Quality Resource Guide –

Diagnosing and Managing the Cracked Tooth - Part 1

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Page 6

The need for evidence-based treatment guidelines

for COF has been identified.

While these are not

yet available, there is some agreement that many

teeth with COF may be treated,

19,20

but it is not clear if

they all require root canal therapy.

The lack of clear

understanding is probably related to the difficulty in

determining if a COF communicates directly with the

pulp, in which case endodontic treatment would be a

part of treatment, or the fracture is cuspal and may not

communicate with the pulp.

Using the commonly accepted criteria for pulpal

diagnosis, Krell and Rivera21 reported the outcomes

of symptomatic, fractured teeth that were initially

diagnosed with reversible pulpitis and treated with full

coverage restorations. The outcomes in their case

series suggest that, if a COF is identified early and the

tooth is diagnosed with reversible pulpitis and a crown

is placed, root canal treatment will be necessary only

about 20% of the time.

An approach that can help the clinician to decide

if endodontic therapy for a tooth with COF is

necessary is to use the following protocol:

4,14

1) If a tentative diagnosis of reversible pulpitis has

been determined (based on no lingering pain to

cold and no spontaneous, severe pain), the tooth

is stabilized with an orthodontic band for about two

weeks; 2) If symptoms subside within that period, the

patient may be offered the option of only placing a

restoration that binds the tooth together, such as a full

crown*, with the awareness that the tooth may later

need root canal therapy.

The reason for waiting after

placement of the orthodontic band is because it takes

some time before cold sensitivity subsides. Davis

and Overton

found that it took two weeks for cold

sensitivity to subside after restoring teeth with bonded

amalgam restorations.

* Treatments described to bind fractured teeth together

include the use of adhesives,

amalgam restorations

with retention on both sides of the fracture,

full coverage

crowns

4,14, ,18,23

and bonded composite overlays.

When a fractured tooth has

irreversible

pulpitis or

pulp necrosis, the need for endodontic therapy is

necessary if the tooth is to be retained. Endodontic

therapy will eliminate pulpal pain and sensitivity to

temperature changes and sweets, but the clinician

should not expect a tooth with a COF to be free

of chewing pain. Pain to mastication is associated

with inflammation in the PDL. Such inflammation is

generated by bacteria in a COF.

11,12

The problem (not

being able to predict if pain on chewing will cease after

completion of the root canal treatment and restoration)

can be addressed by initially placing an orthodontic

band as discussed above, followed by endodontic

therapy if chewing pain subsides. If the patient is not

comfortable with the tooth following application of the

band, extraction becomes the alternative treatment

option.

PROGNOSIS

The outcome of treatment for teeth with COF has

not been extensively reported. Cameron

reported

a 75% success after ten years following placement

of crowns. Brynjulfsen et al.

achieved pain relief in

90% of their patients after protective restorations were

placed on teeth with fractures (endodontic therapy

was included when indicated), and Tan et al.

had an

85% survival rate two years after protective crowns

were placed. More recently, Sim et al.

reported

the 5-year survival of teeth with COFs that were

restored with full coverage crowns and had root canal

treatment when indicated. They found that teeth with

fractures confined to the crowns survived at a rate of

99%, while those with fracture extensions to the pulpal

floor had an 88% survival rate.

The available data is insufficient to use as a basis

for giving individual patients odds on a specific

tooth survival. Patients must be fully informed of

the uncertainty based on lack of data. One must

recognize that in certain situations the prognosis is

poor: teeth in a terminal position within the dentition;

teeth with periodontal involvement related to the

fracture, and; teeth with multiple fractures.

It is

recommended that the clinician search the current

literature regarding the type of clinical situation that

exists, include his/her own experience and seek

the patient’s preferences when creating treatment

recommendations and obtaining informed consent.

PATIENT INFORMATION

Teeth with COFs often present both patients and

dentists with a number of challenges. Patients may

have difficulty in describing symptoms and pointing

out the location of the problem tooth. Dentists may be

able to collect only limited clinical and radiographic

data to establish a definitive diagnosis.

Such a

combination can result in frustration for everyone

involved. Involving the patient in the problem-solving

process may be helpful.

Gathering all the pertinent

information (history, symptom descriptions-regardless

of how unusual they may be and past similar dental

experiences) can provide a framework for suspicion of

a COF.

This gives the clinician an opportunity to share

the complexity of establishing a definitive diagnosis

with the patient.

Such teamwork – patient and their

dentist working together to solve the problem – may

reduce the possibility of later conflicts.

Educating patients about a COF begins with an

explanation about the factors that create symptoms.

Early stages of the development may involve the pulp

only (explaining both the often unusual symptoms

and the inability to localize the tooth); such teeth may

respond to biting tests but not percussion tests. Only

when the fracture line has progressed to involve the root

can localization be expected because of periodontal

ligament involvement. Additional patient education

can occur during discussion about treatment options

and prognosis. The ideal outcome of such discussions

is that the patient clearly comprehends the situation

prior to making treatment choices. A patient will

generally rely on his/her dentist’s recommendations,

but the better informed the patient, the better he/

she will grasp the possible treatment consequences.

Teeth with COF must be considered to have limited

survival expectancy since these fractures cannot

be eliminated and may continue progressing in the

root.

Lack of available data on survival of teeth with

a COF makes it important to prepare a patient for the

likelihood of eventual tooth loss.

The fact that prognosis for teeth with a COF is fair at

best, does not mean that immediate replacement with

a dental implant is the best treatment choice. Long-

term prognosis for dental implants is reasonably good,

but data from the past ten years point to increasing

numbers of problems, such a peri-implantitis.

reasonable approach to providing clinical guidance to

a patient with a COF may be to recommend retaining

such teeth for as long as practical.