Doug Kase
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is a sure bet that at one time or another you have wanted to tell a patient
in your practice, “You’re cracked!” The incidence of cracks
in teeth seems to be on the rise. Whether it is the stressful environment
in which we live that is forcing us into crack-producing habits such as
bruxism and clenching or just the fact that we keep our teeth to an older
age, the cracked tooth and its symptoms are here to stay. The key
to saving these teeth is early diagnosis and treatment.
The diagnosis of a cracked tooth can be a frustrating
and time-consuming experience for dentist and patient. If it is not
done correctly, it can result in too little treatment, which can lead to
premature tooth loss or unnecessary treatment.
Symptoms
“Cracked Tooth Syndrome” symptoms are variable and may not present
themselves consistently due to difference in direction, location, and extent
of the crack. Teeth with cracks may have erratic pain on mastication,
particularly on the release of pressure rather than with the increased
biting force. Additionally, pain, especially to cold, is a telltale
sign. However, absence of pain does not rule out the presence of
a crack.
Usually there is no percussive pain and no radiographic
pathology. Some patients will note a prolonged history of pain or
discomfort that could not be diagnosed or treated. The presence of
the crack does not always involve the pulp, but if the crack extends to
the root surface, a periodontal pocket may be associated with it.
Cracks usually start out small and then grow with time and function.
Thus, an early diagnosis will lead to a better prognosis.
Clinical Tests
When a patient presents for a cracked tooth diagnosis, a number of
clinical tests should be performed. Prior to these tests, a thorough
dental history should be taken. Check for a history of trauma, clenching
or bruxism habits, other masticatory habits (such as chewing ice), or a
history of occlusal adjustments for relief of the symptom or a history
of other cracked teeth.
A clinical and visual exam comes next. Have
the patient point you in the right direction, keeping in mind that the
patient's perceptions may not be accurate. Examine the teeth with a sharp
explorer, check for craze lines in the enamel that are stained darker,
palpate and probe the gingiva for pocketing that may be related to a vertical
root fracture. Usually these pockets are narrow with little movement
of the probe from side to side.
Check for cracked restoration and use transillumination
with magnification to help visualize the suspected crack. The surgical
microscope is a wonderful adjunct and may be all that is necessary to visualize
and diagnose the crack. Using a cotton roll, have the patient
chew down on it like chewing gum, isolating each tooth in the suspected
area. A rubber wheel or bite stick can also be used. A device
called a “Tooth Sleuth” can be used to isolate the individual cusp of the
tooth that is cracked.
A sharp and increased response to a stimulus as
compared to adjacent and contralateral teeth may also indicate the presence
of a crack. A long sustained response may indicate pulpal involvement.
Cracks generally do not show on radiographs unless they are perpendicular
to the X-ray film. However, the long-term effects of cracks may eventually
appear. Changes in the pulp chamber, PDL, or even the beginning of
periapical radiolucency could be signs of the presence of a crack.
Look at endodontically treated teeth for sealer expressed out of a fracture
line or the position, length, and thickness of a post in relation to the
suspected fracture.
Restoration removal may be necessary to help visualize
the crack and assess its position in regards to pulpal involvement. Cracks
versus craze lines can be solved with transillumination. Remember that
most adult teeth have craze lines, which are only in the enamel, are painless
and only of aesthetic concern. When illuminated, craze lines will allow
the light to pass through them and illuminate the whole crown. If there
is actually a crack in the tooth, the light will not pass through the crack
and will not illuminate the complete tooth.
A common crack affecting the dentin but not requiring
endodontics is a cuspal fracture. These fractures are easy to diagnose
and the easiest to restore.
The Patient’s Needs
The diagnosis of a cracked tooth can be difficult, but there is no
doubt that it must be done with expediency.
Prividing a solution to your patient’s elusive problem,
no matter what the prognosis satisfies the patient’s reasons for having
sought your expertise and allows the patient to initiate the appropriate
treatment plan.
11/02/1999
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