CRACKING THE CRACKED OOTH DILEMMA - · PDF fileSymptomatic Irreversible Pulpitis ... 0.75 mm occlusal reduction of #T ... apical 1/3 Courtesy of Dr. Matthew Nechrebecki 59

CRACKING THE CRACKED TOOTH DILEMMA

Brent Rundquist, DDS, MS

November 3, 2016

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Brent Rundquist DDS, MSNovember 3, 2016

Cracking the Cracked

Tooth Dilemma

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The “Classic” Cracked Tooth

“It hurts when I bite on it in just the right spot”

“Cold kind of bothers it too”

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Proper Nomenclature

Pyorrhea Periodontitis

Gums Gingiva

Cracked ToothSyndrome

??

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Cracked Tooth Nomenclature❖ SPECIAL COMMITTEE

ON CRACKED TOOTH INITIATIVE

❖ 2015

❖ Committee formed by the AAE to better describe

fractured teeth

❖ Louis H. Berman, Chair

❖ Scott L. Doyle

❖ Gary G. Goodell

❖ Keith V. Krell

❖ H Mark A. Odom, Board Liaison

❖ Helen Jameson, Staff Liaison

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❖ Cracked tooth — A thin surface disruption of enamel and dentin, and possibly cementum, of unknown depth or extension.

❖ Root fracture — A fracture that exists or extends into the root, to include dentin, cementum, and possibly pulp space, which may progress to or from the enamel.

❖ Longitudinal fracture — A root fracture extending in the axial plane within the tooth.

Special Committee on Cracked Tooth Initiative

a) Vertical Root Fractureb) Split Root

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Proper Nomenclature

Pyorrhea Periodontitis

Gums Gingiva

Cracked ToothSyndrome

Cracked Tooth

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Biting Tenderness but no Percussion Tenderness?

❖ Rosen J Pros Dent 1982;47:36-43

❖ “Until infraction has propagated from pulp to PDL, no percussion sensitivity will occur”

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Physiological Dentinal Pain A- fibers

Pathological Pulpal Pain C - fibers

A-Delta Fibers

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A-Delta

A - delta Fast Sharp Well-localized

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Brannstrom Hydrodynamic

Theory of Dentin JOE 1986;12:453-7

Masticatory pain is due to sudden

fractured portions move independently, activating myelinated A-the pulp and creating a rapid, acute pain response. Stimulation of A-

require

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Diagnosing Cracked Teeth

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Most likely – Naturally occurring through normal mastication (Walton and Rivera 2015, Endo Topics)

Thermocycling (Brown, 1972JDR)

Restored teeth 29x more likely to have cracks

than Unrestored teeth (Ratcliffe et al, 2001)

Why Do Teeth Crack?14

Why Do Teeth Crack?Masticatory Parafunctional Habits (Clenching and

Bruxism)Jantarat J, Palamara JE, Messer H. J Dent. 2001 Jul;

29(5):363-70

Masticatory Accidents (Ice, Hard Candy, Corn Nuts, Popcorn Kernels Etc.) DiAngelis AJ. J Am Dent

Assoc. 1997 Oct;128(10):1438-9

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Age of dentin

factor in dentin fracture.

Dentin from patients < 35 vs >55 shows a 50% reduction in strength of >55

Dentin from patients < 35 vs >55 shows 75% reduction in energy require to FX >55

>55 has greater mineral content and avg rate of crack growth 100 X that of <35.

Arola, D. et al. 2012. Endodontic Topics


Factor Relative to Cracked teeth

We Agree That Patients Will be Retaining Their Teeth

Longer Over Time...

and

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Pin Placement (Standlee et al.,1970, JPD)

Cavity preps (Reeh, et al., 1989. JOE,)Endodontic procedures have only a small effect on the tooth, reducing the relative stiffness by

5%. This was less than that of an occlusal cavity preparation (20%). The largest losses in stiffness

were related to the loss of marginal ridge integrity. MOD cavity preparation resulted in

an average of a 63% loss in relative cuspal stiffness.


