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 »  Home  »  Endodontic Articles 6  »  Incompletely fractured teeth associated with diffuse longstanding orofacial pain: diagnosis and treatment outcome
Incompletely fractured teeth associated with diffuse longstanding orofacial pain: diagnosis and treatment outcome
Introduction - Materials and methods.



A. Brynjulfsen, I. Fristad, T. Grevstad & I. Hals-Kvinnsland
Department of Odontology – Endodontics, School of Dentistry, University of Bergen, Bergen, Norway.
Department of Anatomy and Cell Biology, Medical Faculty, University of Bergen, Bergen, Norway.

Introduction.
Incompletely fractured teeth associated with pain, have been referred to as a diagnostic challenge (Cameron 1964). Various terms have been used to describe this type of tooth fracture, such as ‘green-stick fractures’ (Sutton 1962), ‘split root syndrome’ (Silvestri 1976) and ‘cracked tooth syndrome’ (Cameron 1964). The incompletely fractured tooth has been defined as ‘a tooth with a demonstrable fracture, but no visible separation of the segments’ (Luebke 1984). These dentinal injuries may be asymptomatic, or associated with symptoms and even orofacial pain (Cameron 1964, Homewood 1998, Ailor 2000).
Scarce information is available about the incidence of incompletely fractured teeth. In a clinical study of 1194 molars and premolars (Motsch 1992), incomplete fractures were found in about 3% of the teeth after removal of amalgam fillings. Furthermore, pain was rarely observed with this type of tooth injury, indicating that incompletely fractured teeth mainly exist without symptoms.
Incompletely fractured teeth may, in typical cases, be fairly simple to identify by common test procedures, such as selective bite-tests, use of staining solutions and transillumination. In other cases, however, they may be very difficult to localize because pain symptoms mimic other possible diagnoses like symptoms related to sinusitis, temporomandibular joint disorders, headaches, ear pain, or atypical orofacial pain (Snyder 1976). Traditional diagnostic tools may be less helpful in such cases, and have to be supplemented.
The purpose of this study was therefore to present findings from patients with diffusely localized orofacial pain, investigating the diagnostic value of different clinical findings, and analysing the distribution and pattern of pain experienced from incomplete dentinal fractures. Secondly, the effect of various treatment modalities were of interest.

Materials and methods.
Thirty-two patients referred to the teaching clinic at the Faculty of Dentistry, University of Bergen with diffuse orofacial pain were finally diagnosed with 46 incompletely fractured teeth. Those included in the study represent a selected group of patients with one or more incompletely fractured teeth and associated diffuse orofacial pain.
The 32 patients were referred from general dental practitioners, oral surgeons, periodontists, general medical doctors and medical specialists. More than 50% of them had been suffering diffuse orofacial pain for more than 1 year, and had earlier consulted both dental and medical expertise. Yet, no specific diagnosis had been made.
They were now examined according to standardized questions, radiographic evaluation and clinical procedures, including percussion test, selective bite-test, use of staining solutions and transillumination. None of these patients, however, experienced the typical pain pattern normally associated with incompletely fractured teeth, i.e. pain of sudden onset and short duration provoked by cold and chewing pressure. The information was recorded in a form used at the dental clinic, specially designed for pain evaluation.
The patients were then subjected to a thorough examination in search of suspected incomplete fractures. The usual testing procedures, performed initially, did not directly aid in the detection of a possible incompletely fractured tooth. Radiographs were of little value in detecting an incompletely fractured tooth, but were taken in order to rule out other possible diagnoses. In cases with unilateral diffuse pain spreading to both maxilla and mandible, anaesthesia tests were of great help in determining the correct jaw. Thereafter, fillings were removed routinely, starting with the most posterior tooth, allowing direct inspection of possible fracture lines. Removal of fillings was stopped when a fracture line was discovered. Removal of fillings located more mesially was continued if symptoms persisted after treatment. Methylene blue was, in many cases, used to stain a suspected crack. Microscopic evaluation and transillumination of the stained area provided even more information.
Once the fracture lines were revealed, further information was recorded; source of patient referral, affected jaw, affected tooth, extension of the fracture lines, type of restoration present, number of incompletely fractured teeth in each patient, duration of pain, and finally distribution and pattern of pain experienced by patients with one or more diagnosed incompletely fractured teeth in the same quadrant and by patients with affected teeth on both sides of the midline.