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Review Article

Barodontalgia: More light on less known

Yogita Khalekar, Amit Zope1, Lalit Chaudhari, Ujawal Brahmankar

Departments of Oral Medicine and Radiology and 1Orthodontics and Dentofacial Orthopaedics, ACPM Dental College, Dhule, Maharashtra, India

ABSTRACT
Changes in ambient pressure occur during flying, diving, or hyperbaric oxygen therapy and
can cause different types of pathophysiological conditions and pain including a toothache
known as barodontalgia. Barodontalgia is a symptom that reflects a flare up of pre existing
sub clinical oral disease. Deep sea divers, aircrew members, and passengers are at
increased risk of experiencing barodontalgia due to exposure to increased air pressure.
The key to avoid barodontalgia is good oral health. Hence, it is important for dentists
to understand the etiology and features of barodontalgia to prevent it. Clinicians must
pay close attention to areas of dentin exposure, caries, fractured cusps, the integrity of
restorations, and periapical pathology in those at‑risk. This article reviews the literature
regarding barodontalgia, its etiology, features, prevention, and focuses on those untouched
aspects of barodontalgia which are to be paid attention.

Key words: Barodontalgia, diving, etiology, toothache

INTRODUCTION ETIOLOGY AND PATHOGENESIS

The term “aerodontalgia” was first coined during the
era of World War II. It was the tooth pain experienced
by air crew during flight. However, as this tooth‑related
pain was also observed in divers, a more appropriate term,
barodontalgia was subsequently given to this phenomenon.[1]
The phenomenon can be explained on the basis of Boyle’s
Law which states that “at a given temperature, the volume
of gas is inversely proportional to the ambient pressure.”[2]
Barodontalgia is also defined as an oral (dental or nondental)
pain caused by a change in barometric pressure in an
otherwise asymptomatic organ.[3]
Address for correspondence:
Dr. Yogita Khalekar,
Department of Oral Medicine and Radiology,
ACPM Dental College, Dhule, Maharashtra, India.
E‑mail: yogitakhalekar3@gmail.com
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In most cases, barodontalgia reflects as a flare up of
pre existing oral disease; hence, most common oral
pathologies have been reported as possible sources of
barodontalgia. The common etiologic pathologies for pain
were faulty dental restorations and dental caries without
pulp involvement (29.2%), necrotic pulp/periapical
inflammation (27.8%), vital pulp pathology (13.9%), and recent
dental treatment (“postoperative barodontalgia;”11.1%).
Barosinusitis was the main cause of pain origin in 9.7% of
cases.[4] Kallman proposed three hypothesis for barodontalgia
first, expansion of trapped air bubbles under a root filling
or against dentin that activates nociceptors; second,
stimulation of nociceptors in the maxillary sinuses, with
pain referred to the teeth; and third, stimulation of nerve
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DOI: How to cite this article: Khalekar Y, Zope A, Chaudhari L,

10.4103/0976-433X.188811 Brahmankar U. Barodontalgia: More light on less known. SRM J Res
Dent Sci 2016;7:158-61.

