Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2011; 56: 265–271
REVIEW
doi: 10.1111/j.1834-7819.2011.01340.x

Diving dentistry: a review of the dental implications of scuba

diving
Y Zadik,* S Drucker
*Department of Oral Medicine, Hebrew University–Hadassah School of Dental Medicine, Jerusalem, Israel and Medical Corps, Israel Defense
Forces, Jerusalem, Israel.
School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

ABSTRACT
In light of the overwhelming popularity of self-contained underwater breathing apparatus (SCUBA) diving, general dental
practitioners should be prepared to address complications arising as a result of diving and to provide patients with accurate
information. The aim of this article was to introduce the concepts of diving medicine and dentistry to the dentist, and to
supply the dental practitioner with some diagnostic tools as well as treatment guidelines. The literature was reviewed to
address diving barotrauma (pressure-induced injury related to an air space) to the head, face and oral regions, as well as
scuba mouthpiece-related oral conditions. The relevant conditions for dentists who treat divers include diving-associated
headache (migraine, tension-type headache), barosinusitis and barotitis-media (sinus and middle ear barotrauma,
respectively), neuropathy, trigeminal (CN V) or facial (CN VII) nerve baroparesis (pressure-induced palsy), dental
barotrauma (barometric-related tooth injury), barodontalgia (barometric-related dental pain), mouthpiece-associated
herpes infection, pharyngeal gag reflex and temporomandibular joint disorder (dysfunction). For each condition, a
theoretical description is followed by practical recommendations for the dental practitioner for the prevention and
management of the condition.
Keywords: Barodontalgia, barotrauma, tooth injury, neuropathy, military medicine, military dentistry.
Abbreviations and acronyms: CN = cranial nerve; DCS = decompression sickness; SCUBA = self-contained underwater breathing
apparatus; TMD = temporomandibular disorder; TMJ = temporomandibular joint.
(Accepted for publication 17 November 2010.)

INTRODUCTION Head and face barotrauma

Since the advent of self-contained underwater breathing
apparatus (SCUBA) in the middle of the 20th century,
many of the known in-flight oral phenomena caused by
atmospheric pressure changes have been described in
association with diving as well.
Owing to the overwhelming popularity of scuba
diving, general dental practitioners should be prepared
to address complications arising as a result of diving
and to provide patients with accurate information,
much of which currently comes from Australia and
New Zealand. However, due to a paucity of data from
diving related conditions, many conventions of baro-
metric effects on oral tissues are derived from in-flight
observations, mostly in the military setting.1 The aim of
this article was to introduce the concepts of diving
medicine and dentistry to the dentist, and to supply the
dental practitioner with some diagnostic tools as well as
treatment guidelines.
ª 2011 Australian Dental Association
According to Boyle’s Law, the volume of gas at
constant temperature varies inversely with the sur-
rounding pressure. The changes in gas volume inside
the body’s rigid cavities, associated with the changing
atmospheric pressure, can cause several adverse effects,
which are referred to as barotrauma.2 Barotrauma can
occur during diving, flying, or hyperbaric oxygen
therapy.
Head and face barotrauma include the entities of
barotitis, barosinusitis, barotrauma-related headache,
dental barotrauma and barodontalgia. The first three
entities are briefly discussed here (with reference to
other texts),1,3 and the latter two will be discussed
extensively.
Barotitis-media (also known as middle ear barotrau-
ma and ear squeeze) is an acute or chronic traumatic
inflammation in the middle ear space produced by a
pressure differential between the air in the tympanic
265

Y Zadik and S Drucker
cavity and that of the surrounding atmosphere.4 The
symptoms of barotitis-media range from ear discomfort
to intense earache, tinnitus, vertigo with nausea, and
hearing loss.2 Upper respiratory tract infection may
impair the equalizing function of the Eustachian tube,
thus predisposing the individual to barotrauma, and
may be a (temporary) contraindication for diving.4
A potential complication is facial palsy secondary to
middle ear barotrauma (also called facial baroparesis),
caused when elevated pressure from the middle ear is
transmitted to the facial canal via dehiscence within its
course along the medial wall of the middle ear or via the
fenestra of the chorda tympani, resulting in ischaemic
neurapraxia of the facial nerve. This phenomenon
usually occurs only on a single episode, even in those
who have been recurrently exposed to similar baromet-
ric conditions.5 The condition is unilateral, occurring
during or soon after diving ascent, with the possible
involvement of facial expression muscles and taste
sensation from the anterior tongue. Spontaneous reso-
lution usually occurs within a short time (minutes to
hours), as blood flow rapidly resumes when pressure in
the middle ear becomes less than capillary closing
pressure.6
Several reports have claimed that a relationship exists
between dental malocclusion and Eustachian tube
dysfunction.7 A dental splint was offered as a
preventive and ⁄ or therapeutic measure for barotitis-
media.8,9 Currently, barotitis-media is usually not
considered an indication for a dental splint.
