Cracked tooth syndrome. Part 1: aetiology and diagnosis

Occlusal veneer restoration treatment outcomes of cracked tooth syndrome: A 22.4-month follow-up study

OBJECTIVES

The aims of this clinical study were to investigate success rate, vital pulp survival rate, tooth survival rate and patient-reported masticatory ability by evaluating the pain symptoms and signs of the cracked teeth as well as Index of Eating Difficulty (IED) and Oral Health Impact Profile-14 (OHIP-14) questionnaire after cracked teeth were restored with occlusal veneers.

MATERIALS AND METHODS

27 cracked teeth of 24 patients with cold and/or biting pains without spontaneous/nocturnal pains were recruited in this study. The cracked teeth were restored with occlusal veneers fabricated by lithium disilicate ceramic. Cold test and biting test were used to evaluate pain signs. IED and OHIP-14 questionnaire were used to evaluate masticatory ability. FDI criteria was used to evaluate restorations. The paired Wilcoxon test was used to analyze significant differences of detection rate of pain signs, OHIP scores and IED grade before and after restorations. Kaplan-Meier survival curve was used to describe the success rate, vital pulp survival rate, and tooth survival rate.

RESULTS

27 cracked teeth were restored with occlusal veneers with average of 22.4-month follow-up. Two cracked teeth had pulpitis and pain signs of the other cracked teeth completely disappeared. OHIP total scores were significantly reduced after treatment. Scores of 'pain', 'occlusal discomfort', 'uncomfortable to eat', 'diet unsatisfactory' and 'interrupted meals' reduced significantly after treatment. After treatment, IED grades of 25 vital teeth were significantly lower than those before treatment. FDI scores of 25 restorations except for 2 teeth with pulpitis were no greater than 2. The 12 months accumulated pulp survival rate of the cracked teeth was 92.6%. The 12 months accumulated tooth survival rate was 100%. The success rate at the latest recall was 92.6%.

CONCLUSION

Occlusal veneer restorations with success rate of 92.6% and the same pulp survival rate might be an effective restoration for treating the cracked teeth.

CLINICAL RELEVANCE

The occlusal veneer restorations might be an option for treating the cracked teeth when cracks only involve enamel and dentin, not dental pulp.

Australian Dentist's Knowledge and Perceptions of Factors Affecting Radiographic Interpretation

BACKGROUND

Errors of interpretation of radigraphic images, also known as interpretive errors, are a critical concern as they can have profound implications for clinical decision making. Different types of interpretive errors, including errors of omission and misdiagnosis, have been described in the literature. These errors can lead to unnecessary or harmful treat/or prolonged patient care. Understanding the nature and contributing factors of interpretive errors is important in developing solutions to minimise interpretive errors. By exploring the knowledge and perceptions of dental practitioners, this study aimed to shed light on the current understanding of interpretive errors in dentistry.

METHODS

An anonymised online questionnaire was sent to dental practitioners in New South Wales (NSW) between September 2020 and March 2022. A total of 80 valid responses were received and analysed. Descriptive statistics and bivariate analysis were used to analyse the data.

RESULTS

The study found that participants commonly reported interpretive errors as occurring 'occasionally', with errors of omission being the most frequently encountered type. Participants identified several factors that most likely contribute to interpretive errors, including reading a poor-quality image, lack of clinical experience and knowledge, and excessive workload. Additionally, general practitioners and specialists held different views regarding factors affecting interpretive errors.

CONCLUSION

The survey results indicate that dental practitioners are aware of the common factors associated with interpretive errors. Errors of omission were identified as the most common type of error to occur in clinical practice. The findings suggest that interpretive errors result from a mental overload caused by factors associated with image quality, clinician-related, and image interpretation. Managing and identifying solutions to mitigate these factors are crucial for ensuring accurate and timely radiographic diagnoses. The findings of this study can serve as a foundation for future research and the development of targeted interventions to enhance the accuracy of radiographic interpretations in dentistry.

A narrative review of cracks in teeth: Aetiology, microstructure and diagnostic challenges

OBJECTIVES

To summarize the available evidence of crack formation in teeth and to discuss the limitations of the current clinical diagnostic modalities for crack detection in teeth.

BACKGROUND

Cracks are a common clinical finding in teeth and yet clinicians still struggle to identify the full extent and orientation of cracks for their appropriate timely management. The biomechanics of crack development can be due to multiple factors and can differ from an unrestored tooth to a restored or endodontically treated tooth.

DATA & SOURCES

This narrative review has been designed following the guidelines published by Green et al. 2006 [1] Published literature in the English language that addresses the objectives of this review up to July 2022 was sourced from online databases and reference lists. The relevance of the papers was assessed and discussed by two reviewers. A total of 101 publications were included in this narrative review.

CONCLUSIONS

The initiation and development of cracks in teeth are likely linked to an interplay between the masticatory forces and fracture resistance of the remaining tooth structure. From the identified literature, the quality and quantity of remaining tooth structure in a restored or endodontically-treated tooth affects the biomechanics of crack development compared to an unrestored tooth. The extent, orientation, and size of the cracks do affect a clinician's ability to detect cracks in teeth. There is still a need to develop reliable diagnostic tools that will accurately identify cracks in teeth beneath restorations to enable effective monitoring of their propagation and provide appropriate interventions.

CLINICAL SIGNIFICANCE

The development and propagation of cracks in an unrestored tooth differ greatly from a restored and endodontically treated tooth; mainly linked to the quantity and quality of the remaining tooth structure and the forces acting on them. Identifying the extent of cracks in teeth remains challenging for early clinical intervention.

Management and prognosis of a vital cracked tooth by occlusal veneer for 14 months: A case report

Key Clinical Message

An occlusal veneer is an ultrathin restoration method and a minimally invasive approach that can preserve more dental tissue and provide better aesthetic outcomes, thus increasing patient satisfaction.

