BarodontalgiawhathavewelearnedinthepastdecadeYehudaZadikDMDMHAJer - PDF document

Barodontalgia:whathavewelearnedinthepastdecade?YehudaZadik,DMD,MHA,Jerusalem,IsraelCENTERFORHEALTHPROMOTIONANDPREVENTIVEMEDICINE,MEDICALCORPS,ISRAELDEFENSEThisarticlereviewsthecurrentknowledgeregardingbarodontalgia,abarometricpressure–relatedoral(dentalandother)pain.Contemporaryclassication,prevalence,andincidence,features,etiology,anddiagnosisofthisentityarepresentedregardingightanddivingconditions.Summarizingthepastdecadedata,three-fourthsofepisodesweredescribedassevere,sharp,andlocalizedpain.Barodontalgiaaffects11.9%ofdiversand11.0%ofmilitaryaircrewswitharateof5episodes/1,000ight-years.Upperandlowerdentitionswereaffectedequallyinight,butmoreupperthanlowerdentitionwereaffectedindiving.Themostprevalentetiologicpathologiesforin-ightdentalpainwerefaultydentalrestorations(includingdentalbarotrauma)anddentalcarieswithoutpulpinvolvement(29.2%),necroticpulp/periapicalinammation(27.8%),vitalpulppathology(13.9%),recentdentaltreatment(11.1%),andbarosinusitis(9.7%).Thisreviewrefutes3generallyacceptedconventions:Accordingtotheresults,thecurrentin-ightbarodontalgiaincidenceissimilartotheincidenceinthersthalfofthe20thcentury,theweightedincidenceofbarodontalgiaamongaircrewsaresimilartotheweightedincidenceamongdivers,andtheroleoffacialbarotraumaintheetiologyofin-ightbarodontalgiaisminor.SurgOralMedOralPatholOralRadiolEndod2010;109:e65-e69)Aconsiderableconcernamongaviationphysiciansanddentistsduringthe1940sandquiteforgottenlater,barodontalgia,abarometricpressure–relatedoral(den-talorother)pain,wasrevisitedinthepastdecade.thedivingenvironment,thispainiscommonlycalled“toothsqueeze,”andthepreviousname“aerodontal-gia,”regardingitsfeatureinight,isstillinuse.Althoughrare,in-divingorin-ightbarodontalgiahasbeenrecognizedasapotentialcauseofdiveroraircrew-membervertigoandsuddenincapacitation,whichcouldjeopardizethesafetyofdivingoright.Theaimofthepresentarticleistoreviewthecurrentknowledge,fromthepastdecade,regardingthispainBarodontalgiaissubgroupedintodirect(dental-in-duced)andindirect(nondental-induced)pain.Thecur-rentlyacceptedclassicationofdirectbarodontalgiaconsistsof4classesaccordingtopulp/periapicalcon-ditionandsymptoms⠀TableIPREVALENCEANDINCIDENCEDivingconditionsBarodontalgiahasbeenexperiencedononeormoreoccasionsby9.2%-21.6%ofAmericanandAustralianself-containedunderwaterbreathingappa-ratus(SCUBA)divers⠀TableIIwasmostprevalentinthethirddecadeoflifeandwithoutgenderpreference.Anadditional16.8%and27.2%ofdiverssufferedfrom“jawpain”and“sinuspain,”respectively.Amongmilitarydivers(allmale),anincidenceof17.3%wasreported.FlightconditionsAdistinctionhastobemadebetweenrealin-ightconditionsandaltitude-chambersimulations;barodon-talgiaisapproximatelytenfoldmoreprevalentintheformerthaninthelaterconditions.TableIItheprevalence,incidence,andrateofbarodontalgiainthepastdecadeaccordingtoSpanish,Saudi-ArabianandKuwaiti,Israeli,andTurkishAirForcere-All4reportsareofmaleaircrews.Dif-ferencesinthereportedincidenceareconsiderableandcanbeattributedtotherelativelysmallgroups,differ-encesinoralhealthconditions,andfrequencyofying,compression,andextremeconditionsofying(e.g.,rapidmaneuveringwiththeconsequentrapidpressureIn-ightbarodontalgiaaffects11.0%ofmilitaryaircrewswitharateof5episodes/1,000ight-years.Thecurrentweightedincidenceofbarodontalgiaduringightissimilartothereportedincidence(9.5%)fromthersthalfofthe20thcentury,despitecurrentaircompressioninsideairplanechambers,high-qualitydentalcare,andenhancementoforalhealthinthesecondhalfofthe20thcentury.Regardingthepre-sumedeffectofchamberaircompressiononbarodon-talgia,intheIsraelireportnodifferencewasfoundinincidenceofbarodontalgiabetweenaircrewsofuncom-pressedhelicopters,semicompressedghteraircraft,Head,ZrinCentralDentalClinic.1079-2104/$-seefrontmatter꤀2010Mosby,Inc.Allrightsreserved. andcompressedtransportaircrafts(8.0%,9.0%,and7.0%,respectively).Surprisingly,intheSpanishre-port