On almost a daily basis I am challenged with trying to diagnose a “cracked” tooth. The easy ones are accompanied by the classic symptoms and respond positively to biting on a Tooth Sleuth or Orange Wood stick. It is all of the others that require diligent thinking and some debate about if treatment is necessary. The American Association of Endodontists have classified five types of cracked teeth: craze line, fractured cusp, cracked tooth, split tooth, and vertical root fracture. Unfortunately this classification doesn’t make things any clearer for me as I am still left with this very broad category called “cracked tooth”.
My protocol differentiates cracks that are stained versus ones that aren’t. In my mind if the space between the parts of the tooth is large enough that stain can penetrate, than the risk of caries or continued fracture warrants a preventative treatment. Over the years I have seen more and more teeth that have no apparent interproximal decay on a radiograph, but a fracture line that is stained over a marginal ridge. When I open the tooth up I find a broad band of decay right at the DEJ as the bacteria have migrated into the DEJ in the crack and then spread laterally. Equally disturbing are the cracks that stick an explorer tip. For all three of these types of “cracked tooth” I recommend treatment. Often if the tooth has a small existing restoration and the crack is over a marginal ridge or buccal or lingual grove I will start by attempting to do a direct restoration and prep away the crack. I explain to the patient that once the old filling is out if the crack is more extensive than it appears on the surface I will recommend a crown or onlay. Teeth that are already exhibiting symptoms require more complex restorative options.
Cracked Tooth Symptoms
- Pain on biting describes as sharp or stabbing
- Worse on release
- Disappears as soon as they stop biting
- No spontaneous pain
- No temperature response
This is all fine Lee, if all that is necessary is a simple direct restoration.
I find it, however, very difficult to make a decision, in the cases when endodontics is necessary and the fracture line has reached the mesial or distal edge of the tooth
So often, after placing a cast restoration, I find a few years later that a vertical fracture of the root has developed and the tooth has to be extracted.
In these cases it would have been better to extract the tooth at the outset!!
What is your protocol in these cases?
Avron,
I am going to hold off answering this for a day or two, as there are two upcoming posts that continue this conversation abotu cracked teeth and diagnosing endodontic concerns that may handle it.
Lee
I would add “tingling” sensation patients report as well as occasional cold sensitivity when the crack compresses. I have had these symptoms in patients over the years, as well. Those tend to be the deeper cracks or the teeth that have multiple fracture lines, in my experience. What do you think?
Muna,
This is great information. I have personally not put “tingling” in my differential, but I will from mow on, thank You!
Lee