Abstract

An occlusal veneer is an ultrathin restoration method and a minimally invasive approach that can preserve more dental tissue and provide better aesthetic outcomes, thus increasing patient satisfaction; however, no previous studies reported on treating cracked teeth using occlusal veneer. Accordingly, we described the diagnosis and treatment process of a cracked tooth using occlusal veneer in a single case. A 29-year-old male presented at our dental clinic complaining of biting pain in the mandibular molar on the right-hand side. A routine oral examination with radiography was performed to evaluate the oral condition and treatment planning. The #16 tooth had a crack line surrounding the whole distal-lingual cusp from the occlusal surface. After discussing various therapeutic options with the patient, an occlusal veneer was performed. One week after treatment with occlusal veneer, the patient had no complaints. A 14-month follow-up showed promising clinical and radiographic outcomes. Occlusal veneer is an alternative treatment option for a cracked tooth, as it can preserve more dental tissue and potentially save pulp vitality.

Milled Crown on Post Crack Tooth Syndrome as the Denture Abutment Tooth: A Case Report

This clinical case describes using a milled crown on a cracked tooth as the abutment for a removable partial denture. A 63-year-old male patient diagnosed with lipoma undergoing chemotherapy and radiotherapy presented with symptomatic crack tooth syndrome on tooth 36 and partial edentulism. Conservative treatment using a molar band to extracoronally splint the tooth was conducted to determine the prognosis of the crack line. A lower partial cobalt-chromium denture was constructed by incorporating the milled crown of tooth 36 as the abutment. After six months of follow-up, there were no crack tooth symptoms, and regular review was adopted to monitor the tooth. The construction of a milled crown of a cracked tooth presented good and promising clinical outcomes in preserving tooth vitality and preventing crack propagation in partially dentate dentition for the long term.

Mathematical tools for recovery of the load on the fissure according to the micro-CT results

In the present paper X-ray microtomographic research of a molar tooth was conducted. The study revealed regions with a reduced mineral density in the vicinity of the fissure tip. The basic assumption investigated is that corrosion induced enamel mineral density decrease is enhanced by high tensile stresses generated by mechanical load on the occlusal surface of the tooth during crushing of food. Magnitude and location of tensile stress concentration occurs at the fissure tip and may be determined by solving the problem of the stress-strain state of the tooth crown enamel with a wedge-shaped notch. The study of stresses in the vicinity of fissure tip make it possible to construct the boundaries of enhanced enamel virtual fracture. Comparison of the sizes and locations of areas with a reduced enamel mineral density with the sizes and locations of areas of virtual enamel fracture made it possible to establish their approximate congruence. This circumstance made it possible to recreate by mathematical means the nature and magnitude of the force load on the lateral surface of the fissure. Degree of influence of the main parameters of the fissure on the geometrical characteristics of the virtual fracture, such as its area and diameters, were determined.

Evaluation of the clinical efficacy of quantitative light-induced fluorescence technology in diagnosing cracked teeth

BACKGROUND

This retrospective study evaluated the clinical efficacy of quantitative light-induced fluorescence (QLF) technology for crack detection and the diagnosis of cracked teeth and assessed the possibility of a quantitative evaluation of cracks using QLF technology.

METHODS

Patients who were clinically diagnosed with cracked teeth over a 1-year period were included. The QLF images of the corresponding symptomatic cracked teeth and asymptomatic contralateral teeth with crack lines were taken with Qraypen C (AIOBIO, Seoul, Korea). Fluorescence loss (ΔF), maximum fluorescence loss (ΔFmax), red fluorescence (ΔR), and maximum red fluorescence (ΔRmax) of the crack line were analyzed. The correlation between these parameters and sex, age, tooth position (1st premolar, 2nd premolar, 1st molar, 2nd molar), spontaneous pain (+/-), percussion test (+/-), cold test (++/+/-), and bite test (+/-) were statistically analyzed.

RESULTS

A total of 66 patients were included. Twenty-four patients had asymptomatic contralateral teeth with apparent crack lines; thus, 90 teeth were analyzed. The crack lines in 84 teeth observed as red fluorescent lines on the QLF images showed ΔR values higher than the cut-off value set by the analysis program used. The patient's age and the ∣ΔF∣ and ΔR values were positively correlated. However, there was no statistically significant difference in the QLF parameters between the same patient's symptomatic tooth and the contralateral tooth.

CONCLUSIONS

QLF technology is a useful assistive diagnostic device for diagnosing cracked teeth.

Diagnosis of cracked tooth: Clinical status and research progress

Cracked tooth is a common dental hard tissue disease.The involvement of cracks directly affects the selection of treatment and restoration of the affected teeth.It is helpful to choose more appropriate treatment options and evaluate the prognosis of the affected tooth accurately to determine the actual involvement of the crack.However, it is often difficult to accurately and quantitatively assess the scope of cracks at present.So it is necessary to find a real method of early quantitative and non-destructive crack detection.This article reviews the current clinical detection methods and research progress of cracked tooth in order to provide a reference for finding a clinical detection method for cracked tooth.

An overview of assessment and management of acute dental pain

Dental care practitioners are often the first port of call for patients presenting with acute dental pain. Due to the increasing backlog of patients in the UK resulting from the COVID-19 pandemic, it is expected that an increasing number of patients will present to dental care practitioners with acute dental problems. This article aims to provide an overview of common presentations of acute dental pain, the importance of thorough assessment and accurate diagnosis, and the management of such conditions.

Wavelet Guided 3D Deep Model to improve Dental Microfracture Detection

Epidemiological studies indicate that microfractures (cracks) are the third most common cause of tooth loss in industrialized countries. An undetected crack will continue to progress, often with significant pain, until the tooth is lost. Previous attempts to utilize cone beam computed tomography (CBCT) for detecting cracks in teeth had very limited success. We propose a model that detects cracked teeth in high resolution (hr) CBCT scans by combining signal enhancement with a deep CNNbased crack detection model. We perform experiments on a dataset of 45 ex-vivo human teeth with 31 cracked and 14 controls. We demonstrate that a model that combines classical wavelet-based features with a deep 3D CNN model can improve fractured tooth detection accuracy in both micro-Computed Tomography (ground truth) and hr-CBCT scans. The CNN model is trained to predict a probability map showing the most likely fractured regions. Based on this fracture probability map we detect the presence of fracture and are able to differentiate a fractured tooth from a control tooth. We compare these results to a 2D CNN-based approach and we show that our approach provides superior detection results. We also show that the proposed solution is able to outperform oral and maxillofacial radiologists in detecting fractures from the hr-CBCT scans. Early detection of cracks will lead to the design of more appropriate treatments and longer tooth retention.

