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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
*P.O.Box
495, Dhahran Airport 31932, KSA e mail:
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**College of Dentistry,
King Saud University
e mail:
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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.
Subjects exposed to a sudden reduction or increase of ambient pressure
sometimes complain of toothaches.1 This problem was first reported
in pilots and was called aerodontalgia.2 More recently, dental pain
has also been reported during diving3 and the more general term
barodontalgia was introduced to include both conditions, whether produced
by an increase
or decrease
in barometric pressure.4,5 Barodontalgia is essentially dental pain
provoked by atmospheric pressure changes which usually disappear when the
affected person reaches normal pressure zone again.6
During the 1940s, large numbers of military pilots were subjected to
major barometric changes in unpressurized air craft. In some cases the
variations in atmospheric pressure experienced in flight caused severe dental
pain. Incapacitation due to this pain was a serious problem and stimulated
research into
barodontalgia.7
The incidence of barodontalgia in aircrew has been reported to vary
from 0.26% to 8%.1,2,6,8,9 . The US Army air force reported
a 1.63% prevalence
of Barodontalgia is not
limited to any particular age group. circulatory disturbances in an abnormal pulp,barodontalgia among 12,000 subjects undergoing decompression tests after World War II,10
while Harvey, in 1947, identified only 0.8% incidence of toothaches in a sample
of 5,711 persons taking decompression tests.9 Barodontalgia has been
known to occur across a broad range of altitudes during flying, having been
reported at altitudes as low as 5000 feet and as high as 35000 feet but is more
common between 9000 and 27000 feet.6 Barodontalgia is more common on
ascent,6 and it was shown that the onset of pain occurred at
altitudes ranging from 5,000 to 15,000 ft.46
The causes of barodontalgia have been investigated for many years. In
general, barodontalgia is a condition intimately related to pre-existing dental
pathology.6 Several factors have been speculated to make teeth
susceptible to barodontalgia such as inability of gases within the tooth to
expand to adjust internal pressure when exposed to external pressures by diving
or flying,117
nearness of caries to the pulpal tissue,4 dilation of pulpal vessels
during decreases in pressure, and pulpal hyperemia.4 Precipitating
factors that contribute to barodontalgia include inadequately filled root
canals, chronic pulpitis resulting from insufficient base materials, untreated
caries, and periapical abscesses in which gas had been generated.4
Referred pain from unerupted or partially erupted third molars, new and
recurrent caries or restorations, intra-treatment endodontic symptoms, dental
and periodontal cysts, abscesses or "cracked tooth" and from aerotitis media may complicate the diagnosis
of barodontalgia.12
The diagnosis of barodontalgia should be considered if a patient
complains of dental pain during diving or flying.13 A complete and
thorough dental history and examination
should be performed. A hypobaric chamber is an ideal environment that may be
used for reproducing the conditions of barometric pressure and hypoxia that
flight personnel have to withstand at different altitudes, and their effects.14
If dental examination fails to identify the problem then an examination by a
physician would be appropriate to examine the sinuses or even to evaluate the
potential that the pain was referred from the heart.13
Treatment of barodontalgia is similar to therapy rendered for pain of
dental origin at ground level. Prevention of barodontalgia is based on
maintenance of higher standards in preventive and restorative dentistry.6
No information regarding barodontalgia in the Gulf region have been
reported to date. The aim of the present study was to measure the prevelance of
barodontalgia among pilots and divers in selected bases and centers in Saudi
Arabia and Kuwait.
The study population consisted of pilots and divers
working in selected centers in Saudi Arabia and Kuwait. The group of pilots
targeted were those flying non-commercial war planes, practicing in King
AbdulAziz Air Base (KAAB) in Dhahran, King Khaled Air Base (KKAB) in Khamis
Mishaet, Saudi Arabia and Hammad Al-Jabir Air Base in Kuwait. The divers
targeted in this study were those practicing in King Abdulaziz Naval Base
(KANB) in Jubail and the Al-Sharq Diving School in Al-Khobar, Saudi Arabia and
the Kuwait Diving School in Kuwait.
A questionnaire was developed in English and Arabic and distributed
among all pilots and divers present during the research period between November
2004 to April 2005. The survey contained inquiries about age, type of practice
(pilot or diver or both) and years of experience.
