Clinical Research
Incidence of Pulpal Complications after
Diagnosis of Vital Cracked Teeth
Siwen Wu, BDS, MDS, M Endo RCS (Edin), Hui Pau Lew, BDS, MDS, M Endo RCS (Edin),
and Nah Nah Chen, BDS, MDS, MS
Abstract
Introduction: This retrospective cohort study aimed to
observe the incidence of pulpitis and necrosis in teeth
with cracks that were not endodontically treated.
Methods: One hundred eighty-four patients with 199
cracked teeth that were diagnosed with reversible pulpi-
tis and were treated from January 2010 to December
2013 at National Dental Centre, Singapore, were re-
cruited. Cracked teeth were identified by inspection,
transillumination, and positive bite tests. A diagnosis
of reversible pulpitis was made if the tooth had no his-
tory of spontaneous pain, was positive but non-lingering
to cold, and there was an absence of any periapical pa-
thosis. Upon diagnosis, orthodontic bands were ce-
mented, and these teeth were referred for crowns.
Patients were recalled back at least 3 years after diag-
nosis, except for those patients whose cracked teeth
had undergone endodontic treatment or were extracted.
Results: Fifty-eight out of 199 (29.1%) teeth had pulpal
complications. Thirty-eight of 58 (65.5%) were diag-
nosed as irreversible pulpitis after approximately 1.2
years (437 days), and 20 of 58 (34.5%) were diagnosed
with necrotic pulp after approximately 2 years (755.5
days). The absence of a full-coverage crown increased
the risks of pulp complications (odds ratio = 8.74, P =
.000), and males had an increased incidence of pulp
complications compared with females (odds ratio =
1.96, P = .056). Conclusions: Seventy-one percent
(141/199) of cracked teeth with reversible pulpitis re-
mained healthy after 3 years. It is essential to brace
the cracked tooth to minimize cusp flexion and provide
full coverage of the crack from the oral environment.
When treated early, these teeth may still reasonably sur-
vive for at least 3 years. (J Endod 2019;-:1–5)
Key Words
Cracked teeth, prognosis, reversible pulpitis
From the Department of Restorative Dentistry, National Dental Centre, Singapore.
Address requests for reprints to Dr Siwen Wu, Department of Restorative Dentistry, National Dental Centre Singapore, 5 Second Hospital Avenue, Singapore 168938,
Singapore. E-mail address: wu.si.wen@ndcs.com.sg
0099-2399/$ - see front matter
Copyright ª 2019 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2019.02.003
JOE — Volume -, Number -, - 2019
A cracked tooth is
defined as “an incom-
plete fracture initiated
Significance
When properly managed, cracked teeth with
reversible pulpitis could remain healthy for 3 years
from the crown and ex- or more.
tending cervically and
sometimes subgingivally
and usually directed mesiodistally” (1). Often, the crack involves the marginal ridges
and extends through the proximal surfaces. Accompanying symptoms vary but discom-
fort to pain when chewing and thermal sensitivity are common findings (2). Transillu-
mination is a useful diagnostic test that can visualize centrally located mesiodistal cracks
as a shadow. Depending on the stage of discovery, these teeth may display normal to
deep periodontal probing depth along the crack line.
The pulpal and periapical status of the cracked tooth depend on the extent of the
crack and the duration of its symptoms. When the crack extends into or is in close prox-
imity to the pulp, ingress of bacteria and their by-products will cause pulpal inflamma-
tion or pulpitis, which may progress to pulp necrosis and subsequently periapical
pathoses.
In the early stages of a cracked tooth, the pulp is often vital and asymptomatic or
may be newly symptomatic. In such instances, pulpal inflammation is deemed to be
reversible, and endodontic intervention or root canal treatment is premature. Thus,
managing the crack per se is the primary concern, and this requires external or extrac-
oronal bracing of the cracked tooth with an orthodontic band, which is an interim pro-
cedure followed by a crown or an onlay. These permanent restorations provide cuspal
protection and full coverage of the cracks from the oral environment. The margins of
the restoration should encompass the full extent of the crack lines and where possible
be placed apical to them (3, 4).
Krell and Rivera (5) suggested that if a marginal ridge crack is identified early
enough in teeth with a diagnosis of reversible pulpitis and a crown is placed, root canal
treatment may nevertheless be necessary in about 20% of the cases within a 6-month
period. However, a higher incidence of 42.9% was reported by Kim et al (6).
There is limited evidence on the outcome of cracked teeth that are deemed not to
require or are not subjected to root canal therapy at the point of diagnosis. This retro-
spective cohort study aimed to observe the incidence of irreversible pulpitis and necro-
sis in these teeth with cracks that were not endodontically treated.
Materials and Methods
In this study, 184 patients with 199 cracked teeth diagnosed with reversible pul-
pitis and treated from January 2010 to December 2013 at the National Dental Centre in
Singapore were included. All of these patients exhibited pain during mastication and/or
release of bite and localized sensitivity to cold. Ethics approval for the study was
Pulpal Complications in Vital Cracked Teeth 1
Clinical Research
obtained from the Institutional Review Board of the National Dental
Centre. In conjunction with the first visit, medical history and clinical
findings were recorded. Data collection included the following:
1. The history, duration, and nature of pain.
2. Pulpal responses to a cold test (Hygenic Endo-Ice; Coltene Whale-
dent, Cuyahoga Falls, OH) and an electric pulp test (Analytic Tech-
nology, Redmond, WA).
