C

L I N I C A L

R A C T I C E

Barodontalgia as a Differential Diagnosis:

Symptoms and Findings

Roland Robichaud, BSc (Hon)

Mary E. McNally, MSc, DDS, MA

A b s t r a c t
This paper provides a review of the literature concerning the etiology and manifestations of barodontalgia, as well
as important clinical considerations for its management. Barodontalgia is characterized by exposure to a pressure
gradient, such as that experienced by underwater divers, aviation personnel and air travellers. This form of dental
pain is generally marked by a predisposing dental pathology such as acute or chronic periapical infection, caries,
deep or failing restorations, residual dental cysts, sinusitis or a history of recent surgery. Studies indicate that severity of barodontalgia and the resulting deterioration of dental health correlates with duration of barometric stress.
Restorative materials are also affected by pressure gradients. Resin is indicated as a luting agent of choice for
cementing fixed prostheses in populations at risk for barodontalgia. Under the influence of pressure gradients, resin
cements maintain original bond strength and demonstrate the least amount of microleakage compared with other
cements. The key to avoiding barodontalgia is good oral health. Clinicians must pay close attention to areas of
dentin exposure, caries, fractured cusps, the integrity of restorations and periapical pathology in those at risk. The
Fdration dentaire internationale describes 4 classes of barodontalgia based on signs and symptoms and provides
specific and valuable recommendations for therapeutic intervention.
MeSH Key Words: aerospace medicine; barotrauma/complications; diving/injuries; toothache/etiology
J Can Dent Assoc 2005; 71(1):3942
This article has been peer reviewed.

uring World War II, tooth pain experienced by air

crew in flight was given the name aerodontalgia.
However, as this tooth-related pain was also
observed in divers, a broader, more appropriate term, barodontalgia, was subsequently given to this phenomenon.1
Barodontalgia, which affects air crew and aircraft passengers as well as underwater divers, is pain or injury affecting
teeth due to changes in pressure gradients.2 Boyles Law,
which states that at a given temperature, the volume of a
gas is inversely proportional to the ambient pressure, may
be used to explain barodontalgia.2 Specifically, as a person
descends deeper and deeper below the water surface, pressure exerted on the diver by the water increases and reduces
the volume of gases in enclosed spaces such as teeth and
sinuses. The same law applies if a person climbs to high altitudes (in flight); in this case, outside pressure decreases,
permitting the volume of gases to increase. A problem arises
when the enclosed spaces containing gases cannot expand
or contract to adjust the internal pressure to correspond to
the outside pressure. Aircraft personnel and passengers travelling in non-pressurized cabins are especially at risk.2

Journal of the Canadian Dental Association

The importance of understanding, preventing and,

where necessary, treating barodontalgia is especially evident
when considering pilots of high performance aircraft. A
study using a pressure chamber as a flight simulator revealed
that in some instances barodontalgia was severe enough to
affect flight safety.3 In the past, barodontalgia was especially
problematic for travellers during military flights where
cabins were not sufficiently pressurized. Currently, and of
particular relevance to the general public, are effects occurring during normal commercial flights and recreational
diving. These range from a simple sharp or squeezing tooth
pain to rupture of the alveolar mucosa.2 The phenomenon
begins to occur at an altitude of approximately 3,000 m and
at a water depth of 10 m where the ambient pressures are
0.75 and 1 atmosphere, respectively.4

Etiology
The cause of barodontalgia has been investigated for many
years. Kollman3 refers to 3 important hypotheses to explain
this phenomenon: expansion of trapped air bubbles under
a root filling or against dentin that activates nociceptors;
January 2005, Vol. 71, No. 1

