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December 2000 – A Diagnostic Dilemma

Fig. 1
This month we are presented with an emergency case, sent to me on short notice in the middle of a busy afternoon. The patient is a 44-year-old male physician with a history of minimal dental restoration. His last restoration was placed well over 10 years ago and his overall oral condition is excellent. His current complaint was intermittent toothache provoked by percussion and chewing in the posterior right mandible. The referring dentist could not explain the patient's symptoms in the context of his minimal restorative history and lack of caries. Periodontally, the patient exhibited no unusual findings.

Bitewing radiography (Fig 1) showed no active carious lesions and normal interproximal bone contour. A minimal single surface occlusal amalgam was the only restoration present in #46.

Fig 2 - Bite Wing - Right Side
Periapical Radiography (Fig 2.) showed thickening of the PDL space at the apex of the mesial root of #46. Palpation tests were negative but percussion and occlusion were positive in tooth #46. Pulp tests produced normal responses to hot and cold in all teeth with the exception of #46. This tooth did not respond to any pulp tests. At this point it appeared that the non-vital pulp in #46 was the obvious choice for endodontic treatment but what was the etiology of the necrosis?

Fig. 3 - Distal Marginal Ridge Crack & facets
Closer inspection of the tooth revealed a hint in the distal occlusal aspect of the tooth. There was a small distal -marginal ridge crack, visible with magnification and transillumination. (Fig.3) Marking of the occlusion revealed heavy contact and facets in this area of the tooth.
A decision was made to remove the amalgam (without anesthesia) (Fig. 4). This would serve 2 functions: (1) It would confirm the lack of vitality of the pulp by the most reliable of all tests: The Cavity Test (2) Removal of the amalgam would allow us to examine the depth of the fracture to determine whether it had approached the pulp.

Fig. 4 - Amalgam removed without local anesthesia. A Distal crack on pulpal floor was found.

As I suspected, the coronal pulp was necrotic. The fracture extended down the distal aspect of the tooth into the distal canal orifice.
(Figs. 5 and 6)


Fig. 5
Excavation of distal fracture


Fig. 6 Extension of Crac
into Distal Canal Orifice resulting in Necrosis

After determining that there was some remaining vitality in the apical portions of the mesial canals, the rubber dam was removed and an anesthetic was administered. (Yes, not administering anesthesia immediately may be a little extra work, but it prevents me from ever opening into a vital tooth that I suspected was necrotic) A pulpectomy was performed, the canals dried and the case closed with cotton pellets and Cavit. The occlusion was heavily relieved and the patient was given specific instructions not to use this side for chewing. (If the patient is not going to be seen very soon, an appointment should be scheduled for proper pretreatment – Banding of the tooth- by myself or by the Referral.) Endodontic treatment was completed at the earliest possible date.

It is the responsibility of the restoring Dentist to see that restorative treatment is completed within a reasonable period of time in order to ensure against catastrophic Mesio-Distal splitting of the tooth.

Summary: The case presented with classic symptoms of CTS
(Cracked Tooth Syndrome) and subsequent pulpal involvement with necrosis.

Diagnostic and treatment considerations:

1. Never assume that posterior teeth are vital simply because of their lack of restorations or shallow fillings. (especially mandibular molars !)
2. Examine marginal ridges of all teeth closely for evidence of fractures. Use transillumination if necessary. Be aware of enamel crazing (that occurs in most teeth) but also examine the occlusion for cracks associated with faceted surfaces. Is the patient a bruxer?
3. Radiographic Periodontal lesions can sometimes mimic endodontic involvement. If you suspect necrosis – NEVER administer an anesthetic until necrosis of the coronal pulp and diagnosis is confirmed. Entering a vital pulp in a tooth with a suspected lesion of endodontic origin is a sure sign of misdiagnosis.
4. When the diagnosis of cracked tooth with pulpal involvement is confirmed, always relieve the occlusion, explain the need for immediate post-endo cuspal protection and instruct the patient to avoid chewing on that side. Once symptoms have been relieved, patients can occasionally "forget" and cause the tooth to Split. If the tooth is not going to be restored immediately, banding of the tooth or placement of a cusp relieved core is essential.