3. Responses to pressure, palpation, and percussion.
4. Buccal and lingual periodontal probing depths; these were recorded
at the mesial and distal interproximal spaces and at the furcation re-
gion. Interproximal probings would be more directed at areas
where marginal ridge cracks were identified in order to mark the
site of the deepest probing depth. A total of 6 probing sites were re-
corded for each tooth. Periodontal pocketing was considered pre-
sent if the periodontal probing depth was more than 4 mm.
5. The identification of crack(s) with direct transillumination and visu-
alization with and without magnification; the identified crack had to
Figure 1. The protocol for the management of cracked teeth at the National
block light transmission and display a definite shadow upon light
Dental Centre.
placement from both the buccal and lingual surfaces. Teeth not ex-
hibiting a shadow were considered to have craze lines and were not
included in this analysis. These craze lines were confined within Results
enamel during inspection.
Figure 2 shows the inception cohort of 459 patients with 474 teeth
6. The number of crack(s) and their location (mesial, distal, buccal,
distributed into the following categories:
and/or palatal/lingual surfaces); the tooth was determined to have
single or multiple cracks if the crack(s) was visualized in dentin. 1. Patients not recruited; a total of 263 patients were not recruited and
7. Responses to biting on a wedge. not monitored because of the following reasons: 7 patients were
8. A preoperative periapical radiograph of the cracked tooth. deceased, 28 patients had their teeth extracted but gave an unclear
history of extraction, 173 patients declined recall, and 55 patients
These data were derived from the electronic dental records of the
could not be contacted.
National Dental Centre. On the basis of a positive pain sign on biting and/
2. Patients recruited: 196 patients with 211 teeth, giving a recall rate of
or release of bite, visual examination of crack(s), and a positive trans-
42.7% (196/459). Of the 196 patients who were examined, 12 teeth
illumination, the diagnosis of a cracked tooth was confirmed. A pulpal
in 12 patients were later excluded because of incomplete data
diagnosis of reversible pulpitis was made if the tooth had no history of
collection. The final recall cohort included 184 patients with 199
spontaneous pain, responded positively to electric pulp test and non-
teeth who were examined for the study.
lingering to cold and radiographically showed an absence of periapical
pathosis. The majority of the diagnoses were made by endodontists, The mean age of the 184 patients was 49.7 years (standard devi-
whereas others were made by prosthodontists. The clinicians were ation = 10.1) with a median age of 50.0 years (range, 44.0–56.0 years).
not calibrated. The mean age of the male patients was 49.9 years (standard deviation =
Teeth were excluded if they were split or showed evidence of a 9.6) with a median age of 50.0 years (range, 44.0–56.0 years). The
cusp or root fracture. Following the National Dental Centre protocol mean age of the female patients was 49.4 years (standard deviation =
for the management of a vital cracked tooth, upon diagnosis, an ortho- 10.5) with a median age of 50.0 years (range, 42.0–56.0 years).
dontic band was cemented. The tooth was then reviewed at 3 months Table 1 provides data on the types of teeth included in the study;
before referring for a crown if it had remained vital and asymptomatic mandibular first molars were the most prevalent (33%) followed by
(Fig. 1). All patients were recalled at least 3 years after the initial diag- mandibular second molars (31%) and maxillary first molars (16%).
nosis, except for those patients whose cracked teeth had undergone The results showed that 141 teeth (71%) remained healthy after 3 years
root canal treatment or were extracted during this period. of follow-up. These teeth presented with normal periodontal pocketing
During the recall visit, the tooth was reexamined, and the presence depth and no periapical pathosis. Fifty-eight (29%) teeth initially
or absence of signs and symptoms, pulpal responses to the cold test diagnosed with reversible pulpitis had developed irreversible pulpitis
(Hygenic Endo-Ice), responses to palpation and percussion, and peri- or pulp necrosis. Of these teeth, 38 (66%) were diagnosed with
odontal probing depths were recorded. In addition, a periapical radio- irreversible pulpitis after about 1.2 years (437 days), and 20 (34%)
graph of the involved tooth was taken to assess for any periapical were necrotic after 2 years (755 days). Three teeth were extracted
pathosis. because of deep probing depths. The other 55 teeth presented with
Statistical analyses of the data were performed using STATA 14 normal periodontal pocketing depth. Endodontic treatment was
(StataCorp, College Station, TX). Univariate associations between performed on these 55 teeth by endodontists with the use of a dental
pulp status and explanatory variables were assessed using the chi- operating microscope. During root canal treatment, the number
square test at a significance level of .05. Multivariable analysis (single or multiple), location (mesial, distal, buccal, or palatal/
was performed with the logistic regression model to find out the lingual), and extent of crack lines (coronal or radicular) were
relationship between pulp status and independent explanatory vari- recorded by the endodontists.
ables. A tooth was considered as ‘‘survived’’ if it remained vital at Of the remaining 141 cracked teeth that were deemed to have
the time of review. The 5-year survival was estimated using reversible pulpitis, 123 (87%) had crowns, whereas the remaining
Kaplan-Meier analysis.