Recent Advances in the Diagnosis of Enamel Cracks: A Narrative Review

Cracked teeth can pose a diagnostic dilemma for a clinician as they can mimic several other conditions. The constant physiological stress along with any pathological strain like trauma or iatrogenic causes can lead to the development of microcracks in the teeth. Constant exposure to immense stress can cause the progression of these often-undiagnosed tooth cracks to cause tooth fractures. This review aims to outline the etiology of tooth cracks, their classification, and recent advances in the diagnosis of enamel cracks. Diagnosing a cracked tooth can be an arduous task as symptoms differ according to the location and extension of the incomplete fracture. Early detection is critical because restorative treatment can prevent fracture propagation, microleakage, pulpal or periodontal tissue involvement, and catastrophic cusp failure. Older methods of crack detection are not sensitive or specific. They include clinical examination, visual inspection, exploratory excavation, and percussion test. The dye test used blue or gentian violet stains to highlight fracture lines. Modern methods include transillumination, optical coherence tomography Swept-Source Optical Coherence Tomography (SSOCT), near-infrared imaging, ultrasonic system, infrared thermography, and near-infrared laser. These methods appear to be more efficacious than traditional clinical dental imaging techniques in detecting longitudinal tooth cracks. Clinically distinguishing between the various types of cracks can be difficult with patient-reported signs and symptoms varying according to the location and extension of the incomplete fracture. Cracks are more common in restored teeth. Technological advances such as transillumination allow for early detection and enhanced prognosis.

Mouthwash as a non-invasive method of indocyanine green delivery for near-infrared fluorescence dental imaging

SIGNIFICANCE

X-ray imaging serves as the mainstream imaging in dentistry, but it involves risk of ionizing radiation.

AIM

This study presents the feasibility of indocyanine green-assisted near-infrared fluorescence (ICG-NIRF) dental imaging with 785-nm NIR laser in the first (ICG-NIRF-I: 700 to 1000 nm) and second (ICG-NIRF-II: 1000 to 1700 nm) NIR wavelengths.

APPROACH

Sprague Dawley rats with different postnatal days were used as animal models. ICG, as a fluorescence agent, was delivered to dental structures by subcutaneous injection (SC) and oral administration (OA).

RESULTS

For SC method, erupted and unerupted molars could be observed from ICG-NIRF images at a short imaging time (<1  min). ICG-NIRF-II could achieve a better image contrast in unerupted molars at 24 h after ICG injection. The OA could serve as a non-invasive method for ICG delivery; it could also cause the glow-in-dark effect in unerupted molars. For erupted molars, OA can be considered as mouthwash and exhibits outstanding performance for delivery of ICG dye; erupted molar structures could be observed at a short imaging time (<1  min) and low ICG dose (0.05  mg  /  kg).

CONCLUSIONS

Overall, ICG-NIRF with mouthwash could perform in-vivo dental imaging in two NIR wavelengths at a short time and low ICG dose.

Periodontal Manifestations in Vertical Root Fractured Teeth

Vertical root fractures are more commonly encountered following endodontic treatment and in teeth without endodontic treatment, with habits like bruxism and eating coarse, hard food. The teeth most predisposed to fracture are the premolars of the maxilla and mandible, the mesial roots and mesiobuccal roots of the mandibular molars, maxillary molars and the mandibular incisors. Timely identification of cracked teeth and fractures is the key since it permits a conservative and preventive approach. Delay in diagnosis and treatment will result in the involvement of the underlying periodontium, causing periodontal pockets, abscess formation, and bone loss, thereby further complicating the outcome. Appropriate diagnosis, education, and counseling of the patient by the dentist and coronal restoration following root canal treatment are mandatory to prevent the loss of teeth in patients. The prognosis of multirooted teeth is more favorable. Affected single-rooted teeth may, however, require immediate extraction. MEDLINE database and Scopus search (www.scopus.com) were performed using the key words “vertical root fracture” or “longitudinal root fracture.” Text book chapters were manually checked.

Fatigue analysis of restored teeth longitudinally cracked under cyclic loading

OBJECTIVE

To investigate the fatigue behavior of restored teeth, in particular the mechanisms of longitudinal dentinal cracking under cyclic mechanical loading, using finite element analysis (FEA) and the stress-life (S-N) approach.

METHODS

Ten root-filled premolars restored with resin composites were subjected to step-stress cyclic loading to produce longitudinal cracks. Fracture loads and number of cycles completed at each load level were recorded. FEA was used to predict the stress amplitude of each component under the global cyclic load. Both intact and debonded conditions were considered for the dentin-composite interface in the FEA. The predicted stress concentrations were compared with the fracture patterns to help elucidate the failure mechanisms. The S-N approach was further used to predict the lifetimes of the different components in the restored teeth. Cumulative fatigue damage was represented by the sum of the fractions of life spent under the different stress amplitudes.

RESULTS

Longitudinal cracks were seen in ~50% of the samples with a mean fracture load of 770 ± 45 N and a mean number of cycles to failure of 32,297 ± 12,624. The longitudinal dentinal cracks seemed to start near the line angle of the cavity, and propagated longitudinally towards the root. The sum of fractions of life spent for the dentin-composite interface exceeded 1 after ~7000 cycles when that for dentin was much lower than 1, indicating that interfacial debonding would occur prior to dentin fracture. This was supported by micro-CT images showing widened interfacial space in the cracked samples. In the debonded tooth, FEA showed dentinal stress concentrations at the gingival wall of the cavity, which coincided with the longitudinal cracks found in the cyclic loading test. The sum of fractions of life spent for dentin was close to 1 at ~30,000 cycles, similar to the experimental value.