Barosinusitis (also known as sinus barotrauma and
sinus squeeze) is an acute or chronic inflammation of
one or more of the paranasal sinuses, produced by
the development of a pressure difference (usually
negative) between the air in the sinus cavity and that
of the surrounding atmosphere.4 The pressure gradi-
ent created results in a vacuum, which may cause
mucosal oedema, serosanguinous exudate and sub-
mucosal haematoma. These ailments may conse-
quently cause pain, sometimes abrupt and severe,
and possibly epistaxis. Palsy may occur as a result of
ischaemic neurapraxia of branches of the trigeminal
nerve in the maxillary sinus. The incidence of
barosinusitis during diving descent is about double
that during ascent.
Barotrauma-related headache of 15–20 minute
duration was reported during ascending and descend-
ing.10 In an Israeli study, Potasman et al.11 reported
flight-associated headaches in 5.7% of air-travellers,
rated as 6 on a 1-to-10 severity scale (with 10 the
most severe pain). Distribution between unilateral and
bilateral headache was almost equal, and about one-
fifth of these headaches were diagnosed as migraine.
Indeed, weather (e.g. rain, high humidity, bright
sunshine) and barometric changes (e.g. on-ground
low barometer reading and falling barometer) are
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often considered as major headache triggers by
migraineur patients.12
Dental implications
Barometric-induced otitis-media, sinusitis or headache
can be manifested as pain to the oral region (indirect
barodontalgia).13 Thus, they should appear in the
differential diagnosis of dental pain that is evoked during
diving. Since otalgia while diving is the most common
complaint of scuba divers and almost every diver suffers
from it,14 the dental practitioner must rule out an
extraoral origin when diagnosing oral pain. This must
be taken into consideration especially in higher risk
patients (e.g. recent upper respiratory infection or
corrected cleft palate with Eustachian tube dysfunction).
Moreover, other diving-associated headache conditions
must be ruled out. These include tension-type headache
due to muscle strain and rigidity, and a manifestation of
carbon dioxide toxicity, which is a common diving
related condition caused by hypoventilation (e.g. infre-
quent and shallow breaths).15 Headache may also be a
manifestation of decompression sickness (DCS), in
which rapid ascent with rapid decompression allows
the discharge of dissolved nitrogen and the creation of
gas bubbles with potentially severe consequences in
various body organs (e.g. joint pain, skin rash, itching,
dizziness, nausea, vomiting, tinnitus and fatigue).15,16
In non self-resolving cases of facial baroparesis, the
clinician should rule out DCS, and then treat by steroid
administration. However, despite the common wisdom
among diving medicine practitioners ‘when in doubt –
recompress’, treatment for DCS by recompression ⁄
hyperbaric chamber while there is Eustachian tube
dysfunction (which is the true causative for the baropa-
resis) may worsen symptoms.
Dental barotrauma
Dental barotrauma can manifest as tooth fracture,
restoration fracture (both will be referred as dental
fracture), and reduced retention of dental restoration.
Other than need for dental treatment, potential conse-
quences include aspiration or swallowing of the dis-
lodged restoration or dental fragment,17 and pain,
which may lead to incapacitation while diving and
premature discontinuation of the planned dive.3
The term barodontocrexis (barometric-induced
‘tooth explosion’, Greek) describes the phenomenon
of dental fracture.3,18 Most of the reports regarding
dental fractures under barometric changes considered
in-flight conditions and were published several
decades ago.3 Dental barotrauma occurs while
ascending; upon surfacing after completing the dive,
the diver may report that a tooth broke or has
shattered.19 Dental barotrauma can appear with or
ª 2011 Australian Dental Association

without pain20 similar to dental fracture occurring at
ground level.