“Nonfunctional cusps are more susceptible to

fracture, especially in Mn

teeth”

Agar et. al J Pros Dent 1988;60:145-7

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Which Teeth are at Greatest Risk for Cracking?

Mn MolarsMx MolarsMx PremolarsMn Premolars

Most

Least

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What are the Treatment Options?1. Extract it

2. Crown it and monitor it for endodontic tx need

3. RCT followed by crown

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TreatmentThe single most important question you

need to ask when treating a cracked tooth is?

Are you going to crown it and monitor it, or do RCT

prior to the crown

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Treatmentmake when deciding how to best treat a cracked tooth

is?

What is the pulpal status of the cracked tooth

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Cracked Tooth Pulpal Digression

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“Full coverage restorations will usually alleviate any pain as long as the crack

does not involve the pulpal tissues”

Seltzer et al Gen Dent 1997;45:148-59

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Reversible pulpitis- no periodontal pockets associated with the crack-

Crown it!Around 20% will eventually need RCT

within a year (Krell and Rivera, 2007. JOE)

Treating Cracked Teeth26

Krell and Rivera JOE 2007;33:1405-7Study of 796 cracked teeth Diagnosed With Reversible Pulpitis, crowned and

Followed for 6 years

Mn 2nd Molars 28% Mx 1st Molar 27% Mx 2nd Molar 25% Mn 1st Molar 17%

No Premolars required follow-up Endo

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Symptomatic Reversible Pulpitis

Symptomatic Irreversible Pulpitis

Short, non-lingering response to cold Lingering pain to cold stimulation

No percussive tenderness Percussion tenderness

No history of spontaneous pain Positive history of spontaneous pain

No history of heat hypersensitivity Heat hypersensitivity worse than cold

No history of need to use OCA’s Pt has been using OCA’s to control pain

Symptoms should not be trending worse over time Symptoms are worsening over time

NO radiographic pathosis evident Radiographic evidence of pathosis is present

DO NOT CROWN A TOOTH WITH SIP!

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Conclusions:*A cracked tooth correctly diagnosed with RP that gets a crown will go on to

need RCT about 20% of the time (premolars excluded)

*Some cracked teeth have a higher risk of needing follow-up RCT than others: Mn 2nd molars greatest, premolars the least

*Older dentin will crack faster and more frequently than younger dentin

*If symptoms resolve after the crown is placed and remain resolved past 6 months, the treatment is likely to be successful

(6 months)

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Q?30

ODONTOGENIC INFECTION: HOW BAD COULD IT BE?

Matthew Karban, DMD, MD Diplomate, American Board of Oral & Maxillofacial Surgery

The Dental Specialists

November 3, 2016

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An everyday infection32

51 yr female, healthy, ASA I

Presented with pain/swelling tooth #30 on a Friday

Seen by endo, opened tooth, purulent drainage encountered

Instrumented canals, calcium hydroxide, cotton/cavit

Sent home with clindamycin

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Over next few days pt has increased swelling, trismus and pain

Antibiotic changed to Augmentin

5 days following endo tx, pt returns, I&D attempted along buccal aspect of tooth, minimal drainage

Condition deteriorates over next 24hrs with dysphasia and increasing submandibular/cervical swelling

Pt referred to OMS for emergency intervention

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Emergency situation

Airway restriction

Inability to swallow

Spreading infection

Inability to open for airway intervention

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Emergency Intervention

Sedation not an option due to airway control

Decision to remove tooth 30

Explore region to provide drainage

Dissection along buccal/lingual aspect and as far posterior as possible under local anesthesia

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Abundant purulence from posterior lingual

1/4" Penrose drains placed buccal/lingual

Sent for immediate CT scan

IV clindamycin

Emergency Intervention37

CT+1cm abscess inferior border/lingual aspect

Decision to take to OR following day, stable overnight, trismus/pain improved

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OR

GA w/awake nasal intubation

Anesthesia concerned of airway and recommend leaving tube in overnight in ICU!!!!!!!