SIGNIFICANCE

Debonding of the dentin-composite interface may occur prior to longitudinal cracking of dentin in root-filled teeth under cyclic loading. The approximate time of occurrence for these events could be estimated using fatigue analysis with stresses provided by FEA. This methodology can therefore be used to evaluate the longevity of restoration designs for root-filled teeth.

Review of Cracked Tooth Syndrome: Etiology, Diagnosis, Management, and Prevention

Cracked tooth syndrome refers to a series of symptoms caused by cracked teeth. This article reviews the current literature on cracked tooth syndrome from four aspects, etiology, diagnosis, management, and prevention, to provide readers integrated information about this. The article begins with an introduction to the odontiatrogenic factors and then covers the noniatrogenic factors that induce cracked tooth syndrome. While the former discusses inappropriate root canal therapy and improper restorative procedures, the latter covers the topics such as the developmental and functional status of cracked tooth syndrome. This is then followed by the description of common clinical diagnosis methods, the prospects of new technologies, and summaries of current clinical management methods, including immediate management and direct and indirect restoration. In the final section, preventive methods and their importance are proposed, with the aim of educating the common population.

"THE CORRELATION OF CRACK LINES AND DEFINITIVE RESTORATIONS WITH THE SURVIVAL AND SUCCESS RATES OF CRACKED TEETH: A LONG-TERM RETROSPECTIVE CLINICAL STUDY"

INTRODUCTION

Cracked teeth (CT) frequently require protective adhesive restorations. This long-term, longitudinal retrospective clinical study aimed to evaluate the factors influencing the success and survival rates of CT with crack lines (CLs) in different directions, when restored early with onlays or full-coverage crowns.

METHODS

The dental records of 71 patients with a total of 86 CT, with different pulpal and periapical diagnoses, and with follow-ups spanning over 1-11 years were included. Data regarding the demographics; clinical symptoms and signs; bruxism; occlusal interferences; eating habits; pulpal and periapical diagnoses; number, direction, location, and extent of crack lines; probing depth; and coronary condition before and after the placement of definitive restorations were collected. Univariate associations between tooth survival and explanatory variables were assessed. The long-term survival rate was estimated using the Kaplan-Meier analysis and the log-rank test. A multivariate analysis was performed using Cox regression analysis.

RESULTS

The overall success rate was 93.0%, and the overall survival estimates of CT restored early were 98.6%, 94.9% and 55.9% at the 1-, 5-, and 11-year follow-ups, respectively. The direction of the CLs did not influence the survival of the tooth. No significant association was observed between the type of tooth, probing depth, root canal treatment (RCT), and tooth loss (P>0.05). The multivariate analysis showed that previously treated CT (P<0.05), provision of onlay restorations (P<0.05), and placement of posts (P<0.05) had higher correlations with tooth loss. Additionally, placement of full-coverage crowns resulted in lower tooth loss compared with the placement of onlays (P<0.05).

CONCLUSION

Previous endodontic treatment in teeth that subsequently develop CLs has a negative impact on the survival rate of the teeth. Moreover, early placement of full-coverage crowns should be implemented for CT, regardless of the direction or number of CLs, since it is associated with a higher cracked tooth survival rate.

Sucrose Is Not the Whole Story: Risk Factors and Oral Health at the Contact (Yakutia, Siberia-16th/19th)

Simple Summary

We have studied the dental epidemiology of 96 frozen bodies from north-eastern Siberia (Yakuts) before and after the contact—with an accurate chronology–between Autochthonous and European populations. The peculiarities of the Yakut population are the rarity of cavities and the relative frequency of dental pathologies leading to death. Dental health evolves only two centuries after the contact; assimilation into the Russian Orthodox culture has decreased tooth wear and increased tooth loss. A comparison with historical data suggests that this evolution is not linked to the increasing importance of sucrose, but to the combined action of the substitution of dendrophagia with cereal flour; a decrease in immunity associated with the development of chronic infectious diseases; smoking as well as the mandibular torus: a risk factor favoring apical cysts.

Abstract

(1) Background: contact between indigenous and European populations has often resulted in changes in oral health attributed to the introduction of sucrose. Most studies are per tooth over considerable periods and with few ethnological references. (2) Aim: dental epidemiology of 96 autochthonous frozen bodies from Yakutia between the early 17th century and the late 19th century; comparisons with historical texts and ethnographic data. (3) Material and methods: we use descriptive statistics and discriminant factorial analyses to identify dominant variables in the dataset and compare periods and subjects, considering all variables. (4) Results: the peculiarities of the population are the rarity of cavities and the relative frequency of dental pathologies leading to death. Assimilation into the Russian Orthodox culture has led to decreased tooth wear and an increase in tooth loss. Dental health evolves only two centuries after the contact. (5) Conclusions: the confrontation with historical data suggests that changes are not related to the growing importance of sucrose but to a combined action: the substitution of dendrophagy by cereal flour; the decrease in immunity linked to the development of chronic infectious diseases; tobacco addiction and the mandibular torus: a risk factor promoting apical cysts.

The Effectiveness of a Quantitative Light-induced Fluorescent Device for the Diagnosis of a Cracked Tooth: A Case Report

Diagnosing a cracked tooth is a challenge for dental clinicians. This report describes the use of a quantitative light-induced fluorescent (QLF) device that detects fluorescence reactions with visible light (405 nm) to visually identify microscopic tooth cracks during the diagnosis and treatment of cracked teeth that caused pulp disease. Fluorescence images of the occlusal surface, before and after removal of the restoration, and inside of the access cavity for root canal treatment were obtained using an intraoral capture-type QLF device (Q-ray penC; AIOBIO, Seoul, Korea). The device provided visual information such as enhanced magnification and fluorescent images to identify cracks on the exterior of the tooth, around restorations, and inside the cavity after removal of the restoration by a simple image capture process. The device was able to demonstrate the existence of the crack line and to predict the depth of cracks during treatment.The QLF device showed a potential benefit in the diagnosis and characterization, including the location and depth, of tooth cracks.

