Cracked tooth delimma

The Cracked Tooth Dilemma

The incidence of what we call ‘cracked teeth’ is quite high in Trinidad and Tobago. Cracked teeth present with a variety of symptoms with the most common being extreme pain when chewing. Another common complaint is pain to different temperature extremes.

The problem with cracked teeth is that it goes undiagnosed in most cases. For one, cracks of the tooth crown cannot be detected on regular dental x-rays. Secondly, cracks when present on the tooth are not always easy to detect, especially with the naked eye. Therefore, when patients (who have cracks) present with severe symptoms of pain when chewing or temperature extremes, root canal treatment is often initiated without knowledge of a crack or cracks being present.

The unfortunate result of this most commonly would be failure of the root canal treatment. This usually presents as persistent pain or recurrent abscesses/infection after root canal treatment has been completed.

Case 1

In this first example, this patient presented for a second opinion on her upper left first molar. She had root canal treatment started by her general dentist months ago but had a persistent abscess related to this tooth. She was given two course of antibiotics with no relief.

On presentation, she was in no pain. The tooth was sound clinically with no mobility. There was an old amalgam restoration on the mesial and distal and a temporary filling in the access. There was also a small buccal abscess. The radiograph (shown below) revealed periapical infection related to both the mesiobuccal and distobuccal roots.

The patient was advised of the possibility of the crack being present but that an attempt at root canal treatment would be made. The presence of a crack could only be detected once the tooth was entered and viewed under the dental operating microscope. On entering the tooth, a crack was detected on the mesial aspect of the tooth extending onto the pulp chamber floor.

What this means is the crown of the tooth has been split (separated). Even if we place a crown on this tooth, it is still susceptible to infection and the possibility for further spread of the crack exists. The patient was advised that extraction would be necessary.

Case 2

This patient presented to her dentist with extreme pain on the right side of her face. The pain came on mostly after chewing. Her dentist identified the tooth in question to be the upper right second premolar. This tooth had no restorations or any visible abnormalities. When the tooth was tapped on the palatal cusp she experience some discomfort. The tooth responded normally to cold and the other teeth in that quadrant seemed fine.

When viewed under the microscope however, the tooth appeared to have a crack occlusally with a small breakage of enamel on the mesio-occlusal aspect:

She was advised of the presence of a crack and of the need for root canal therapy once the crack did not extend too deep. On entry to the tooth the presence of a crack was confirmed:

This crack again was a disastrous one as it spread from one side of the tooth to the next “splitting” it in two. This patient was again advised of the need for extraction.

Predisposing factors

There are various predisposing factors for cracked teeth. The most common in our country seem to be the presence of large amalgam restorations that have been present for several years on posterior teeth. The presence of the amalgam fillings tends to put stress on the remaining tooth structure in conjunction with normal biting forces. Over the years, the stresses add up and make the tooth susceptible to these cracks.

Another important factor is diet. Constantly chewing hard food such as bone, ice, nuts or bottle opening are common causes of cracked teeth. In addition some people may have parafunctional habits such as bruxism (grinding) or clenching their teeth. This may predispose to cracked teeth by itself or in conjunction with the other factors.

In summary, it is important to be aware of the early signs of cracked teeth and to get this diagnosed or ruled out early by the appropriate clinician. The microscope in conjunction with other aids are appropriate means in diagnosing cracked teeth.

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