,aircrewsofcompressedaircrafts(5.1%)weremoreaffectedthanthoseofuncompressedaircraftsTheweightedincidenceofbarodontalgiaamongaircrews(11.0%)issimilartodivers(11.9%)despiterequirementoforalhealthmaintenanceandlesserpres-surechangesamongaircrews.Generally,diversaresubjectedtomoreenvironmentpressurethanaircrews;whereasinightthetheoreticallypossiblepressurechangesrangefrom1atmosphereatgroundlevelto0atmosphereatouterspace,indivingthechangesaremoresignicantsinceeach10meters(32.8feet)de-scentelevatesthepressurebyanother1atmosphere.Althoughbarodontalgiawasreportedalsoinmoun-tainclimbingandhyperbaricchamber,researchisavailablefordivingand(military)yingconditionsTableIIIDivingconditionsPainappearsatawaterdepthof33feet,atdepthsof60-80feet.In-diving,upperteetharemoreaffectedthanlowerteeth,andvastmajorityofepi-sodesappearedupondescent.Becauseappearanceofbarosinusitisisusuallyupondescent,whereasdirectbarodontalgiafavorsascension(especiallyinvitalpulpthese2features(i.e.,affectingupperteethmoreandappearingupondescent)mayindicateagreaterroleformaxillarysinuspathologyintheetiol-ogyofin-divingbarotrauma;moreresearchisneeded,FlightconditionsUpperandlowerteethareaffectedequally.Themostaffectedintraoralareasareposteriorupper(50.0%)andlower(37.5%)dentitions,withupperrstmolar(30.8%)andlowerrstmolar(30.8%)themostaffectedteeth.Painintensitywasratedassevere(75.0%)andsevere(25.0%).MostepisodeswerecharacterizedasTableI.Classicationofdirect(dentalinduced)bar- ClassPathologyIIrreversiblepulpitisSharptransient(momentary)painonIIReversiblepulpitisDullthrobbingpainonascentIIINecroticpulpDullthrobbingpainondescentIVPeriapicalpathologySeverepersistentpain(onascent/TableII.Prevalence,incidence,andrateofbarodontalgia* Tayloretal.,2003GonzalezSantiagoMdeletal.,2004Al-Hajri&Al-Madi,Zadiketal.,2007Sipahietal.,2007Jaggeretal.,SpanishmilitaryaircrewsSaudi-Arabian&KuwaitimilitaryaircrewsIsraelimilitaryaircrewsTurkishmilitaryaircrewsPrevalence†需NRNRNR0.3%需0.3%Incidence‡需2.4%49.6%8.2%NR需11.0%Rate§需2NR10NR需5Altitude-chambersimulationsIncidence‡需0.2%NRNRNR需0.2%PopulationAmericanandAustraliancivilianSCUBAdiversSaudi-Arabian&KuwaitimilitarydiversAustraliancivilianSCUBAdiversn709需127需需125Incidence‡9.2%需17.3%需需21.6%11.9%notreported;self-containedunderwaterbreathingapparatus.Theauthorsanalyzed10,651ightsratherthanaircrews-basedanalysisasotherreports.Casesoutofallights.Affectedaircrewsof1

episode.Episodesper1,000ight-years. April2010 sharp(76.9%)andlocalized(76.9%)ratherthandull(23.1%)anddiffuse(23.1%).Appearanceofin-ightbarodontalgiawasreportedataltitudesof3,000-25,000feet.Thepainmayceaseonreturningtoapproximateonsetlevel(3,000-10,000feet)orgroundatmosphericlevel,butinmanycases(61.5%inonereport),suchaswhenpainiscausedbyperiapicaldiseaseorbyfacialbarotrauma,itlastsupto3daysafterlanding.Becausebarodontalgiaisasymptomratherthanapathologicconditionitself,andinmostcasesreectsaare-upofpreexistingsubclinicaloraldisease,mostofthecommonoralpathologieshavebeenreportedaspossiblesourcesofbarodontalgia.TableIVmarizesthemostcommonconditionsthatwerere-portedascausesofbarodontalgiaduringights.Thecommonetiologicpathologiesforin-ightpainwerefaultydentalrestorationsanddentalcarieswithoutpulpinvolvement(29.2%),necroticpulp/periapicalin-ammation(27.8%),vitalpulppathology(13.9%)andrecentdentaltreatment(“postoperativebarodontalgia”;11.1%).Barosinusitiswasthepainoriginin9.7%ofCasesofbarodontalgiaduetoexternalotiticbaro-trauma(causedbyexpansionofairinearphone)todentalbarotrauma(barometricpressure–relatedfrac-tureofdentalhardtissueand/orrestoration)beenreported.Togetherwithbarosinusitis,theseexam-plesoffacialanddentalbarotrauma,respectively,areuniqueasbarometric-relatedpathologicconditionsthataregeneratedduringightfrompressurechangesratherthanpressure-relatedare-upofpreexistingcon-ditions.Barodontalgiaoriginatedfromreferredpainoffacialbarotraumaistermed“indirectbarodontalgia”(incontrasttodental-induced“directbarodontalgia”).Thecurrentdataareprovingthatindirectbarodontalgiaisresponsiblefortheminority(one-tenth)ofcases,incontrasttosomeargumentsthatthevastmajorityorallbarodontalgiacasesareactuallyreferredpainfromRobichaudandMcNallysuggestedthatperforationintheoraltissue(e.g.,aftersurgicalprocedure)maybepronetobarodontalgiainaircrewsanddiverswhowearoxygenmask,owingtoairpushingintothetissues.BarodontalgiaisstillknownforthedifcultyofobtainingonthegroundadenitivediagnosisoftheTableIII.Featuresofbarodontalgiaepisodes