Survival and prognostic factors of managing cracked teeth with reversible pulpitis: A 1- to 4-year prospective cohort study

AIM

This prospective clinical study evaluated the clinical performance of managing cracked teeth with reversible pulpitis through a combination of internal and external splinting and investigated factors that can affect pulp survival after splinting.

METHODOLOGY

Thirty-four teeth diagnosed with cracks and reversible pulpitis were enrolled and treated with bidirectional crack splinting: 1) immediate splinting with a stainless-steel band, 2) internal splinting with crack line removal and resin filling and 3) external splinting with a temporary crown followed by final crown placement. If the symptoms remained/recurred, root canal treatment was performed. Patients were followed up at 3, 6 and 12 months, then annually thereafter. Kaplan-Meier survival analysis to calculate the survival of the treated teeth and Cox univariate proportional hazards regression model to investigate prognostic factors were performed.

RESULTS

Twenty-nine (97%) teeth were followed up for up to 4 years. The pulp survival rate was 72% after banding and 91% after final crown cementation. No tooth was extracted (100% tooth survival rate). In the univariate Cox proportional hazard test, pain on percussion was the only statistically significant factor (hazard ratio = 11.77). Teeth with pain on percussion at the first visit had a pulp survival rate of 46% during the follow-up period. In comparison, their counterparts without pain had a 94% pulp survival rate.

CONCLUSIONS

Bidirectional splinting successfully managed cracked teeth with reversible pulpitis. Pain on percussion (mechanical allodynia) may be an important factor in deciding whether to attempt root canal treatment on symptomatic cracked teeth. A step-by-step approach with bidirectional crack splinting should be encouraged for a cracked tooth with a vital pulp without mechanical allodynia rather than pre-emptive root canal treatment.

Laboratory simulation of longitudinally cracked teeth using the step-stress cyclic loading method

AIM

To simulate in a laboratory setting longitudinal cracking in root filled premolar teeth, using cyclic mechanical fatigue.

METHODOLOGY

Mesial-occlusal-distal (MOD) cavities were prepared in twenty root filled, single-rooted, mandibular premolars restored with fibre posts and resin composites. The samples were randomly divided into two groups based on the loading approaches: static loading with a crosshead speed of 0.5 mm/min and step-stress cyclic loading (1 Hz) with increasing amplitude. The loads and numbers of cycles to failure were recorded. Micro-CT was also used to identify the fracture modes. Statistical analysis was performed using Student's t-test. The level of significance was set at 0.05.

RESULTS

The mean fracture loads for the static loading and cyclic loading groups were 769 ± 171 N and 720 ± 92 N, respectively. There was no significant difference between the two groups (P > 0.05). The proportions of longitudinal, cuspal and mixed-mode fractures under cyclic loading were 50%, 20% and 30%, respectively. Longitudinal fractures occurred with larger numbers of cycles and higher average loads per cycle compared with the other fractures. Static loading produced only cuspal fractures.

CONCLUSIONS

Longitudinally cracked premolar teeth with root fillings were successfully produced using the step-stress cyclic loading method. This provides a more clinically representative methodology for studying cracked teeth in a laboratory setting.

Survival rate after endodontic treatment in general dentistry for cracked teeth with different coronal restorations

OBJECTIVE

The aim of this study was to analyse the survival rate of cracked teeth after endodontic treatment. The secondary aim was to compare the survival rate of cracked teeth restored with composite filling/crown and those restored with a full crown.

MATERIALS AND METHODS

The study was conducted retrospectively from three general dental clinics in Stockholm, which are all part of the national dental service organisation. Two-hundred patients with teeth receiving endodontic treatment due to symptomatic cracks were included. The patient data range from year 2001 to 2016.

RESULTS

The mean age of the patients was 48 years (range 29-69). Fifty-five per cent had cracks located above the pulpal cavity, 11% within the pulpal cavity and 3% located in the root canal. The cracks were located most commonly on the proximal surfaces. The survival rate for teeth with cracks was 68% and 54% after 5 and 10 years, respectively. The survival rate was significantly higher (97%) for cracked teeth receiving a full crown after endodontic treatment compared to teeth restored with either a composite filling or composite crown.

CONCLUSION

The overall survival rate for cracked teeth was 68% after 5 years, while it was significantly higher for cracked teeth restored with a full crown. The results suggest within the limitations of this study that cracked teeth should be restored with a full crown after endodontic treatment.

Cracked teeth: Distribution and survival at 6 months, 1 year and 2 years after treatment

BACKGROUND/PURPOSE

The unpredictable condition of cracked teeth warrants further investigation and clinical experiences. The purpose of this study was to collect and record data on demographics, clinical characteristics, different treatment modalities and survival of cracked teeth at 6-month, 1-year and 2-year recalls.

METHODS

77 cracked teeth from 65 patients were included. Data on demographics, clinical parameters, treatment modalities and recall were collected. Binomial, multinomial and chi square tests were used for statistical analysis.

RESULTS

Most cracked teeth occurred in patients greater than 40 years old (p < 0.01). Cracked teeth themselves were most often molars (79.22%; p < 0.01), a non-terminal tooth in the arch (62.34%; p < 0.05) and nonendodontically-treated teeth (94.81%; p < 0.01). Cracked teeth exhibited pain to percussion (63.64%, p < 0.05) or biting (74.03%; p < 0.01), and no or only positive mobility (76.62%; p < 0.01). Cracks were most often oriented in the mesiodistal direction (68.83%; p < 0.01). Higher survival rates were noted in cracked teeth lacking pre-operative pain to palpation or spontaneous pain, and with no or only positive mobility at 6-month and 1-year recalls. In vital cracked teeth, higher survival rates were noted in teeth lacking pre-operative pain to palpation and with no or only positive mobility at 2-year recalls.

