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Cracked Tooth Syndrome : How to detect it

  • July 7, 2020
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Craked Tooth or tooth fractures are one of the most common causes of visiting the dental emergency room. While fractures are appreciably easy to detect, the severity and consequences of a fracture can range from minor, needing no treatment at all, to severe, generating the need for extensive root canals. One specific form of tooth fracture, cracked tooth syndrome (CTS) often presents as a diagnostic conundrum to the dentist because of its unrecognizable and extremely minuscule symptom manifestations. You may even be disillusioned or oblivious of the crack in your teeth right now!

We discuss this peculiar dental condition and how to detect it at the right time!

What is cracked tooth syndrome?

Cracked tooth syndrome (CTS) is a dental phenomenon that involves the incomplete fracture of a vital tooth (mostly posterior) and involves the enamel and dentin, occasionally even extending into the pulp. Sometimes described in the literature as “greenstick fracture”, it presents as an incompletely cracked tooth without any part of the tooth that has broken off yet. Due to this partial tooth fracture, the presentation is much more subtle and is notoriously difficult to diagnose.

Unfortunately, by the time a cracked tooth becomes symptomatic, the tooth may already be destined for a root canal therapy or extraction.

Types of a cracked tooth

The American Association of Endodontists (AAE) has identified five types of cracks in teeth, namely:

  1. Craze lines: They are small cracks on the enamel. They do not cause pain and require no treatment.

  2. Fractured cusp: They generally occur around a dental filling and usually do not involve the pulp, with no symptoms of pain.

  3. Cracks that extend into the gum line: They are vertical cracks on the teeth extending into the gum line, and may not be restorable. They usually require extraction.

  4. Split tooth: They are cracks on teeth that travels below the gum line, successfully dissecting the tooth into two halves. It is unlikely to be saved.

  5. Vertical root fracture: They are cracks that begin below the gum line and travels upwards, will need to be extracted.

Causes of a cracked tooth

Several behavioral and procedural incidents may be responsible for a cracked tooth. The Canadian Dental Association (CDA) has listed a few of the major etiological and potential risk factors for cracked teeth.

  • Over-preparation of cavities for tooth fillings
  • Insufficient cuspal protection in inlay/onlay design
  • Physical forces during placement of restorations
  • Sudden and excessive biting forces on the tooth while chewing hard foods
  • Large untreated carious lesions
  • Pressure from teeth grinding or bruxism
  • Excessively large restorations that weaken the integrity of the tooth
  • Traumatic blows to the mouth in a car accident, contact sports, etc.
  • Abrupt changes in temperature in the mouth, like eating something extremely hot and then following it up with extremely cold foods
  • Elderly, mostly above the age of 50

Symptoms of cracked teeth

Not every cracked tooth will emulate the same symptoms. The reported symptoms are very variable, some of the common ones reported by the American Academy of Endodontists (AAE) are:

  • Erratic pain when chewing, possibly with the release of biting pressure
  • “Rebound pain”, sharp, fleeting pain when the biting force is released from the tooth
  • Sensitivity to heat, cold, or sweetness
  • Pain that comes and goes, rarely continuous
  • Swelling of the gums around the affected tooth
  • The pain may be well-localized at times enough to identify the exact tooth affected

If the crack permeates into the pulp, irreversible pulpitis, necrosis, and periapical periodontitis may develop, with the respectively associated symptoms.

Diagnosing a cracked tooth

The diagnosis of cracked tooth syndrome is problematic at best, even for many experienced clinicians. The features of this syndrome are extremely variable and can mimic many other craniofacial conditions such as sinusitis, temporomandibular disorders, facial pain, etc. When diagnosing cracked tooth syndrome, the dentist has to take many things into consideration. Timely management and good prognosis of cracked tooth syndrome are linked to its swift diagnosis. X-rays offer little benefit in visualizing cracks.

Every diagnostic exam is preceded by a detailed history-taking process that may address some of the symptoms of cracked tooth syndrome. History may reveal localized pain that flares up on the release of pressure when eating or sharp pan when consuming foods of extreme temperatures. Various habits that may predispose to cracked tooth syndrome include chewing ice, pens, hard sweets, etc.

  • Clinical examination

The inability to visualize the extent of the crack through clinical exam alone is one aspect that leads to the problematic nature of its diagnostic abilities. However, some clues may help detect cracked tooth on clinical examination, such as:

  • Presence of wear faceting on the occlusal surfaces of the teeth indicating excessive forces (due to clenching or grinding)
  • Presence of isolated deep periodontal pockets found where cracks extend below the gum line (subgingivally)
  • Induction and aggravation of symptoms by sweet or thermal stimuli (when eating or drinking hot or sweet foods)

Many experts often remove existing restorations to help visualize the cracks better but beware that removing a restoration may do little good for your teeth. The tactile examination may also be done by scratching the surface of the tooth with the tip of a sharp instrument in hopes of the tip catching in a crack.

  • Dye tests

Dyes such as Gentian Violet or methylene blue stains aid in the visualization of fractures. Your dentist may also use rubber dams to isolate a tooth and highlight the crack with a contrasting background to confirm or rule out the presence of cracks. The technique, however, requires 2 to 5 days to be effective and will require placement of a provisional restoration.

  • Transillumination

Transillumination is the best method to locate a traditional crack whether it is complete or not, as in the case of cracked tooth syndrome. The tooth is cleaned and a light source (fiber-optic light) is placed directly on the tooth. A crack that penetrates into the dentine of the tooth causes a disruption in the light transmission. However, transillumination may dramatize the cracks making them appear enlarged as well as causing color changes to become invisible.

  • Bite Test

The principle of “bite tests” are implemented to visualize the discrete cracks on tooth surfaces where the patient is instructed to bite on various items such as a toothpick, cotton roll, wooden stick, or commercially available tooth slooth. Pain increases with the impact of occlusal forces and relieved when the pressure is withdrawn.

If you suspect that you may have a cracked tooth, visit your endodontist immediately. Don’t have an endodontist yet? With 4Smile, you can connect with numerous experienced endodontists to get your cracked tooth fixed! Crack a smile, not a tooth!

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