Vertical Root Fracture?

[Mike949]

Hello. I had RCT on tooth #4 in May. I began experiencing a constant dull pain in Oct. An endodontist at that time said there may be a small VRF based on a "thin mesial wall and small bony defect" seen on CBCT Scan but he wasn't certain. It began hurting even more over the last few weeks, so I saw a different endodontist on Monday. He said he didn't think it was a VRF. Told me to try a week of Amoxicillin, despite there being no infection seen on his CBCT. There was slight discomfort on percussion and bite stick testing but periodontal probing was normal. Although if it's on the mesial side (between tooth #4 and #5), I don't see how you would get a probe in between the teeth. The pain has gotten even worse over the last few days. Anyway, here is an image of the CBCT Scan taken in Oct. Does this look like VRF? Thanks.

 

[Dr M]

Can't see clearly on the x-ray.
What is the condition of the adjacent teeth? Any deep carious lesions or fillings?

 

[Mike949]

Yes. I just got a root canal on tooth #5 a few weeks ago. The pain on #4 got worse after that because #5 is out of occlusion until I get the permanent crown. All the force of my bite is on #4 and #3 as a result. And I grind my teeth at night. I believe there was a pre existing VRF that was made worse. Also have malaise, night sweats.

 

[Brause]

I am not a dentist, hence I cannot interpret your CBCT scan...but I notice this black spot...a dentist would possibly know whether this is indicative of something or just an imaging artifact.

I was wondering because I have a similar problem.

 

[Mike949]

I noticed that too, Brause. I could be wrong but I believe it is a large area of bone loss.

 

[Brause]

To catch a VRF, the clinician has to orient the X-ray/CBCT scan so that he/she looks along it. All CBCT scans I have seen lack the resolution to spot one.

Getting the X-ray orientation right is luck (as it is 2 dimensional).

I am having the same issue with my #21 (Canadian/European count): upper left central incisor. Phase 1 RCT was performed 12 days ago, the pain never subsided. I doubt whether it will ever be obdurated but rather pulled.

Endodontist: "everybody has fractures".

It appears that my Endo is performing RCTs as part of a diagnosis by elimination...if it does not work, there must the a VRF...and the tooth is lost. Probably the generally accepted workflow.

This happened to me with #46 just before Christmas. 4 root canals for nothing.

What nobody does is 1. isolate the bacterial culture and 2. explicitly image for fracture detection.

But, to be honest, fracture detection and an unambiguous diagnosis are difficult.

 

[Painful teeth]

To catch a VRF, the clinician has to orient the X-ray/CBCT scan so that he/she looks along it. All CBCT scans I have seen lack the resolution to spot one.

Getting the X-ray orientation right is luck (as it is 2 dimensional).

I am having the same issue with my #21 (Canadian/European count): upper left central incisor. Phase 1 RCT was performed 12 days ago, the pain never subsided. I doubt whether it will ever be obdurated but rather pulled.

Endodontist: "everybody has fractures".

It appears that my Endo is performing RCTs as part of a diagnosis by elimination...if it does not work, there must the a VRF...and the tooth is lost. Probably the generally accepted workflow.

This happened to me with #46 just before Christmas. 4 root canals for nothing.

What nobody does is 1. isolate the bacterial culture and 2. explicitly image for fracture detection.

But, to be honest, fracture detection and an unambiguous diagnosis are difficult.

If a fracture shows up on cbct it is almost big enough to show up on normal X ray too. J shaped leasion or by probing the gum are essentially the only ways to diagnose fracture.

I have the same problem by the way but I am a year in. How do you know your pain is not neuropatic? My endo says you should never pull without clear diagnosis. If there is a neuropatic component the pain can worsen.

 

[Mike949]

I feel your frustration. I'm in somewhat of a similar situation. Although my RCT treatments for both teeth were definitely warranted, based on the decay seen on X Ray and my symptoms. They had to be independently reviewed by a dentist who works in the approval department of my insurance before being authorized.

RCT should never be done as a process of elimination. Between symptoms, percussion, cold, and bite tests, X Ray, and CBCT, a dentist or endodontist should at least have an idea of what's going on. However, if you've got deep decay that is near a nerve, it is difficult to pinpoint whether the pain is from irreversible pulpitis or a pre existing VRF.

I watched a very good presentation on VRF on YouTube. When they look at the CBCT and X Ray, they are not necessarily looking for the fracture directly, but more or less the bone loss and radiolucency that accompanies VRF. That, followed by probing depths, history of RCT, and symptoms.

When I was physically in the office of the first endodontist, he told me he found absolutely nothing and wanted to take a wait and watch approach. Only when I asked for a copy of the CBCT a week later did he send me a random text message to say I might have a VRF...ridiculous.

"Everybody has fractures." Everybody has things like craze lines and very small fractures that never become symptomatic, but that is an asinine statement to make regarding VRF and the pain that accompany them.