Questions
about the occurrence of tooth pain during flight or diving were presented as
well as inquiries regarding whether the pain was during ascending or descending
(pilots), diving or resurfacing to sea level (divers), the altitude or depth at
which the pain occurred, whether they had visited a dentist to treat the pain
or not, what the dentist diagnosed the pain as, what kind of treatment was
rendered at the dental office, and if they had any recurrence of the pain after
treatment. The questionnaire was designed in Arabic and a pre-test
questionnaire was done on 20 subjects. A translation of the questionnaire was
devised to be presented to non-arabic speaking divers.
A total of 350 questionnaires each were distributed, with 50
questionnaires to KAAB, KKAB, KANB, and Hammad Al-Jabir Air Base and the Kuwait
Diving School in Kuwait, and 100 questionnaires to Al-Sharq Diving School in
Al-Khobar.
The collected data were analyzed using the Statistical Package for
Social Science (SPSS) program version 10. Descriptive statistics were performed
and Chi-square test was used to determine the relationship of pain among pilots
and divers.
Two hundred and sixty-two subjects responded from both
Saudi Arabia and Kuwait. The response rate was 72.8% (182) in Saudi Arabia and
80% (80) in Kuwait. The distribution of pilots and divers is shown in Table 1.
The age of the pilots and divers ranged between 25 and 36 years with the mean
age of 33 years. About 42.9% of the respondents were under thirty years of age.
Distribution regarding years of experience showed that 39.3% had 7-12 years of
experience, while 36.3% had only 1-6 years of practice, and 24.2% had more than
13 years of practice.
This study showed that 33.6 % of the sample had
incidence of barodontalgia at least at one point in time during their
activities. Significantly more pilots had an occurrence of pain while flying
(49.6%) than did divers while diving (17.3%) (P<0.0001). For
individuals that were both pilots and dived (10) as a hobby, the prevalence
rose to 40.0 %.
Most of the participants (21.4%) indicated that they
had experienced pain while flying and diving several years previously, while
7.3% indicated that they had pain one year previously and only 5% indicated
they felt pain while flying and diving several months previously.
Pilots had a higher incidence of pain while ascending
(31.2%) than descending (19.2%), while divers had a higher incidence of pain
while diving (13.4%) than when resurfacing to sea level (3.9%).
The highest percentage of tooth pain with pilots was
while flying with an altitude that ranged from 11.000 - 20.000 ft (33000 - 6000
m) and with divers while diving at a depth that ranged from 60 - 80 ft (18 - 24
m) as illustrated in Table 2.
A total of 81.8% of pilots and divers visited their
dentists after they had tooth pain. The diagnosis that was rendered by their dentists is shown in Figure 1. The types of treatment provided
are shown in Figure 2. Restorative treatment was provided significantly more
than any other treatment (P<0.0001), as was root canal therapy (P=0.007).
Recurrence of tooth pain after treatment occurred in 16.4% in pilots and 25.0%
in divers during their practice.
This study was conducted to measure the incidence of
barodontalgia among 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 this phenomenon before more elaborate studies
can be designed.
The data showed that there was a high 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. Although all flight personnel are
initially examined and treated dentally before flying, poor
oral hygiene, maintenance and recall may be
factors that significantly increased prevalence of barodontalgia during
subsequent flights. An in-depth investigation of the factors leading to the
high significance of barodontalgia is required.
There was no correlation between either the age of the pilots or divers
and their age. Similar results were reported by SGADF-HPD411.6
Higher prevalence of barodontalgia was reported among pilots (49.6%)
than among divers (17.3%). This could be due to higher pressure changes that
pilots are exposed to during flying than divers are during diving. The
prevalence among pilots was more common with an altitude that ranged from
11,000 - 20,000 feet. Similar results were reported by Kollman,1 Hodges,4
and the SGADF-HPD411.6
Not surprisingly, the prevalence among pilots was common on ascent in
the study. Similar finding had been reported in SGADF-HPD411.6
Furthermore, it had been suggested that pain on ascent was associated with an
inflamed tooth, while pain on descent was associated with a necrotic tooth.15
This seemed logical in this population as they had undoubtadely been dentally
examined at some point before flying and it was unlikely that dental decay
could progress to lead to necrosis in a short period of time.
The pain was mostly diagnosed as tooth pain (73.6%). This is in
contrast to Kollman, who found the most common pain was earache (2.27%)
followed by pain from teeth and from the paranasal sinuses at 0.26% and 0.18%,
respectively.1 This difference could be attributed to the fact that
many centers internationally have flight surgeons as the primary health
personnel performing the diagnosis, whereas in this study all pilots and divers
reported to a dentist who was expected to be more adept at diagnosing dental
pain.
