Articles and Position Statements
AADC Position Statement: Cracked Tooth Syndrome

Cracked Tooth Syndrome

Position Statement

Introduction

The diagnosis “cracked tooth syndrome” (CTS) is commonly encountered by dental consultants when reviewing dental claims and is poorly understood by many dental clinicians. Attempts by several authors to clarify a diagnosis have resulted in many “facts” that vary by author and year of the publication. The American Association of Dental Consultants (AADC) Positions Committee has investigated evidence-based literature in an attempt to establish a standard position regarding criteria for and diagnosis of “Cracked Tooth Syndrome.”

Because of the complexity of the diagnosis and the lack of specificity by clinicians who seek benefits for treatment of a cracked tooth, this paper will outline criteria based on information from a literature search to determine a scientific basis for the evaluation and need for treatment of the syndrome.

The focus of this paper is to review suggested diagnostic criteria currently used in determining management of the “cracked tooth.” The need for treatment of “cracked tooth” remains subjective and recent literature suggests initial conservative management.

Methods

MEDLINE, articles, the Cochran Library and personal interviews were used to review diagnostic methods and suggested treatments of CTS. The papers reviewed fit AADC criteria for sample size and duration to determine standard diagnosis. Conclusions were arrived at by an aggregate review of this literature search

Background

There is no standard definition of CTS; definition and diagnosis varies widely from author to author. Our review was complicated because some of the articles reflected a subjective analysis based on case reports. Some authors define a cracked tooth based upon appearance; e.g., fissures, stains or chips. Nearly all of the authors stated that the diagnosis of cracked tooth is hard to make, and often a crack is not visible on radiographs. Generally, association with pain unresolved or of lingering duration is necessary to make this diagnosis.

Years ago, craze lines were used for diagnosis, but recent available conservative reversible procedures bring the question of definitive diagnosis without unresolved attempts to treat symptoms conservatively, into question. The presence of repeated and unresolved pain, often triggered by occlusal forces, along with personal habits; e.g., bruxism and clenching and cold sensitivity, as well as restorative history are now required to arrive at a diagnosis. Treatment, such as full coverage with or without endodontic services is no longer accepted dental practice as standard initial treatment.

CTS is frequently used as a rationale for benefits when insurance claims are filed. A study of a group of general dentists in North Carolina revealed that 44% of the crowns performed were to “prevent” tooth fracture in spite of other groups reviewing the patients with opposing views. Since radiographs may not “show” a crack in a tooth, clinicians often submit photographs taken after a restoration is removed. If a crack is visible, the question becomes: “are there treatment choices to be made?” Does this “crack” need to be treated with a crown?

The term “cracked tooth syndrome” was first suggested by Cameron in 1964 though cases were present before by Ritchey in 1957 and Gibbs in 1954.10,12, 15 Gibbs used the name “cuspal fracture odontalgia”.15 According to the International Association for the Study of Pain, the syndrome was defined as “brief, sharp pain in a tooth, often not understood until a piece fractures off the tooth”.11

The term “cracked tooth” is used in many ways. Sometimes it is used when there is a fracture of a cusp or when there is a stained developmental groove. There may be complete cracks or incomplete cracks; some will confuse a cracked tooth for a tooth with craze lines in the enamel or a tooth exhibiting minimal chips. The American Association of Endodontics has a chart available displaying types of cracks.

Attempts have been made to describe/diagnose a ‘cracked tooth’ which include specific criteria. In the past ‘cracked tooth’ has been used in presentations as a “catch all” phrase for unexplained ora facial pain that has no other obvious cause.

Evaluation

While there are many criteria suggested in a literature review, there is only one common denominator: i.e., pain, localized to the tooth, associated with function and temperature sensitivity. The general rule is: if a patient presents with no pain or no trigger point, then no treatment is necessary or appropriate.

Other suggested findings, such as the presence of: craze lines, cracks, positive staining of a crack, external or internal transillumination, positive test results from the use of objects such as a pressure stick (“tooth sleuth”) or some other chewing test are often inconclusive and by themselves are not diagnostic of a cracked tooth.

There are attempts to reduce the subjectivity of diagnosis. The first is the use of CT scan (cone beam) technology, which has cost and radiation consequences beyond the proven value of the service. The second uses a biometric pressure system, which is still considered investigatory. We found no linear relationship between CTS and cuspal fracture. Fractures, by their nature will define the treatment options. A history of trauma should be determined. Occasionally a tooth may be traumatized and have no initial evidence of a problem until pain starts and/or the anatomical crown turns pink.

Often the CTS has no significant history. Occasionally, the patient may state they experience pain when they bite on a hard object such as a pit, bone or ice.