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Robichaud, McNally

stimulation of nociceptors in the maxillary sinuses, with pain

referred to the teeth; and stimulation of nerve endings in a
chronically inflamed pulp. He strongly supports the last 2
hypotheses and states that, for the latter, histologic evidence
shows that chronic pulpal inflammation can still be present
even when a thin dentin layer covers the pulp, for example,
as in a deep cavity preparation.
Most cases of barodontalgia are associated with teeth
already affected by some sort of pathology.1 Clinically,
people affected by barodontalgia were found to have one or
more of the following: acute or chronic periapical infection,
caries, deep restorations, residual dental cysts, sinusitis
and a history of recent surgery.5 The latter is of particular
concern for people wearing oxygen regulators when diving
using self-contained underwater breathing apparatus
(scuba) or when wearing oxygen masks during highperformance aircraft flights due to the risk of air being
pushed into the tissues. Sinusitis may also contribute to
barodontalgia, although it may not be related to any tooth
pathology. For example, Holowatyj1 described a patient as
having pain in his left infraorbital area, as well as in the
maxillary left canine and maxillary left first molar during
both a commercial flight and while flying a Tutor jet
trainer. Although no tooth pathology was present, the
patient did have mild congestion in his left maxillary sinus,
with referred pain in his maxillary teeth. Barosinusitis is
distinguishable from barodontalgia, as the former will
always occur on descent, whereas the latter always begins
on ascent.5 Recognizing that symptoms only appear to
arise in teeth (or sinuses) affected by some type of pathology, researchers concluded that a pressure gradient is a
contributing factor, not the actual cause of the problem.2
Calder and Ramsey6 tested whether large, rapid pressure
changes generated within a capsule would create visibly
detectable damage to extracted restored and nonrestored
teeth. Of 86 extracted teeth subjected to the high-pressure
environment, only 5 showed visible evidence of trauma.
However, all 5 had inferior-quality restorations (i.e., deteriorating or leaking restorations present before extraction or
placed after extraction). None of the unrestored teeth,
regardless of the presence of caries, suffered any damage,
suggesting that failing restorations play a major role in the
occurrence of physical damage.

Underwater Diving
Scuba diving is one of the fastest growing sports in the
world.7 Thus, it is important for dentists to be aware of
dental-related problems that may arise for scuba divers. The
most common way for air from the pressurized tanks to
enter a tooth is by being forced in through carious lesions
or defective margins.7 As atmospheric pressure decreases
during ascent, trapped gases may expand and enter dentin
tubules, thereby stimulating nociceptors in the pulp or
causing the movement of pulp chamber contents through
the apex of the tooth, also causing pain.7
In their study, Calder and Ramsey6 mention that the
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January 2005, Vol. 71, No. 1

physical properties of the gas mixture used during deep sea

diving may contribute to barodontalgia. In scuba tanks,
oxygens natural diluent gas, nitrogen, is replaced by
helium, resulting in a gas of lower viscosity. This gas can
enter tissues, including teeth, and can sometimes become
trapped in closed spaces, such as the pulp chamber and root
canal. There are 2 mechanisms by which gases can be
trapped in spaces: if there is a space between a tooth and its
restoration, gas may be forced into it during an increase in
pressure; and dissolved gas may diffuse from tissues into
spaces as pressure decreases. Consistent with Boyles Law,
trapped gas will expand and the resulting stress may cause
tooth fracture. This process has been called odontecrexis, a
Greek word meaning tooth explosion.

