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Journal of Dentistry 70 (2018) 67–73

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Journal of Dentistry 70 (2018) 67–73 Journal of Dentistry 70 (2018) 67–73 Contents lists available at ScienceDirect Journal of Dentistry journal homepage: www.elsevier.com/locate/jdent Associations of types of pain with crack-level, tooth-level and patient-level T characteristics in posterior teeth with visible cracks: Findings from the National Dental Practice-Based Research Network ⁎ Thomas J. Hiltona, , Ellen Funkhouserb, Jack L. Ferracanec, Valeria V. Gordand, Kevin D. Huffe, Julie Barnaf, Rahma Mungiag, Timothy Markerh, Gregg H. Gilberti, National Dental PBRN Collaborative Group1 a Department of Restorative Dentistry, School of Dentistry, Oregon Health & Science University, 2730 S.W. Moody Ave., Portland, OR 97201-5042, United States b School of Medicine, University of Alabama, 1720 2nd Avenue South, Birmingham, AL 35294-0007, United States c Department of Restorative Dentistry, School of Dentistry, Oregon Health & Science University, 2730 S.W. Moody Ave., Portland, OR 97201-5042, United States d Dept of Restorative Dental Sciences, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, United States e Private Practice, 217 W 4th St, Dover, OH 44622, United States f Private Practice, 222 JPM Rd, Lewisburg, PA 17837, United States g Department of Periodontics, School of Dentistry, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 8258, San Antonio, TX, 78229-3900, United States h Private Practice, 2210 Kulshan View Rd., Mount Vernon, WA 98273, United States i Department of Clinical and Community Sciences, School of Dentistry, University of Alabama, Birmingham, AL, United States ARTICLE INFO ABSTRACT Keywords: Objectives: The objective of this study was to determine which patient traits, behaviors, external tooth and/or Cracked teeth crack characteristics correlate with the types of symptoms that teeth with visible cracks exhibit, namely pain on Cracked tooth biting, pain due to cold stimuli, or spontaneous pain. Practice-based research Methods: Dentists in the National Dental Practice-Based Research Network enrolled a convenience sample of Symptoms subjects each of whom had a single, vital posterior tooth with at least one observable external crack (cracked teeth); 2858 cracked teeth from 209 practitioners were enrolled. Data were collected at the patient-, tooth-, and crack-level. Generalized estimating equations were used to obtain significant (p < .05) independent odds ratios (OR) associated with teeth that were painful for 10 outcomes based on types of pain and combinations thereof. Results: Overall, 45% of cracked teeth had one or more symptoms. Pain to cold was the most common symptom, which occurred in 37% of cracked teeth. Pain on biting (16%) and spontaneous pain (11%) were less common. Sixty-five percent of symptomatic cracked teeth had only one type of symptom, of these 78% were painful only to cold. No patient-, tooth- or crack-level characteristic was significantly associated with pain to cold alone. Positive associations for various combinations of pain symptoms were present with cracks that: (1) were on molars; (2) were in occlusion; (3) had a wear facet through enamel; (4) had caries; (5) were evident on a radiograph; (6) ran in more than one direction; (7) blocked transilluminated light; (8) connected with another crack; (9) extended onto the root; (10) extended in more than one direction; or (11) were on the distal surface. Persons who were < 65 yo or who clench, grind, or press their teeth together also were more likely to have pain symptoms. Pain was less likely in teeth with stained cracks or exposed roots, or in non-Hispanic whites. Conclusions: Although pain to cold was the most commonly noted pain associated with symptomatic cracked teeth, no patient-, tooth- or crack-level characteristic was significantly associated with pain to cold alone. Characteristics were only associated with pain on biting and/or spontaneous pain with or without pain to cold. Clinical significance: Although often considered the most reliable diagnosis for a cracked tooth, pain on biting is not the most common symptom of a tooth with a visible crack, but rather pain to cold. ⁎ Corresponding author. E-mail address: [email protected] (T.J. Hilton). 1 The National Dental PBRN Collaborative Group comprises practitioner, faculty, and staff investigators who contributed to this network activity. A list of these persons is at http:// www.nationaldentalpbrn.org/collaborative-group.php. https://doi.org/10.1016/j.jdent.2017.12.014 Received 29 September 2017; Received in revised form 1 December 2017; Accepted 27 December 2017 0300-5712/ © 2017 Elsevier Ltd. All rights reserved. T.J. Hilton et al. Journal of Dentistry 70 (2018) 67–73 1. Introduction crack-level characteristics. Initial analyses with patient demographics and behaviors were used to inform categorization for the regression Cracks in teeth, particularly posterior teeth, are a common finding. model. Associations between characteristics present in less than one A comprehensive review on cracked teeth reported incidence rates percent of the