In a 10-year longitudinal study that was conducted in
the German navy, there was a four-fold increase in
missing teeth and a 10-fold increase in crown placement
among navy divers, who were constantly exposed to
barometric changes (200–300 annual hours of under-
water diving), in comparison to an almost three-fold
increase in missing teeth and a five-fold increase in
crown placement among submariners who usually
served under normal pressure conditions.21 These
authors concluded that increased exposure to baromet-
ric stress was associated with elevated dental deterio-
ration.22 In a recent survey among 125 Australian
divers, Jagger et al.23 reported one diver who experi-
enced tooth shattering and two divers who experienced
restoration displacement during diving. The authors
concluded that dental barotrauma was uncommon and
was reported by less than 1% of the divers.23 However,
since no data of time length of participants’ diving
experience was reported, no further conclusions can
be made from these results.
Calder and Ramsey18 reported on an in vitro
decompression study on extracted teeth. They applied
a pressure drop of 1035 kPa (approximating a com-
mon diving pressure) to ground atmosphere pressure
within two minutes on 86 extracted teeth. Five of the
teeth studied were damaged. All the damaged teeth
had either poor-quality amalgam restorations with
undesired clearance between the tooth and the amal-
gam or secondary caries under the restoration. The 81
non-damaged teeth included unrestored teeth with
carious lesions. The authors concluded that the main
predisposing factor for tooth fracture was leaking
restoration rather than caries.
The predisposing factors that appeared repeatedly in
dental barotrauma reports were pre-existing leaked
restoration and ⁄ or occult remaining ⁄ recurrent caries
lesions underneath restoration in the affected tooth
prior to exposure to the barometric changes. Although
the destructive potential of arrested or remaining
carious lesions in daily life is minimal, it seems that
these lesions may not be as innocent in a pressure-
changed environment. Nevertheless, recently Gunepin
et al. reported a unique case of fracture of previously
intact molar during flight.24
Pressure changes in micro air bubbles in the cement
layer underneath crowns can lead to a significant
reduction of the prosthetic device’s retention and even
to dislodgement, especially if the crown was cemented
with zinc phosphate cement.25,26 Lyons et al. studied
the effect of cycling environmental pressure changes
(up to 3 atm) on the retention of crowns to extracted
teeth. The crowns that were cemented with either zinc
phosphate cement or glass-ionomer cement had signif-
icantly reduced retention (in approximately 90% and
ª 2011 Australian Dental Association
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Dental implications of scuba diving
50% of cases, respectively), whereas crowns that were
cemented with resin cement did not have reduced
retention after pressure cycling.25 This may be attrib-
uted to porosities generated during the preparation of
zinc phosphate cement and glass-ionomer cement, and
the expansion and contraction of these microbubbles
upon pressure changes cause weakening of the cement.
Indeed, microleakage was detected in the zinc phos-
phate and glass-ionomer cements after pressure cycling,
whereas no microleakage was detected in the resin
cement,26 probably owing to dentinal tubule obstruc-
tion by resin tags or cement flexibility.27 In the
aforementioned survey of 125 Australian divers, no
diver reported loosening of a crown or bridge occurring
during diving.23
Although reduced barometric pressure can impair
the retention of full removable dentures (especially
maxillary dentures),3 this consequence has only been
observed in flight conditions.
Dental implications
The dentist should carry out preventive measures and
periodically examine his or her patients who dive and
search for occult pathologies, such as leaked restora-
tions and secondary caries lesions.
For prevention of dislodgement and aspiration,
patients should be advised not to dive while having
provisional restorations or temporary cement in the
mouth. Resin cement should be used when treating
patients who are subjected to pressure changes. Since
dislodged partial removable prostheses could be acci-
dentally aspirated during diving (with one reported case
of resulting death),19 these devices should be removed
before diving, unless they are securely retained. Reten-
tion by adequate osteointegrated dental implants is
probably the best resolution for edentulous divers.