Thorough dissection of masticatory space with additional purulence, cultures obtained

Neck incision with dissection to inferior border and placement of 2 drains (dependent drainage)

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Hospital

Overnight stay w/o concern

Improvement overnight, dismissed in AM

Drains left in place for 3 days

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Post op

Loss of soft tissue over lingual aspect of mandible

2x1cm area of exposed lingual bone

Continued low dose abx/Peridex with progressive improvement over following month

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PearlsNever underestimate an infection

Always consider early antibiotics rather than observation

Infections can spread fast

Dysphasia, breathing difficulty or trismus constitute ER visit

Airway is biggest concern

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Thanks!

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HOW TO BEHAVIOR MANAGE PARENTS: UNDERSTANDING CHANGES IN PARENTAL

ATTITUDE AND EXPECTATIONS

Xu Han, DDS, MS The Dental Specialists Seminar: Dental Dilemas

November 3, 2016

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Discussion Topics:

Changing nature of parenting in America How to assess parents and recognize their needs

3 clinical scenarios How we managed the child

How we managed the parent Review of management techniques

Review of current literature

Summary of key lessons

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Changing nature of parenting in America

Increased focus on parenting

Family trends

Role of stress Impact of culture

What do pediatric dentists think?!

Long, N. Pediatric Dentistry-26:2, 2004 Casamassimo, P et al. Pediatric Dentistry-24:1, 2002

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How to assess parents and manage their needs

What type of parent are they?

Are you listening to the parent’s chief concerns?

What is the parent’s literacy level? Does the parent trust you?

Should the parent be allowed in the operatory?

Are there cultural/language barriers?

Are there parental concerns about special needs?

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Clinical Scenario 1: RestorativeJonny: Healthy 4 yo Caucasian male

CC: Emergency visit – #T pain with eating for 3 days, no nocturnal/spontaneous pain

Clinical assessment: #T large cavitated lesion, percussion (-), no sinus tract/vestibular swelling, 4 quads of decay

Radiographic assessment: BW: Caries on #I, J, K, L, S, T PA: #T no furcal involvement

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Pulp/SSC

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Managing cooperation: Jonny

Initial Assessment

Child cooperation: Shed tears during x-rays Non-combative

Responded to directions during exam

Management techniques:

Child: N2O Tell-Show-Do

Distraction Observe eyes for distress

Avoid irreversible treatment

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Managing expectations: Jonny’s mom

Initial Assessment Parent cooperation:

Lenient

Avoid conflict with child

Nice, responsive

Management techniques Parent:

Assess parent style/needs

Address parent questions/concerns

Keep big picture in mind Set expectations

Planned treatment

What if things go South?

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Treatment outcomePatient cooperation:

Hands-up, shaking head profusely, in tears

Treatment: 0.75 mm occlusal reduction of #T

Deferred pulp/SSC All treatment to be completed in the OR

Patient is not traumatized

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Key Concepts: Jonny

Behavioral Management Techniques (BMT)

Attitude of contemporary parents towards BMT

Effects of parenting style on child’s behavior

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Behavior Management Techniques

Non-pharmacological Tell-Show-Do

Nonverbal communication Voice control Behavior shaping/reinforcement Modeling Distraction Changing control Protective stabilization*

Pharmacological Nitrous oxide

Conscious sedation* General Anesthesia (GA)*

*Advanced BMT

Oliver, K et al. Journal of Dentistry for Children-82:1, 2015

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Attitude of contemporary parents

Basic methods preferred Advanced methods

Most accepted Pharmacological (sedation/GA)

Acceptance increased over the past 20 years

Least accepted Physical (HoM, restraint)

Active restraint preferred over passive restraint Degree of acceptance related pain/urgency