CONCLUSION

The absence of pre-operative palpation discomfort, spontaneous pain and minimal mobility, as well as the presence of pulp vitality were associated with higher survival rates of cracked teeth at all recall times. Results are useful for diagnosis and outcomes-based treatment planning of cracked teeth.

Association of probable bruxism with periodontal status: A cross-sectional study in patients seeking periodontal care

OBJECTIVE

The goals of this study were to investigate the prevalence of probable bruxism in a group of patients seeking a periodontal care and the association between probable bruxism and periodontal status.

BACKGROUND

The results of previous studies evaluating the relationship between bruxism and periodontitis are contradictory. In addition, the relationship between probable bruxism and periodontitis in adults has not been evaluated, yet. Therefore, new studies are required in this field to clarify the relationship between bruxism and periodontitis.

METHODS

Patients seeking periodontal care at a university periodontology unit were considered in this study. Their periodontal diagnosis, number of missing teeth, presence of probable bruxism, and sociodemographic characteristics were recorded. The periodontal status of each study participant was defined according to the latest consensus of the American Association of Periodontology/European Federation of Periodontology, and the 2018 consensus report on the assessment of bruxism was used to evaluate probable bruxism. A multiple logistic regression analysis was performed to determine the effects of bruxism on periodontitis.

RESULTS

A total of 541 patients (289 females and 252 males, mean age 42.1 ± 15.9 years) were enrolled in the present study. The prevalence of probable bruxism was 36.6%. Additionally, 40.9% of the study population was diagnosed with periodontitis. The probable bruxers were older (P < 0.001), had a higher number of missing teeth (P < 0.001), and had poor periodontal status (P < 0.001). The multivariate logistic regression analysis suggested that probable bruxism was associated with periodontitis, after adjusting relevant factors (odds ratio: 2.243, 95% CI: 1.465-3.434, P < 0.001).

CONCLUSIONS

It was observed that the prevalence of probable bruxism was 36.6% and probable bruxers showed higher odds of periodontitis. Future studies with prospective randomized design should be conducted to confirm these results among a larger study population.

Baseline characteristics as 3-year predictors of tooth fracture and crack progression: Findings from The National Dental Practice-Based Research Network

BACKGROUND

The authors of this practice-based study estimated the risk of experiencing tooth fractures and crack progression over 3 years and correlated baseline patient-, tooth-, and crack-level characteristics with these outcomes.

METHODS

Two-hundred-and-nine National Dental Practice-Based Research Network dentists enrolled a convenience sample of 2,601 participants with a cracked vital posterior tooth that had been examined for at least 1 recall visit over 3 years. Data were collected at the patient, tooth, and crack levels at baseline, annual follow-up visits, and any interim visits. Associations between these characteristics and the subsequent same-tooth fractures and crack progression were quantified.

RESULTS

Of the 2,601 teeth with a crack or cracks at baseline, 78 (3.0%; 95% confidence interval, 2.4% to 3.7%) subsequently developed a fracture. Of the 1,889 patients untreated before year 1, 232 (12.3%; 95% confidence interval, 10.9% to 13.8%) had some type of crack progression. Baseline tooth-level characteristics associated with tooth fracture were the tooth was maxillary and had a wear facet through enamel and a crack was detectable with an explorer, on the facial surface, and in a horizontal direction. Crack progression was associated with males and teeth with multiple cracks at baseline; teeth with a baseline facial crack were less likely to show crack progression. There was no commonality between characteristics associated with tooth fracture and those associated with crack progression.

CONCLUSIONS

Development of tooth fractures and crack progression over 3 years were rare occurrences. Specific characteristics were associated with the development of tooth fracture and crack progression, although none were common to both.

PRACTICAL IMPLICATIONS

This information can aid dentists in assessing factors that place posterior cracked teeth at risk of experiencing adverse outcomes.

Ten-year retrospective study of the effectiveness of quantitative percussion diagnostics as an indicator of the level of structural pathology in teeth

STATEMENT OF PROBLEM

Conventional dental diagnostic aids are only partially effective in diagnosing structural defects such as cracks in teeth. A more predictable diagnostic for structural instability in the mouth is needed.

PURPOSE

The purpose of this clinical study with an increased population size was to evaluate the effectiveness of diagnosing structural instability by using the quantitative percussion diagnostics (QPD) system and to evaluate the influence of independent variables on the relationship between normal fit error (NFE) and observed structural instability found during the clinical disassembly of teeth.

MATERIAL AND METHODS

Twenty-two participants with 264 sites needing restoration were enrolled in an institutional review board-approved 10-year retrospective clinical study. Each site had been tested with the QPD system before being disassembled microscopically with video documentation, and the clinical disassembly results were recorded on a defect-assessment sheet. The NFE data were separately recorded from the preexisting records. The classification of structural pathology based on the disassembly observations for each of the 264 sites was conducted by the clinical researcher (C.G.S.) who was blinded to the NFE values.

RESULTS

The 264 sites from 22 patients were classified as 8 in the none group, 87 in the moderate group, and 169 in the severe group based on the disassembly findings. The NFE data for the sites were analyzed by using the predefined NFE cutoffs that were independently generated from the previous cumulative logistic regression and decision tree model. For the cumulative logistic regression, 235 out of 264 sites were correctly classified with an agreement of 0.89 (adjusted 95% CI: 0.83-0.95). The number of correctly classified sites for the decision tree model was 234, and the agreement was also 0.89 (adjusted 95% CI: 0.83-0.94). For both cumulative logistic regression and decision tree models, the overall misclassification rate was less than 20% for any restoration material or restoration type. Therefore, the overall performance of NFE classification was consistently good, regardless of restoration material or type. In addition, the sensitivity of the severe category was above 90% for any restoration material or type for the decision tree model.

CONCLUSIONS

The QPD system was found to be a reliable diagnostic aid for classifying structural damage in the categories of none, moderate, or severe based on clinical disassembly findings under the clinical microscope and NFE values. Furthermore, it was determined that restoration type and restoration design were not significant factors in correlating structural pathology with NFE.