Alternatively, a ‘custom edentulous mouthpiece’ which
combines a mouthpiece with a prosthesis, may be
offered.28
Barodontalgia
Barodontalgia is an intraoral pain evoked by a change
in barometric pressure, in an otherwise asymptomatic
oral cavity. In a diving environment, this pain is
commonly called tooth squeeze. Although rare,
in-diving or in-flight barodontalgia has been recog-
nized as a potential cause of diver or aircrew-member
vertigo and sudden incapacitation, thus could jeopar-
dize the safety of diving or flight, respectively.19,29
Barodontalgia is a symptom rather than a pathologic
condition itself and in most cases reflects a flare-up of
pre-existing subclinical oral disease. Most of the
common oral pathologies have been reported as
possible sources of barodontalgia,30,31 with faulty
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Y Zadik and S Drucker

dental restorations and dental caries without pulp Table 3. Features of in-diving barodontalgia episodes
involvement (29.2%), necrotic pulp ⁄ periradicular
Population Saudi-Arabian Australian
inflammation (27.8%), vital pulp pathology (13.9%) and Kuwaiti civilian divers23
and recent dental treatment (postoperative barodon- military divers34
talgia, 11.1%) being the most common. Barosinusitis N 22 55
was reported in 9.7% of cases.32 Barodontalgia due to Affected Upper NR 48.1%
barotrauma is unique because it arises during diving, teeth Lower NR 29.6%
Appearance Descent 77.5% NR
rather than acts as a flare-up of a pre-existing upon Ascent 22.5% NR
condition. Barodontalgia is classified as direct (dental (surfacing)
induced) and indirect (non-dental induced) pain. The
currently accepted classification of direct barodontal- NR, not reported.
22.2% suffered from dental pain in both upper and lower dentition.
gia consists of four classes according to pulp ⁄ perira-
dicular condition and symptoms (Table 1). Currently,
there is no consensus about the mechanism underlying
Dental implications
barodontalgia.
Barodontalgia has been experienced on one or more Periodic examination, including periapical radiographs
occasions by 9.2% to 21.6% of American and Austra- and vitality tests, is suggested for the prevention of
lian civilian divers (Table 2).23,33 Barodontalgia was barodontalgia in divers, with special attention to apical
most prevalent in the third decade of life and demon- pathology, faulty restorations and secondary caries
strated no gender preference. An additional 16.8% and lesions.
27.2% of divers suffered from ‘jaw pain’ and ‘sinus During the restoration of a carious tooth, the
pain’, respectively.23 An incidence of 17.3% was clinician should carefully examine the cavity floor to
reported among (male) military divers.34 Weighted rule out penetration to the pulp chamber and apply a
incidence among divers was 11.9%, similar to that in protective cavity liner (e.g. glass-ionomer cement).30
aircrews (11.0%).32 When performing multi-visit endodontic treatment,
Pain appears at a water depth of 33 feet and deeper,30 the dentist must carefully place the temporary resto-
usually at a depth of 60 to 80 feet.34 Upper teeth are ration and educate the diver to confirm that the
more commonly affected than lower teeth23 (in contrast restoration is intact before diving. In a pressure-
to flight, in which upper and lower teeth are affected changing environment, open unfilled root canals may
equally) and the vast majority of the episodes occurred cause subcutaneous emphysema, as well as leakage of
upon descent34 (Table 3), which may indicate a greater the intracanal infected content to the periradicular
role of the maxillary sinuses in the aetiology of in- tissues.35 During surgery in the posterior upper arch,
diving barodontalgia. especially when the sinus is augmented, the dentist
must rule out the existence of oroantral communica-
tion, which can lead to sinusitis and potentially
Table 1. Classification of direct (dental induced)
adverse consequences upon exposure to a pressure-
barodontalgia
changing environment. When oroantral communica-
Class Pathology Features tion is diagnosed, referral to an oral surgeon for its
I Irreversible pulpitis Sharp transient
closure is indicated.36
(momentary) Temporary diving restriction after dental and surgical
pain on ascent procedures is still a powerful tool for prevention of
II Reversible pulpitis Dull throbbing
pain on ascent
postoperative barodontalgia.1 Patients should not dive
III Necrotic pulp Dull throbbing within 24 hours of a restorative treatment requiring
pain on descent anaesthetic and within at least seven days of having
IV Periradicular pathology Severe persistent pain
(on ascent ⁄ descent)
surgery.22 In suspected or actual oroantral communica-
tion, diving should be restricted for at least two weeks.37
Until otherwise indicated, the cautious dentist may
consider all sinus augmentation procedures as poten-
Table 2. Incidence of in-diving barodontalgia tially inducing oroantral communication. Thus, the
Population American Saudi-Arabian Australian Weighted dentist may recommend a longer restriction of diving to
and Australian and Kuwaiti civilian average prevent failure of the procedure and pain during diving.