From what I understand, bacterial cultures in dentistry are very rare because almost anything that infects the tooth will be killed by either Amoxicillin or Clindamycin.

 

[Brause]

In my current case, there is no cavity, necrotic pulp was assigned to dental trauma ("trauma from occlusion"), possibly from bruxism.

In an X-ray, the effects of VRFs and "trauma from occlusion" may look the same (for example a widened periodontal ligament around the whole root)...see attached photo.

The oral surgeon in my family always recommends "Aggressives Zuwarten" (= aggressive non-treatment, waiting it out)

I dipped a bit into the scientific literature on how to diagnose VRFs:

"...CBCT is expected to be a powerful tool in the detection of VRF. However, the results of three human studies show that a definite diagnosis of VRF depends on additional clinical examinations such as periodontal probing, palpation, and percussion besides CBCT imaging..."

————————————

"...They [=VRFs ] are also difficult to diagnose, as they mimic other conditions. Hence, the diagnosis of vertical root fractures requires more of a predictive rather than a definitive identification. A cumulative assessment of the clinical signs and symptoms and the radiographic fea- tures may help us reach a definitive diagnosis..."

-----------------------------------

"...The diagnosis of vertical root fracture can be problematic, and it often requires prediction rather than definitive identification. The clinical scenario of vertical root fracture may resemble that of a periodontal disease or of a failed root canal treatment. So it is important to differentially diagnose vertical root fracture from other similar clinical conditions. Radiographic diagnosis of vertical fracture of root is also difficult, as not all the classical radiographic signs of vertical root fracture may be present in every case. The accuracy of radiographic diagnosis also depends on the proper radiographic angulation, contrast, density and sensitivity of the clinician in interpreting the radiographic findings. There is need for the development of a diagnostic strategy depending on the patient's dental history, clinical signs and radiographic observations. CBCT has been used in recent studies with a high accuracy and sensitivity in detecting vertical root fracture..."

 

[Brause]

As to antibiotics...according to the American Association of Endodontists, all they do is preventing the infection from spreading to other parts of the body.

They apparently do not affect signs and symptoms before and after RCT.

Antibiotics: A Risky Prescription - American Association of Endodontists

The adverse effects of overusing and misusing antibiotics are highly publicized in the health professional literature, most recently in the August issue of the Journal of the American Dental Association. According to the Centers for Disease Control and Prevention, more than 2 million people in...

www.aae.org

Michael Hülsmann from the University of Zürich writes:

"...The lack of effectiveness of the antibiotic despite the penicillin sensitivity of the bacteria is due to the fact that an antibiotic can only work effectively if it can infiltrate the inflamed tissue, reach the infection and is present at the site of action in a sufficient concentration and that the effectiveness of the antibiotics is impaired due to the reduced blood flow within the apical abscess..."

 

[Mike949]

"The diagnosis of vertical root fracture can be problematic, and it often requires prediction rather than definitive identification." This hits the nail on the head.

Bruxism - As someone who grinds their teeth at night, I'm sure it was a contributory factor for the initial decay.

Tooth #5, however, was due to the dentist error, unfortunately. The cavity was moderately sized but nothing that a filling wouldn't take care of without hitting the nerve. The dentist advanced too far past the cavity and the material was practically touching the nerve and he also did not seal it properly. This allowed bacteria to get into the space and the cavity to continue advancing. So by the time symptoms started appearing several months later, it was diagnosed as irreversible pulpitis and you could literally see both the restoration material and the classic radiolucency of a cavity touching the nerve on X ray.

I don't know what your personal situation is but Covid played a big role in all of this for me. I went to my exam, cleaning, and x ray in 2019 but skipped it all of 2020 and 2021. They were telling us not to engage in non essential travel and the Delta variant was killing vaccinated people left and right. I figured because my last exam was squeaky clean and I brushed and flossed every day, I would be ok until I felt comfortable to go back. That was in early 2022. I was told then that I had two cavities and one of them (tooth #4) likely needed a crown. I just kept putting it off until late 2022 and have been dealing with this ever since. The fillings turned into root canals and at least one of them probably has a VRF and will eventually needed to be extracted. However, I had already had a filling in both teeth and with the grinding, I think earlier intervention may not have saved the teeth anyway. From what I understand, you can only have so many fillings on one tooth before there is no longer any structure to support it and you end up needing a crown.

 

[Painful teeth]

"The diagnosis of vertical root fracture can be problematic, and it often requires prediction rather than definitive identification." This hits the nail on the head.

Bruxism - As someone who grinds their teeth at night, I'm sure it was a contributory factor for the initial decay.