Most of the pilots and divers included in our study
had restorative treatment done after reporting to the dental office. It may be
that their complaint was an obvious one that could have been apparent on ground
level and not present a diagnostic difficulty. If this were the case, proper
diagnosis and treatment could have prevented the problem in the first place.
In this study, recurrence of pain after treatment was reported by a
relatively smaller groups of pilots and divers at 16.4% and 25% respectively,
which indicated that proper diagnosis was done. For the cases in which there
was recurrence, the causes might be non-odontogenic pain or another offending
tooth than was treated. Many cases of recurrence need further invesitigations
that may involve leaking restorations and periapical pathology which were
beyond the scope of our study.
In this study, no clinical examination was conducted. Correlation of
the information obtained from the questionnaires with clinical findings
obtained from examination could provide more specific results in term of
incidence and causes of barodontalgia.
Our sample was a convenient one targeting pilots flying non-commercial
war planes. No attempt was made to specify the type of planes as this was
considered classified information and this could limit any attempt to
generalize pilots flying different kind of war planes. Also all types of divers
were considered in this study, and no attempt was made to specify which kind of
diving equipment was used. The safety of aircrew and diving personnel can be
comprised by barodontalgia as the intensity of pain is often such that
effective performance is not possible.6 Distractions during critical
flights or dives, or abortion of important missions can occur as a result of
pain during a flight or dive.
Prevalence of barodontalgia was higher (33.6%) in
Saudi Arabia and Kuwait. Pilots reported higher incidence than divers. It was
common on ascent while flying and descent while diving. Recurrence of pain
after treatment was uncommon.
The prevalence of barodontalgia was higher in Saudi
Arabia and Kuwait when compared to reports from other countries. It is a
phenomenon that should not be dismissed as unimportant, as it can pose a
serious safety risk to divers, submariners, pilots and airline passengers.11
Federation Dentaire International (FDI) recommends an annual check-up for
divers, submariners and pilots, with oral hygiene instructions from dentists
familiar with their dental requirements.11 It is therefore
recommended that dental services in clinics servicing pilots and divers (air
and naval bases) in Saudi Arabia and Kuwait should be organized to provide
regular check-ups, treatment and oral hygiene education for this population.
Also, based on the results of this study and within its limitations, it is
recommended that more studies specific to air flight and diving centres be
performed to realize the full extent of the problem, the factors affecting the
incidence, preventive measures in the form of increased awareness among pilots
and divers to the importance of therapy and maintenance, differential diagnosis
and methods of diagnosis and treatment.
The authors would like to express their thanks to all
those who participated in this study and their families for their help and support,
and to Dr. Nazeer Khan for his assistance in the statistical analysis.
Sincere thanks and
appreciation is given to (Retired) Major Birjes Al-Otabi from K.A.A.B in Dhahran, Dr.
Abdullah Al-Hajri, the former Minister of Kuwait and General Yossef Al-Dhwayan,
the Kuwait Air Force Commander, for their great cooperation in facilitating the
questionnaires distribution among the pilots and divers.
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W. Incidence and possible causes of dental pain during simulated high altitude
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HL. Aerodontalgia. Dent Dig 1945; 51:16-18.
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Shiller WR.
Aerodontalgia under hyperbaric conditions. An analysis of forty-five case
histories. Oral Surg Oral Med Oral Pathol 1965; 20:694-697.
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Hodges FR.
Barodontalgia at 12,000 feet. J Am Dent Assoc 1978; 97(1):66-68.
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Rauch JW.
Barodontalgia - Dental pain related to ambient pressure change. Gen Dent
1985;313-315.
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Surgeon General
Australian Defense Force (SGADF) Health Policy Directive No 411. Aviation and
Diving - Dental Considerations. 20 April 1995. p. 5 (electronic version)
retrieved Sept 10th 2005 from http://www.defense.gov.au/dpe/dhs/infocentre/publications/
directives/HPD411.pdf
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Senia
E.S, Cunningham KW, Marx RE. The diagnosis dilemma of barodontalgia. Report of
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Gonzalez-Santiago MM,
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O'Brien DM. (ed) Flight
Surgeon's Guide. 1995 ed. In: Ch.12 Aerospace Dentistry- Odontalgia-
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