Cracked Tooth Syndrome: Characteristics and Distribution among Adults in a Nigerian Teaching Hospital Christopher I. Udoye, BSc, BChD, FMCDS, and Hamid Jafarzadeh, DDS, MSc Abstract This study highlighted the characteristics and distribu- tion of cracked tooth syndrome (CTS) and the associated factors in adult attendees in the University of Nigeria Teaching Hospital. Three hundred seventy patients aged 18 years to 77 years with CTS-like conditions were included and studied over 12 months. The following information was recorded: suspected tooth and the dental arch, restorative status of the tooth, age and sex of the patient, results of bite test and trans- illumination, and the pulpal and periapical status of the tooth. CTS was seen most often in the 41 to 50 years age band (36.4%), in molars (63.6%), and in the maxillary arch (51.5%). Also, it was more frequent in men (55.8%). About 82% of CTS occurred in amalgam- restored teeth. All cases had a positive response to the bite test and a normal response to the electric pulp test. Only 10% gave a positive history of mastica- tory accident as against none with history of bruxism habits. It was concluded that patients with unexplained pain in a vital, amalgam-restored tooth (especially in maxillary molars), with or without a history of a mastica- tory accident, may have a cracked or fractured tooth. (J Endod 2009;35:334–336) Key Words Associated factors, bite test, cracked tooth syndrome T he term ‘‘cracked tooth syndrome’’ (CTS) was first used by Cameron (1), although other researchers had reported on the condition 7 years earlier (2). It may be defined as a fracture plane of unknown depth initiated from the crown passing through the tooth structure and extending subgingivally, which may progress to communicate with the pulp space and/or periodontal ligament. The fracture may be extended through either or both of the marginal ridges and also through the proximal surfaces of the tooth (3, 4). CTS often evolves from a cracked tooth, and the latter does not always induce pain (5). Some workers believe that CTS is limited to vital posterior teeth (6), but it can also present in nonvital teeth (7). However, a true cracked tooth cannot be found among anterior teeth (4). A relationship between CTS and restorative status of the teeth has been re- ported (1). Other predisposing factors are some morphologic and physical factors such as deep fissures and pronounced intraoral temperature fluctuation, iatrogenic factors (such as poor cavity design and wrong selection of restorative materials), heavy occlusal forces, masticatory accidents, and bruxism habits. The pain of CTS is elicited by releasing a clenching pressure. It is also worsened by extreme temperature, especially cold (4, 8, 9). The complications of CTS include the involvement of pulpal tissue and/or periodontal ligament, cuspal fracture, and tooth mortality (10). The occurrence of CTS is unknown, but an incidence of 34% to 74% has been cited (1, 10). It occurs more frequently in the 30- to 50-year-old patients (3), and it has predilection for females (5). The CTS is most frequently observed in the mandibular second molar followed closely by the first molars and then by either maxillary premo- lars or maxillary second molars (4, 10, 11). The clinical importance of CTS lies in difficulties in its diagnostic procedures and frustration faced by both the patient and the dentist. Cameron (1) drew the attention of the dentistry world to the symptoms of the patient. All dentists should be aware that cracks are expectable in all cases. The cracks generally shear toward the buccal or lingual side toward one root surface, usually the lingual surface. Because the crack begins on the occlusal surface, it grows from this area toward the cervical surface and down the root. The application of wedging forces produces no separable segments that would indicate complete fracture, as with a split tooth (4). Sharp acute pain on chewing hard objects may be observed in this situation. In fact, the patients experience some intermittent episodes of acute pain radiating over the entire side of the face. A sharp short-duration pain may also be observed by cold stimuli. These cases may present with a variety of symptoms ranging from mild to very severe spontaneous pain consistent with pulp necrosis, irreversible pulpitis, or even an apical periodontitis. Both cracked and crazed teeth are considered incomplete tooth fractures, but a challenging form is CTS. The fracture line of a cracked tooth usually runs mesiodistally, whereas the craze line is limited to the enamel tissue (4, 12, 13). It should be remembered that the symptoms and signs in CTS are highly variable so the signs and symptoms are not the same in all cases of CTS (4). The recognition of patient symptoms, early diagnosis, and suitable treatment are important factors to salvaging a cracked tooth. The purposes of this prospective clinical study were to inves- tigate the characteristics and distribution of CTS among Nigerians and to highlight any other associated factors, including age and sex. From the Faculty of Dentistry, College of Medicine Univer- sity of Nigeria, Enugu Campus, Nigeria; and Department of Endodontics, Faculty of Dentistry and Dental Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. Address requests for reprints to Dr Hamid Jafarzadeh, Faculty of Dentistry and Dental Research Center, Vakilabad Blvd, Mashhad, Iran. E-mail address: hamid_j365@yahoo. com. and JafarzadehBH@mums.ac.ir. 0099-2399/$0 - see front matter Copyright ª 2009 American Association of Endodontists. doi:10.1016/j.joen.2008.12.011 Clinical Research 334 Udoye and Jafarzadeh JOE — Volume 35, Number 3, March 2009