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Khalekar, et al.: Barodontalgia: More light on less known
endings in a chronically inflamed pulp.[5] Among these, the
last two hypotheses were strongly supported with histological
evidence.
BARODONTALGIA IN PILOTS
At high altitudes, during air travel, the outside pressure
decreases, the volume of the gases increases. This creates a
problem in tooth chambers and canals since the gases cannot
expand or contract in a manner needed to adjust the internal
pressure to match the external pressure.[6] During flying,
barodontalgia has been reported to occur across a broad range
of altitudes, having been reported at altitudes as low as 5000
feet and as high as 35,000 feet but is more common between
9000 and 27,000 feet[1] when pain is caused by periapical
disease, it has been reported to the last as long as 3 days.[7]
BARODONTALGIA IN DIVERS
In the present world, self‑contained underwater breathing
apparatus (SCUBA) diving is one of the popular sports. Thus,
it is important for dentists to be aware of dental‑related
problems that may arise for SCUBA divers. Pain has been
reported to appear at depths ranging from 33 feet to 80 feet.
Pain due to barodontalgia in diving conditions affects more
commonly the upper teeth than lower teeth,[8] and the
vast majority of episodes appeared on descent.[9] The pain
experienced is according to the diver’s depth, and usually
improves when the diver ascends, thereby relieving the
pressure. As the diver descends, air is forced into the pulp
due to the increased pressure of the inspired air. Compressed
air reaches the dentinal tubules or the pulp through primary
caries, recurrent caries along the margins of restorations, or
leaking restorations.[10]
The second type of barodontalgia is referred to as barotrauma
of ascent and is caused by compressed air that has been
trapped in an enclosed space and then expands as the diver
ascends. This kind of injury is seen in teeth with incomplete
root canal treatments or neglected restorations.[11] During
descent, compressed air slowly enters these teeth due to a
poor physical seal between the tooth and restoration, but
cannot escape quickly enough during ascent.[12] As the
diver’s depth decreases, there is pressure build‑up within
the tooth due to the expansion of the trapped air, leading
to severe pain, and sometimes even fracture. Displacement
of the intracanal medicaments through the root apex has
been reported.[13] In severe cases, the pressure build‑up
in the tooth may lead to an explosion of the tooth called
odontecrexis.[14]
CLASSIFICATION
Widely accepted the classification of barodontalgia was
given by Ferjentsik and Aker in 1982 and is primarily based
on the underlying causes and clinical symptoms [Table 1].[15]
SRM Journal of Research in Dental Sciences | Vol. 7 | Issue 3 | July-September 2016
Table 1: Classification of barodontalgia
Class Cause Symptoms
I Irreversible pulpitis Sharp pain on ascent
II Reversible pulpitis Dull pain on ascent
III Necrotic pulp Dull pain on descent
IV Periapical pathology Severe persistent pain
on ascent or descent
Barodontalgia is a symptom rather than a disease according
to various authors it could have direct or indirect etiology.
Table 2 compares the pulp‑related (“direct”) barodontalgia and
barotitis/barosinusitis‑induced (“indirect”) barodontalgia.[3]
MANAGEMENT AND PREVENTION
The Fédération dentaire internationale (FDI) has divided
barodontalgia into four groups from moderate to severe and
has listed out a description of clinical symptom, findings,
and therapy [Table 3].[16]
FDI also recommends that annual check‑ups be done for
divers, submariners, and pilots, with oral hygiene instructions
from dentists. After a dental treatment requiring anesthetic
or 7 days following a surgical treatment, patients should be
instructed not to dive or fly in nonpressurized cabins for
the next 24 h.[16]
Dental surgeons should consider cementing fixed prosthesis
with resin cements for patients who are exposed to marked
variations in environmental pressure, such as divers and
submariners during escape drills. Endodontically treated teeth
that have been open for endodontic treatment and temporarily
sealed have been report to be explode on deep sea diving known
as odontocrexis, full porcelain crowns have been reported to
shatter at a dive of 65 ft; hence, meticulous oral health advice
should be given to the divers, all carious lesions should be
restored, all ill‑fitting crowns should be replaced with a good
cementing medium, active periodontal lesion treatment and
completion of endodontic treatment should be done. It is
sometimes recommended that if we are unable to complete the
treatment before deep sea diving or flight, extraction may be
the treatment of choice. Furthermore, removable dentures are
not recommended rather an FPD or an implant is indicated.[17]
Summary of dental care to prevent barodontalgia is explained
in Table 4.[3]
CONCLUSION
According to the literature, barodontalgia is a rare
phenomenon as the incidence of barodontalgia may be
underestimated. Although rare, barodontalgia can cause
serious risk to SCUBA divers, submariners, air crew, and
passengers. This article described these conditions and
provided the dentists with some useful tools and guidelines.
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Khalekar, et al.: Barodontalgia: More light on less known

Table 2: Difference between direct and indirect barodontalgia

Direct barodontalgia owing to pulp disease Indirect barodontalgia
with or without periapical involvement
Cause Pulp and periapical disease Barosinusitis, barotitis media
Appearance Pulpitis: During takeoff/ascent. Pain usually appears during During landing. Pain usually continues on ground
landing at the appearance‑level
Periapical periodontitis: Usually at high altitude
(38,000 ft) during ascent or landing
Symptoms Irreversible pulpitis: Sudden sharp penetrating pain Toothache in upper premolar/molar region
Reversible pulpitis or necrotic pulp: Beating dull pain
Periapical periodontitis: Continuous strong pain, swelling
History Recent dental treatment. Recent dental sensitivity Present acute upper respiratory infection
(e.g., to cold drinks, percussion/eating) Past sinusitis
Clinical findings Extensive caries lesions or (faulty) restoration. Acute pain Pain on sinus palpation
on cold or percussion test Pain upon a sharp change in the head position
Radiological findings Pulpal caries lesions and/or restoration close to pulphorn. Opacity (fluid) on the maxillary sinus image
Peri‑apical radiolucency. Inadequate endodontic obturation

Table 3: Fédération dentaire internationale classification of barodontalgia

Chief complaint
I Sharp momentary pain during
ascent (decompression)
Asymptomatic on descent
(compression) and afterward
II Dull throbbing pain during
ascent (decompression)
Asymptomatic on descent
(compression) and afterward
III Dull throbbing pain during
descent (compression)
Asymptomatic on ascent
(decompression) and afterward
IV Severe persistent pain after
ascent (decompression) or
descent (ascent)
Clinical findings
Caries or restoration with
inadequate base
Tooth is vital
No periapical pathosis
Deep caries or restoration
Tooth is vital/nonvital
No periapical pathosis
Caries or restoration
Tooth is nonvital
Periapical pathosis is
present
Caries or restoration
Tooth is nonvital
Definite Periapical
pathosis is present
Diagnosis Treatment
Acute pulpitis Zinc oxide eugenol temporary
followed by a well‑based permanent
restoration after 2 weeks
Endodontic therapy, if irreversible
Chronic pulpitis Root canal therapy or extraction of
unrestorable tooth
Necrotic pulp Root canal therapy or extraction of
unrestorable tooth
Periapical Root canal therapy and/or surgery
abscess or cyst or extraction of unrestorable tooth

Table 4: Summary of dental care to prevent needed for further augmentation of speculative as well as
barodontalgia hands‑on knowledge of barodontalgia.
Discipline Principle
Prevention Balanced diet with regular meals, avoidance Financial support and sponsorship
of high‑energy snacks
Nil.
Timely oral self‑care
Periodic Vitality test to extensively restored teeth
examination Special attention to defective restorations, Conflicts of interest
restorations with poor retention, and There are no conflicts of interest.
secondary caries lesions
Rule out bruxism
Panoramic radiograph REFERENCES
Restorative Removal of all carious tissue and placement
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