Eaton, J. Pediatric Dentistry-27:2, 2005 Patel, M. Pediatric Dentistry-38:1, 2016

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Parenting styles & child behavior

Authoritative: “Model parent”

Best behaved child

Authoritarian: “My way or the highway”

Permissive: “Anything you want, dear”

Neglectful: “I don’t care”

Aminabadi, N et al. Pediatric Dentistry-37:4, 2015 Howenstein, J et al. Pediatric Dentistry-37:1, 2015 Darling, N et al. Psychological Bulletin-113:3, 1993 Aunola, K et al. Journal of Adolescence-23:1, 2000

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Clinical Scenario 2: TraumaAbdi: Healthy 5 yo Somali male CC: Emergency visit – Fell on face at school, loose maxillary teeth Clinical assessment:

#E and F have class I mobility #F is extruded by 1 mm #F has mild occlusal interference with opposing, not traumatic

Radiographic assessment: #E and F have external root resorption (consistent with previous trauma) #F has horizontal root fracture in the apical 1/3

Courtesy of Dr. Matthew Nechrebecki

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Extraction

or

No Treatment

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Managing cooperation: Abdi

Initial Assessment

Child cooperation: Visibly anxious

Repeatedly asked me if I was going to pull his tooth

Very cooperative during exam


Child: Acknowledge child’s concern

Be honest

Distraction-change the subject Tell-Show-Do

Voice control

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Managing expectations: Abdi’s dad

Initial Assessment

Parent cooperation: Concerned but trusting Asked good questions

Reassured his child

Management techniques

Parent: Assess parent style/needs Address language/literacy/cultural concerns Keep big picture in mind

Set expectations Potential extractions

Silent observer

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Very cooperative, interactive “…but are you going to pull my tooth?”

Treatment: No treatment Thoroughly reviewed trauma sequelae

Discoloration

Pain

Abscess/swelling

Recommended follow-up: 4 weeks

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Key Concepts: Abdi

Parenting attitude towards being in the operatory

Parent compliance with remaining silent

Language, literacy & culture

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Parent in the operatoryPrimary reason parents want to be present

Comfort (~80%)

~2/3 of parents want to be present for: Exam/xrays Filling/crowns/extractions

Sedation/restraint

38% of parents are ok with dentist making unilateral decision on parental presence

Shroff, S et al. Pediatric Dentistry-37:1, 2015

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Parental compliance with remaining silent

78% complied when given written instructions 86% complied when given written + verbal instructions

Parents’ ability to assess dental fear in their child is: poor-fair

Jain, C et al. Pediatric Dentistry-35:1, 2013 Klein, U et al. Pediatric Dentistry-37:5, 2015

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Language, literacy & cultureRecognizing parents with low literacy skills Communicate in simple terms

Don’t use jargon

Use pictures/graphics

Informed parent more likely to accept BMT, regardless of culture Ask if an interpreter is need

Head nodding does not always mean full understanding

Ask for clarification if unsure of cultural preferences

Jackson, R. Pediatric Dentistry-28:1, 2006 Scott, S et al. Journal of Dentistry for Children-128:1, 1998 Abushal, M et al. Journal of Dentistry for Children-70:2, 2003

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Clinical Scenario 3: Special Needs

Rosie: Autism spectrum 3 yo Caucasian female CC: Cavities on front teeth, no pain Clinical assessment:

Caries on #D lingual, #E and M mesial-lingual

Radiographic assessment: Occlusal PA: Consistent with clinical findings BWs: #I distal D1 lesion, multiple posterior E1 lesions

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Restorative in clinic or

Operating Room

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Managing cooperation: Rosie

Initial Assessment

Child cooperation: Sleepy, irritable

Covered eyes with hands Followed instructions


Child: Sun glasses

Adjust N2O Very slow LA

Observe eyes for distress

Avoid irreversible treatment

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Managing expectations: Rosie’s mom

Initial Assessment Parent cooperation:

Explained child’s disability Very confident in child’s ability to cooperate Clear, direct with child and provider

Management techniques Parent:

Assess parent style/needs Listen to the parent Ask parent for recommendations Keep big picture in mind Set expectations

Planned treatment

What if things go South?

