Cracked-Tooth Syndrome: Is A Common Result of Incomplete Tooth Fracture. Patients Suffering

lec.4 Operative and Esthetic Dentistry ‫سعدي شرشاب‬.
‫د‬
Evaluation of tooth wear, integrity, and fractures:

Cracked-tooth syndrome: is a common result of incomplete tooth fracture. Patients suffering
cracked tooth syndrome often experience cold sensitivity and sharp pain of short duration while
chewing. The cusps most commonly fractured are the nonfunctional cusps. Often patients with
multiple cracked teeth have parafunctional habits or malocclusions. Cracked tooth syndrome is an
age related phenomenon; the greatest occurrence is found among patients between 33-50 years of
age. This syndrome is often difficult to be diagnosed. The patient is unable to identify the offending
tooth & evaluation tools such as radiograph, visual examination, percussion, and pulp tests are
typically non-diagnostic. The two most useful tests are:
a. Transillumination: when a tooth with a crack is transilluminated from either the facial or the
lingual direction, light transmission is interrupted at the point of the crack. So the portion of the
tooth on the side away from the light appearing quite dark.
b. Biting test: it is the most definitive means of localizing the crack, by having the patient bite a
wooden stick, rubber wheel; the dentist will be able to reproduce the patient's symptom & identify
the fractured tooth.
In treatment of incomplete tooth fracture, the tooth sections are splinted together with a cuspal
coverage restoration. This may include the use of an amalgam restoration, a crown or indirectly
fabricated onlay or resin composite.
Attrition: excessive occlusal wear caused by occlusal parafunctional (bruxism). In these instances,
facets on opposing teeth match well. Prevention is accomplished with use an occlusal resin appliance
(night guard, bite plane) and education of the patients.
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Abrasion: the loss of tooth substance induced by mechanical wear other than that of mastication.
Abrasion results in wedge-shaped indentations with a smooth, shiny surface.
Erosion: It can be defined as a loss of tooth substance by a chemical process that does not involve
known bacterial action. The eroded area appears smooth, hard and polished.
Abfraction: microfractures which appear in the enamel and possibly the dentine caused by flexion
of the cervical area of the tooth under heavy loads.
Erosion: It can be defined as a loss of tooth substance by a chemical process that does not involve
known bacterial action. The eroded area appears smooth, hard and polished.
2. Evaluation of the periodontium:

From a restorative dentistry perspective, the periodontium must be evaluated for two reasons:
a. To determine the effect of t the periodontal health of the teeth on the restorative treatment plan.
b. To determine the effect of that planned or existing restorations on the health of the periodontium.
The most consistent clinical indicator of periodontal inflammation is bleeding on probing. Any
bleeding by gentle probing should be noted. Mobility of a tooth should also be tested, by placing a
finger or blunt end of the instrument on either side of the crown and pushing it and assessing any
movement with other finger. During examination of periodontium, the dentist must estimate the
location of margins for future restorations and their potential to impinging on the biologic width (the
area approximately 2mm in the apicocoronal dimension, occupied by the junctional epithelium and
the connective tissue attachment).
3. Evaluation of occlusion:
The occlusal examination should be considered for restorative treatment plan. The inter arch space
available for placement of needed restoration and the number and position of occlusal contacts as
well as the stress placed on the occlusal contacts should be assessed.
Evaluation of radiograph: Radiograph is one of the most important tools in making a diagnosis.
Without radiograph, case selection, diagnosis and treatment would be impossible as it helps in
examination of oral structure that would otherwise be unseen by naked eye. Clinical situations for
which radiograph may be indicated includes:
Pervious periodontal or root canal therapy.
History of pain or trauma.
Large or deep restorations.
Deep carious cavity.
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Swelling mobility of teeth, fistula or sinus tract infection.
Abutment teeth for fixed or removable partial prosthesis.
Unusual tooth morphology or color.
Missing teeth with unknown reason.
In evaluating radiographic findings for restorative purposes, the dentist should note open
interproximal contacts, marginal openings, overhanging restoration, periapical radiolucency of the
tooth.
Evaluation of diagnostic casts:
The dentist can gain valuable information through an evaluation of diagnostic casts. The dentist can
see areas that are visually inaccessible during the clinical examination. Facets and marginal openings
that may be difficult to be seen intraorally, are readily visible on the diagnostic casts. In addition,
cases involving, multiple missing teeth need the evaluation of casts mounted on a semi adjustable
articulator. This enable dentist to assess the occlusal relationship and to plan restorative treatment.
Cariology
Cariology: A science that deals with the study of etiology, histopathology, epidemiology, diagnosis,
prevention and treatment of dental caries.
Dental caries: defined as multifactorial, transmissible, infectious oral disease caused primarily by
complex interaction of cariogenic oral flora with fermentable dietary carbohydrates on the tooth
surface over time.
Diagram showing local factors involved in etiology of dental caries
Etiology of dental caries: Many factors involved in the caries process such as the tooth, dental
plaque, diet, time, saliva, social & demographic factors:
Tooth: it consists of calcium phosphate minerals that demineralizes when the pH lowers. As the
environmental pH recovers, dissolved calcium & phosphate can precipitate, the process called
(remineralization). Susceptible areas on tooth for caries are deep and narrow pits and fissures and
exposed root surfaces.
Abnormal tooth: Position also affects the initiation of dental caries, it becomes difficult to clean, and
hence retain more food and debris.
Dental plaque: Dental caries do not occur if the oral cavity is free of bacteria. Streptococcus mutans
considered the main causative factor for caries because of their ability to adhere to tooth surfaces,
produce abundant amounts of acid and lower pH level.
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Diet: dietary carbohydrates are necessary for the bacteria to produce energy; the acids formed as a
by-product, so that initiate demineralization.
Time: affects the caries process, as dietary carbohydrates must be present for a sufficient length of
time to cause demineralization, in fact, caries lesions do not develop so fast but it takes time, it may
take years for cavitation to occur. This gives the dentist and the patient time for preventive treatment
strategies.
Saliva: (How does saliva help to prevent tooth decay?): Saliva plays a very important role in process
of fighting tooth decay. Here is a list of some of the benefits that saliva provides:
a. Bacterial cleanser: saliva lubricates oral tissues and bathes teeth and the biofilm.
b. Saliva contains buffering agents that can neutralize the acid created by the bacteria, which inhibit
dental plaque and cause tooth demineralization (tooth decay).
c. Saliva contains the minerals that must be present for the tooth remineralization process to occur.
d. Saliva contains antibacterial agents that can inhibit the proliferation of oral bacteria.
Social & demographic factors: many studies have shown that dental caries is more prevalent in the
lower socioeconomic categories.
Rate of Caries Progression and caries risk assessment:

