General Updates

Diagnosing Cracked Teeth. Operation Complex.

 

In Australia, the average dentist sees at least one patient with cracked tooth syndrome (CTS) per week (Bader et al 1995), so managing this condition is bread and butter work.  When dealing with CTS a good outcome relies on an accurate diagnosis but this can vary from straightforward diagnostic results to complex, inconsistent signs and symptoms that are difficult to distinguish from other dental and non-dental pathologies.

A detailed pain history is a good place to start. First and foremost, look out for pain on biting. Sensitivity to cold/sweet/hot, and symptoms of reversible/irreversible pulpitis may be reported too. Where there is periodontal involvement due to advanced CTS or vertical root fracture, there may also be recurrent swelling, or a feeling of vague pain or pressure. Patients with a cracked tooth often report having made multiple dental visits, with only temporary pain relief achieved.

I think it’s important to distinguish between what we refer to as CTS, and vertical root fracture. CTS usually occurs in a vital tooth. The pain that is felt is a response of the vital pulp and progression of the condition relates to increasing inflammation of the pulp due to bacterial infiltration of the crack. Vertical root fracture occurs most commonly (but not exclusively) in root filled teeth. The pain that is felt is periodontal in nature and relates to infection of the crack.

When it comes to conducting the examination, we’re looking to confirm first the diagnosis of CTS, and secondly diagnose the pulp. These include, in order of importance:

  • Bite tests to reproduce the chief complaint. By far the best method is to use a ‘Tooth Slooth’ or ‘FracFinder’. Cotton rolls, rubber wheels etc. can be used, but they can’t as accurately isolate pressure to one part of the tooth.

Note: Though pain on release is considered to be a classic sign of a cracked cusp, one study actually found that 68% of cracked tooth cases had pain only when pressure was applied (Abbott & Leow 2009). That said, if you do find that the pain is significantly worse on release than on biting, you can be comfortable with the diagnosis of CTS.

  • Perio probing – presence of a deep, narrow pocket at a single site may indicate a vertical root fracture or endo lesion draining through the periodontium.

In this xray you can see the two molars present with lucencies that surround the coronal portion of the mesial roots. The video below is not the best quality, but you get the drift of how a vertical root fracture presents. A vertical root fracture usually presents as a deep, narrow pocket. Locating a pocket such as this can only be done adequately under local anaesthesia.

Note the lucency surrounding the mesial roots of the first and second molars, yet there is no distinct periapical lucency. This is suggestive or vertical root fracture. The video below shows the periodontal probing pattern.

httpv://youtu.be/8P5trYcaNII

  • Visual examination (with dental operating microscope and rubber dam for best results). Pay particular attention to marginal ridge areas. Restoration removal is ESSENTIAL to visualise the crack completely.
Diagnosis of Cracked Tooth

Removal of the restoration allows the full extent of the crack to be visualised.

  • Staining and/or transillumination – staining the crack with methylene blue + transillumination is a good combination to confirm the presence of a crack. (Wright et al. 2004).
  • Pulp testing – The pulp is usually vital in CTS and non-vital in vertical root fracture, but you need to confirm this, because the status of the pulp will help determine treatment.
  • Palpation, percussion testing, mobility testing as per ususal to confirm pulpal and periapical status.
  • Radiographic examination – may not be useful in actually identifying the crack, but it can help to rule out other options during your differential diagnosis stage. In cases of complete vertical root fracture, you may be able to see periradicular bone loss (a ‘halo’ radiolucency). There is plenty of debate as to whether CBCT can confirm the presence of a crack, and I would be wary of relying on this for diagnosis.

I’ll discuss my preferred method of management of CTS in an upcoming post.

References

Abbott, P,  Leow, N 2009. Predictable management of cracked teeth with reversible pulpitis. Aust Dent J, 54, 306-15.

Bader, JD, Martin, JA,  Shugars, DA 1995. Preliminary estimates of the incidence and consequences of tooth fracture. J Am Dent Assoc, 126, 1650-4.

Wright, HM, Jr., Loushine, RJ, Weller, RN, Kimbrough, WF, Waller, J,  Pashley, DH 2004. Identification of resected root-end dentinal cracks: a comparative study of transillumination and dyes. J Endod, 30, 712-5.

1 thoughts on “Diagnosing Cracked Teeth. Operation Complex.

  1. Pingback: Classifying Cracked Teeth. Operation Complex Part II | the endo spot

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