Tooth #5, however, was due to the dentist error, unfortunately. The cavity was moderately sized but nothing that a filling wouldn't take care of without hitting the nerve. The dentist advanced too far past the cavity and the material was practically touching the nerve and he also did not seal it properly. This allowed bacteria to get into the space and the cavity to continue advancing. So by the time symptoms started appearing several months later, it was diagnosed as irreversible pulpitis and you could literally see both the restoration material and the classic radiolucency of a cavity touching the nerve on X ray.

I don't know what your personal situation is but Covid played a big role in all of this for me. I went to my exam, cleaning, and x ray in 2019 but skipped it all of 2020 and 2021. They were telling us not to engage in non essential travel and the Delta variant was killing vaccinated people left and right. I figured because my last exam was squeaky clean and I brushed and flossed every day, I would be ok until I felt comfortable to go back. That was in early 2022. I was told then that I had two cavities and one of them (tooth #4) likely needed a crown. I just kept putting it off until late 2022 and have been dealing with this ever since. The fillings turned into root canals and at least one of them probably has a VRF and will eventually needed to be extracted. However, I had already had a filling in both teeth and with the grinding, I think earlier intervention may not have saved the teeth anyway. From what I understand, you can only have so many fillings on one tooth before there is no longer any structure to support it and you end up needing a crown.

I wonder or doubt you have a VRF. Apperently by the time the VRF is very symptomatic it can be found with probing.

I think majority, if not all tooth with VRF have been endotontically treated. If you have a crown fracture/micro fractures, the bacterial cannot process down the pulp chamber straight away to the apex and start causing infection. However the chamber is not empty anymore but is filled up with Gutta Percha and sealer which is airtight and anti bacterial. So it will take many months for bacteria to reach the apex in case of a crown fracture AFTER rc.

I had in total three tiny fillings. Did not even pass the enamel. ALL 3 tooth were necrotic or partially necrotic upon opening. The severe pain resolve after the RC but I still have pain on and off a year later now. The pain is sometimes up to 6/10 on 2 out of 3 teeth. I wondered if I had VRF, canals not properly cleaned, missed accesoiry canals you name it. But even a year nothing showed up on the CBCT. I'm now suspecting the dental sealer to might cause my pain, see the topic i made. I'm ready to take all three teeth out. Since the fillings 1.5 year ago I have been in this situation with pain. However my endo, dentist and orofacial specialist say that pulling MIGHT NOT resolve the pain. They will also not retreat. They would recommend only to pull upon evidence of infection, fracture or failure.

Oh yeah, i clench too.

Sometimes you have to accept and play the waiting game. Maybe it will show up. Maybe it will not.

 

[Mike949]

I have heard an overfill of the sealant can cause inflammation. I have the same thing but I believe it's the gutta percha, not the sealant. One endodontist said an apicoectomy might help but two other endodontists said it's pretty typical to have a slight overfill and it should not be causing pain. I looked at your pictures and cannot say how bad yours is. Did you bring it up to the endo who did it?

Btw, if you really wanted, I'm sure you can find a dentist who would be willing to extract the tooth based on your pain. I can understand if these dentists who refuse to do it are contracted with your insurance, and that makes for a tricky situation. But you could find a private dentist and pay out of pocket. I would wait to do that as a very last resort, however.

Trust me, many VRF's cannot be found on probing, even when the pain is significant. If you have an hour, watch this presentation.

 

[Brause]

Iatrogenic cause of your problem, not good, Mike. I have no filling in the affected tooth. I recently had the same issue with molar #46 (first molar lower right), RCT did not do anything and it was pulled 11 weeks later, prior to obturation. The tooth had not been endodontically treated before but supposedly had a root fracture.

Oh, Mr Painful T., and pulling #46 resolved the pain (my endo had also claimed the opposite).

As to clenching, I have had a custom-made retainer for three weeks now.

Thanks for the video, I will watch it. No problem here in Canada having your tooth pulled.

As to my images above: the left one is mine, the right greenish one is from the literature. And yes, plenty of X-rays and a CBCT scan exist...see attachments.

The regular dentist diagnosed "trauma from occlusion" (bruxism) based on the Jan X-ray. Both endo and the dentist changed it to an "abscess" based on the Feb X-rays.

Abscess could be caused by VRF, which could have been caused by occlusal trauma/bruxism. They are all related.

As to apicoectomy...not recommended by many as it has a high failure rate. And it really weakens the tooth even further.

 

[Brause]

If a fracture shows up on cbct it is almost big enough to show up on normal X ray too. J shaped leasion or by probing the gum are essentially the only ways to diagnose fracture.

I have the same problem by the way but I am a year in. How do you know your pain is not neuropatic? My endo says you should never pull without clear diagnosis. If there is a neuropatic component the pain can worsen.

Diagnosis by exclusion:

1. Pulp testing with cold test.

2. Periapical test with percussion and radiographs.

Not perfect but a first step.

If pain is neuropathic, I expect it not to become worse and the tooth not responding to any of the tests.