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Dental Tribune Asia Pacific Edition | 1+2/2018 TRENDS & APPLICATIONS 13 crown, you drill straight through it two days later. Indeed, whatever you do, the tooth may be unsavea- ble. A dental nurse in a specialist setting complained of toothache all of a sudden with no prior warning or preamble. The pain was excruci- ating; it was visible on her face. Her expression was tethered on the side of this incredibly painful upper first molar. She would hold the suction with one hand and her cheek with the other. She could not bite or chew and the dentists she worked with all sympathised. She saw one endodontist in the unit and, despite all the signs being inconclusive at the time, he suggested a crack (Fig. 1). Of course, it was at the back of everyone’s mind that this tooth was unrestored and she had a pris- tine mouth. She saw a second endo- dontist in the practice owing to the escalation of her symptoms. By this time, she wanted the tooth ex- tracted, but the romantic amongst us all felt the tooth could be saved, so it was extirpated! The pulp posi- tively nuked and the tooth dead. That should have sorted it right? Unfortunately, her symptoms con- tinued. Could it have been some- thing atypical? She had been stressed and grinding. More deliberation, still no further was the diagnosis. The tooth was dressed once again, with a change in the medicament. Still no joy. A restorative dentist then proceeded to drill the crack out and restore with composite. Still no joy. The tooth was taken out of occlu- sion when one dentist noticed the development of periodontal liga- ment widening on one of the long- cone periapical radiographs. The root canal treatment was com- pleted jointly by two excellent en- dodontists and the second mesio- buccal canal was located. Under any other circumstances, it was a fan- tastic clinical outcome. Unfortu- nately, the pain was unabating (Fig. 2). Let us see as much as we can. A CBCT scan was taken that was also inconclusive (Fig. 3). Was it some- thing to do with the sinus? The ra- diographic report was suggestive, but again nothing conclusive. To- wards the end of the two weeks, the patient marched herself into the office of the exodontist to have Aws Alani qualified from King’s College London in 2003 and after hos- pital and prac- tice positions completed his MSc from the Eastman Dental Insti- tute in 2006. He subsequently com- pleted specialist training in Restora- tive Dentistry afterwhich he became an ITI Scholar in Toronto, Canada. In 2014, he was appointed Consultant in Restorative Dentistry at King’s College Hospital and is lead clinician for the management of congenital abnormalities. the tooth extracted. Misery. We had failed. With the tooth in hand and a wry smile, the nurse dipped the tooth in disclosing solution, which identified one large crack in the fur- cation area of the palatal root with several accessory ones (Fig. 4). The relief was palpable on her face. De- spite losing a tooth, the culprit had finally been identified. It seems as though the mechanical failure of teeth, unlike our old adversary, bac- teria, has the ability to trump us, from diagnosis through to treat- ment, despite our best intentions, knowledge and experience. The question that crosses my mind as I see the slow but steady in- crease in “crackitis” is how are we going to manage this contempo- rary problem? Will we see the emer- gence of crackologists? The first step is raising awareness among pa- tients and the profession. Patients need to stop themselves from grinding their teeth needlessly dur- ing the day and have to instigate strategies to reduce the likelihood of parafunction in the night. One emerging issue is psychological health. Patients are increasingly stressed and depressed, which is a recognised risk factor. One fairly paradoxical issue is that medica- tion may actually increase the like- lihood of bruxism, so the pharma- ceutical industry may be perpetuat- ing the problem in that stressed people who already grind are medi- cated and grind even more. Cracking the code of fractured teeth is going to be difficult and will be a contemporary challenge for us all. One of my trainers from yester- year, who had more wisdom than Yoda, once said, “From these words never depart, lips together and teeth apart”. AD Benefit from more performance. M a d e i n A U S T R I A High quality dental solutions by W&H. Restoration & Prosthetics Sterilization, Hygiene & Oral Surgery & Implantology Prophylaxis & Periodontology Maintenance Now available from your dental supplier or via wh.com