“ I Haven’t Got Time for the Pain”

Paul Feuerstein, DMD


With patients downplaying fractured tooth treatment, your final statement usually is this: “Don’t call me in the middle of your sister’s wedding and tell me that the almond you bit into broke your tooth in half.”

Figure 1. Transillumination with AdDent’s Microlux unit.
Figure 2. View using DEXIS’s CariVu unit.
Figure 3a. Direct view using ACTEON’S SoproCare unit.
Figure 3b. Fluorescence view using SoproCare.

We as dentists have often heard this from a patient: “I have a tooth that hurts sometimes on the left side.” The patient—let’s call him Dave—points to the cheek (not inside the mouth) and says “somewhere around here.” On questioning, Dave is often unsure if it is top or bottom or what triggers the pain. He further states that the tooth is not consistently sensitive and really doesn’t react to hot or cold, but he refrains from chewing on that side.

The suspicion here is that we are dealing with a tooth fracture. Using low-tech tests like having the patient bite on cotton or soft wooden sticks or using instruments such as the Tooth Sleuth sometimes helps us locate the source and in fact helps the patient duplicate the source of the pain. Once we have identified the tooth or teeth, a simple high-intensity light such as the Microlux Transillluminator (addent.com) placed on the tooth can identify a fracture. Thinking of enamel as a fiberoptic “pipe.” If there is a break, the light stops. You can see this in Figure 1. The CariVu (dexis.com) allows you to see this fracture and take a photo of it (Figure 2). (This device is also quite helpful in caries detection, as I noted in one of my earlier columns). Of course, a good high-resolution intraoral camera with good lighting is also not only helpful to the practitioner’s diagnosis but also for patient education. The use of fluorescence with some of the cameras can also enhance the view of a fracture (Figures 3a and 3b).

This brings up 2 “must-haves” that will define your practice as a high-tech operation: an intraoral camera and digital radiography. Of course, these technologies assume that you have access to a computer and monitor in the treatment room so you can see an image and have the ability to show it to the patient. Most of my readers already have networked systems, while some are using laptops or mobile devices. Also, the advent of excellent tablets has opened new possibilities for show and tell.

Once you have located the pain-causing culprit, the discussion begins with the patient. One problem even at this point is the extent of the fracture. The American Academy of Endodontics has actually classified fractures. And there is an excellent article, “The Cracked Tooth Syndrome,” written by Dr. John West from The Center for Endodontics in Tacoma, Wash, that appeared in Dentistry Today 14 years ago (May, 2002) that explains this well. (Editor’s note: This article can be accessed online at dentistrytoday.com.) At this point, the real discussion begins. The problem is explained to the patient, and many times the treatment plan is to propose a crown. There is usually a necessary disclaimer here, implying that the crown may in fact stop the symptom, but depending on the path of the fracture, it could continue like a crack in glass, with future endodontics required and even the chance of tooth loss. With new 3-D radiographic imaging, you can get a better view of the extent of the fracture. Or in a more conservative approach, a bonded restoration—either direct or indirect—can be placed. In a recent report, Dr. Gordon Christensen stated that cuspal coverage with an onlay makes the tooth less susceptible to fracture than in its natural state.

The conversation with the patient then continues and often goes like this: “You know doc, it’s not that bad. It only happens once in a while. I don’t really have to do anything right now.” And then the infamous “if it ain’t broke, don’t fix it” comment emerges. You can argue all you want, but your final statement is usually this: “Well, don’t call me in the middle of your sister’s wedding and tell me that the almond you bit into broke your tooth in half.”

I was talking recently with a well-known dental consultant, Dr. Rhonda Savage, CEO of Miles Global, and asked her how she handles this situation. She said that using the term fracture conjures up an image of a broken bone—something that can be repaired. Why not just say “your tooth is broken,” and tell the patient that it has to be fixed before he or she utters the “ain’t broke” phrase? That simple change of terminology has had a change in my patients’ perceptions. (That is why Dr. Savage is the consultant, and I am the tech guy.) She continued by saying this: “Add the word ‘yet’ to the ‘not broken’ phrase, This is more forceful and tells the patient it will happen.”

Of course, if we do a careful exam with the cameras or high-intensity lighting and magnification, we will see fractures in almost every tooth. Many are asymptomatic and could be craze lines stemming from the actual operative procedure with a handpiece, a prematurity in a virgin tooth, or as even some say, thermocycling. These should be noted, and images stored in the patient record. Then perhaps address occlusion and discuss with the patient how proactive you want to be. Of course, always use your own clinical judgment and these tools as diagnostic aids.