al. 2006

3 History World War II –dentistry in space medicine 1960 –Astronautical dental training 1970 –NASA 2000 – The National Academy of Science Institute of Medicine Committee 2007 – The term aeronautic dentistry 2009 –Simulated microgravity on the oral cavity Rai and Kaur. 2011

4 Galaxy Questions 1. How to manage-abscess, tooth fracture or oral cavity during a mission 2. How an astronaut can maintain proper oral hygiene 3. The effect of extraterrestrial environments on the oral cavity 4. Whether normal dental procedures are applicable during a mission Rai and Kaur. 2014

5 Medical risks Credit: NASA

6 JBR study: Oral Health

7 Oral Health Rai and Kaur. 2011

8 Design parameters for monitoring DeviceReal-time Automatic Non-invasive Multiple biomarkers Very small samples High sensitivity and specificity Low in mass, small in volume Fluctuations in Different parameters No waste artifacts and noninfectious Heavy data storage capabilities and reusable Not time consuming to use and little or no skill required for use Rai and Kaur. 2012

9 JBR SaliBod chipTM Rai and Kaur. 2012The panel of 36 Saliva Based Biomarkers for Space dentistry and Medicine Rai and Kaur. 2012

10 Periodontal status, salivary immunoglobulin, and microbial countsSalivary IgG levels and Streptococcus mutans activity were significantly higher Clinical periodontal parameters (probing depth, bleeding on probing, and clinical loss of attachment) significantly Periodontal condition might worsen due to poor oral hygiene during the mission Rai and Kaur. 2014

11 Effect of simulated microgravity on salivary and serum oxidants, antioxidants, and periodontal status Serum and salivary vitamin C and E concentrations were significantly decreased MDA and 8-OHdG levels were significantly increased CAL and PD were higher Antioxidant-Oral Health Rai and Kaur. 2011

12 Association between stress, sleep quality and temporomandibular joint dysfunctionTMD group endorsed more affective descriptors of their pain experience-Poor Sleep Higher levels of salivary cortisol and salivary melatonin were reported in the TMD group TT-Melatonin and proper sleep Rai and Kaur. 2013

13 Mental and physical workload, salivary stress biomarkers and taste perceptionAfter the mental and physical tasks, the perceived duration of bitter, sour, and sweet taste sensations was significantly shortened relative to control group. There were good correlations between average time intensity of sweetness, bitterness, sourness and cortisol levels. Taste alterations Rai and Kaur. 2012

14 Wound healing and mucosal immunity during short Mars analog environment missionSignificant differences in the proportion of the wound size healed between vacation and the mission. Salivary IgA, IgM, IgG and cortisol levels showed significant differences. Wound repair Rai et al. 2012

15 Evaluation by an aeronautic dentist on the adverse effects of a six-week period of microgravity on the oral cavity Lactate dehydrogenase, MIP 1 alpha, malonaldehyde, 8-hydroxydeoxyguanosine, and thiocyanate were found to increase significantly, while flow rate, sodium, potassium, calcium, phosphate, protein, amylase activity, vitamin E and C, and mouth opening were decreased Moderate pain of teeth, facial oedema, mild pain, loss of sensation of pain and temperature, decreased tongue, and mandibular movement  Reversible effect -oedema of face, change in taste, abnormal expression of face, teeth pain, and xerostomia Rai et al. 2011

16 Salivary amylase and stress during stressful environmentSignificant differences in values of salivary amylase  Significant correlation between salivary amylase and state and trait anxiety  Effect the physiological-salivary amylase Rai et al. 2012

17 Human mandible and alveolar bone under conditions of simulated microgravityBone mineral density and bone mineral content were significantly lower under conditions of simulated microgravity  Greater in women than in men Rai et al. 2010

18 Albano. 2009; Rai et al. 2010 Barotrauma and BarodontalgiaDifference in pressure between a gas space inside the human body and the surrounding fluid during flight, diving, or hyperbaric oxygen therapy Barodontalgia-acute symptom of subclinical oral or dental disease due to the changes in barometric pressure at high altitude ft (2134 m)-increasing in incidence Albano. 2009; Rai et al. 2010

19 Bennett. 2012; Rai et al. 2010 Barotrauma and BarodontalgiaNew restorations, sinusitis, and tooth or jawbone infections Pulpal necrosis is responsible for 40%-56% of barodontalgia during flight Frequently missed-underlying conditions Teeth with suspected pathosis: Annual examinations. Bennett. 2012; Rai et al. 2010