Physical Manifestations
Although understanding the etiology of barodontalgia is
of great importance, its physical manifestations also deserve
some attention. In their study, Goethe and coworkers8
attempted to identify early and late damage due to barodontalgia by examining 50,000 tooth-related clinical problems (e.g., carious lesions, tooth trauma, deteriorating
restorations) at the Nautical Medical Institute of the
German Navy at Kiel. Among these findings, 13,618 were
from 2,580 navy divers, frogmen and submariners. The
patients were divided into 2 categories: those working
under normal atmospheric pressure (1,291 submariners)
and those working under changed atmospheric pressure
(1,289 divers and frogmen). Navy divers spend an average
of 200300 hours a year under water whereas frogmen
usually spend longer times at shallower depths.
An initial examination revealed that overall, divers and
frogmen had better oral health than submariners. Dental
findings were reviewed at 3, 6, and 9 years. At 9 years, deterioration in the teeth of navy divers and frogmen had
occurred at significantly higher rates than those of the
submariners in terms of missing or crowned incisors,
canines, premolars and molars. More specifically, although
they were healthier at baseline, frogmen were in the poorest state of dental health after 9 years, surpassing even
the navy divers. This suggests a correlation between the
deterioration of dental health and increased exposure to
barometric stress.
To further support these results, another longitudinal
study8 was conducted on navy divers and submariners from
the time of their entry into the navy until they had served
for more than 10 years. Once again, the dental health status
of navy divers was initially slightly better, but after 10 years,
they demonstrated a 300% increase in missing teeth and
a 900% increase in the placement of crowns. The
submariners examination at 10 years revealed an increase
of only 186% missing teeth and 375% crown placement.
These findings confirm that navy divers teeth have a faster
rate of deterioration than submariners. Again, this is attributed to higher levels of barometric stress.
Journal of the Canadian Dental Association

Barodontalgia as a Differential Diagnosis: Symptoms and Findings

Dental Materials

Recommendations

We have described the signs and symptoms of barodonAlthough barodontalgia is not common, it should not be
talgia, such as pain and physical damage to the oral tissues,
dismissed as unimportant, as it can pose a serious safety risk
but it would also be an advantage to the clinician to know
to divers, submariners, pilots and airline passengers. The
the effect of pressure changes on certain dental materials in
Fdration dentaire internationale (FDI) has classified baroterms of bond strength and microleakage. The following
dontalgia into 4 groups according to its signs and symptoms;
outlines important considerations for cast-crown placement
from moderate to severe, they are acute pulpitis, chronic
in people who regularly engage in activities associated with
pulpitis, necrosis of the pulp and periapical abscess or a cyst.8
Each category contains a description of clinical symptom,
barometric stress.
findings and therapy. FDI also recommends an annual
Lyons and coworkers4 examined whether pressure cycles
would cause microleakage in teeth with full cast crowns
checkup for divers, submariners and pilots, with oral hygiene
cemented with zinc phosphate cement, tri-cured glass
instructions from dentists familiar with their dental requireionomer cement or a resin cement. They also investigated
ments. In addition, patients should not dive or fly in nonwhether the retention of these crowns would be affected.
pressurized cabins within 24 hours of a dental treatment
Sixty single-rooted extracted premolars were divided into
requiring anesthetic or 7 days following a surgical treatment.8
The key feature in avoiding barodontalgia is good oral
3 groups of 20 teeth according to the cement used. Each
health. When dealing with patients involved in diving or
group was then subdivided into 2 groups of 10, an experiaviation, clinicians should pay close
mental group and a control group.
attention to areas of dentin expoEach experimental tooth was then
sure, caries, fractured cusps, fillings
subjected to 15 compression cycles,
and periapical pathology.2 If a
ranging from 0 to 3 atmospheres, in a
Barodontalgia can pose a
patient arrives in the office
pressure chamber. Maximum pressure
serious safety risk to divers,
complaining of symptoms of barowas attained in 3 minutes and maindontalgia, the examiner should
tained for 3 minutes, and decompressubmariners, pilots and
establish whether there is a history
sion occurred over 3 minutes.
airline passengers.
of recent flying or diving.
Microleakage was detected in all
Examination should include an estiexperimental teeth where the crowns
mate of the age of restorations in the
were luted with zinc phosphate
suspected area, screening for caries
cement. Seven teeth in the glass
and poor-quality restorations, a percussion test on
ionomer experimental group showed microleakage during
suspected teeth, an evaluation of the response to electrical
pressure cycling, and no microleakage was detected in the
stimulation or heat and cold, as well as a radiographic
resin cement group.
examination.4 One clinical benefit of barodontalgia is that
Lyons and coworkers offer several explanations for the
it may help a dentist locate early caries, leaking restorations
microleakage in the glass ionomer and zinc phosphate
and periodontal abnormalities.5 Also of clinical importance,
groups, including volumetric contraction or internal stress
the placement of a zinc oxide eugenol (ZOE) base was
within the materials, or porosities caused by mixing that
found to prevent barodontalgia when reversible pulpitis was
may have expanded and contracted during pressure cycling.
the underlying cause.1 This is attributed to the well-known
They further suggest that microleakage may not have
sedative affects of ZOE. Another study3 suggested that
occurred in the resin cement group because the dentinal
when treating people who are subjected to large pressure
tubules were obstructed by resin tags, or simply because
changes, it is best to avoid procedures such as pulpectomy
fracture did not occur because the material was flexible.
and capping of an exposed pulp. Rather, endodontic treatThe tensile bond strength of the cements was also tested
ment is indicated.
using a universal testing machine (with a speed of
0.5 mm/minute and a 100-kg load).4 Results indicated that
Conclusion
the force required to dislodge the crowns in the experimenAccording to the literature, barodontalgia is a rather rare
tal group cemented with zinc phosphate was only a tenth
phenomenon. However, Kollmann3 has suggested that the
that of the controls, and that for glass ionomer was reduced
incidence of barodontalgia may be underestimated. For
by a half compared with its controls. Pressure cycling did
example, aviators may be reluctant to report pain as they
not affect the bond strength of the resin cement group.
could be refused flying certificates.
Based on the results of this study, it is possible that baroIt appears that controversy still exists as to the exact etioldontalgia may develop as a result of microleakage following
ogy of barodontalgia and the mechanisms of the pain.
a reduction in lute bond strength during or following presNevertheless, research has provided useful ways to anticisure cycling. Lyons and coworkers suggest that dentists
pate, recognize and treat the phenomenon, thereby preventconsider using a resin cement when luting fixed prostheses
ing what could easily turn into a tragedy. Agreement has
in patients who will be exposed to significant variations
been reached on 2 factors: the influence of a pressure
in pressure.
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January 2005, Vol. 71, No. 1