During the dental examination: the presence of open cavities and fillings represents the prevalence of
the disease that is the most important indicator of the balance between resistance factors and caries
inducing agents. The incidence of the disease must also be evaluated. Caries incidence may be
determined by observing the speed at which existing lesion enlarge, or by observing the
development of new carious lesions between two clinical examinations.
Classification of caries:
Carious lesions can be classified in different ways:
1. According to their Anatomical Site:
a. Pit and Fissure Caries: This caries is usually seen in pit and fissures on occlusal surfaces of
posterior teeth and buccal and lingual surfaces of molars and on lingual surface of maxillary
anteriors.
b. Smooth Surface Caries: This is usually seen on all smooth surface of teeth, gingival third of
buccal and lingual surfaces and proximal surfaces.
c. Root Caries: Root caries occurs on exposed root surface.
2. According to speed of caries progression:
a. Active Carious Lesion: Rapidly invading caries involving several teeth. If untreated, acute caries
can result in pulp exposure. It is soft in consistency and light colored.
b. Inactive/Arrested Carious Lesion: Stopped progressing, long-standing caries characterized by a
large open cavity or intact surfaces, which no longer retains food and becomes self cleansing. It is
hard in consistency and dark-colored.
c. Rampant Caries: Is the name given to multiple active carious lesions occurring in the same
patient, frequently involving surfaces of teeth that are usually caries free. Typically occur in (bottle
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feeding baby) and (patient undergo radiation therapy).
Rampant caries Nursing Bottle Caries
Based on Extent of Caries

a. Incipient Caries: It consists of demineralized enamel, which has not extended to DEJ. This lesion
can be remineralized by proper preventive procedures, hence called as reversible caries.
b. Cavitated Caries: In this stage, caries extend beyond enamel into the dentin. This lesion result in
breaking the integrity of the tooth. So also termed as irreversible caries.
Diagnosis:
Dental caries is diagnosed by the following:
1. Visual changes in tooth surface.
2. Tactile sensation while using explorer.
3. Radiography: definite radiolucency indicating a break in the continuity of tooth structure.
4. Transillumination: producing a characteristic shadow on the proximal surface indicates presence
of caries.
New Detection Devices:
1. Direct digital radiographs for caries detection: This systems use a wire- based sensor that
contains a computer chip inside a protective casing, the sensor is connected to a PC by wire. The
sensor is placed in the patient's mouth, when this sensor hit by x-ray the information is transmitted
directly to the computer and displayed as an x-ray image on the computer screen.
2. Intraoral camera: for caries detection and for patient motivation.
3. Caries detector dyes.
4. Laser: Argon laser, Diode lasers.
5. Electrical conductance measurement: are based on the principle that porous carious lesions have
higher conductive values than intact tooth structure.
Prevention and management of the dental caries:

Main objectives of caries prevention are to reduce number of cariogenic bacteria and to create an
environment favorable for remineralization of the tooth. These objectives can be met by:
a. Increasing resistance of tooth surface to demineralization.
b. Increasing pH of biofilms.
c. Inhibiting microbial growth and metabolism.
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lec.4 Operative and Esthetic Dentistry ‫سعدي شرشاب‬.

Evaluation of tooth wear, integrity, and fractures:

2. Evaluation of the periodontium:

Diagram showing local factors involved in etiology of dental caries

Rate of Caries Progression and caries risk assessment:

Rampant caries Nursing Bottle Caries

Based on Extent of Caries

Prevention and management of the dental caries:

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