Davis et al studied 40 teeth in 38 patients over 1 year. The initial symptoms included chewing pain and cold sensitivity.5

Conflicting authors note that most “cracked tooth” cases are reported in first molars that had previously been restored, in patients over the age of 40, 12. While Roh found most cracked teeth to be greater in maxillary molars with no restorations. The only criteria he and the others agreed upon was age,16. The general opinion observed concluded that symptoms were necessary to move forward with a treatment determination. No symptoms? No prophylactic treatment needed.

Observations Concerning Treatment

Our literature review showed a variance in treatment. Treatment options were dependent on the diagnosis of the crack, i.e. extent, location, and status of the tooth. Presenting criteria helps consultants make proper treatment or benefit decisions. The major criteria noted in the articles was pain. Some of the articles reviewed based conclusions on the opinions of the authors. These were noted in our conclusions.

Immediate therapy seems to reduce the risk of irreversible pulpitis.14 Conservative treatment is suggested. The pain is often relieved with a NSAID.13 If the occlusion is heavy, it may help to reduce the pressure on the tooth, but this has limited benefit since function may still put pressure on the tooth. The use of a direct bonded composite may act to splint the tooth14. The use of sedative restorations may relieve symptoms.

The American Association of Endodontics has recommended that if pain persists after conservative treatment, endodontic treatment may be considered. However, most studies suggest no endodontic treatment is needed initially.

Full coverage is rarely needed14. One study showed a 93% success rate using bonded indirect composite onlays8.  Full coverage is needed in a small minority of cases when partial coverage or an internal bonded restoration does not relieve symptoms.

Conclusions

1. Cracks and craze lines in teeth are common

2. Molars are most commonly involved

3. Asymptomatic teeth do not need to be treated

Recommendations

1. Pain must be documented.

2. Conservative treatment should be tried first; e.g., composites with or without onlay of cusp.

3. Endodontic treatment may be needed for irreversible pulpitis after other conservative treatment has failed to relieve pain.

4. Possible crown when there has been cuspal fracture or if needed after endodontic procedures.

Position Statement

Given the preponderance of current best evidence, it is the position of the AADC that conservative treatment be initially recommended for a tooth demonstrating symptoms consistent with “cracked tooth syndrome.” Furthermore, an asymptomatic tooth or a tooth with craze lines does not require endodontic services, crowns, or additional treatment. An asymptomatic tooth, with no history of pain cannot be defined as CTS.

References

1. Opdam NJM, et al. Seven-year clinical evaluation of the painful cracked tooth restored with a direct composite restoration, JOE 2008; 34: 808-811

2. Cracking the cracked tooth code. Endodontics: AAE Colleagues for excellence 1997; (fall/winter):1-13

3. Christensen GJ. When is a full crown indicated? JADA 2007; 138:101-3

4. Homewood CI. Cracked tooth syndrome: clinical findings and treatment. Aust Dent J 1998; 43:217-22

5. Davis R, Overton JD. Efficacy of bonded and non bounded amalgam in the treatment of teeth with incomplete fractures. JADA 2000;131:469-78

6. Bearn DR, et al The Bonded amalgam restoration of the cracked-tooth syndrome. Quintessence Int 1994;25321-6

7. Opdam NJM, Roeters FJM. The effectiveness of bonded restorations in the treatment of the painful cracked teeth: six-month clinical evaluation. Oper Dent 2003; 28:327-33.

8. Signore A, et al. A 4-6 year retrospective clinical study of cracked teeth restored with bonded indirect resin composite onlays. Int J Prosthodont 2007;20:609-16

9. Deog-Gyu Seo, et al. Analysis of Factors Associated with Cracked Teeth. JOE 2012;38:288-292

10. Turp, JC and Gobetti, JP. The cracked tooth syndrome: An elusive Diagnosis. JADA 1996;127:1502-1507

11. Merskey H, Bogduk N. Classification of chronic pain. 2nd ed. Seattle: IASP Press;1994:75

12. Lubisich EB et al. Cracked Teeth: A Review of Literature. J Esthet Restor Dent 2010; 22:158-167

13. Rodriguez DS and Sarlani E. Decision Making for the Patient Who Presents with Acute Dental Pain. AACN Clinic Issues 2005;16:359-372

14. Banerji S et al. Cracked tooth syndrome. Part 2: restorative options for the management of cracked tooth syndrome. Brit Dent J 2010; 208:503-514

15. Abbott p and Leow N. Predictable management of cracked teeth with reversible pulpitits. Aust. Dent J 2009; 54:306-315

16. Roh BD, Lee YE. Analysis of 154 cases of teeth with cracks, Dent. Traumato 2006; 22:118-123.

 

AADC Positions Committee  

Dr. Michael D. L. Weisenfeld

Dr. Bob Arm, Primary author

Dr. Andy Mogelof

Dr. Dee FitzGerald

Dr. Cary Sun

Dr. Marc Zweig

Dr. Stephanie Lepsky

Dr. Darlene Chan, Ex Officio