20 Susarla et al. 2003; Rai et al. 2015 Tooth extractionCaries, periapical lesions, periodontal disease, trauma, recurrent infections Healing process in the early postextraction period- pressure changes-dissolve the blood clot- excessive intraoral bleeding and interference with normal functions, particularly speech Posterior maxillary tooth-oroantral communication Susarla et al. 2003; Rai et al. 2015

21 Zadik. 2003; Rai et al. 2016 Tooth extractionOroantral communication-sinusitis-developing emphysema Unpleasant conditions-reduce the flight capabilities of aircrew members Restriction time after dental extractions is hours cases of oroantral communication, grounding should be advised Zadik. 2003; Rai et al. 2016

22 Odontogenic tumors and cystsAltitude increased-increase in barometric pressure-rapid cyst expansion Sudden decreases in atmospheric pressure -transient inferior alveolar nerve compression-expansion of the cyst External pressure changes -temporary pressure on the sensory fibers of the alveolar nerve. Zadik. 2003; Rai et al. 2016

23 Odontogenic tumors and cystsSudden pressure changes -capillary collapse-depriving oxygen to nerves and blocking conduction-longer latency period before recovery Airplane climb rates -produce varying symptoms Faster the climb rate-more rapidly a cyst expands Werner et al. 2002; Rai et al. 2013

24 Aviation Medicine Advisory Service.2017; Rai.2015Botulinum toxin Treatments Botulinum toxin type A-esthetic applications, such as masking a gummy smile, treatment of focal dystonias, hypertrophies, parafunctions, and malfunctions of the salivary glands Botulinum toxin-optimize TMD US Federal Aviation Administration (FAA) standards-after 72 hours Aviation Medicine Advisory Service.2017; Rai.2015

25 Aviation Medicine Advisory Service.2017; Rai.2015Botulinum toxin Treatments Botulinum toxin type A-esthetic applications, such as masking a gummy smile, treatment of focal dystonias, hypertrophies, parafunctions, and malfunctions of the salivary glands Botulinum toxin-optimize TMD US Federal Aviation Administration (FAA) standards-after 72 hours Aviation Medicine Advisory Service.2017; Rai.2015

26 Bruxism Bruxism -excessive clenching of the jaw or grinding of teeth Bruxism-irreversible damage to the teeth, periodontium, masticatory muscles, and temporomandibular joints Aircrew members -chronic stress-higher prevalence of jaw parafunctional activity in aircrew members -G-forces, vibrations, or centrifugal forces, irregular shifts Abrasion of teeth, periodontal problems, and dysfunction of the TMJ-headache and facial myalgia More prevalent among pilots than nonpilots Zadik.2003; Rai.2015

27 Bruxism Different treatment-TMJ disorders Combinations-pharmaceutical treatment ,physical therapy As medications- dizziness or lack of concentration- grounding of aircrew members Surgery-the second choice of treatment Zadik.2003; Rai.2017

28 Zadik. 2003; Dittmer.2007; Rai et al. 2012Dental implants Dental implant-improvement in phonation, nutrition, and feelings of well-being In 2006, the Institute of German Aviation Medicine- After wound healing Quality criteria-fixation, radiographic examinations, mucous membrane–gingival harmony, occlusion, and articulation Flight restriction-maxillary sinus augmentation surgery due to pressure changes during flight Zadik. 2003; Dittmer.2007; Rai et al. 2012

29 Incaudo et al.2006; Rai et al. 2017 Dental implantsTooth loss -pneumatization of the sinus -poor drainage problems-granulomatous tissue formation- halitosis- unpleasant taste-soft tissue polyps in the sinus cavity Maxillary sinus augmentation surgery and dental implant rehabilitation of the aircrew - Oral and maxillofacial surgeons (flight physiology) Incaudo et al.2006; Rai et al. 2017

30 Dental restorations and prostheticsEarly diagnosis and periodic oral examinations –aircrews Maintenance of dental health-prevents in-flight incapacitation-oral disorders (increased discomfort, decreased performance, and nutrition difficulties) Panoramic radiographs -diagnosis of asymptomatic dental pathoses Fractures, incomplete restorations - repaired or replaced at the time of preflight dental examinations Jagger et al.1997; Rai et al. 2007

31 Dental restorations and prostheticsAmalgam restorations -higher prevalence of dental fractures as compared to composite resin restorations Increased corrosion of amalgam restorations-inhalation of pure oxygen. Composite resins are more desirable for dental restorations Protective cavity liner -effective Lyons et al.1997; Rai et al. 2010

