Dental Tribune Asia Pacific Edition No. 1+2, 2018

12 TRENDS & APPLICATIONS Dental Tribune Asia Paciﬁ c Edition | 1+2/2018 Cracking the code of fractured teeth By Aws Alani, UK The need for an endodontic skill set within the profession is higher than it has ever been. Culturally and so- cially, there have been signiﬁ cant changes in patient perception to the news that a tooth is in trouble, where the solution is either root canal treat- ment or removal. I am old enough to We are aware that cracked teeth are difﬁ cult to diagnose owing to the clinical picture being variable and inconsistent between patients and their presentations. Of course, parafunction has been shown to in- crease the risk of crack and subse- quent fracture. Outside of contin- of vitality is considered and root ca- nal treatment is delivered, protect- ing what remains to prevent crack formation seems to be the consen- sus through cuspal coverage. This apparent susceptibility may be caused by a weakened tooth, but may also be due to the loss of pro- the hope of seeing something of note, nothing. The patient pro- tests: “I get the pain every now and then, but when it happens, it’s re- ally something else … can’t you see anything?” You sit the patient back down again and look at the amal- gam ﬁ lling with the suspicious eye. might not propagate, it may stay the “same” and the patient may not need any treatment as long as he avoids the tooth. What about their Snickers though? Some patients may accept this. in two Generally, patients are 1 3 have treated patients who needed the replacement of complete den- tures that were a “wedding gift” in their youth. As a gesture of goodwill to the bride in waiting, wholesale ex- tractions and the provision of com- plete dentures were gifted to ensure the absence of dental problems or expense their new found love. throughout How things have changed. Pa- tients can now attend seemingly determined and adamant that they will not have teeth removed, de- spite our professional opinion that unfortunately may be wholly dif- ferent to what they want or would like. Indeed, if a tooth is clearly un- restorable, exhibiting a lack of coro- nal tooth tissue or a signiﬁ cant api- cal lesion, patients may already be sensitive to the fact that it cannot be saved. A resigned look may come over their faces, conﬁ rming their fears. What could be a more difﬁ cult patient and professional situation in endodontics? The cracked tooth. ual habitual forceful actions in pa- tients who brux, solitary incidents of biting down on something unex- pectedly hard, such as an olive stone, are also common. Such cata- strophic incidences may be more common in undermined, weak- ened heavily restored teeth. The prevalence increases in patients who are middle-aged and is greater in females than males, with the overwhelming majority affecting posterior teeth. The fate of such teeth varies from simple repair of a busted cusp to the need for endo- dontics and extraction. One inter- esting feature in the literature seems to point to teeth with steeper cuspal inclines being more suscep- tible to fracture. This morphologi- cal feature is likely to result in the wedging effect of deep cusp–fossa relationships between teeth. Fre- quently ﬁ rst molars have been im- plicated as common teeth to frac- ture owing to their closeness to the masseter muscle and the temporo- mandibular joint hinge. When loss 2 4 feedback prioceptive the now-removed pulp once provided on occluding. that 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 ﬁ fth stroke of their mandible from left to right they get a shooting pain. Forget simple hot and cold sensation; the pain can be brought on by things that the patient likes eating the most. So, you are there looking at the pa- tient, looking at the tooth, back at the patient hoping that tapping this tooth will provide a reaction to aid your tentative diagnosis of api- cal periodontitis. Nothing from the patient, not even a whimper. “Hmm. Let’s take an X-ray… Long- cone periapical please.” You take your Hubble Telescope-type mag- niﬁ ers and examine the radio- graph. You change the contrast in It looks the same as every other asymptomatic amalgam you have ever placed during your career; your thumbprint is uncanny. As your senses have been sparked, the eye of faith takes over: there is a bit of faceting on the cusps, there are some craze lines, the patient does tend to wear her restorations. “It’s cracked, the tooth is cracked.” Your patient creeks their neck up to look at you more intensely: “Can you ﬁ x it?” You see our patients, as much as we do, are perplexed by cracked teeth. The tooth looks “normal”, feels “normal” outside of the occa- sional painful episode; why can it not be “mended” or “stuck together again” like some old china vase? The diagnostic conundrum is over. On balance, you know what the problem is, as does the patient now, despite being fairly un- convinced with your antics. The next riddle is how to treat, if at all. Although you cannot be 100 per cent sure that there is a crack, it camps with whatever diagnosis we provide them with. Some are pro- active “Right there’s a crack, you can’t mend it. Let’s whip it out—I’ve still got another six teeth in my top jaw I can chew on, no worries”, while others are reactive “You know, let’s just sit on it and if it gives me a problem, then I’ll come back”, to which you may reply it could cata- strophically snap or fracture. The alternative, and the evidence for this is fairly light on the ground at the current time, is to instigate strategies to reduce the likelihood that the tooth will become more symptomatic—in other words, you want to brace the crack. Similar to my uncle’s wrinkly belt and his ever expanding waistline, you can hear the leather strain as he tucks into his pie. What did we get taught? Use a copper band or an orthodontic band, both of which may be difﬁ - cult to source in primary care. Or we could crown the tooth and risk it going pulpitic. I imagine that to be so humbling. Having ﬁ tted the

Dental Tribune Asia Pacific Edition No. 1+2, 2018

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