2 Wu et al. JOE — Volume -, Number -, - 2019

 Clinical Research

Figure 2. Patients who had cracked teeth diagnosed with reversible pulpitis and treated at the National Dental Centre.

18 teeth (13%) had been treated with orthodontic bands. The latter
group of patients had declined crown restorations.
Univariate analysis using the chi-square test (Table 2) showed that
teeth that were not crowned and remained cemented with orthodontic
bands were more likely to have pulp complications. Sex had a significant
effect on pulp complications, with males more likely to develop pulpal
problems. Multivariate analysis with the logistic regression model
(Table 3) showed that the absence of a full-coverage crown increased
the risks of pulp complications (odds ratio = 8.74; 95% confidence in-
terval, 4.04–18.91; P = .000), and males had an increased incidence of
pulp complications compared with females (odds ratio = 1.96; 95%
confidence interval, 0.98–3.91; P = .056).
The Kaplan-Meier plot of the survival of teeth (Fig. 3) showed that
the 5-year survival rate was 71%. The 5-year survival estimate in the
presence of a crown was 81% versus 37% in the absence of a crown
(Fig. 4).
Discussion
Of the cracked teeth examined in this study, 29% had pulpal com-
plications, whereas the remaining 71% remained vital without symp-
tomatology of irreversible pulpitis or necrosis after 3 years of
examination. The data are in agreement with the findings of Kang
et al (7), who reported that root canal treatment was required in an
identical percentage of teeth in which cracks were identified early
and a provisional crown was placed. Krell and Rivera (5) evaluated
127 patients with cracked teeth diagnosed with reversible pulpitis in
which the treatment included placement of a crown restoration without
performing root canal treatment. Twenty percent of these cases devel-
oped irreversible pulpitis or necrosis within 6 months and required
root canal treatment. None of the other teeth required root canal treat-
ment over the 6-year evaluation period. By contrast, Kim et al (6)
reported a higher incidence of 42.9% of pulpal complications. Symp-
toms of mastication persisted in 9 teeth out of 21 teeth initially diag-
nosed with reversible pulpitis after a provisional crown was placed,
so root canal treatment was performed before permanent crown resto-
ration. These authors explained that their high prevalence of root canal
treatment could be a result of the late diagnoses of the cracks because
many patients were referred to an endodontist after a long time lapse of
the presenting symptoms.
This observation underlies the importance of early detection of a
cracked tooth and prompt treatment in order to maintain pulp vitality
and to prevent or retard further crack propagation. Besides the bracing
function, crowns provide cuspal protection and full coverage of the
cracks from the oral environment. These teeth can, according to our
data, have a fairly high chance of preserving pulp vitality.
Mandibular first and second molars were found to be the most
commonly affected teeth followed by maxillary first and second mo-
lars. This distribution corroborates the earlier findings of various
studies (5, 7, 8, 9). The high incidence of cracks in mandibular

TABLE 1. Number of Cracked Teeth by Tooth Type with Reversible Pulpitis Eventually Requiring Root Canal Treatment
Maxillary Maxillary Maxillary Maxillary Maxillary Mandibular Mandibular Mandibular Mandibular
third second first second first third second first second
molar molar molar premolar premolar molar molar molar premolar Totals
Cracked 1 21 32 10 4 1 62 66 2 199
Reversible / 0 8 10 4 0 0 17 19 0 58
irreversible
pulpitis or
necrosis