GonzalezSantiagoMdeletal.,Al-Hajri&Al-Madi,Sipahietal.,Jaggeretal.,2009MilitaryaircrewsMilitaryaircrewsMilitaryaircrewsAffectedteethAppearanceupon61.9%NR38.1%NRLevel,feetMilitarydivers需CivilianSCUBAdiversAffectedteethAppearanceupon需NRAscent(resurfacing)需NRLevel,feet需NR需NRAbbreviationsasinTableII*Regardingthecasesinwhichthepainsubsidedduringight.†22.2%sufferedfromdentalpaininbothupperandlowerdentition. Volume109,Number4 causativepathology,becauseevendiagnosticalti-tude-chambersimulationisnotalwayseffectivenorAccordingtoonereport,asmanyas14.8%ofcaseseventuallyremainedundiagnosed.Inthediagnosticprocessingofapatientwhosufferedfrombarodontalgia,obtaininghistoryofrecentdentaltreatments,on-groundprecedingsymptoms,andpainonset/cessation(onascentordescent)andnaturepro-videsinvaluabledata.Theclinicianisadvisedtolookforfaultyrestorations(includingdislodgedrestorationsoveravitalpulp)andsecondary(remaining)cariestoperformvitalitytestandneededperiapicalradiographs,andtoruleoutsinusitisinepisodesofpainintheupperposteriorregionandpainoriginatedfromthetemporomandibularjointormasticatorymusclesinepisodesofin-divingoralpain.Accordingtoonereport,despitepostepisodeevaluationandtreatment,recurrenceofbarodontalgiawasreportedin16.4%ofin-ightand25.0%ofin-divingcases.Therewasnopublishedresearchregardingthepathogenesisofbarodontalgiainthepastdecade.De-spitesometheories,mostofferedinthersthalfofthe20thcentury,thepathogenesisofthisuniquedentalpainremainsoccult.Periodicoralanddentalexaminations,includingperia-picalradiographsandvitalitytests,arerecommendedforthepreventionofbarodontalgiainhigh-riskpopulations(e.g.,aircrews,divers).Inaddition,screeningpanoramicradiographsarerecommendedforthesepopulationsat3-5-yearintervals.Specialattentionneedstobepaidforperiapicalpathosis,faultyrestorations,secondarycar-ieslesions,andsignsofteethattrition.Temporaryightrestriction(grounding)afterdentalandsurgicalproceduresisstillapowerfultoolforpreventionofpostoperativebarodontalgia.dictatesthegroundingofmilitaryaircrewsfromtimeofdiagnosingtheneedforendodontictreatmentuntilthecompletionoftreatment.Inaddition,toprevent(sub-clinical)pulpitisorpulpnecrosisandpotentialbaro-metricpressure–relatedconsequences,thesameauthorcontraindicatesdirectpulpcappinginthemilitaryaircrewpatientandindicatespulpectomyandendodon-tictreatmentinallcariesmanagementinwhichinva-siontothepulpchamberisevidentorsuspected.Thepresentarticlereviewedtheupdatedknowledgeregardingbarodontalgia.Althoughitmayseemthatbarodontalgiawasalmostneglectedindentaleducationandresearchinthesecondhalfofthe20thcentury,duringthepastdecadereportsweregatheredtodrawanupdatedimageofthispainentity.Thisreviewrefutes3generallyacceptedconven-tions:Accordingtotheresults,thecurrentweightedincidenceofin-ightbarodontalgiaissimilartotheincidenceinthersthalfofthe20thcentury,theweightedincidenceofbarodontalgiaamongaircrewsissimilartotheweightedincidenceamongdivers,andtheroleoffacialbarotraumaintheetiologyofin-ightbarodontalgiaisminor.Moreresearchers’,educators’,andclinicians’effortsareneededforfurtherenhancementoftheoreticaswellaspracticalknowledgeofbarodontalgia.1.ZadikY.Aviationdentistry:currentconceptsandpractice.BrDentJ2009;206:11-6.2.EidelmanD.Vertigoofdentalorigin:casereports.AviatSpaceEnvironMed1981;52:122-4.TableIV.Etiologiesofreportedin-ightbarodontalgiaepisodes GonzalezSantiagoMdeletal.,2004Al-Hajri&Al-Madi,Zadiketal.,Sipahietal.,Barosinusitis(“indirectbarodontalgia”)18.5%6.3%9.7%Recentdentaltreatment(“postoperative0NR29.6%011.1%Faultyrestoration/dentalcarieswithoutapparentpulpinvolvement30.8%NR3.7%50.0%29.2%Vitalpulppathology(i.e.,exposure,pulpitis)7.7%NR7.4%21.9%13.9%Necroticpulp/periapicalpathology(includingVRF)53.8%NR22.2%21.9%27.8%Impactedtooth7.7%NR3.7%02.8%notreported;verticalrootfracture.