32 Lyons et al.1997; Rai and Kaur. 2008Dental restorations and prosthetics Placement of a cuspal coverage crown-severely damaged tooth. Crowns cemented with glass ionomer or zinc phosphate cement could easily be weakened Use of resin cements -aviation dentistry Use of a provisional restoration or temporary cementation is not recommended Lyons et al.1997; Rai and Kaur. 2008

33 Dental restorations and prostheticsDental implants -choice for edentulous aircrew members Management of bruxism in aviators suffering from chronic stress -dental implants for aircrews Implant made of titanium alloys-aircrew members suffering from bruxism Lyons et al.1997; Rai.2015

34 Effects of Incudent mouth wash on Bone Metabolism in a simulated Microgravity EnvironmentCurTM might be inhibited or decreased the activity of cyclin-dependent kinases, and decreased the rate of deposition of calcium as well as formation of mineralized nodules Rai et al. 2015

35 Rai B. 2017 Incudent Tooth Paste Formulation in Peri-ImplantitisAt 7 day: significantly lower bacterial loads for 30 individual bacteria including Porphyromonas gingivalis, Treponema socranskii, Actinomyces naeslundi type 1, Actinomyces gerensceriae, Actinomyces israelii, Actinomyces naeslundi type 1 and type 2 and Actinomyces odontolyticus At Day 210 : levels of Porphyromonas gingivalis, Treponema socranskii, Actinomyces naeslundi type 1, Actinomyces gerensceriae, Actinomyces israelii, Actinomyces naeslundi type 1 and type 2 and Actinomyces odontolyticus   Effective in prevention of peri-implantitis Rai B. 2017

36 Anticancer Property of Incudent Tooth Paste FormulationLevels of TNF-alpha, IL-6, and IL-8 in serum and saliva showed significantly decreased in all groups after brushing. Pain scores and size of lesion in oral leukoplakia improved significantly. New formulation active ingredient mediates its beneficial effects in patients with oral leukoplakia through the suppression of proinflammatory cytokines Singhal R. 2017

37 Remineralization Potential of Three Tooth Pastes on Enamel CariesThe remineralizing ability of Incudent toothpaste for artificial enamel lesions was found to be significantly higher than that of Colgate® and Crest toothpaste Singhal R, Rai B

38 Remineralization Potential of Three Tooth Pastes on Enamel CariesThe remineralizing ability of Incudent toothpaste for artificial enamel lesions was found to be significantly higher than that of Colgate® and Crest toothpaste Singhal R, Rai B

39 Rai B . 2017 Oral-dental problems:AstronautBarotrauma Periodontitis Dental caries Bone loss and fractures of the jaw bone Facial pain and numbness of teeth and oral cavity Stones of the salivary duct and oral cancer Headache Nasal congestion Acute maxillary sinusitis Rai B

40 Rai B . 2017 Dental Kit for Long Manned MissionsRarely in space flights during ISS missions and Moon landings-during missions to Mars is likely to higher Dental problems -real medical emergency during these long duration missions Typically dental problems -5% or less of all recorded missions Prevented -regular and complete preflight examinations and preventive measures during crew training Potential emergencies specific dental instruments, materials and other important supplies should be included in dental kit Best selection of analgesics and antibiotics appropriate for dental treatment and inclusion in the dental kit for a space mission Rai B

41 Kit Design Lightweight, non-toxic Meet relevant packaging criteria for the retention of the instruments under gravity-free, thermal free conditions and should be resistant Rai B

42 Dental Training for AstronautsTrained personally in emergency dental treatments 15 to 180 days Manual contains detailed instructions on procedures, information on diagnosis Rai B

43 Recommendations for the Space and Aeronautical Dentist or Space Oral PhysicianStandard dental or oral health guidelines Dental examination at least 6 months before launch Treatment required should be done 3 to 6 months Crew medical officers and crew dental officers-possible dental emergencies during pre flight briefings Rai B

44 Rai B . 2017 Fellowship of Aeronautic DentistryFellowship of Aeronautic Dentistry: 60 hours Certification in Aeronautic Dentistry:20 hours Rai B

45 News

46 News

47 Conclusion Dental emergencies are real medical emergencies space dentist-screen and select-astronauts with optimal oral health prior-dental emergency kits Dentists-gain awareness about space dentistry Education-Fellowship in Aeronautical and Space Dentistry by Our organization-Fee 2000 USD Rai B.2017

48 Thanks