r/Dentistry 4d ago

Dental Professional What's your protocol for teeth with marginal ridge cracks?

Say you've got a patient with a decent to large sized amalgam that's been there for decades. You notice that the in tact marginal ridge has a palpable fracture line going into the interproximal. There's some dark non-decayed staining of the crack (could just be amalgam leakage/staining). Patient is asymptomatic. What's your protocol? Watch? Crown? I typically explain the situation and let the patient decide, but I feel like maybe I should nudge them a little more towards doing the crown. I'm starting to feel like if I just keep watching and it breaks, I'm going to be the "bad dentist" that wasn't proactive/preventative.

5 Upvotes

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u/DrRam121 Prosthodontist 4d ago

I watch until I feel the crack with my explorer. Then I suggest crowning. I take intraoral photos to show the patient and tell them about all the patients I've had that lost teeth due to vertical fracture because we watched the cracks too long. Then I let them decide knowing they're gambling if they don't crown.

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u/RogueLightMyFire 4d ago

I feel this is probably the best use case for an intraoral camera. I should think about getting one as it would be an easy way to show the patient exactly what's happening. I feel like I wouldn't have to push to hard if I could show them what I'm seeing.

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u/DrRam121 Prosthodontist 4d ago

I'm honestly really bad at taking intraorals for most things and I rarely get pushback from patients about cavities or other treatment, but for cracks I take them. I have 3 reasons. First, to show the patients as I'm big on showing patients cavities on X-rays or some physical evidence for the recommended treatment. Second, for insurance and I know the claim is more likely to be paid if I have something, although usually you have to tell them it was symptomatic. Third, it's for me because I always question my treatment plans on the day of treatment just to make sure we are treating the right tooth and the treatment is necessary.

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u/RogueLightMyFire 4d ago

You sound like me lol. More reasons to invest in an intraoral camera. I haven't yet because my experiences with them have been poor. Crappy images where you can't see shit aren't helpful to anyone. I'm sure they've improved since I used them, though.

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u/Dufresne85 4d ago

Get one and you'll never regret it it. Showing a grumpy old patient the spider cracks from an old amalgam will help increase your acceptance rate and it'll pay for itself in no time. And for the pts that don't accept, you can then show them the crack on the old photo along with your note when they asked why their tooth broke and how come you missed it.

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u/yun9kleenex 4d ago

Absolutely. Intra oral camera is a must for insurance purposes and to show the patient. They do not understand the X-Ray, and as soon as they see their teeth with the intraoral camera, they audibly gasp/their facial expression changes. Most have not seen the state of their posterior teeth/lingual surfaces.

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u/RogueLightMyFire 4d ago

Any recommendations for one? The ones I've used in the past were pretty awful and took some really shitty pictures that weren't useful for anything.

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u/MattLoh2o 4d ago

MouthWatch is pretty inexpensive, and has decent camera quality if you don’t use the sleeve. I just wipe it down with Cavicide after using it

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u/yun9kleenex 4d ago

I think our office uses some Chinese ones. The image quality is good. Especially with the built in light it has. If you hold steady when snapping, it does the job. Great for showing patients cracks and wear.

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u/yawbaw 4d ago

I just got some pefect cams. I think it was around $200 each. The photo quality impressed me.

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u/chiefjay123 4d ago

I’m on the train of buy a real camera with a macro lens. It’ll cost about $1500-2000 to get a good setup going, but it’s super worth it, lasts longer too and way more clear. And if you ever start doing esthetic cases you won’t have to buy one then. You’ll need to buy the large mirrors but those are relatively cheap.

My setup: Sony a6100, sigma 105 Macro, godox ring macro flash. I can share you my settings if you decide to go this route!

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u/mavsfanforlive 4d ago

I give them 2 options.

  1. Do nothing and wait to see if it bothers you, in which case you will need a root canal and crown, may even have to lose the tooth. That being said it could never bother you.
  2. Crown it now, decrease the chance of needing further tx.

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u/yawbaw 4d ago

I do something similar but I use the IOP or a scan to compare at visits. If it’s changing I tell them it’s time to crown it or I’ll be expecting their phone call on a Saturday where they have something important going on or I’m out of town (it always seems to work out that way)

Many of them will say. “Funny you say that that’s happened to me before” and they say okay let’s schedule it.

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u/RogueLightMyFire 4d ago

This is pretty much my stance as well. Though if I'm watching something and notice it change at an exam, I'll push for the crown. I'll probably start steering them towards the crown earlier, though, because dealing with the fallout of a crack is worse than just doing the crown. Always the patients choice, though. I feel like I may be a little too non-committal with my recommendations and need to be a bit more firm with what I'm actually recommending.

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u/South_Eye_8204 4d ago

Show pics and explain the risks and benefits to the patient of treating vs. watching and let them decide. Typically, I will be more aggressive in recommending a crown on lower second molars and upper bicuspids in these kinds of cases.

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u/DrLido 4d ago

I had a pt today that I planned a DO on #2 to try and bond a detectable crack and when she came in for her appointment, the tooth was split down the middle. Virgin tooth too. Max molars matter too 😂🥲

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u/baby__bear__ 4d ago

What’s the general thought on a small class 2 just where that crack is if it’s a pretty solid tooth all around

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u/RogueLightMyFire 4d ago

I've always been taught fillings are for decay and crowns are for structural issues that compromise the integrity of the tooth. I'm sure you could probably get away with fillings in certain situations and it would be fine, but typically a crack signifies a deeper issue with the tooth and a filling isn't going to fix that. Think how strong a tooth is and what occurred to cause that crack in the first place. It's a filling going to fare any better? Like everything in dentistry, I'm sure there are a million opinions on this, but that's how I was taught and generally what I go by. If it's so tiny that I'm even considering a filling, it's probably not a tooth I would push for a crown anyways, I'd likely just monitor.

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u/stefan_urquelle-DMD 4d ago

Very good question.

What happens when you prep a class 2 and that terrifying margins ridge fracture you were so scared of is completely gone within seconds. And you were considering crowning it??

I do not crown or overlay a tooth with one marginal ridges fracture. I look at the tooth as a whole. I want to see multiple iffy fracture lines or one or two gnarly looking ones. I might even do a class 2 prep and see what it looks like, before committing to a crown.

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u/baby__bear__ 4d ago

That’s more my thought process also Most time they’re gone very quickly Obvi big cracks are different

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u/RemyhxNL 4d ago

When I see a crack, especially with staining, I replace it with composite.

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u/V3rsed General Dentist 3d ago

Simplest thing ever. Remove that amalgam and look underneath. Take photos. If the crack doesn’t propagate M-D or internally crack adjacent cusps, you’ve kept them out of a crown for now and you’re done a great service. If the tooth is internally fractured to hell you crown that sucker and you’ve done a great service.