*Mixedpopulationofmilitaryaircrewsanddivers.†14.8%ofthisseriesremainedundiagnosed.‡NotincludingAl-HajriandAl-Madiowingtoincompleteavailabledata.§Althoughnotdiagnosedasbarodontalgiaorigin,30.8%and7.7%concomitantlysufferedfrombarosinusitisandbarotitis,respectively. April2010 3.RottmanK.Barodontalgia:adentalconsiderationfortheSCUBAdivingpatient.QuintessenceInt1981;12:979-82.4.JaggerRG,JacksonSJ,JaggerDC.Inatthedeepend—aninsightintoscubadivingandrelateddentalproblemsfortheGDP.BrDentJ1997;183:3

80-2.5.FerjentsikE,AkerF.Barodontalgia:asystemofclassication.MilMed1982;147:299-304.6.IngleJI,DudleyHG.Differentialdiagnosisandtreatmentofdentalpain.In:IngleJI,BaklandLK,editors.Endodontics.4thed.Baltimore:WilliamsandWilkins;1994.p.444.7.TaylorDM,O’TooleKS,RyanCM.ExperiencedscubadiversinAustraliaandtheUnitedStatessufferconsiderableinjuryandmorbidity.WildernessEnvironMed2003;14:83-8.8.JaggerRG,ShahCA,WeerapperumaID,JaggerDC.Theprevalenceoforofacialpainandtoothfracture(odontocrexis)associatedwithSCUBAdiving.PrimDentCare2009;16:9.Al-HajriW,Al-MadiE.PrevalenceofBarodontalgiaamongpilotsanddiversinSaudiArabiaandKuwait.SaudiDentJ10.ZadikY.Barodontalgia.JEndod2009;35:481-5.11.GonzalezSantiagoMdelM,Martinez-SahuquilloMarquezA,Bullon-FernandezP.Incidenceofbarodontalgiasandtheirrela-tiontooral/dentalconditioninpersonnelwithresponsibilityinmilitaryight.MedOral2004;9:98-105.12.ZadikY,ChapnickL,GoldsteinL.In-ightbarodontalgia:anal-ysisof29casesinmilitaryaircrew.AviatSpaceEnvironMed13.SipahiC,KarMS,DurmazC,DikicierE,BengiU.TürkHavaKuvvetleriuçucupersonelindegörülenbarodontaljiprevalansý.Gülhane哽瀀Dergisi2007;49:1-4.14.KollmannW.Incidenceandpossiblecausesofdentalpainduringsimulatedhighaltitudeights.JEndod1993;19:15.ZadikY.Barodontalgiaduetoodontogenicinammationinthejawbone.AviatSpaceEnvironMed2006;77:864-6.16.HolowatyjRE.Barodontalgiaamongyers:areviewofsevencases.JCanDentAssoc1996;62:578-84.17.GibbonsAJ.In-ightoral-facialpain.BrDentJ2003;194:5.18.ZadikY,EinyS,PokroyR,etal.Dentalfracturesonacuteexposuretohighaltitude.AviatSpaceEnvironMed2006;19.GrossM,EliasharR.Otolaryngologicalaspectsoforofacialpain.In:SharavY,BenolielR,editors.Orofacialpainandheadache.Edinburgh:Mosby;2008.p.95-6.20.ZadikY.Dentalbarotrauma.IntJProsthodont2009;22:354-7.21.HutchinsHC,ReynoldsOE.Experimentalinvestigationofthereferredpainofaerodontalgia.JDentRes1947;26:3-8.22.ShillerWR.Aerodontalgiaunderhyperbaricconditions.OralSurgOralMedOralPatholOralRadiolEndod1965;20:694-7.23.MumfordJM(editor).Painfromtheperiodontaltissues.In:Orofacialpain,3rded.Edinburgh:ChurchillLivingstone;1982.p.234-5.24.RobichaudR,McNallyME.Barodontalgiaasadifferentialdi-agnosis:symptomsandndings.JCanDentAssoc2005;71:25.SeniaES,CunninghamKW,MarxRE.Thediagnosticdilemmaofbarodontalgia:reportoftwocases.OralSurgOralMedOralPatholOralRadiolEndod1985;60:212-7.26.BoggiaR.Theupsanddownsofbarodontalgia.BrDentJ27.LyonKM,HoodJAA,RoddaJC.Barodontalgia:areview,andtheinuenceofsimulateddivingonmicroleakageandontheretentionoffullcastcrowns.MilMed1999;164:222-7.28.AldridgeRD,FenlonMR.Prevalenceoftemporomandibulardysfunctioninagroupofscubadivers.BrJSportsMed29.RauchJW.Barodontalgia—dentalpainrelatedtoambientpres-surechange.GenDent1985;33:313-5.30.ZadikY,EinyS.Aviationdentistry.In:GoldsteinL,editor.Aviationmedicine.TelAviv:IsraeliMinistryofDefense;2006.p.197-208.31.LurieO,ZadikY,EinyS,TarraschR,RavivG,GoldsteinL,etal.Bruxisminmilitarypilotsandnonpilots:toothwearandpsychologicalstress.AviatSpaceEnvironMed2007;78:137-9.32.RossiDG.Healthpolicydirectiveno.411:aviationanddiving-dentalconsiderations.Melbourne:SurgeonGeneral,AustralianDefenceForce;1995.Reprintrequests:Dr.Y.Zadik16ShlomoZemachSt.96190Jerusalem