Equine cheek teeth occlusal fissures: Prevalence, association with dental wear abnormalities and occlusal angles

BACKGROUND

Fissures of the occlusal surface of equine cheek teeth are commonly encountered during oral examination but their aetiology is unknown.

OBJECTIVES

To examine the prevalence and characteristics of occlusal fissures in cadaver teeth. It is hypothesised that their prevalence is influenced by masticatory forces. Consequently, their possible association with wear disorders and occlusal angles were examined.

STUDY DESIGN

Cross-sectional survey.

METHODS

The dental abnormalities and occlusal fissure findings in the cheek teeth of 143 cadaver heads were recorded. The cheek teeth occlusal angles were measured using the stiff-hinge technique. Multiple regression analyses were performed to establish possible relationships between age, sex, dental wear, occlusal angle and fissure prevalence.

RESULTS

Occlusal fissures were found in 103/143 (72%) heads. Sex and age were determining factors in the prevalence of fissures. A similar prevalence was found in mandibular (54.1%) and maxillary teeth (45.9%, OR = 1.10; 95% CI = 0.95-1.29, P = 0.2). Mandibular fissures were more commonly located on the buccal aspect (OR = 1.42; 95% CI = 1.16-1.65, P < 0.001), whereas for maxillary fissures there was no difference in prevalence between palatal and buccal aspects (OR = 1.19; 95% CI = 0.97-1.46, P = 0.1). Two main fissure types were identified. Type 1a fissures were the most prevalent type (39.5%). No significant correlation was found between the presence of wear abnormalities or the occlusal angle of cheek teeth, and the prevalence of fissures.

MAIN LIMITATIONS

No dental histories were available.

CONCLUSION

Equine cheek teeth show a high prevalence of occlusal fissures. Despite some evidence of predilection sites on the tooth surface that might indicate a mechanical aetiology for these lesions, no associations were found with wear abnormalities or occlusal angles of affected cheek teeth. Further histological and ultrastructural studies are warranted to elucidate their aetiology and possible role in other dental diseases.

A Novel Technique for Bulk-Fill Resin-Based Restorations: Achieving Function and Esthetics in Posterior Teeth

Advances in the mechanical properties of composite resins have allowed for their use in posterior teeth. Conventional resins have several problems associated with polymerization shrinkage stress. The development of “bulk-fill” resins has allowed for their use in single increments up to depths of 4 mm, with very low polymerization shrinkage stress. Nevertheless, differences in anatomy and the desire for optimal esthetics present unique difficulties. This article describes a step-by-step technique using flowable bulk-fill resin as a substitute for dentin in a single increment, together with a high-reflective-index resin to restore enamel and decrease clinical time, obtaining anatomically and esthetically acceptable results without detriment to the mechanical properties required to restore the functionality of the posterior teeth.

Analysis of the characteristics of cracked teeth and evaluation of pulp status according to periodontal probing depth

Background

The purpose of this study was to analyze the characteristics of cracked teeth and to evaluate pulp status according to periodontal probing depth (PPD).

Methods

A total of 182 cracked teeth were included. The location and type of the cracked teeth, age and gender of the patients, restoration type, pulp status, PPD, and radiographic findings were analyzed.

Results

Mandibular second molars (25.3%) were the most frequently involved teeth, followed by mandibular first molars (22.5%), maxillary first molars (22.0%), and maxillary second molars (17.6%). The patient age was most frequently 50–59 years. Cracks occurred mainly in nonbonded restorations, such as gold (26.9%), and were usually found in intact teeth (37.9%). A total of 103 teeth (56.6%) had an initial PPD of less than 3 mm, while 40 (22.0%) had a PPD of 4–6 mm, and 39 (21.4%) had PPD of 7 mm or more. A total of 33 cracked teeth (18.1%) were diagnosed with pulp necrosis, 40 (22.0%) with irreversible pulpitis, and 97 (53.3%) with reversible pulpitis. The incidence of pulp necrosis was 31.8% among cracked teeth with a PPD of 4–6 mm, and 28.6% among those with a PPD of 7 mm or more.

Conclusions

Cracks occurred mainly in molar teeth, and were commonly found in intact teeth with no restoration. Patients with cracked teeth were most frequently aged 50–59 years. Cracked teeth showing a PPD of more than 4 mm were more likely to show pulp necrosis.

Complications of an Ageing Dentition Part 1: Occlusal Trauma and Cracked Teeth

A growing problem in dentistry is complications associated with failing amalgam restorations that have been in place for many years. At present, there is a wide variety of treatment options available in the clinician’s armamentarium when this situation arises, however, without the correct diagnosis, the prognosis for the tooth may quickly diminish, despite the clinician’s best efforts. A confusing array of symptoms and failures may confound even the most experienced dentist, which will inevitably lead to invasive and time consuming approaches in a desperate attempt to rectify the initial problem. This paper, the first part of a three-part series, discusses the possible aetiological factors responsible for restoration failure, including occlusal issues and cracks within the tooth structure. The second part of the series will focus on restorative options and root-treated teeth. The third, and final, part of the series will provide an overview of the previous papers and conclude with a case report. Clinical relevance: Failure of amalgam restorations is a commonly encountered clinical problem in general practice and no one case presents in the same way. A competent diagnosis regarding the occlusion and tooth structure, followed with implementation of the most appropriate, minimally invasive treatment option, requires an adequate knowledge of current literature.

Limited Evidence Suggests That Symptomatic Cracked Teeth Share Characteristics Such as Clenching, Grinding, and Molars With Distal Cracks

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Correlation between symptoms and external characteristics of cracked teeth. Hilton TJ, Funkhouser E, Ferracane JL, Gilbert GH, Baltuck C, Benjamin P, Louis D, Mungia R, Meyerowitz. JADA 2017; 148(4):246-56.e1.

SOURCE OF FUNDING

National Institutes of Health grant U19-DE-22516 TYPE OF STUDY/DESIGN: Cross-sectional study.