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Robichaud, McNally

gradient and some sort of pathology in oral tissues or

sinuses must both be present to result in symptoms of barodontalgia. Certain populations have been specifically identified as having a high risk for barodontalgia. Dentists will
be able to provide more efficient diagnosis and care by
referring to FDI guidelines, as well as knowing how certain
dental materials respond to pressure gradients. Although its
occurrence has been known for some time, more research
to improve the understanding of barodontalgia would be
useful for those providing care. Understandably, many
studies are military based because of the potential impact of
barodontalgia on the professional activities of pilots and
divers. With a significant number of these professionals in
the military, there is an optimum environment for carrying
out well-controlled research and follow-up. However, a
richer understanding of diagnosis and treatment challenges
would undoubtedly be gained from research broadened to
include recreational divers and civilian aviators. C

Roland Robichaud is a third-year dental student in the

faculty of dentistry, Dalhousie University, Halifax,
Nova Scotia

Dr. McNally is assistant professor, department of dental

clinical sciences, faculty of dentistry, Dalhousie
University, Halifax, Nova Scotia.
Correspondence to: Dr. Mary McNally, Department of Dental
Clinical Sciences, Faculty of Dentistry, Dalhousie University,
Halifax, NS B3H 3J5. E-mail: mary.mcnally@dal.ca.
The authors have no declared financial interests.

References
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3. Kollmann W. Incidence and possible causes of dental pain during
simulated high altitude flights. J Endod 1993; 19(3):1549.
4. Lyons KM, Rodda JC, Hood JA. Barodontalgia: a review, and the
influence of simulated diving on microleakage and on the retention of full
cast crowns. Mil Med 1999; 164(3):2217.
5. Rauch JW. Barodontalgia dental pain related to ambient pressure
change. Gen Dent 1985; 33(4):3135.
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8. Goethe WH, Bater H, Laban C. Barodontalgia and barotrauma in the
human teeth: findings in navy divers, frogmen, and submariners of the
Federal Republic of Germany. Mil Med 1989; 154(10):4915.

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