Volume109,Number4 sharp(76.9%)andlocalized(76.9%)ratherthandull(23.1%)anddiffuse(23.1%).Appearanceofin-ightbarodontalgiawasreportedataltitudesof3,000-25,000feet.Thepainmayceaseonreturningtoapproximateonsetlevel(3,000-10,000feet)orgroundatmosphericlevel,butinmanycases(61.5%inonereport),suchaswhenpainiscausedbyperiapicaldiseaseorbyfacialbarotrauma,itlastsupto3daysafterlanding.Becausebarodontalgiaisasymptomratherthanapathologicconditionitself,andinmostcasesreectsaare-upofpreexistingsubclinicaloraldisease,mostofthecommonoralpathologieshavebeenreportedaspossiblesourcesofbarodontalgia.TableIVmarizesthemostcommonconditionsthatwerere-portedascausesofbarodontalgiaduringights.Thecommonetiologicpathologiesforin-ightpainwerefaultydentalrestorationsanddentalcarieswithoutpulpinvolvement(29.2%),necroticpulp/periapicalin-ammation(27.8%),vitalpulppathology(13.9%)andrecentdentaltreatment(“postoperativebarodontalgia”;11.1%).Barosinusitiswasthepainoriginin9.7%ofCasesofbarodontalgiaduetoexternalotiticbaro-trauma(causedbyexpansionofairinearphone)todentalbarotrauma(barometricpressure–relatedfrac-tureofdentalhardtissueand/orrestoration)beenreported.Togetherwithbarosinusitis,theseexam-plesoffacialanddentalbarotrauma,respectively,areuniqueasbarometric-relatedpathologicconditionsthataregeneratedduringightfrompressurechangesratherthanpressure-relatedare-upofpreexistingcon-ditions.Barodontalgiaoriginatedfromreferredpainoffacialbarotraumaistermed“indirectbarodontalgia”(incontrasttodental-induced“directbarodontalgia”).Thecurrentdataareprovingthatindirectbarodontalgiaisresponsiblefortheminority(one-tenth)ofcases,incontrasttosomeargumentsthatthevastmajorityorallbarodontalgiacasesareactuallyreferredpainfromRobichaudandMcNallysuggestedthatperforationintheoraltissue(e.g.,aftersurgicalprocedure)maybepronetobarodontalgiainaircrewsanddiverswhowearoxygenmask,owingtoairpushingintothetissues.BarodontalgiaisstillknownforthedifcultyofobtainingonthegroundadenitivediagnosisoftheTableIII.Featuresofbarodontalgiaepisodes GonzalezSantiagoMdeletal.,Al-Hajri&Al-Madi,Sipahietal.,Jaggeretal.,2009MilitaryaircrewsMilitaryaircrewsMilitaryaircrewsAffectedteethAppearanceupon61.9%NR38.1%NRLevel,feetMilitarydivers需CivilianSCUBAdiversAffectedteethAppearanceupon需NRAscent(resurfacing)需NRLevel,feet需NR需NRAbbreviationsasinTableII*Regardingthecasesinwhichthepainsubsidedduringight.†22.2%sufferedfromdentalpaininbothupperandlowerdentition. Volume109,Number4 causativepathology,becauseevendiagnosticalti-tude-chambersimulationisnotalwayseffectivenorAccordingtoonereport,asmanyas14.8%ofcaseseventuallyremainedundiagnosed.Inthediagnosticprocessingofapatientwhosufferedfrombarodontalgia,obtaininghistoryofrecentdentaltreatments,on-groundprecedingsymptoms,andpainonset/cessation(onascentordescent)andnaturepro-videsinvaluabledata.Theclinicianisadvisedtolookforfaultyrestorations(includingdislodgedrestorationsoveravitalpulp)andsecondary(remaining)cariestoperformvitalitytestandneededperiapicalradiographs,andtoruleoutsinusitisinepisodesofpainintheupperposteriorregionandpainoriginatedfromthetemporomandibularjointormasticatorymusclesinepisodesofin-divingoralpain.Accordingtoonereport,d

espitepostepisodeevaluationandtreatment,recurrenceofbarodontalgiawasreportedin16.4%ofin-ightand25.0%ofin-divingcases.Therewasnopublishedresearchregardingthepathogenesisofbarodontalgiainthepastdecade.De-spitesometheories,mostofferedinthersthalfofthe20thcentury,thepathogenesisofthisuniquedentalpainremainsoccult.Periodicoralanddentalexaminations,includingperia-picalradiographsandvitalitytests,arerecommendedforthepreventionofbarodontalgiainhigh-riskpopulations(e.g.,aircrews,divers).Inaddition,screeningpanoramicradiographsarerecommendedforthesepopulationsat3-5-yearintervals.Specialattentionneedstobepaidforperiapicalpathosis,faultyrestorations,secondarycar-ieslesions,andsignsofteethattrition.Temporaryightrestriction(grounding)afterdentalandsurgicalproceduresisstillapowerfultoolforpreventionofpostoperativebarodontalgia.dictatesthegroundingofmilitaryaircrewsfromtimeofdiagnosingtheneedforendodontictreatmentuntilthecompletionoftreatment.Inaddition,toprevent(sub-clinical)pulpitisorpulpnecrosisandpotentialbaro-metricpressure–relatedconsequences,thesameauthorcontraindicatesdirectpulpcappinginthemilitaryaircrewpatientandindicatespulpectomyandendodon-tictreatmentinallcariesmanagementinwhichinva-siontothepulpchamberisevidentorsuspected.Thepresentarticlereviewedtheupdatedknowledgeregardingbarodontalgia.Althoughitmayseemthatbarodontalgiawasalmostneglectedindentaleducationandresearchinthesecondhalfofthe20thcentury,duringthepastdecadereportsweregatheredtodrawanupdatedimageofthispainentity.Thisreviewrefutes3generallyacceptedconven-tions:Accordingtotheresults,thecurrentweightedincidenceofin-ightbarodontalgiaissimilartotheincidenceinthersthalfofthe20thcentury,theweightedincidenceofbarodontalgiaamongaircrewsissimilartotheweightedincidenceamongdivers,andtheroleoffacialbarotraumaintheetiologyofin-ightbarodontalgiaisminor.Moreresearchers’,educators’,andclinicians’effortsareneededforfurtherenhancementoftheoreticaswellaspracticalknowledgeofbarodontalgia.1.ZadikY.Aviationdentistry:currentconceptsandpractice.BrDentJ2009;206:11-6.2.EidelmanD.Vertigoofdentalorigin:casereports.AviatSpaceEnvironMed1981;52:122-4.TableIV.Etiologiesofreportedin-ightbarodontalgiaepisodes GonzalezSantiagoMdeletal.,2004Al-Hajri&Al-Madi,Zadiketal.,Sipahietal.,Barosinusitis(“indirectbarodontalgia”)18.5%6.3%9.7%Recentdentaltreatment(“postoperative0NR29.6%011.1%Faultyrestoration/dentalcarieswithoutapparentpulpinvolvement30.8%NR3.7%50.0%29.2%Vitalpulppathology(i.e.,exposure,pulpitis)7.7%NR7.4%21.9%13.9%Necroticpulp/periapicalpathology(includingVRF)53.8%NR22.2%21.9%27.8%Impactedtooth7.7%NR3.7%02.8%notreported;verticalrootfracture.*Mixedpopulationofmilitaryaircrewsanddivers.†14.8%ofthisseriesremainedundiagnosed.‡NotincludingAl-HajriandAl-Madiowingtoincompleteavailabledata.§Althoughnotdiagnosedasbarodontalgiaorigin,30.8%and7.7%concomitantlysufferedfrombarosinusitisandbarotitis,respectively. April2010 3.RottmanK.Barodontalgia:adentalconsiderationfortheSCUBAdivingpatient.QuintessenceInt1981;12:979-82.4.JaggerRG,JacksonSJ,JaggerDC.Inatthedeepend—aninsightintoscubadivingandrelateddentalproblemsfortheGDP.BrDentJ1997;183:380-2.5.FerjentsikE,AkerF.Barodontalgia:asystemofclassication.MilMed1982;147:299-304.6.IngleJI,DudleyHG.Differentialdiagnosisandtreatmentofdentalpain.In:IngleJI,BaklandLK,editors.Endodontics.4thed.Baltimore:WilliamsandWilkins;1994.p.444.7.TaylorDM,O’TooleKS,RyanCM.ExperiencedscubadiversinAustraliaandtheUnitedStatessufferconsiderableinjuryandmorbidity.WildernessEnvironMed2003;14:83-8.8.JaggerRG,ShahCA,WeerapperumaID,JaggerDC.Theprevalenceoforofacialpainandtoothfracture(odontocrexis)associatedwithSCUBAdiving.PrimDentCare2009;16:9.Al-HajriW,Al-MadiE.PrevalenceofBarodontalgiaamongpilotsanddiversinSaudiArabiaandKuwait.SaudiDentJ10.ZadikY.Barodontalgia.JEndod2009;35:481-5.11.GonzalezSantiagoMdelM,Martinez-SahuquilloMarquezA,Bullon-FernandezP.Incidenceofbarodontalgiasandtheirrela-tiontooral/dentalconditioninpersonnelwithresponsibilityinmilitaryight.MedOral2004;9:98-105.12.ZadikY,ChapnickL,GoldsteinL.In-ightbarodontalgia:anal-ysisof29casesinmilitaryaircrew.AviatSpaceEnvironMed13.SipahiC,KarMS,DurmazC,DikicierE,BengiU.TürkHavaKuvvetleriuçucupersonelindegörülenbarodontaljiprevalansý.Gülhane哽瀀Dergisi2007;49:1-4.14.KollmannW.Incidenceandpossiblecausesofdentalpainduringsimulatedhighaltitudeights.JEndod1993;19:15.ZadikY.Barodontalgiaduetoodontogenicinammationinthejawbone.AviatSpaceEnvironMed2006;77:864-6.16.HolowatyjRE.Barodontalgiaamongyers:areviewofsevencases.JCanDentAssoc1996;62:578-84.17.GibbonsAJ.In-ightoral-facialpain.BrDentJ2003;194:5.18.ZadikY,EinyS,PokroyR,etal.Dentalfracturesonacuteexposuretohighaltitude.AviatSpaceEnvironMed2006;19.GrossM,EliasharR.Otolaryngologicalaspectsoforofacialpain.In:SharavY,BenolielR,editors.Orofacialpainandheadache.Edinburgh:Mosby;2008.p.95-6.20.ZadikY.Dentalbarotrauma.IntJProsthodont2009;22:354-7.21.HutchinsHC,ReynoldsOE.Experimentalinvestigationofthereferredpainofaerodontalgia.JDentRes1947;26:3-8.22.ShillerWR.Aerodontalgiaunderhyperbaricconditions.OralSurgOralMedOralPatholOralRadiolEndod1965;20:694-7.23.MumfordJM(editor).Painfromtheperiodontaltissues.In:Orofacialpain,3rded.Edinburgh:ChurchillLivingstone;1982.p.234-5.24.RobichaudR,McNallyME.Barodontalgiaasadifferentialdi-agnosis:symptomsandndings.JCanDentAssoc2005;71:25.SeniaES,CunninghamKW,MarxRE.Thediagnosticdilemmaofbarodontalgia:reportoftwocases.OralSurgOralMedOralPatholOralRadiolEndod1985;60:212-7.26.BoggiaR.Theupsanddownsofbarodontalgia.BrDentJ27.LyonKM,HoodJAA,RoddaJC.Barodontalgia:areview,andtheinuenceofsimulateddivingonmicroleakageandontheretentionoffullcastcrowns.MilMed1999;164:222-7.28.AldridgeRD,FenlonMR.Prevalenceoftemporomandibulardysfunctioninagroupofscubadivers.BrJSportsMed29.RauchJW.Barodontalgia—dentalpainrelatedtoambientpres-surechange.GenDent1985;33:313-5.30.ZadikY,EinyS.Aviationdentistry.In:GoldsteinL,editor.Aviationmedicine.TelAviv:IsraeliMinistryofDefense;2006.p.197-208.31.LurieO,ZadikY,EinyS,TarraschR,RavivG,GoldsteinL,etal.Bruxisminmilitarypilotsandnonpilots:toothwearandpsychologicalstress.AviatSpaceEnvironMed2007;78:137-9.32.RossiDG.Healthpolicydirectiveno.411:aviationanddiving-dentalconsiderations.Melbourne:SurgeonGeneral,AustralianDefenceForce;1995.Reprintrequests:Dr.Y.Zadik16ShlomoZemachSt.96190Jerusalem Volume109,Number4 andcompressedtransportaircrafts(8.0%,9.0%,and7

.0%,respectively).Surprisingly,intheSpanishre-port,aircrewsofcompressedaircrafts(5.1%)weremoreaffectedthanthoseofuncompressedaircraftsTheweightedincidenceofbarodontalgiaamongaircrews(11.0%)issimilartodivers(11.9%)despiterequirementoforalhealthmaintenanceandlesserpres-surechangesamongaircrews.Generally,diversaresubjectedtomoreenvironmentpressurethanaircrews;whereasinightthetheoreticallypossiblepressurechangesrangefrom1atmosphereatgroundlevelto0atmosphereatouterspace,indivingthechangesaremoresignicantsinceeach10meters(32.8feet)de-scentelevatesthepressurebyanother1atmosphere.Althoughbarodontalgiawasreportedalsoinmoun-tainclimbingandhyperbaricchamber,researchisavailablefordivingand(military)yingconditionsTableIIIDivingconditionsPainappearsatawaterdepthof33feet,atdepthsof60-80feet.In-diving,upperteetharemoreaffectedthanlowerteeth,andvastmajorityofepi-sodesappearedupondescent.Becauseappearanceofbarosinusitisisusuallyupondescent,whereasdirectbarodontalgiafavorsascension(especiallyinvitalpulpthese2features(i.e.,affectingupperteethmoreandappearingupondescent)mayindicateagreaterroleformaxillarysinuspathologyintheetiol-ogyofin-divingbarotrauma;moreresearchisneeded,FlightconditionsUpperandlowerteethareaffectedequally.Themostaffectedintraoralareasareposteriorupper(50.0%)andlower(37.5%)dentitions,withupperrstmolar(30.8%)andlowerrstmolar(30.8%)themostaffectedteeth.Painintensitywasratedassevere(75.0%)andsevere(25.0%).MostepisodeswerecharacterizedasTableI.Classicationofdirect(dentalinduced)bar- ClassPathologyIIrreversiblepulpitisSharptransient(momentary)painonIIReversiblepulpitisDullthrobbingpainonascentIIINecroticpulpDullthrobbingpainondescentIVPeriapicalpathologySeverepersistentpain(onascent/TableII.Prevalence,incidence,andrateofbarodontalgia* Tayloretal.,2003GonzalezSantiagoMdeletal.,2004Al-Hajri&Al-Madi,Zadiketal.,2007Sipahietal.,2007Jaggeretal.,SpanishmilitaryaircrewsSaudi-Arabian&KuwaitimilitaryaircrewsIsraelimilitaryaircrewsTurkishmilitaryaircrewsPrevalence†需NRNRNR0.3%需0.3%Incidence‡需2.4%49.6%8.2%NR需11.0%Rate§需2NR10NR需5Altitude-chambersimulationsIncidence‡需0.2%NRNRNR需0.2%PopulationAmericanandAustraliancivilianSCUBAdiversSaudi-Arabian&KuwaitimilitarydiversAustraliancivilianSCUBAdiversn709需127需需125Incidence‡9.2%需17.3%需需21.6%11.9%notreported;self-containedunderwaterbreathingapparatus.Theauthorsanalyzed10,651ightsratherthanaircrews-basedanalysisasotherreports.Casesoutofallights.Affectedaircrewsof1episode.Episodesper1,000ight-years. April2010 