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Azerbaycan Saytlari

 »  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
Discussion - References.

In our selected material, 28 out of 32 patients with incompletely fractured teeth and associated pain had suffered pain for more than 3 months, most of them for years. Despite numerous visits to different dental and medical specialists, the correct diagnosis was not made. This may indicate a lack of knowledge concerning this special problem, or it may be other contributing factors making the diagnosis difficult. The fact that some patients had multiple infractured teeth, ranging from two to six infractions, makes the pain pattern in this group confusing and the diagnostics difficult. If incompletely fractured teeth were present on both sides of the midline, and the patient presented with a history of numerous visits to dentists and/or medical doctors, the patient most often arrived at our clinic with the diagnosis ‘atypical pain’, and the real cause remained undetected. We advocate that the dentist should suspect an incompletely fractured tooth in all cases with obscure aetiology and mixed chronic symptoms.
The pain pattern in patients with one diagnosed incompletely fractured tooth was not distinguishable from patients with more infractions in one quadrant.

Incompletely fractured teeth related to type of restoration.
The majority of the infractions occurred in heavily restored teeth. Many studies (Mondelli et al. 1980, Abou-Rass 1983, Cavel et al. 1985), have shown how cavity design affects the strength of the tooth.
In teeth with extensive amalgam restorations, systematic removal of fillings proved to be the most efficient way of tracing incompletely fractured teeth in our material.
The most difficult diagnostic cases, were incomplete dentinal fractures in intact teeth and in teeth with class I restorations. Those patients had reported pain for a period of 2–10 years, and the pain was often projected to the ear region, radiating to both mandibular and maxillary regions. The affected teeth were, in these cases, premolars.
The best method for detecting infractions in intact teeth and in teeth with a small restoration, is transillumination by use of fibre-optics. The tooth should be properly cleaned before placing the light source directly against the tooth surface.

Treatment or observation?
Pain connected to incompletely fractured teeth is usually not acute, and does not require immediate treatment. The dentist should not feel compelled to treat all cases with symptoms. Misdiagnosis and mistreatment may easily follow. In this material we observed ‘unnecessarily’ root-filled and extracted teeth in search of the affected tooth, if there was any.
On the other hand, it is important to prevent the pain from becoming chronic. Sessle et al. (1986) described how neurones in the brain stem receiving input from skin, oral mucosa, neck muscles and TMJ become operative in longstanding pathophysiological situations, neurones which are normally ineffective in exiting the nociceptive transmission neurones. Thus, both peripheral and central sensitization are involved to varying degrees in different types of hyperalgesia (Treede & Magerl 1995).
In our material, we found that in cases with longstanding pain, the perception of pain changed and the pain projected more diffusely throughout orofacial tissues, thus making the diagnosis more difficult. This indicates the importance of a thorough evaluation in the search for a diagnosis at an early stage in cases with orofacial pain. The specially designed form for pain evaluation used at our clinic was of great help in determining whether a dental cause of pain was present or not.

Treatment considerations.
 The treatment principles used in this study were in line with recommendations given by Homewood (1998). In about 50% of the cases, the diagnosis of irreversible pulpitis was determined, and endodontic treatment was performed. All of the incompletely fractured teeth with infraction lines running centrally in dentine were in this group.
Further studies may be necessary in order to determine whether teeth with centrally running infractions and a history of pain should be more readily root filled to avoid recurrence of pain. Later follow-up studies from this patient group support such a view.
In conclusion, this study shows that diagnosis of incompletely fractured teeth with symptoms is time consuming and represents a diagnostic problem. With appropriate endodontic and/or restorative treatment, symptoms were relieved in the majority of cases.


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