civilian military divers23 Before diving is allowed after extraction, implantation
33 34
divers divers
and ⁄ or sinus augmentation, it is reasonable that the
N 709 127 125 patient be invited back to the office for verification of
Incidence 9.2% 17.3% 21.6% 11.9%
wound healing and an absence of signs or symptoms of
Affected divers of at least one episode. sinus inflammation. The regulations of the Australian
268 ª 2011 Australian Dental Association
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Dental implications of scuba diving

Defence Force’s Surgeon General37 dictates such a Table 4. Direct versus indirect barodontalgia
restriction from the time of diagnosing the need for
Direct Indirect
endodontic treatment until the completion of treatment, barodontalgia owing barodontalgia
when the patient has remained asymptomatic for to pulp disease
24 hours. In addition, in order to prevent pulp inflam- with or without
periradicular involvement
mation or necrosis and their potential barometric
pressure-related consequences, this guideline contrain- Cause Pulp ⁄ periradicular disease. Barosinusitis,
barotitis media.
dicates direct pulp capping in such patients, and Appearance During ascent. During descending.
indicates endodontic treatment in all caries management Pain usually
in which invasion to the pulp chamber is evident or continues on
ground.
suspected.37 Symptoms Reversible pulpitis Toothache in upper
Studies emphasized the challenge of obtaining a or necrotic pulp: premolar ⁄ molar
definitive diagnosis of the causative pathology of beating dull pain. region.
Irreversible pulpitis:
barodontalgia38,39 owing to the need for identifying sudden sharp
the offending tooth, which could be any tooth with penetrating pain.
existing restoration or endodontic treatment (often Periradicular periodontitis:
continuous strong
clinically accepted) and ⁄ or adjacent anatomical struc- pain, swelling.
tures (e.g. maxillary sinus), without the ability to History Recent dental Present acute upper
reproduce the pain trigger factor (i.e. barometric treatment. Recent respiratory infection.
dental sensitivity Past sinusitis.
pressure change) with ordinary dental facilities. (e.g. to cold
According to one report, as many as 14.8% of cases drinks, percussion ⁄
eventually remained undiagnosed.31 Moreover, accord- eating).
Clinical findings Extensive caries Pain on sinus
ing to another report, despite post-event evaluation and lesions or palpation. Pain upon
treatment, recurrence of barodontalgia was reported in (faulty) restoration. a sharp change
25.0% of in-diving cases.34 As always, meticulous Acute pain in the head position.
upon cold or
history taking and examination are the mainstay of percussion test.
diagnosis (Table 4). History of recent dental treat- Radiological Pulpal caries lesions Opacity (fluid) on the
ments, on-ground preceding symptoms, pain onset ⁄ findings and ⁄ or maxillary sinus
restoration close image.
cessation (on ascent or descent) and nature of the pain, to pulp-horn. Periradicular
are invaluable data. The clinician is advised to look for radiolucency. Inadequate
faulty restorations (including dislodged restorations endodontic obturation.
over a vital pulp) and secondary (residual) caries
lesions, to perform a vitality test and necessary
periapical radiographs, and to rule out sinusitis or pain Robichaud and McNally22 suggested that air pushing
originating from the temporomandibular joint (TMJ) by mouthpiece into post-surgical wound may induce
or masticatory muscles (discussed later).30 intraoral pain, mimicking barodontalgia. Owing to
the helium in scuba tanks and the resulting lower gas
viscosity, air from the pressurized tanks can be forced in
Mouthpiece-related conditions
through carious lesions and defective margins of
The diving mouthpiece has obvious relevance to oral restorations as well.19,22
tissues and conditions. The scuba diver gets air from a Potasman and Pick42 identified the diving mouth-
compressed air tank, which is transmitted to the mouth piece as a possible vector for transmission of herpes
via a regulator with a mouthpiece that is held by the simplex virus between mates, especially during under-
teeth (usually the canines and premolars). An airtight water drills, in which the mouthpiece is exchanged
seal has to be created between teeth and lips. Inability frequently between participants to simulate emergency
to hold the mouthpiece due to complete or partial conditions.
edentulism is one of the contraindications for scuba Mouthpiece-associated pharyngeal (gag) reflex dur-
diving.28 Basically, there are three mouthpiece designs: ing depth diving, when accompanied with stress (which
commercial, semi-customized and customized mouth- is relatively common during diving), often causes the
pieces. Most mouthpieces are currently made from diver to perform a quick escape to surface level
silicone or soft acrylic resins. There is an argument that (a ‘panic ascent’). This manoeuvre may cause DCS.