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Clinical Research
TABLE 2. Univariate Analysis of Pulp Complications Depending on Clinical Variables
Reversible / irreversible Proportion with pulp
Variables No. of teeth pulpitis or necrosis complications (%) P value
Terminal abutment .494
Yes 65 21 32.3
No 134 37 27.6
No. of cracks .875
1 126 38 30.2
2 63 18 28.6
3 9 2 22.2
4 1 0 0
Crown .000
Yes 155 29 18.7
No 44 29 65.9
Sex .039
Male 94 34 36.2
Female 105 24 22.9

molars can be explained by the palatal cusps of maxillary molars,
which act as plungers, leading to structural fatigue in the lower
antagonists (3, 10). Furthermore, the lingual inclination of crowns
of mandibular posterior teeth in relation to their root bases causes
a sloping load on these teeth. Cavities prepared perpendicularly
weaken the lingual cusps of the mandibular posterior teeth (10). In
contrast, the oblique ridge of the maxillary molars increases resistance
to crack formation (11).
In this study, a 3-month observation period for any pulpal symp-
toms was necessary after initial stabilization with orthodontic bands.
This allowed us to ensure complete resolution of clinical symptoms
at the 3-month recall, thus confirming the original diagnosis of revers-
ible pulpitis before subjecting the tooth to a crown preparation. Imme-
diate crown preparation at the diagnosis stage could also induce pulpal
inflammation. It can be clinically difficult to differentiate this from the
pulpal inflammation that arose because of the crack. Studies (12,
13) have shown that pulps display tissue repair and healing over an
observation period of 30 to 60 days after an episode of bacterial
insult. Hence, the 3-month observation period used in this study would
allow ample time for pulpal healing.
In the study, teeth that were not crowned and remained with ce-
mented orthodontic bands were more likely to have pulpal complica-
tions. It can be inferred that the splinting ability of the restoration is
a crucial factor in the management of cracked teeth. When the tooth
is splinted, the incompletely fractured tooth parts are immobilized.
This reduction of movement or flexion along the fracture lines will
greatly help to alleviate symptoms, prevent further crack propagation,
and reduce the ingress of bacteria into the pulp. Compared with a
customized crown, an orthodontic band is a thin, stainless steel ring
that is less well fitting and may not be fully adapted to the tooth contours,
resulting in less optimal splinting. The exposure of the occlusal cement
lines to the oral environment and masticatory function may also cause
cement breakdown and washout, further reducing the efficacy of the or-
thodontic band. More importantly, for these banded teeth, the absence
of an occlusal coverage may contribute to a higher incidence of pulp
complications. On the other hand, a customized crown is fully adapted
to the tooth structure and contours. It is made of a rigid material and
covers the clinical crown completely. It has been shown in various
studies (3, 4) that occlusal cuspal coverage is critical for the success
of restoration of cracked teeth. When a crack is present, cuspal
flexure under loading forces induces high stresses at the internal line
angles of the crack. The presence of cuspal coverage results in a
more favorable stress distribution and provides a bracing effect to
reduce cuspal mobility (14). Furthermore, the crown preparation
may remove cracks completely, hence enhancing the longevity of the
pulp. Among the various types of indirect restorations that provide cus-
pal coverage, the full cast crown provides the greatest protection and
ability to encompass the crack, especially in the coronal-apical extent.
In this study, males had higher odds of developing pulpal compli-
cations compared with females. This can be attributed to the higher bite
force in males in comparison with females (15), and these high masti-
catory forces can potentially allow for both initiation and further prop-
agation of the crack, resulting in a higher incidence of pulpal
complications. However, this is a weak association given that the
odds ratio of 1.96 was slightly more than 1.0, the wide 95% confidence
interval, and the lower limit of the confidence interval of 0.98 was close

TABLE 3. Multivariate Analysis of Pulp Complications Depending on Clinical

Variables
Odds ratio (95%
Variables confidence interval) P value
Terminal abutment 0.88 (0.42–1.87) .746
No. of cracks
2 versus 1 0.85 (0.40–1.82) .676
$3 versus 1 0.53 (0.097–2.85) .458
Without crown 8.74 (4.04–18.91) .000
Male 1.96 (0.98–3.91) .056
Figure 3. A Kaplan-Meier plot of the survival of teeth.

4 Wu et al. JOE — Volume -, Number -, - 2019


Figure 4. A Kaplan-Meier plot of the survival of teeth with and without a
crown.
to 1.0. Further investigation of this variable with a larger cohort study is
required.
A common assumption is that teeth with multiple cracks are more
likely to require root canal treatment than teeth with a single crack
because they will be structurally weaker. As these crack lines propagate,
some may communicate and result in complete fracture (16). However,
in our data, the number of cracks seemed to be an insignificant outcome
predictor.
Conclusion
In conclusion, 71% (141/199) of cracked teeth with reversible
pulpitis remained healthy after 3 years. It seems essential to brace the
cracked tooth, minimize cusp flexion, and provide full coverage of
the crack from the oral environment. When properly managed, a sub-
stantial number of teeth with cracks may have pulpal survival for an
extended period of time.
JOE — Volume -, Number -, - 2019
Clinical Research
Acknowledgments
The authors deny any conflicts of interest related to this study.
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Pulpal Complications in Vital Cracked Teeth 5