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Survival Rate After Endodontic Treatment in General Dentistry for Cracked Teeth With Different Coronal Restorations
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Tooth cracks are a frequent clinical problem in general dentistry commonly characterized by an acute pain from mastication and a sharp, brief pain with cold. The American Association of Endodontists define cracked tooth as an incomplete tooth fracture initiating from the crown and extending subgingivally. In this retrospective study, 200 patients were evaluated from three general dental clinics from 2001 to 2016. The majority of the cases (55%) involved upper and lower molars, and more than half of the teeth had visible cracks stopping above the pulp chamber. Almost half of the patients experienced tooth grinding but only 17% used a bite splint. About 95% of the teeth had either an occlusal or proximal filling prior to endodontic treatment, and 78% of the antagonizing teeth had an occlusal filling. Prior to endodontic treatment, approximately half of the teeth were diagnosed with pulp necrosis (51%) and 38% were diagnosed with irreversible pulpitis. After endodontic treatment, 61% were restored with a composite filling, 24% with a full crown (indirect crown), and 14% were restored with a composite crown. The data clearly indicate a better survival rate of 97% after 5 years and 95% after 10 years for the full crown compared with 57% and 37% after 10 years for teeth restored with a composite restoration (filling or crown).
- Earlier studies indicated the importance of full cuspal coverage for cracked teeth in order to prevent further cracking linked to the ability to stabilize the individual fragments together and thereby enable the occlusal forces to be distributed evenly. The authors concluded that cracked teeth should be restored with a full indirect crown after endodontic treatment.
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
The aim of this study was to analyse the survival rate of cracked teeth after endodontic treatment. The secondary aim was to compare the survival rate of cracked teeth restored with composite filling/crown and those restored with a full crown.
MATERIALS AND METHODS
The study was conducted retrospectively from three general dental clinics in Stockholm, which are all part of the national dental service organisation. Two-hundred patients with teeth receiving endodontic treatment due to symptomatic cracks were included. The patient data range from year 2001 to 2016.
RESULTS
The mean age of the patients was 48 years (range 29-69). Fifty-five per cent had cracks located above the pulpal cavity, 11% within the pulpal cavity and 3% located in the root canal. The cracks were located most commonly on the proximal surfaces. The survival rate for teeth with cracks was 68% and 54% after 5 and 10 years, respectively. The survival rate was significantly higher (97%) for cracked teeth receiving a full crown after endodontic treatment compared to teeth restored with either a composite filling or composite crown.
CONCLUSION
The overall survival rate for cracked teeth was 68% after 5 years, while it was significantly higher for cracked teeth restored with a full crown. The results suggest within the limitations of this study that cracked teeth should be restored with a full crown after endodontic treatment.
Additional Info
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Survival Rate After Endodontic Treatment in General Dentistry for Cracked Teeth With Different Coronal Restorations
Acta Odontol. Scand. 2020 Oct 26;[EPub Ahead of Print], W Nguyen Thi, L JanssonFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The findings in this study (SRAET) suggest that cracked teeth treated with endodontic intervention should be restored with a full-coverage restoration to optimize survival over time in comparison with restoring the tooth with either a composite crown or filling. The survival rate for teeth restored with a full coverage crown was 95% after 10 years compared with 57% if restored with a composite crown and 37% if restored with a composite filling.
In this study, 200 retrospectively selected patient cases from the regional Swedish Dental Service met inclusion criteria for the investigation if a visible, incomplete fracture originating in the clinical crown was present prior to the initiation of endodontic intervention.
Hilton et al1 reported that the prevalence of cracks in adult teeth is as high as 70%, which poses as a significant challenge for dentists and their patients in their clinical decision–making on how to best manage this common finding. In the SRAET study, Krell and Rivera were cited as reporting prevalence of cracks as 9.7% out of 8175 examined teeth.2 The multivariable factors of patient-level, tooth-level, crack-level, as well as provider-level characteristics may explain the significant statistical scatter in reporting the presence of cracks in teeth and the complexity of the evidence-based decision-making in managing the cracked tooth.
A comparison of the results from the US National Dental Practice-Based Research Network (NDPBRN 2020) evaluating cracked, vital posterior teeth is of note where 2858 teeth were evaluated for treatment prospectively. Of the 1040 cracked teeth where some type of intervention was determined, only 0.1% (9) were recommended for endodontic treatment and only 2% (20) were recommended for endodontic treatment and a restoration. For the teeth where endodontic intervention was recommended, either spontaneous pain, biting pain, or cold pain was significantly associated with increased odds of recommending a restoration, and the restoration of choice was a full-coverage crown 61% of the time.
In the SRAET study, reported pain was not an inclusion criterion. Prior to endodontic treatment, 51% were diagnosed with pulp necrosis and 38% were diagnosed with irreversible pulpitis, which may explain the aforementioned. More to it, the most common initial treatment for a cracked tooth was a direct filling, and, within 2 years, 93% of these teeth received endodontic treatment. These findings likely reflect the nature of retrospective analyses of clinical decisions made, as only 0.1% of teeth from the NDPBRN study were treated with endodontic treatment prospectively. Their survival was not determined here; yet, in another study looking to quantify symptom and crack changes over time, no meaningful progression of symptoms or crack propagation was noted over a 1-year follow-up.3
With all that in mind, although there is general agreement that extracoronal cusp protection with an indirect restoration after endodontic intervention is prudent to attain better long-term prognoses, the survival rates in this SRAET study may not reflect the survival rate seen with a prospective analysis that the clinician may encounter day to day.
This was a retrospective study whereby the decision to initiate endodontic treatment was an inclusion criterion, with the decision to initiate endodontic treatment prospectively on a non-symptomatic cracked tooth is as important a consideration because coronal cracks in the adult posterior dentition are so common and the potential healthcare burden is real.
References