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Prevalence of Barodontalgia among pilots and

divers in Saudi Arabia and Kuwait
Wadha Al-Hajri,* BDS
Ebtissam Al-Madi,** BDS, MSc

Barodontalgia is defined as tooth pain occurring with changes in pressure environment. It commonly affects pilots and
divers, as they are frequently subjected to barometric pressure changes during their work. AIM: To measure the prevalence
of barodontalgia among pilots flying non-commercial war planes and divers practicing in air bases, naval bases and diving
schools in Saudi Arabia and Kuwait. MATERIAL AND METHODS: Three-hundred and fifty questionnaires consisting of
demographic data and questions about the occurrence of tooth pain during flying or diving were distributed among pilots
and divers. RESULTS: There was a response rate of 72.8% in Saudi Arabia and 80% in Kuwait. Almost thirty-four percent
of the sample experienced barodontalgia at one point in time during their practice. More pilots had an occurrence of pain
while flying (49.6%) than did divers while diving (17.3%). Pilots had higher incidence of pain while ascending (30.4%) than
descending (19.3%), while divers had higher incidence of pain while diving (13.9%) than resurfacing to sea level (3.6%).
The highest percentage of tooth pain occurred in pilots while flying at an altitude that ranged from 11,000 - 20,000 ft (3300
- 6000 m) and with divers while diving with a depth that ranged from 60 - 80 ft (18 – 24 m). Recurrence of tooth pain
after treatment occurred in 16.4% of pilots and 25.0% of divers during their practice. CONCLUSIONS: Barodontalgia is
common in Saudi Arabia and Kuwait with a prevalence rate as high as 33.6%. Pilots reported high occurrence than divers.
It was common on ascent while flying and descent while diving. Recurrence of pain after treatment was not frequent.

INTRODUCTION decrease in barometric pressure.4,5

Barodontalgia is essentially dental pain
Subjects exposed to a sudden reduction provoked by atmospheric pressure
or increase of ambient pressure sometimes changes which usually disappear when
complain of toothaches.1 This problem the affected person reaches normal
was first reported in pilots and was called pressure zone again.6
aerodontalgia.2 More recently, dental pain During the 1940s, large numbers of
has also been reported during diving3 and military pilots were subjected to major
the more general term barodontalgia was barometric changes in unpressurized
introduced to include both conditions, air craft. In some cases the variations
whether produced by an increase or in atmospheric pressure experienced
Received 3 October 2005; Revised 21 May 2006 in flight caused severe dental pain.
Accepted 12 June 2006 Incapacitation due to this pain was a
College of Dentistry, King Saud University
serious problem and stimulated research
P.O.Box 495, Dhahran Airport 31932, KSA into barodontalgia.7 The incidence of barodontalgia in
**Assistant Professor aircrew has been reported to vary from
Department of Restorative Dental Sciences
College of Dentistry, King Saud University
0.26% to 8%.1,2,6,8,9 The US Army air force reported a 1.63% prevalence of

