134 SAUDI DENTAL JOURNALSAUDI DENTAL JOURNAL SAUDI DENTAL JOURNAL

Prevalence of Barodontalgia among pilots and divers in and 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 1 changes which usually disappear when complain of toothaches. 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 3 During the 1940s, large numbers of has also been reported during diving 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 *Intern serious problem and stimulated research College of Dentistry, King Saud University 7 P.O.Box 495, 31932, KSA into barodontalgia. [email protected] The incidence of barodontalgia in **Assistant Professor aircrew has been reported to vary from Department of Restorative Dental Sciences 0.26% to 8%.1,2,6,8,9 The US Army air College of Dentistry, King Saud University [email protected] force reported a 1.63% prevalence of

Saudi Dental Journal, Volume 18, No. 3, September - December 2006 AL-HAJRI and AL-MADI 135

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 (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 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 136 PREVALENCE OF BARODONTALGIA AMONG PILOTS AND DIVERS

Questions about the occurrence of Table 1. Distribution pilots and divers tooth pain during flight or diving were Number of pilots and Place of employment Percent % presented as well as inquiries regarding divers included 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 AL-HAJRI and AL-MADI 137

Table 2. The incidence of occurrence of barodontalgia 25 versus altitude and depth No. of No of Altitudes % Depth % pilots divers 20.2 20 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% 5.7 5 their dentists is shown in Figure 1. The types of treatment provided are shown 2.3 2.3 in Figure 2. Restorative treatment was 0 provided significantly more than any Restoration R.C.T. Extraction Other other treatment (P<0.0001), as was root Dental Treatment P canal therapy ( =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. DISCUSSION 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 40 population inquiring about incidence, nature of the incident and the treatment

Percentages rendered, as this was a pioneer study in this field in the area, and preliminary 20 data was required about the incidence of 15.3 5.6 this phenomenon before more elaborate 2.8 2.8 studies can be designed. 0 Tooth Pain & MaxillaryNothing alrus pain The data showed that there was a high Tooth Pain Maxillary alrus pain Other incidence of barodontalgia (49.6%) among pilots. This rate was higher than that 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 138 PREVALENCE OF BARODONTALGIA AMONG PILOTS AND DIVERS

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. 6 SGADF-HPD411. 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 1 at 0.26% and 0.18%, respectively. 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 AL-HAJRI and AL-MADI 139

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. RECOMMENDATIONS REFERENCES

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. instructions from dentists familiar with 4. Hodges FR. Barodontalgia at 12,000 feet. J 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 http://www.defense.gov.au/ 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. form of increased awareness among pilots Report of two cases. Oral Surg Oral Med and divers to the importance of therapy Oral Pathol 1985; 60(2):212-217. and maintenance, differential diagnosis 8. Orban B, Ritchey BT. Toothache under and methods of diagnosis and treatment. conditions simulating high altitude flight. J Am Dent Assoc 1945; 32:145-180. ACKNOWLEDGMENTS 9. Harvey W. Dental pain while flying or during decompression tests. Br Dent J The authors would like to express their 1947; 82:113. 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.

Saudi Dental Journal, Volume 18, No. 3, September - December 2006 140 PREVALENCE OF BARODONTALGIA AMONG PILOTS AND DIVERS

12. The Online Journal of Dentistry and Oral 15. O’Brien DM. (ed) Flight Surgeon’s Medicine. www.epub.org.br/ojdom/ Guide. 1995 ed. In: Ch.12 Aerospace vol04n04.htm Dentistry- Odontalgia- Barodontalgia. 13. Stein, LA. (electronic version) The rarest USAF School of Aerospace Medicine barotrauma. Alert Diver 1993; Sept/Oct retrieved Sept 10th 2005 from: http:// 14. Gonzalez-Santiago MM, Martinez- wwwsam.brooks.af.mil/af/files/fsguide/ Sahuquillo-Marquez A, Bullon-Fernandez html/Chapter_12.html#Odontalgia P. Incidence of barodontalgias and their relation to oral/dental condition in personnel with responsibility in military flight. Med Oral 2004; 9:92-105.

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