patient population and type of symptoms were not ex- varying between 0%−70%, depending on the tooth type and location amined because of difficulty modeling and imprecise estimates. In a [1]. A recent practice-based study found that 70% of patients had at univariable fashion, each patient-, tooth-, and crack-level characteristic least one posterior tooth with visible fracture lines, 21% of which were was entered into a logistic regression model that used generalized es- symptomatic. [2]. A variety of symptoms have been attributed to timating equations (GEE) method that adjusted for clustering of pa- cracked teeth, some of which are quite rare, such as trigeminal auto- tients within the practice, implemented using PROC GENMOD in SAS nomic cephalalgia [3,4], The most commonly reported symptoms of with CORR = EXCH option. All characteristics with p < .05 after ad- cracked teeth are pain to cold and pain on biting [5–8]. A study of 154 justing only for clustering of patients within the practice were entered symptomatic cracked teeth reported that 96% were painful on biting into a full model. This was followed with backwards elimination, again and 45% were sensitive to cold [9]. No clinical study to date has re- using GEE to adjust for clustering to identify independent associations ported on commonalities of various factors to symptomology. There- with symptomology, being retained if p < .05, in a reduced model. The fore, the purpose of this observational practice-based study was to models were further refined by requiring a magnitude of association to correlate various patient-, tooth- and crack-level characteristics with be either greater than an odds ratio (OR) of 1.5 or less than 0.6. After the type of symptoms (spontaneous pain, pain on biting, pain to cold) fitting the final model, all interaction terms were tested for significance exhibited by symptomatic cracked teeth in patients from selected at the 0.05 level. All analyses were performed separately by type of practices participating in the National Dental Practice-based Research symptoms. The referent group for all comparisons was the asympto- Network (National Dental Network). matic group. Additional analyses were performed examining associations with 2. Methods patients having only one type of symptom, then for each combination of two types of symptoms, and lastly for those with all three types of A detailed description of the enrollment and data collection pro- symptoms. This was done to better ascertain if identified characteristics cesses is provided in a previous publication [10]. Briefly, a convenience were associated with solely or primarily one type of symptom, if the sample of subjects between 19 and 85 years old having a single, vital magnitude of association differed for the type of symptoms, and if the posterior tooth with at least one observable external crack (referred to magnitude of associations increased or changed with combinations of in this paper as cracked teeth) was enrolled by dentists in the National symptoms. Because power was limited for one symptom type alone and Dental Practice-based Research Network [11]. Dentists were asked to specified combination analyses, the significance level for entry into the enroll 20 eligible subjects, or as many as they could in eight weeks, full model and then retention in the reduced model was relaxed (in- whichever came first. The Institutional Review Board (IRB) of the lead creased) to 10%. Associations among patient-, tooth- and crack-level investigators (TH & JF) reviewed and approved the study, as did the characteristics were examined, using GEE, to help explain/understand IRBs for the network’s six regions. All subjects were consented for en- variations in associations across models (Supplemental Tables 1–3). All trance into the study. odds ratios (ORs) and p-values reported below were adjusted for clus- Dentist and practice personnel were trained in data collection; data tering of patients within practitioner with GEE. All analyses were per- were collected at the patient-, tooth-, and crack level. Data forms are formed using SAS software (SAS v9.4, SAS Institute Inc., Cary NC). publicly available at [http://nationaldentalpbrn.org/study-results/ cracked-tooth-registry.php]. Tooth vitality was confirmed, preferably with cold [12] (e.g., refrigerant, ice) although some dentists used other 3. Results methods such as air, air/water spray, or electric pulp testing. Sponta- neous pain information was obtained via patient report, with pain to In all, 2858 patients/cracks were enrolled by 209 practitioners, with cold determined using the aforementioned refrigerant, ice, or air/water a mean/median of 14.8/15 patients per practice and a range of 1 to 20; – spray, and pain on biting confirmed by having the patient occlude on a 1561 (54%) of the teeth were asymptomatic. Figs. 1 3 show the device or instrument placed on the occlusal surface of the cracked tooth. To help patients distinguish pain, i.e., a heightened response to the cold or bite assessment, from an ordinary response, dentists were asked to also perform these tests on a “normal” (e.g., contralateral) tooth.
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