Saudi Dental Journal, Volume 18, No. 3, September - December 2006


barodontalgia among 12,000 subjects history and examination should be

undergoing decompression tests performed. A hypobaric chamber is an
after World War II,10 while Harvey, in ideal environment that may be used for
1947, identified only 0.8% incidence reproducing the conditions of barometric
of toothaches in a sample of 5,711 pressure and hypoxia that flight personnel
persons taking decompression tests.9 have to withstand at different altitudes,
Barodontalgia has been known to occur and their effects.14 If dental examination
across a broad range of altitudes during fails to identify the problem then an
flying, having been reported at altitudes examination by a physician would be
as low as 5000 feet and as high as 35000 appropriate to examine the sinuses or
feet but is more common between 9000 even to evaluate the potential that the
and 27000 feet.6 Barodontalgia is more pain was referred from the heart.13
common on ascent,6 and it was shown Treatment of barodontalgia is similar
that the onset of pain occurred at to therapy rendered for pain of dental
altitudes ranging from 5,000 to 15,000 origin at ground level. Prevention of
ft.4 Barodontalgia is not limited to any barodontalgia is based on maintenance
particular age group.6 of higher standards in preventive and
The causes of barodontalgia have been restorative dentistry.6
investigated for many years. In general, No information regarding barodontalgia
barodontalgia is a condition intimately in the Gulf region have been reported to
related to pre-existing dental pathology.6 date. The aim of the present study was to
Several factors have been speculated to measure the prevelance of barodontalgia
make teeth susceptible to barodontalgia among pilots and divers in selected bases
such as inability of gases within the tooth and centers in Saudi Arabia and Kuwait.
to expand to adjust internal pressure
when exposed to external pressures by MATERIAL AND METHODS
diving or flying,11 circulatory disturbances
in an abnormal pulp,7 nearness of caries The study population consisted of
to the pulpal tissue,4 dilation of pulpal pilots and divers working in selected
vessels during decreases in pressure, and centers in Saudi Arabia and Kuwait. The
pulpal hyperemia.4 Precipitating factors group of pilots targeted were those flying
that contribute to barodontalgia include non-commercial war planes, practicing
inadequately filled root canals, chronic in King AbdulAziz Air Base (KAAB) in
pulpitis resulting from insufficient Dhahran, King Khaled Air Base (KKAB)
base materials, untreated caries, and in Khamis Mishaet, Saudi Arabia and
periapical abscesses in which gas had Hammad Al-Jabir Air Base in Kuwait. The
been generated.4 Referred pain from divers targeted in this study were those
unerupted or partially erupted third practicing in King Abdulaziz Naval Base
molars, new and recurrent caries or (KANB) in Jubail and the Al-Sharq Diving
restorations, intra-treatment endodontic School in Al-Khobar, Saudi Arabia and
symptoms, dental and periodontal cysts, the Kuwait Diving School in Kuwait.
abscesses or “cracked tooth” and from A questionnaire was developed in
aerotitis media may complicate the English and Arabic and distributed
diagnosis of barodontalgia.12 among all pilots and divers present during
The diagnosis of barodontalgia should the research period between November
be considered if a patient complains of 2004 to April 2005. The survey contained
dental pain during diving or flying.13 inquiries about age, type of practice (pilot
A complete and thorough dental or diver or both) and years of experience.

Saudi Dental Journal, Volume 18, No. 3, September - December 2006


Questions about the occurrence of Table 1. Distribution pilots and divers

tooth pain during flight or diving were Number of
pilots and
presented as well as inquiries regarding Place of employment
divers included
Percent %
whether the pain was during ascending or in study
descending (pilots), diving or resurfacing K.A.A.B * & K.K.A.B** 101 38.4%
to sea level (divers), the altitude or depth K.A.N.B*** 13 5.0%
at which the pain occurred, whether they Diving School in Al-Khobar 68 26.0%
had visited a dentist to treat the pain or Hammad Al-Jabir Air Base
34 13.0%
not, what the dentist diagnosed the pain in Kuwait
as, what kind of treatment was rendered Diving School in Kuwait 46 17.6%
at the dental office, and if they had any Total 262 100%
recurrence of the pain after treatment. *King Abdulaziz Air Base in Dhahran, Eastern Province,
The questionnaire was designed in Saudi Arabia
**King Khaled Air Base in Khamis Moshaet, Southern
Arabic and a pre-test questionnaire was Province, Saudi Arabia
done on 20 subjects. A translation of the ***King Abdulaziz Naval Base in Jubail, Eastern Province,
questionnaire was devised to be presented Saudi Arabia
to non-arabic speaking divers.
A total of 350 questionnaires each This study showed that 33.6 % of the
were distributed, with 50 questionnaires sample had incidence of barodontalgia
to KAAB, KKAB, KANB, and Hammad at least at one point in time during their
Al-Jabir Air Base and the Kuwait Diving activities. Significantly more pilots had
School in Kuwait, and 100 questionnaires an occurrence of pain while flying (49.6%)
to Al-Sharq Diving School in Al-Khobar. than did divers while diving (17.3%)
The collected data were analyzed using (P<0.0001). For individuals that were
the Statistical Package for Social Science both pilots and dived (10) as a hobby, the
(SPSS) program version 10. Descriptive prevalence rose to 40.0 %.
statistics were performed and Chi- Most of the participants (21.4%)
square test was used to determine the indicated that they had experienced
relationship of pain among pilots and pain while flying and diving several years
divers. previously, while 7.3% indicated that they
had pain one year previously and only 5%
RESULTS indicated they felt pain while flying and
diving several months previously.
Two hundred and sixty-two subjects Pilots had a higher incidence of pain
responded from both Saudi Arabia and while ascending (31.2%) than descending
Kuwait. The response rate was 72.8% (19.2%), while divers had a higher
(182) in Saudi Arabia and 80% (80) in incidence of pain while diving (13.4%)
Kuwait. The distribution of pilots and than when resurfacing to sea level
divers is shown in Table 1. The age of the (3.9%).
pilots and divers ranged between 25 and The highest percentage of tooth pain
36 years with the mean age of 33 years. with pilots was while flying with an
About 42.9% of the respondents were altitude that ranged from 11.000 - 20.000
under thirty years of age. Distribution ft (33000 – 6000 m) and with divers while
regarding years of experience showed that diving at a depth that ranged from 60 - 80
39.3% had 7-12 years of experience, while ft (18 – 24 m) as illustrated in Table 2.
36.3% had only 1-6 years of practice, A total of 81.8% of pilots and divers
and 24.2% had more than 13 years of visited their dentists after they had tooth
practice. pain. The diagnosis that was rendered by