clenching on the mouthpiece, which may be increased Although there is a controversy in the literature, most
due to the emotional stress and cold environment often authors agree that owing to mouthpiece usage there
present while diving, may participate in deterioration of is an elevated prevalence of signs and symptoms of
dental restorations,40 even though the mouthpiece is temporomandibular disorder (TMD) among divers,
flexible.41 especially women. TMD symptoms were reported
ª 2011 Australian Dental Association 269

Y Zadik and S Drucker
among 24% to 68% of divers, in comparison to about
one-quarter of the general population.43–45 Pre-existing
TMJ problems may be worsened by the use of a diving
mouthpiece,44 but symptoms may appear even in
previously symptom-free divers. TMD symptoms were
more prevalent in diving in cold water than in warm
water,45 probably because of the impairment of the lips’
contracting capability in the cold environment, thus
enforcing over-effort of the masticatory muscles.19
Among New Zealand divers, TMD was the second
most prevalent head and neck disorder and comprised
24% of these disorders (with ear pathology the most
common disorder comprising 65%, and nasal and sinus
disorders comprising only 10% of disorders).46 Diving
related TMD symptoms, also called diver’s mouth
syndrome (or regulator mouth), may include all the
TMD symptoms (e.g. muscle pain, joint pain, internal
derangement of TMJ-disc, headache) in various
degrees, and may be limited to diving time or become
chronic and constant. These symptoms are attributed to
the protruded mandibular position and the biting force
exercised on the anterior occlusion (usually canines and
premolars) during diving. A semi-customized mouth-
piece required less muscle activity for retention than
commercial type,47 and fully customized mouthpieces
are reported to cause the least mandibular displacement
from the normal resting position, thus usage results in
the least discomfort, muscle pain, fatigue and effort.41
Dental implications
To prevent post-surgical forcing of air into the tissues
and dry socket, diving should be restricted for at least
one week following oral surgery; prior to diving the
dentist should confirm healing.
The dental team must educate the diver patient of the
infectious potential of the mouthpiece and recommend
using only a private one, and encourage maintenance by
hygiene procedures after each use, similar to other
removable oral devices. The diver should not dive in
times of illness, for the concern of his or her mate.
Dentists should be familiar with the signs and symp-
toms of primary herpetic gingivostomatitis.
Possible solutions for divers with prominent pharyn-
geal reflex include: avoidance of personal gagging
contributing factors (e.g. anxiety, stress), desensitiza-
tion training (repeated introduction of devices to the
sensitive region), trimming the intraoral trigger parts in
the mouthpiece, or use of the (more expensive) full face
mask. Anti-gagging medications should not be taken
before diving to avoid a possible hazardous effect.
Diving related TMD symptoms should be differen-
tiated from barotitis symptoms. Despite the potential
limitations in the construction process because of the
number of stages involved, the greater expense and the
possible reluctance of experienced divers to change
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from the standard commercial mouthpiece, Hobson
and Newton recommended the fabrication of a custom
mouthpiece for divers, with a bite platform at
least 4 mm in thickness, especially for divers who
experience diving-associated TMD symptoms.27,41
Scully and Cawson further recommended the exten-
sion of the mouthpiece’s interdental bite platform to
cover the molars, in addition to the accepted canines
and premolars, in order to balance the weight of the
regulator and relieve the stress on the TMJ.28 Jagger
et al. emphasized the safety aspects of the fabrication
of the custom mouthpiece; the mouthpiece must be
easily removed and compatible with the mate’s use in
emergency (when air sharing by alternate breathing is
needed), and the prepared custom mouthpiece should
be pretested in a training pool before being used in
open-water diving.19 However, if a custom mouthpiece
is not an option, the diver should remember that there
are design differences between manufacturers. Thus,
when choosing his or her equipment, the diver should
test out (in a trial dive) a number of mouthpieces in
order to find the design with the least likelihood of
causing joint symptoms; at least 15 minutes of diving
followed by a rest period of 15 minutes, and adequate
disinfection of devices between trials.41,48
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Address for correspondence:
Dr Y Zadik
Department of Oral Medicine
Hebrew University –
Hadassah School of Dental Medicine
PO Box 91120
Jerusalem
Israel
Email: yzadik@gmail.com
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