You have to deal with each case individually. These are the major things that run through my mind when I examine patients with cracks like that:

1. How motivated is the patient (especially from a financial perspective) to be proactive and crown multiple asymptomatic teeth as a preventative measure?

2. Do the cracks appear to communicate (ie. do they look like they might meet up in the middle)? This could indicate a deeper fracture and thus the need for endo.

3. Are the crack lines stained? This indicates that they are open enough to allow bacteria in. If bacteria have gotten in, pulpal sequela are not usually far away.

4. Any trouble with bite stick testing?

5. Do the cracks look deeper, more serious with transillumination?

6. Symptoms of pulpitis? Cold testing response relative to other teeth?

7. Parafunctional habits? This is very important.

So rough rules of thumb that I use:

Let patient know what’s going on. If they are grinders/clenchers, make a night guard. In addition to that, if the cracks are discoloured badly and on multiple teeth, recommend crowns to keep things together.

The pt needs to be aware that endos could be necessary on any of these teeth afterwards.

If symptoms of pulpitis, do endo prior to crown. Endo can also allow us to trace depth of cracks into roots and decide whether tooth is worth trying to save or not.

If finances are a problem and the pt can’t do all of that, make sure you keep your eye on them at regular recalls.

Again, dealing with these cases is difficult because we have no idea what exactly is going on inside the teeth. It’s similar to deciding whether or not to endo a particular asymptomatic tooth prior to placing a crown.

Some dentists prefer to be more cautious and do the endo, others will inform patients of the possibility of the need for endo and crown the tooth without doing the endo.

It becomes one clinical decision among others that eventually shapes the philosophy and nature of your particular practise of dentistry.

But I can’t seem to work out what we’re supposed to do here. I see cracks like this all the time on mesial and distal marginal ridges. I usually only treat symptomatic ones but I met a prosthodontist who drills these cracks and then crowns them all. What am I supposed to be doing about these things?

I’m actually a little worried. On one side I want to diagnose well, but on the other side, I really would hate to do treatment on an asymptomatic tooth lest it should be made worse.

Anyway, she must have back-tracked my link to her site because my comment is back up now…

I’ve gotta try to stay out of trouble. Is it too late to make a new year’s resolution?

i can understand why she deleted the comments – her new practice, she probably has some patients and/or colleagues visiting her site and critiquing or praising her work. i don’t think there is room in that blog for open discussion and constructive criticism, as i think she posts specifically to show off, follow what i’m saying?

i see what you’re saying about the fracture line. i’ve treated a lot of cases like that, esp with failing amalgams, and i find that usually a crack like that is removed during interproximal box preparation. i usually trans-illuminate with the curing light right before i place a liner and/or fill and that can show if the crack has extended sagitally or not (one of my endo attendings taught me that trick in dental school). caries indicator applied and vigorously rinsed off is pretty revealing, too. she probably went through all those motions and/or is confident enough in her work to display it, so why didn’t she just say that in reply to your comment?

personally, i don’t think that particular restoration looks that nice (i would have placed an inlay in a resto that large or maybe added some staining and anatomy to make it look more lifelike) but that’s just my opinion. hmm, maybe i should post that comment on her site….