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N2O very helpful

Did not feel LA

Treatment in office: #D lingual composite

#E and F mesial-lingual composite

Next Visit: #I distal composite

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Key Concepts: RosieParents are well-attuned to their child’s special needs

Listening to parents

Use of restraint: when is it appropriate?

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Parents are well-attuned to their child’s special needs

Parents of autistic children are: Accurate in predicting child’s ability to cooperate for exam & x-rays (>84%)

Variability in how children tolerate dental/oral care Orally averse

Parents physically may restrain their child to brush at home

Waiting room challenge Noise

Duration of wait

BMT is not the same for child with special needs

Marshall, J et al. Pediatric Dentistry-30:5, 2008 Lewis, C et al. Pediatric Dentistry-37:7, 2015

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Listen to the parentsParents want to provide input Discuss options of sedation, GA and restraint with parents

The most acceptable BMT (>90%) for autistic children:

Positive verbal reinforcement Tell-Show-Do Distraction Rewards Hand-holding by parent

Mouth props GA

Marshall, J et al. Pediatric Dentistry-30:5, 2008 Lewis, C et al. Pediatric Dentistry-37:7, 2015

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Use of restraint: when is it appropriate?

Emergency Facial swelling or trauma

When pharmacological methods:

Not available Not accepted by parents

Overall acceptance of passive restraint (papoose):

32%

Acceptance of protective stabilization (ASD):

Parent restraint (84%)

Staff restraint (63%) Passive restraint (54%)

Marshall, J et al. Pediatric Dentistry-30:5, 2008 Brill, W. Journal of Dentistry for Children-2002

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Summary of key conceptsCase 1

Behavioral Management Techniques (BMT) Attitude of contemporary parents towards BMT Effects of parenting style on child’s behavior

Case 2 Parenting attitude towards being in the operatory Parent compliance with remaining silent Language, literacy & culture

Case 3 Parents are well-attuned to their child’s special needs Listening to parents Use of restraint: when is it appropriate?

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Thank you! ☺

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ESTHETIC EVALUATION OF CANINE SUBSTITUTION VS. IMPLANTS FOR

CONGENITALLY MISSING MAXILLARY LATERAL INCISORS

Benjamin Allen, DMD, MD, MS

November 3, 2016

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IntroductionAgenesis of one or both of the upper laterals affects 2% of the population

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Treatment Options

1. Tooth replacement Usually with implant-borne prosthesis

2. Space closure with canine substitution Ancillary procedures - Tooth recontouring - Cosmetic buildups - Bleaching

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Schneider et al. 201684


Treatment Options

Advantages Can maintain teeth in natural positions Orthodontics may be simpler Less need to alter morphology of other teeth Occlusion? Esthetics?

Tooth replacement

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Treatment Options

Disadvantages Space maintenance until implant can be placed Implants in the esthetic zone can be unforgiving Retreatment can be difficult Long-term periodontal concerns Cost?

Tooth replacement

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Treatment Options

Advantages Avoid retention period Periodontal condition Retreatment is easier

Space closure with canine substitution

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Treatment Options

Disadvantages Ancillary procedures - Canine may be recontoured, bleached, restored - Premolar may be recontoured, restored Occlusal concerns? Poor esthetics?

Space closure with canine substitution

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A Dilemma in DentistryEach has advantages and disadvantages Many factors influence the choice - Age - Sagittal malocclusion - Degree of crowding - Smile line - Tooth size, shape, color In many cases either option would be possible Which one do you prefer?

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Preference for Tooth Replacement

Preference among general dentists and laypersons to replace the missing tooth - GD 70%, LP 63% Esthetic or functional concerns? - 84% GD cite esthetic concerns Does the literature support this Preference?

