Thursday, July 10, 2014

Cracked Tooth Syndrome (CTS)

What is CTS?
Minuscule cracks can form on your teeth, threatening your dental health. Why? 
  • Age plays a factor - as we get older, our teeth tend to weaken, making them susceptible to tiny hairline fractures that are not visible to the naked eye. 
  • We increase our chances of developing cracked teeth by exposing them to trauma, such as bruxism and chewing on hard objects.
  • When teeth have been heavily filled, it is not unusual that they develop cracked (or split) tooth syndrome (CTS). 
Symptoms include a sharp pain when you bite down into something hard. When you open your mouth and the teeth are no longer touching, the pain goes away. The pain does not usually linger after the biting action is finished. The fact that you feel pain when pressure is applied to the tooth means that the nerve is being affected. If the problem is not solved quickly, the nerve may die and the tooth will then require endodontic treatment (root canal).

Why does it hurt when I eat?
Pressing an object against the tooth opens the crack, causing the underlying dentin to move and irritating the pulp chamber (which contains the tooth's nerves). When the pressure is released, the crack immediately closes, causing a sharp pain. If left untreated, the pulp will eventually become damaged, and you will start to feel sensitivity to hot and cold or prolonged pain.

Common sites of cracked teeth
  • Premolars and molars, the back teeth that grind and crush food 
  • A tooth that has recently been drilled and a great amount of tooth structure has been lost
  • A tooth that has an extensive filling (usually silver amalgam) that has been in place for a long time 
  • Or a tooth that only has a small silver filling  
    • The filling has weakened the tooth just enough so that when you chew or bite, the tooth and filling separate slightly (flex), causing immediate and sometimes severe pain.
Types of cracked teeth:
  • Fractured Cusp: When the cusp (the raised section of the biting surface of your tooth) becomes fractured. If a fractured cusp does not break off on its own, it will need to be removed by a dentist and replaced by a dental crown.
  • Cracked Tooth: Run vertically, originating from the top part of the crown and working their way down. Treatment typically entails a root canal followed by a dental crown. If the crack has extended below the gum line, the tooth may require a tooth extraction. 
  • Split Tooth: When a cracked tooth is not treated, the crack can extend beyond the root, causing the tooth to split. Although these teeth are difficult to save, they can sometimes be treated with a root canal. 
  • Vertical Root Fracture: Sometimes the crack starts at the bottom of the root and works its way up. If caught early, endodontic dental surgery may correct the situation. 
Treatment
Vertical Fracture

  • Treatment will involve at least one x-ray to assist in the diagnosis and to rule out other causes. We will try to find the section of the tooth that is causing the problem by pushing on the various sections of the tooth or having you bite on a hard object.  
  • When the section of the tooth that is cracked is found, it makes treatment easier. First, the tooth is anesthetized and the old filling is removed. 
  • Then we carefully inspect the area to determine whether the cracked section can be seen. Very often it is visible at this point. 
  • The next step is to see whether the split area can be fixed with a direct filling (bonded). This is the ideal situation if the crack is small.  If the crack is small enough, it may be removed by replacing the filling. Bonded white fillings and bonded amalgam filling will hold the tooth together making it less likely to crack
    • Crown
    • Your dentist may first place an orthodontic band around the tooth to keep it together. If the pain settles, the band is replaced with a filling that covers the fractured portion of tooth (or the whole biting surface).
  • Unfortunately, this rarely occurs. If the crack goes too far vertically, there is a possibility the tooth may need to be removed and replaced with an artificial one (bridge, denture, or implant). More often (over 95% of the time), the biting surfaces of the tooth must be entirely covered and protected first with a provisional (temporary) onlay or crown. 
  • If this is successful in eliminating the pain (we usually wait for a few weeks to be sure the problem is resolved), an impression for a laboratory-fabricated casting - either a porcelain or resin onlay or a crown - is made. If adequate tooth structure remains, a partial coverage restoration - an onlay - is preferred. If the tooth has been badly cracked or if not much tooth remains, then a crown will be necessary. The purpose of either type of cast restoration is to unite all sections of the tooth so it cannot move or separate under normal biting forces. If the provisional restoration is successful in eliminating the pain, we expect that the final cast crown or onlay will correct the problem. 
  • The nerve may sometimes be affected so badly that it dies. Root canal treatment will be required if the tooth is to be saved.
The earlier a split tooth is diagnosed and treated, the better success there is in treating it. If the split is severe, a root canal may be necessary to save the tooth. Depending on the symptoms you describe, we may choose to treat it as a bite adjustment, small filling, or larger preparation for an onlay or  crown. If these do not work, the treatment plan will be modified. If left untreated, the tooth may eventually be lost. It is also possible that the initial split of the tooth may be such that it cannot be saved, despite our best efforts.

Delaying Treatment
What happens if CTS is not treated quickly? The best you can hope for is that the tooth continues to hurt only when you chew or bite. This does not often happen. Usually, the broken section of tooth gets weaker and weaker until it fractures off. Additionally, if the crack gets deeper into the tooth, the nerve will die and the tooth will need endodontic treatment before the crown or onlay is placed. Sometimes the nerve is immediately affected by the initial split and dies. This may occur quickly or may take years before it is evident. Every case of CTS is unique. If it is any consolation, the cracked tooth is not your fault. It is a result of your teeth being drilled and filled with big silver fillings when you were younger. We see this particular dental problem mostly in patients who are between 25 and 45 years old.

Unfortunately, cracked teeth do not go away. Many times, they only hurt when you bite on them from one particular angle. If the fractured segment is not stressed, the tooth feels normal. You might also be able to "train" yourself to chew on different teeth and avoid the cracked tooth. At best, you only postpone necessary treatment while the nerve may be slowly dying.

After Treatment
If treated by adjusting your occlusion (bite) on the tooth
This will lessen the symptoms. If the discomfort you feel when you bite is not eliminated within one week of treatment, please call our office and let us know. If the split is still present, a different approach will have to be tried. Give the tooth a few days to "calm down" before you try to bite down on hard foods.

If treated by removing the old restoration and placing a bonded filling in its place 
If the split is small, this may eliminate the problem. Do not bite down hard on the tooth for a few days, then gradually place more pressure on the tooth. Call our office in one week and let us know how it feels. If the split is still causing a problem, a different approach must be tried. If left untreated, the tooth may split further and you may need endodontic treatment and a crown. If the tooth splits severely, it may have to be extracted.

If treated by cementing a temporary crown onto the cracked tooth with temporary cement 
Because the crack was so severe, this procedure was used to determine whether or not the tooth can be treated without performing a root canal. Please give the tooth several days of rest before you try biting down on hard foods. Expect the tooth to be sensitive for a few days after the temporary is placed. This is normal. Gradually apply more force when you bite into foods, and gradually try to eat harder foods. Expect the temporary crown to remain in place for several weeks, until it can be determined whether or not the problem is solved.

If you have any questions about cracked tooth syndrome, please feel free to ask us.

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