Saudi Dental Journal, Volume 18, No. 3, September - December 2006


Table 2. The incidence of occurrence of barodontalgia 25

versus altitude and depth
No. of No of
% Depth
% 20.2
Below 10,000 ft 60-80 ft
25 18.5% 95 74.8%
(3000 m) (18-24 m)
11,000-20,000 ft 81-100 ft
44 32.5% 16 12.6%
(3300-6000 m) (24-30 m) 15
21,000-30,000 ft 101-120 ft
37 27.4% 5 3.9%
(6300-9000 m) (30-36 m)
31,000-40,000 ft 121-130 ft
29 21.5% 11 8.6% 10
(9300-12000 m) (36-39 m)
Total 135 100% Total 127 100%
their dentists is shown in Figure 1. The
types of treatment provided are shown 2.3 2.3
in Figure 2. Restorative treatment was
provided significantly more than any 0
Restoration R.C.T. Extraction Other
other treatment (P<0.0001), as was root Dental Treatment
canal therapy (P=0.007). Recurrence Fig. 2. Percentage of dental treatment rendered (does not
of tooth pain after treatment occurred add up to 100% as not all subjects had treatment or they
in 16.4% in pilots and 25.0% in divers may have had more than one treatment).
during their practice.
80 73.6
This study was conducted to measure
the incidence of barodontalgia among
60 pilots and divers in Saudi Arabia and
Kuwait. The study design depended on
questionnaires distributed to the target

population inquiring about incidence,
nature of the incident and the treatment
rendered, as this was a pioneer study in
this field in the area, and preliminary
data was required about the incidence of
15.3 this phenomenon before more elaborate
2.8 2.8
studies can be designed.
0 The data showed that there was a high



incidence of barodontalgia (49.6%) among



pilots. This rate was higher than that

ry a


reported by Surgeon General Australian



Defence Force, Health Policy Directive


No. 411 (SGADF-HPD411),6 Hodges4 and


Gonzalez-Santiago et al.14 This difference


in rate may be related to difference in


study design and different societies.

Diagnosis of Barodontalgia Although all flight personnel are initially
Fig. 1. The percentage of the various etiological factors
examined and treated dentally before
of barodontalgia flying, poor oral hygiene, maintenance

Saudi Dental Journal, Volume 18, No. 3, September - December 2006


and recall may be factors that significantly Most of the pilots and divers included
increased prevalence of barodontalgia in our study had restorative treatment
during subsequent flights. An in-depth done after reporting to the dental office.
investigation of the factors leading to It may be that their complaint was
the high significance of barodontalgia is an obvious one that could have been
required. apparent on ground level and not present
a diagnostic difficulty. If this were the
There was no correlation between
case, proper diagnosis and treatment
either the age of the pilots or divers and
could have prevented the problem in the
their age. Similar results were reported by first place.
SGADF-HPD411.6 In this study, recurrence of pain after
Higher prevalence of barodontalgia treatment was reported by a relatively
was reported among pilots (49.6%) than smaller groups of pilots and divers at
among divers (17.3%). This could be due 16.4% and 25% respectively, which
to higher pressure changes that pilots indicated that proper diagnosis was
are exposed to during flying than divers done. For the cases in which there was
are during diving. The prevalence among recurrence, the causes might be non-
pilots was more common with an altitude odontogenic pain or another offending
that ranged from 11,000 - 20,000 feet. tooth than was treated. Many cases of
Similar results were reported by Kollman,1 recurrence need further invesitigations
Hodges,4 and the SGADF-HPD411.6 that may involve leaking restorations and
Not surprisingly, the prevalence among periapical pathology which were beyond
pilots was common on ascent in the the scope of our study.
study. Similar finding had been reported In this study, no clinical examination
in SGADF-HPD411.6 Furthermore, it had was conducted. Correlation of the
been suggested that pain on ascent was information obtained from the
associated with an inflamed tooth, while questionnaires with clinical findings
pain on descent was associated with a obtained from examination could provide
necrotic tooth.15 This seemed logical in more specific results in term of incidence
this population as they had undoubtadely and causes of barodontalgia.
been dentally examined at some point Our sample was a convenient one
targeting pilots flying non-commercial
before flying and it was unlikely that
war planes. No attempt was made to
dental decay could progress to lead to
specify the type of planes as this was
necrosis in a short period of time.
considered classified information and
The pain was mostly diagnosed as
this could limit any attempt to generalize
tooth pain (73.6%). This is in contrast to
pilots flying different kind of war planes.
Kollman, who found the most common Also all types of divers were considered in
pain was earache (2.27%) followed by pain this study, and no attempt was made to
from teeth and from the paranasal sinuses specify which kind of diving equipment
at 0.26% and 0.18%, respectively.1 This was used. The safety of aircrew and
difference could be attributed to the fact diving personnel can be comprised by
that many centers internationally have barodontalgia as the intensity of pain is
flight surgeons as the primary health often such that effective performance is
personnel performing the diagnosis, not possible.6 Distractions during critical
whereas in this study all pilots and divers flights or dives, or abortion of important
reported to a dentist who was expected to missions can occur as a result of pain
be more adept at diagnosing dental pain. during a flight or dive.

