Pathways of referrals to the endodontists.
The referred patients had consulted their own general practitioner (GP) due to pain problems in the orofacial region, 26 patients more than twice. Nineteen patients (63%) were referred directly from the GP to the endodontist, four (9%) from oral surgeons, two from periodontists (6%) and seven (22%) from medical services. In the latter group, five patients had consulted an ear, nose and throat physician and two patients had consulted a neurologist. Three patients in this group were hospitalized. Still, the correct diagnosis was not made.
Incidence of crack lines.
Analysis of the 46 teeth showed that the majority of the incompletely fractured teeth occurred in the maxilla, evenly distributed between premolars and molars, whereas molars predominated in the mandible (Fig. 1).
Twenty-three patients (72%) were diagnosed with only one incompletely fractured tooth. Nine patients (28%) exhibited incomplete fractures in more than one tooth, ranging from two to six. In four of these patients fracture lines were located in the same quadrant, and in five patients they occurred on both sides of the midline. No patients were recorded with infracted teeth in both jaws on one side only.
The majority (89%) of the incompletely fractured teeth occurred in heavily restored teeth (Fig. 2). Three infractions (7%) were found in teeth with class I restorations, and two (4%) in teeth without restorations.
Figure 1. Distribution of infracted maxillary and mandibular teeth with symptoms. _ = maxilla, _ = mandible.
P1, first premolar;
P2 second premolar;
M1, first molar;
M2, second molar.
Extension of fracture lines.
All fracture lines extended in the mesio-distal direction, and in 10% of the cases they were running centrally in the tooth.
In maxillary teeth, 70% of the infractions were localized in the dentine supporting the buccal cusps, whilst 20% were on the lingual side. In the mandible, the situation was opposite, 20% buccally and 70% lingually.
Duration of pain prior to treatment.
Twenty-five patients had been suffering pain for more than 3 months, one for as much as 11 years (Fig. 3). No connection was observed between duration of pain and the number of incompletely fractured teeth. Likewise, the duration of pain did not negatively effect the treatment outcome.
Distribution of pain.
In cases with incompletely fractured mandibular teeth, the pain was felt throughout the arch and in tissues including neck, ear, chewing muscles and TMJ on the same side. In addition, it was regularly projected to maxillary teeth and tissues. In most cases the patient felt that the pain was located anterior to the affected tooth.
When one or more incompletely fractured teeth were diagnosed only in the maxilla, pain projecting to the mandible was reported infrequently. The pain was usually located anterior to the affected tooth. Location to the ear-region was infrequent.
The longer the duration of pain before the diagnosis of an incompletely fractured tooth was established, the more diffuse was the distribution of pain. Often symptoms projected to both jaws.
In five patients, incomplete dentinal fractures occurred on both sides of the midline, in three of them in the maxilla. In these cases, pain was diffusely distributed throughout the mandibular and maxillary tissues including neck, ear, chewing muscles and TMJ on both sides. Headaches occurred in the group of patients with symptoms for more than 5 years prior to treatment.
Figure 2. Symptomatic incomplete dentinal fracture under an amalgam filling.
(a) An incomplete dentinal fracture (arrow) is seen after removal of an amalgam filling.
(b) Access preparation reveals a fracture line involving the pulp chamber.
Endodontic or restorative treatment relieved the symptoms in 90% of the patients during a two-year follow-up, whilst persisting symptoms in 10% were considered as part of an orofacial pain complex of unknown aetiology. The patients who had been hospitalized were all made symptom free.
If symptoms persisted after temporary treatment, including reduction of occlusal load and stabilization of the fracture lines, a diagnosis of irreversible pulpitis was made and root canal treatment was performed without delay. About half of the group was treated in this way, whilst the other half was treated with either cast restorations (cemented) or conventional fillings, always with cuspal coverage (Fig. 4).
Figure 3. of pain prior to treatment. _ represents acute pain; represents pain of chronic character.
Figure 4. Types of treatment performed.