Stop Treating Cracked Teeth with Retention or Adhesion (Do This Instead)

Dentists have been attempting to treat cracked teeth for decades, with the goal of alleviating patient pain and conserving teeth through restorative treatment. But as Dr. David Alleman, DDS, describes in this episode, “it’s a coin toss of success.” Methods such as retention to hold the crack together or bonding over the crack with adhesion are unpredictable. Sometimes the treatment works, and sometimes it doesn’t, leaving patients and practitioners frustrated. 

The solution: treat cracked teeth like engineers have been treating cracks for over a century. 

The challenge: applying these techniques to a biological environment and accounting for bacteria, dentin hydration and dental adhesives.

Dr. David Alleman, DDS, discusses the history and treatment protocols for predictable cracked tooth treatment in this episode of the Six Lessons Approach podcast.

Articles referenced in this episode:

• Brannstrom M. The hydrodynamic theory of dentinal pain: sensation in preparations, caries, and the dentinal crack syndrome. Journal of Endodontics. 1986;12(10)-453-457
• Gordon, J. E. The New Science of Strong Materials: Or, Why You Don't Fall Through the Floor. Princeton, N.J: Princeton University Press, 2006.
• Abbott P, Leow N. Predictable management of cracked teeth with reversible pulpitis. Australian Dent J. 2009; 54:306-315.

