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ePaper created 2018-03-06, 08:52:14 | version 1.38.0
| patient communication Cracking the code of fractured teeth Aws Alani, UK The need for an endodontic skill set within the profes- sion is higher than it has ever been. Culturally and so- cially, there have been significant changes in patient per- ception to the news that a tooth is in trouble, where the solution is either root canal treatment or removal. I am old enough to have treated patients who needed the re- placement of complete dentures that were a “wedding gift” in their youth. As a gesture of goodwill to the bride in waiting, wholesale extractions and the provision of com- plete dentures were gifted to ensure the absence of den- tal problems or expense throughout their new found love. Fig. 1 How things have changed. Patients can now attend seemingly determined and adamant that they will not have teeth removed, despite our professional opinion that unfor- tunately may be wholly different to what they want or would like. Indeed, if a tooth is clearly unrestorable, exhibiting a lack of coronal tooth tissue or a significant apical lesion, pa- tients may already be sensitive to the fact that it cannot be saved. A resigned look may come over their faces, confirm- ing their fears. What could be a more difficult patient and professional situation in endodontics? The cracked tooth. We are aware that cracked teeth are difficult to diag- nose owing to the clinical picture being variable and in- consistent between patients and their presentations. Of course, parafunction has been shown to increase the 34 roots 1 2018 risk of crack and subsequent fracture. Outside of con- tinual habitual forceful actions in patients who brux, soli- tary incidents of biting down on something unexpectedly hard, such as an olive stone, are also common. Such catastrophic incidences may be more common in under- mined, weakened heavily restored teeth. The prevalence increases in patients who are middle-aged and is greater in females than males, with the overwhelming majority af- fecting posterior teeth. The fate of such teeth varies from simple repair of a busted cusp to the need for endodon- tics and extraction. One interesting feature in the literature seems to point to teeth with steeper cuspal inclines be- ing more susceptible to fracture. This morphological fea- ture is likely to result in the wedging effect of deep cusp– “We are aware that cracked teeth are difficult to diagnose owing to the clinical picture being variable and inconsis- tent between patients and their presentations.” fossa relationships between teeth. Frequently first molars have been implicated as common teeth to fracture owing to their closeness to the masseter muscle and the tem- poromandibular joint hinge. When loss of vitality is con- sidered and root canal treatment is delivered, protecting what remains to prevent crack formation seems to be the consensus through cuspal coverage. This apparent susceptibility may be caused by a weakened tooth, but may also be due to the loss of proprioceptive feedback that the now-removed pulp once provided on occluding. Cracked teeth provide patients with an odd experience. The pain is brought on when they eat a Snickers with their coffee on a Tuesday morning (between 7.30 and 7.32 a.m.), chewing from side to side, and on the fifth stroke of their mandible from left to right they get a shooting pain. Forget simple hot and cold sensation; the pain can be brought