Barodontalgia:whathavewelearnedinthepastdecade?YehudaZadik,DMD,MHA,Jerusalem,IsraelCENTERFORHEALTHPROMOTIONANDPREVENTIVEMEDICINE,MEDICALCORPS,ISRAELDEFENSEThisarticlereviewsthecurrentknowledgeregardingbarodontalgia,abarometricpressure–relatedoral(dentalandother)pain.Contemporaryclassication,prevalence,andincidence,features,etiology,anddiagnosisofthisentityarepresentedregardingightanddivingconditions.Summarizingthepastdecadedata,three-fourthsofepisodesweredescribedassevere,sharp,andlocalizedpain.Barodontalgiaaffects11.9%ofdiversand11.0%ofmilitaryaircrewswitharateof5episodes/1,000ight-years.Upperandlowerdentitionswereaffectedequallyinight,butmoreupperthanlowerdentitionwereaffectedindiving.Themostprevalentetiologicpathologiesforin-ightdentalpainwerefaultydentalrestorations(includingdentalbarotrauma)anddentalcarieswithoutpulpinvolvement(29.2%),necroticpulp/periapicalinammation(27.8%),vitalpulppathology(13.9%),recentdentaltreatment(11.1%),andbarosinusitis(9.7%).Thisreviewrefutes3generallyacceptedconventions:Accordingtotheresults,thecurrentin-ightbarodontalgiaincidenceissimilartotheincidenceinthersthalfofthe20thcentury,theweightedincidenceofbarodontalgiaamongaircrewsaresimilartotheweightedincidenceamongdivers,andtheroleoffacialbarotraumaintheetiologyofin-ightbarodontalgiaisminor.SurgOralMedOralPatholOralRadiolEndod2010;109:e65-e69)Aconsiderableconcernamongaviationphysiciansanddentistsduringthe1940sandquiteforgottenlater,barodontalgia,abarometricpressure–relatedoral(den-talorother)pain,wasrevisitedinthepastdecade.thedivingenvironment,thispainiscommonlycalled“toothsqueeze,”andthepreviousname“aerodontal-gia,”regardingitsfeatureinight,isstillinuse.Althoughrare,in-divingorin-ightbarodontalgiahasbeenrecognizedasapotentialcauseofdiveroraircrew-membervertigoandsuddenincapacitation,whichcouldjeopardizethesafetyofdivingoright.Theaimofthepresentarticleistoreviewthecurrentknowledge,fromthepastdecade,regardingthispainBarodontalgiaissubgroupedintodirect(dental-in-duced)andindirect(nondental-induced)pain.Thecur-rentlyacceptedclassicationofdirectbarodontalgiaconsistsof4classesaccordingtopulp/periapicalcon-ditionandsymptoms⠀TableIPREVALENCEANDINCIDENCEDivingconditionsBarodontalgiahasbeenexperiencedononeormoreoccasionsby9.2%-21.6%ofAmericanandAustralianself-containedunderwaterbreathingappa-ratus(SCUBA)divers⠀TableIIwasmostprevalentinthethirddecadeoflifeandwithoutgenderpreference.Anadditional16.8%and27.2%ofdiverssufferedfrom“jawpain”and“sinuspain,”respectively.Amongmilitarydivers(allmale),anincidenceof17.3%wasreported.FlightconditionsAdistinctionhastobemadebetweenrealin-ightconditionsandaltitude-chambersimulations;barodon-talgiaisapproximatelytenfoldmoreprevalentintheformerthaninthelaterconditions.TableIItheprevalence,incidence,andrateofbarodontalgiainthepastdecadeaccordingtoSpanish,Saudi-ArabianandKuwaiti,Israeli,andTurkishAirForcere-All4reportsareofmaleaircrews.Dif-ferencesinthereportedincidenceareconsiderableandcanbeattributedtotherelativelysmallgroups,differ-encesinoralhealthconditions,andfrequencyofying,compression,andextremeconditionsofying(e.g.,rapidmaneuveringwiththeconsequentrapidpressureIn-ightbarodontalgiaaffects11.0%ofmilitaryaircrewswitharateof5episodes/1,000ight-years.Thecurrentweightedincidenceofbarodontalgiaduringightissimilartothereportedincidence(9.5%)fromthersthalfofthe20thcentury,despitecurrentaircompressioninsideairplanechambers,high-qualitydentalcare,andenhancementoforalhealthinthesecondhalfofthe20thcentury.Regardingthepre-sumedeffectofchamberaircompressiononbarodon-talgia,intheIsraelireportnodifferencewasfoundinincidenceofbarodontalgiabetweenaircrewsofuncom-pressedhelicopters,semicompressedghteraircraft,Head,ZrinCentralDentalClinic.1079-2104/$-seefrontmatter꤀2010Mosby,Inc.Allrightsreser