Saudi Dental Journal, Volume 18, No. 3, September - December 2006


CONCLUSION given to (Retired) Major Birjes Al-Otabi

from K.A.A.B in Dhahran, Dr. Abdullah
Prevalence of barodontalgia was higher Al-Hajri, the former Minister of Kuwait
(33.6%) in Saudi Arabia and Kuwait. Pilots and General Yossef Al-Dhwayan, the
reported higher incidence than divers. It Kuwait Air Force Commander, for their
was common on ascent while flying and great cooperation in facilitating the
descent while diving. Recurrence of pain questionnaires distribution among the
after treatment was uncommon. pilots and divers.

The prevalence of barodontalgia was 1. Kollmann W. Incidence and possible
higher in Saudi Arabia and Kuwait when causes of dental pain during simulated
compared to reports from other countries. high altitude flight. J Endod 1993; 19(3):
It is a phenomenon that should not be 154-159.
dismissed as unimportant, as it can pose a 2. DeVoe K, Motley HL. Aerodontalgia. Dent
serious safety risk to divers, submariners, Dig 1945; 51:16-18.
pilots and airline passengers.11 Federation 3. Shiller WR. Aerodontalgia under
Dentaire International (FDI) recommends hyperbaric conditions. An analysis of
an annual check-up for divers, forty-five case histories. Oral Surg Oral
submariners and pilots, with oral hygiene Med Oral Pathol 1965; 20:694-697.
4. Hodges FR. Barodontalgia at 12,000 feet. J
instructions from dentists familiar with
Am Dent Assoc 1978; 97(1):66-68.
their dental requirements.11 It is therefore
5. Rauch JW. Barodontalgia - Dental pain
recommended that dental services in
related to ambient pressure change. Gen
clinics servicing pilots and divers (air and
Dent 1985;313-315.
naval bases) in Saudi Arabia and Kuwait 6. Surgeon General Australian Defense
should be organized to provide regular Force (SGADF) Health Policy Directive
check-ups, treatment and oral hygiene No 411. Aviation and Diving - Dental
education for this population. Also, based Considerations. 20 April 1995. p.
on the results of this study and within its 5 (electronic version) retrieved Sept 10th
limitations, it is recommended that more 2005 from
studies specific to air flight and diving dpe/dhs/infocentre/publications/
centres be performed to realize the full directives/HPD411.pdf
extent of the problem, the factors affecting 7. Senia E.S, Cunningham KW, Marx RE.
the incidence, preventive measures in the The diagnosis dilemma of barodontalgia.
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and divers to the importance of therapy Oral Pathol 1985; 60(2):212-217.
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J Am Dent Assoc 1945; 32:145-180.
ACKNOWLEDGMENTS 9. Harvey W. Dental pain while flying or
during decompression tests. Br Dent J
1947; 82:113.
The authors would like to express their
10. Bureau of Medicine and Surgery News
thanks to all those who participated in
Letter, Vol 6, No. 1, 1946.
this study and their families for their help
11. Robichaud R, McNally ME. Barodontalgia
and support, and to Dr. Nazeer Khan for as a differential diagnosis: Symptoms and
his assistance in the statistical analysis. findings. J Can Dent Assoc 2005; 71(1):
Sincere thanks and appreciation is 39-42.

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12. The Online Journal of Dentistry and Oral 15. O’Brien DM. (ed) Flight Surgeon’s
Medicine. Guide. 1995 ed. In: Ch.12 Aerospace
vol04n04.htm Dentistry- Odontalgia- Barodontalgia.
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14. Gonzalez-Santiago MM, Martinez-
Sahuquillo-Marquez A, Bullon-Fernandez html/Chapter_12.html#Odontalgia
P. Incidence of barodontalgias and their
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flight. Med Oral 2004; 9:92-105.

Saudi Dental Journal, Volume 18, No. 3, September - December 2006