Armbruster et al. World Journal of Orthodontics (2005) 6:376-381.

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Robertsson and Mohlin 2000

Assessed patient satisfaction with esthetics of CS vs. TR, 7 years after treatment completion CS significantly more satisfied with the appearance of their teeth Implants were not used

Robertsson and Mohlin. European Journal of Orthodontics (2000) 22: 697-710

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Armbruster et al. 2005Judged the esthetic outcomes of implants vs. Maryland bridges vs. CS Using intraoral photos Laypersons, general dentists, and orthodontists

LP: CS > nat > MB > Imp GD: nat, CS > MB > Imp Ortho: nat> CS > MB > Imp

Armbruster et al. World Journal of Orthodontics 2005;6:369-375

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Armbruster et al. 200599






De-Marchi et al. 2014

Photos of the lower facial third for patients restored with CS or TR (Implant) Dentist, laypersons and the patient Esthetics rated as similar for both treatment modalities

De-Marchi et al. J Prosthet Dent 2014; 112: 540-546

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Jamilian et al. 2015

Patients restored with CS or TR (implant) Rated satisfaction with esthetic result 5 years after completion of treatment Satisfaction with esthetics was similar in both groups

Jamilian et al. Progress in Orthodontics 2015;16:2

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Esthetics of natural vs. CS vs. Implants Intraoral photographs Laypersons, general dentists, orthodontists

LP: CS, natural > Imp GD: natural > CS, Imp Ortho: natural > CS, Imp

Schneider et al. AJODO 2016;150:416-24

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Conclusion

In terms of esthetics, CS and TR seem to offer similar results for the treatment of congenitally missing maxillary lateral incisors Esthetic concerns should carry less weight when deciding between these two treatment options

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ConclusionWhat about this guy?

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Conclusion

Ed Helms

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“Excellence is my muse.” -Laurence Rifkin, DDS

drlaurencerifkin.com

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ReferencesArmbruster P, Gardiner D, Whitley J, Flerra J. The congenitally missing maxillary lateral incisor. Part 1: Esthetic judgment of treatment options. World Journal of Orthodontics 2005;6:369-375

Armbruster P, Gardiner D, Whitley J, Flerra J. The congenitally missing maxillary lateral incisor. Part 2: Assessing Dentists’ preferences for treatment. World Journal of Orthodontics 2005;6:376-381

De-Marchi L, Pini N, Ramos A, Pascotto R. Smile attractiveness of patients treated for congenitally missing maxillary lateral incisors as rated by dentists, laypersons, and the patients themselves. J Prosthet Dent 2014;112:540-6

Jamilian A, Perillo L, Rosa M. Missing upper incisors: a retrospective study of orthodontic space closure versus implant. Prog Orthod 2015;16:2

Kokich V, Kinzer G, Janakievski J. Congenitally missing maxillary lateral incisors: Restorative replacement. Am J Orthod Dentofacial Orthop 2011;139:435-445

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ReferencesRobertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment. Eur J Orthod 2000;22:697-710

Schneider U, Moser L, Fornasetti M, Piattella M, Siciliani G. Esthetic evaluation of implants vs canine substitution in patients with congenitally missing maxillary lateral incisors: Are there any new insights? 2016;150:416-24

Silveira G, Valli de Almeida N, Pereira D, Mattos C, Mucha J. Prosthetic replacement vs space closure for maxillary lateral incisor agenesis: A systematic review. Am J Orthod Dentofacial Orthop 2016;150:228-37

Zachrisson B, Rosa M, Toreskog S. Congenitally missing maxillary lateral incisors: canine substitution. Am J Orthod Dentofacial Orthop 2011;139:435-44

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Documents

CRACKING THE CRACKED OOTH DILEMMA - · PDF fileSymptomatic Irreversible Pulpitis ... 0.75 mm occlusal reduction of #T ... apical 1/3 Courtesy of Dr. Matthew Nechrebecki 59