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Transcript

0:36

Welcome to season four, episode three of the Six Lessons podcast. We're so glad that you joined us. We've had over 10,000 views of this podcast. We're excited to spread the word of new treatments, new techniques that it can allow long lasting restorations without destructive preparations for fillings, crowns, root canals, and obviously extractions and implant. But each of you in this episode, will learn the history of what has been tried to help teeth that have cracks in them And of course, if a tooth has a crack and it's into the root and the PDL is hurting, even if the pulp has been taken out, it hurts. so the first pain that comes from a crack is from the pulp, the second source of pain is from the PDL. And so cracks can kill pulps but still cause pain. And that PDL sensing the pain will not make the patient comfortable. And so quite often those cracks at the roots have been the catastrophic failures where teeth are extracted. when I went to dental school in the middle 70s, 75 to 78, we did understand that there was a symptom of repeated pain on biting that could be diagnosed. Then there was a treatment that was taught since the middle 60s, for ten years, first recommended by Cameron out of the University of Southern California for what he titled crack tooth syndrome, now cracked two syndrome in the 60s was before the book that was actually published on in 1982, and that was by Martin Brannstrom. And we've referred to Martin Brannstrom diagnosing pain and the source of pain in a vital tooth being the movement of the pulpal fluid, but the source of pain after the pulp has been taken out. was pioneered by this team from the University of Southern California. Cameron. And so when I was in dental school, I was taught the pathology and taught the diagnosis of cracked tooth syndrome, repetitive pain on biting. We had an instrument called the tooth sleuth that could reproduce. When you bit on it, you know, it wasn't an expensive plastic instrument, kind of like the end of a toothbrush handle. And you could find out. And every time they beat down. Yeah, it hurts. Yeah. It hurts. Well, you've got crack tooth syndrome. the diagnosis was crack tooth syndrome. But the treatment that Cameron had been using at University of Southern California, which had some success, was full coverage. And his theory was mechanical holding together of two pieces that are moving. Again, he was not sophisticated in the hydrodynamics theories of pain that were published by Brannstrom 15 years later. But the idea is that everybody knew that if you have a tooth you can't bite on, that's a problem. The dentist, what's the solution when he hurts? Well, to take the pulp out, that was something that happened quite often. if you take the pulp out of a tooth that has a crack in it, and you do any kind of restoration, you still have the potential to have that crack continue to propagate. And of course, that piece of science comes from engineers. It didn't come from dentists. And I've never found a dentist that's really talks in those terms that the engineers have been using for, again, 100 years. Crack initiation, crack propagation, catastrophic failures. These have happened on bridges, have happened in ships, have happened in airplanes. These kind of engineering ideas of crack initiation, crack propagation and the stresses that it takes for that to happen. This is something that was not in any dental school. If there's any dental school right now that's teaching in those terms, I'm not aware of But crack treatment with the crack two syndrome has only had mixed results. How do I know? Well, I've talked to one of dentists over the last 22 years I've trained hundreds, maybe a thousand dentists in the specific technique that I developed to treat crack tooth syndrome in the year 2000. so in the year 2000, I started to talk to engineers. I knew two that were friends, one in lives in my neighborhood named Dennis Grow, and then another engineer that actually worked at Ultra Dent, which is obviously a dental company, but his expertise had altered. It was not on cracks, but I was using Ultra Dent library. And so his name was Robert. And I said, Robert, what did you learn in engineering school about cracks? And he talked about crack initiation stresses and strains, the stress strains, con curve that's related to Young's modulus or modulus of elasticity. I mean, this is a foreign language. This is something that most people every day don't learn about. the idea is when I start talking to engineers and they had the same language and they referred me to some books and some literature, and I'm going to bring out a book right now, just happen to have one on my shelf. I hope it's still there. So here is the book that we're going to recommend, The New Science of Strong Materials. The subtitle is Why You Don't fall through the floor. That's a joke. It's not a joke. If your floor is solid and you're not falling through a floor. But there are ways to create situations where you would fall through a floor, and we won't get into the history of that. But Gordon is the engineer that actually first integrated some dental ideas into his book, and it had to do with cracks and those cracks that were in dentin This illustration, for example, shows that a crack, this is all cracks of all materials, all strong materials. Once they start separating, there's always a point of energy concentration at the tip of a crack. So what do engineers do if they have that situation in $1 billion airplane? They actually blunt that crack. They go to the bottom at the tip, they have a round burr, and they make it round instead of pointed. What does that do? It means that if you have a round area and you have stresses that are coming into this hard material, if you have a crack, the heart starts to concentrate stresses right here and it's enough to break the molecules. if you have a rounded surface free of cracks, then the stresses that are coming into the material or distributed through the whole round surface, and that distribution means that there's no new crack formations. And so, I hope that each of you are inspired to become at least conversant with the engineering terminology. And how many books do you have to read? I've read dozens of books, but basically I needed a mentor. I needed a mentor who actually could help me understand the illustrations, the pictures. The mathematics was usually not something I was. Because I grew up in a house of mathematicians, I knew that mathematics didn't get really beyond where I'm what I need practically. But the idea is that once I understood that the traditional idea of mechanically holding a crack together didn't work, that was what led me to talk to engineers. Say, what does work? What do you do on $1 billion airplane? Could I apply that to what I do on a tooth that I'm going to fix for $1,000? And they said, oh, absolutely. Of course, the engineers don't know anything about biology. They don't know anything about connective tissue or bacteria. They really don't know anything about the hydration of body. But the idea is that water is something that is essential to life, the life of a tooth can't happen without hydration. In dentin we have 20% of the dentin is water pulpal Fluid is mostly water. That gives a toughness and a flexibility to dentin but it also means that repairing the dissection is going to be a little tricky because you're using materials that are hydrophobic. Epoxy is hydrophobic. All of our bonding systems come from the initial invention of polymerized epoxy resins that came by Castan in the 1930s. this overcoming of the difficulty of bonding, that's our expertise. But the idea of crack dissection, that's the foundation. And there have been many studies that have tried to do what Cameron and the traditional crack tooth syndrome treatment did, and they had maybe 60% success, quite often 50% success at five years. One important was published in 2016 by Botocciari and he had a whole chapter on cracks. He photographed him very nicely, then he was honest enough to say the adhesive techniques that we've been using and media Denton sealing resin coating composite in the box area restoration and deep margin elevation. He had 80% of he needed to have complete success, but he was honest enough to say these cracks, they they didn't respond the way we would like to. The idea of adhesive dentistry holding these together. You know, mechanically it didn't The adhesive restorations that didn't work and documented. I showed many studies from Europe showed the same thing. There was only one study that really shined a little bit of light on the potential of a new technique. when I developed my technique independently, I didn't know anything about the indigenous that using crack dissection. That was published in the Australian Journal of Dentistry in 2009. But Abbott and Leow in their practice in Perth, Australia, which is way out west, it's not very people know about Western Australia. But the guys out west, they got the right answer. They had teeth referred to them by dentist saying they can't bite on this tooth. You know, we're going to do a root canal. We want you to do the root canal. Abbott alone knew enough about pulps. They have more training in pulp biology, they felt like the pulpitis was a reversible pulpitis not an irreversible pulpitis. And of course, that diagnosis has to change based on what you believe. And you have used the pulp in the healing mode. And my basic diagnosis now of irreversible pulpitis is that I never make that diagnosis. It's a pulps dead. You won't have a pulpitis. You could have pain on biting. that's not a pulpItis pain on biting in a dead pulp. Does come from the PDL anyway, so these evolving concepts that get mixed up in general, dentists eyes and minds and ended on us, you know, ended on us. That is you know, those who get paid whenever they take a pulp out, they just take the pulps out. the downside of taking a pulp out is the loss of that 20% hydration in the crown and in the root. And that means that you have three times less toughness three times more brittleness. Those are engineering terms again, that need to understood. You can look those up in any dictionary should give you that that difference. if you have a tough material have some give. You have some shock absorption. If it's a brittle material, at a certain point you have a fracture. And that has to do again with this other concept. Modulus elasticity or Young's modulus. But the old technique of putting a crown on maybe a coin toss of of success. Then the next situation of adhesive again a coin toss of success. Why were these sometimes successful is because the crack can go in three different ways. It can go sideways, it can go in a oblique manner, or it can go vertical. Every crack that goes vertical always gets to the pulp. That's going to be Every crack that goes sideways doesn't get to the PDL, and every crack that goes obliquely can get to the PDL, but also has the risk of going through the pulp horn. so the diagnosis between a vertical and oblique and a horizontal crack, unless you understand that it's based on anatomy and it's based on understanding the origin of pain, is it hydrodynamic source of pain, or is it the nerves that are in the PDL, the connective tissue around the root that are causing the pain. So you need to be very clear in those when you make your diagnosis. Davey has an excellent lecture. I believe we occasionally make that available as a webinar, But that signature lecture that Davey gives us a two hour lecture, he's given it in forms around the world, and it's been borrowed by Sema Belli and presented in in Japan. if you understand that this dissection of cracks and restoration using adhesive principles we've developed has been 100% successful, that as we get doctors every day that posts in our WhatsApp group. Yeah, patient came in, they had cracked two syndrome. We restored it, but with dissection and see factor control using small increments and rib on and time to decouple the developing hybrid layers of all of these ideas that we've used for over 25 years now, quarter of a century, it solves the problem. That is the third leading cause of tooth loss. I mean, why wouldn't every dentist the world be interested in learning the way to prevent the third leading cause of tooth You have to ask every dentist. That's not easy to do, but you are interested and you have the opportunity to learn more. And in our next lecture, we'll talk even more about how to prevent tooth loss from cracks using the best system that's ever been developed. Till next time. Get bonded. Stay bonded.