The clinical findings and managements in 44 cases of cracked vital molars

Background/purpose

The aim of this study was to evaluate the associations between the clinical findings and managements in cracked vital molars that were caused by various factors including restoration and occlusion.

Materials and methods

The subjects' gender, age, chief complaint, type of tooth, percussion test results, pulp vitality, restoration material and cavity classification, clinical depth of the crack, evaluation of occlusion, depth of periodontal probing, and final management were recorded.

Results

A total of 44 vital cracked teeth (molars) were diagnosed in 40 patients. Regarding the type of tooth, a greater number of mandibular molars were affected than maxillary molars. Nonworking-side interference (NWI) was recognized in 38 cases (86.4%). Eight teeth (18.2%) had not been restored. Thirty-six teeth (81.8%) had been restored; 26 teeth (72.2%) with a metal inlay, 6 (16.7%) with an amalgam, and 4 (11.1%) with a composite resin. Regarding the final treatment in the endodontically-treated group, all 17 teeth were covered with a metal full crown. Regarding the final treatment in the pulp-reserved group, 19 teeth (70.4%) were covered with a metal full crown, and the other managements were as follows: occlusal adjustment (n = 4, 14.8%), composite resin (n = 2, 7.4%), and only follow-up without treatment (n = 2, 7.4%). All of the cases showed a good clinical prognosis.

Conclusion

The NWI group restored with 58% of metal inlay accounted for more than 86% of the cracked teeth. Thus, in order to achieve a good outcome, cracked teeth, particularly those originating due to occlusal interference should be protected with coverage-type restorations.

Pain Part 4: Odontogenic Pain

Pain is one of the major reasons that lead patients to seek dental care. For the majority of patients, the pain is of odontogenic origin, as a consequence of dental disease. The timely diagnosis and management of dental pain is an essential component of dental care, and this article reminds readers of the common presenting symptoms of simple dental pain, diagnoses and pragmatic management.

CLINICAL RELEVANCE

Pain of odontogenic origin is common, and distressing. However, the pathology is consistent, as are the symptoms, and an understanding of this underpins the careful history-taking that will lead the clinician to the diagnosis.

Cracked tooth syndrome: A report of three cases

Cracked tooth syndrome (CTS), the term was coined by Cameron in 1964, which refers to an incomplete fracture of a vital posterior tooth extending to the dentin and occasionally into the pulp. CTS has always been a nightmare to the patient because of its unpredictable symptoms and a diagnostic dilemma for the dental practitioner due to its variable, bizarre clinical presentation. The treatment planning and management of CTS has also given problems and challenges the dentist as there is no specific treatment option. The management of CTS varies from one case to another or from one tooth to another in the same individual based on the severity of the symptoms and depth of tooth structure involved. After all, the prognosis of such tooth is still questionable and requires continuous evaluation. This article aims at presenting a series three cases of CTS with an overview on the clinical presentation, diagnosis and the different treatment options that varies from one case to another.

Cracked tooth syndrome: Overview of literature

Pain is defined as an “unpleasant sensory and emotional feeling which is associated with actual or potential injury of tissue or expressed in terms of such injury.” Tooth pain usually refers to pain around the teeth or jaws mainly as a result of a dental condition. Mostly, toothaches are caused by a carious cavity, a broken tooth, an exposed tooth root or gum disease. The toothache may sometimes be the result of radiating pain from structures in the vicinity of tooth and jaws (cardiac pain, ear, nose, throat pain, and sinusitis). Therefore, evaluation by both dentists and physicians are sometimes necessary to diagnose medical illnesses causing “toothache.” Cracked tooth syndrome is a major diagnostic challenge in clinical practice. Accurate diagnosis and appropriate treatment are complicated due to lack of awareness of this condition and its bizarre clinical features. Early diagnosis has been linked with successful restorative management and good prognosis. This article provides a detailed literature on the causes, classification, signs and symptoms, diagnosis, and treatment planning of cracked tooth syndrome.

Cracked tooth diagnosis and treatment: An alternative paradigm

This article reviews the diagnosis and treatment of cracked teeth, and explores common clinical examples of cracked teeth, such as cusp fractures, fractures into tooth furcations, and root fractures. This article provides alternative definitions of terms such as cracked teeth, complete and incomplete fractures and crack lines, and explores the scientific rationale for dental terminology commonly used to describe cracked teeth, such as cracked tooth syndrome, structural versus nonstructural cracks, and vertical, horizontal, and oblique fractures. The article explains the advantages of high magnification loupes (×6-8 or greater), or the surgical operating microscope, combined with co-axial or head-mounted illumination, when observing teeth for microscopic crack lines or enamel craze lines. The article explores what biomechanical factors help to facilitate the development of cracks in teeth, and under what circumstances a full coverage crown may be indicated for preventing further propagation of a fracture plane. Articles on cracked tooth phenomena were located via a PubMed search using a variety of keywords, and via selective hand-searching of citations contained within located articles.

Clinical issues in occlusion - Part I

Good occlusal practise provides an important cornerstone to optimal patient care. Occlusal problems can manifest in different areas of dentistry but these are more apparent when there are restorative aspects to the patient׳s problem. This review highlights areas of restorative dentistry where the appreciation of occlusal aspects can optimise diagnosis and follow up care.

Orofacial pain: a guide for the headache physician

Orofacial pain represents a significant burden in terms of morbidity and health service utilization. It includes very common disorders such as toothache and temporomandibular disorders, as well as rare orofacial pain syndromes. Many orofacial pain conditions have overlapping presentations, and diagnostic uncertainty is frequently encountered in clinical practice. This review provides a clinically orientated overview of common and uncommon orofacial pain presentations and diagnoses, with an emphasis on conditions that may be unfamiliar to the headache physician. A holistic approach to orofacial pain management is important, and the social, cultural, psychological and cognitive context of each patient needs to be considered in the process of diagnostic formulation, as well as in the development of a pain management plan according to the biopsychosocial model. Recognition of psychological comorbidities will assist in diagnosis and management planning.