Case 11
triggering the pain. He has not noticed the pain being pro-
Dental history
Pain on biting
SUMMARY
A 32-year-old man presents at your general dental
practice surgery with intermittent pain on biting.
Identify the cause and discuss treatment options.
Fig. 11.1 The teeth in the lower right quadrant.
History
Complaint
He complains of pain on biting which is unpredictable,
extremely painful and sharp but poorly localized. It origi-
nates in the lower right quadrant and lasts a very short time,
only as long as the teeth are in contact, and is so painful that
he has become accustomed to eating on the left. The pain
only arises on biting hard foods or deliberately clenching
his teeth. Apart from these sharp electric shock-like pains
he has no other symptoms.
History of complaint
The pain is a recent phenomenon, having been first noticed
a month or two ago. At first it was frequent but it has
become less of a problem now that he has learnt to avoid
voked by hot or cold.
The patient has been a regular attender at your practice
since childhood. He has a small number of relatively small
restorations. At his last appointment, some 4 months
ago you placed an amalgam restoration in the lower right
second molar.
Based on what you know already what are the likely
causes? Explain why.
A pulpal pain is the most likely cause because the pain
appears to originate in a tooth and is poorly localized. Pain of
periodontal ligament origin should be well localized.
However, pulpitis appears not be present because there is no
sensitivity to hot or cold. Pulpitis caused by placement of the
recent amalgams and pain due to caries or exposed dentine
can be excluded for the same reasons.
A crack in the tooth or electrogalvanic pain are possible
causes suggested by pain on biting. Both are triggered by
toothtooth contact.
Trigeminal neuralgia should be considered as an unlikely
nondental cause. It causes paroxysmal stabbing or electric
shock-like facial pain in distributions of the trigeminal nerve
and may be initiated by touching or moving trigger zones. It
usually affects the middle-aged or elderly. The history of pain
on biting is almost conclusive of a dental cause but it can be
difficult to exclude trigeminal neuralgia in some patients,
particularly when trigger zones lie in the mouth or attacks are
triggered by eating. If no dental cause is found, the possibility
of trigeminal neuralgia may need further investigation.
Acute periodontitis caused by an occlusal high spot on
the recently placed amalgam needs to be considered.
However, although this could cause great tenderness on
biting it would be expected that the pain from the bruised
periodontium would be present at other times. Also, such
periodontally-sensed pain would be well localized.
What additional questions would you ask? Why?
The patient should be asked about clenching or bruxing of
the teeth because the additional occlusal load can cause
fracture and will determine treatment options.
The patient describes a habit of nocturnal bruxism with
some tenderness of masticatory muscles at times of stress.
Examination
Extraoral examination
There is a suspicion of hypertrophy of the masseter muscles
on clenching.
Intraoral examination
The incisal edges of the upper and lower anterior teeth are
worn and the dentine is exposed. The cusps of the posterior
teeth are slightly flattened or rounded consistent with mild
attrition. There is no evidence of any loss of attachment or
gingival recession.
 11
CASE 54
Pa i n o n b i t i n g
The appearance of the teeth in the lower right quadrant
is shown in Figure 11.1. The lower right molars and premo-
lars contain small- to moderate-sized MOD amalgam resto-
rations, those in the molars having small buccal extensions.
The upper molars have small separate MO and DO amal-
gams, the DO amalgams having buccal extensions. The
upper premolars are unrestored.
What features of the restorations would you note
particularly?
The restorations should be inspected for occlusal high spots,
indicated by a burnished mark on the occlusal surface.
Premature occlusal contact could be confirmed with
articulating paper and relieving the area might cure the pain
indicating the diagnosis.
Though they are unlikely causes for this particular pain,
marginal caries, poor marginal adaptation or a cracked
restoration should be sought.
Differential diagnosis
What is your differential diagnosis? Why?
The pain is almost certainly caused by a cracked cusp or
crown. The presence of masseteric hypertrophy and attrition
on the occlusal surfaces of the teeth would suggest a
parafunctional habit that could predispose the tooth to
cracking.
Galvanic pain may be excluded because there are no
occluding restorations of dissimilar metals.
Which tooth would you suspect? Why?
The lower second molar appears the most likely to be
cracked. It should be investigated first because the pain
seems to have started shortly after restoration. The risk of
cracking depends on the size of restorations. The upper teeth
have small restorations which are limited to fissures and
mesial and distal surfaces. In the upper molar the ridge of
Table 11.1Identifying the causative tooth
Investigation
Tests of vitality of all teeth in the lower right quadrant should be performed,
either with an electric pulp tester or a cold stimulus.
Close examination with a good light (a bright fibre optic is especially useful for
transillumination). A soluble dye such as a disclosing agent may be painted
onto the crown. After the excess is washed off small amounts may remain in
the crack rendering it visible.
Attempts to stimulate the pain by pressing the handle of an instrument against each
cusp, preferably from more than one direction.
Ask the patient to bite hard on a soft object such as a cotton wool roll.
Place a wooden wedge against each cusp in turn and ask the patient to bite on each.
Radiograph
enamel joining the distobuccal to mesiopalatal cusps is intact
so that cusps are unlikely to be undermined.
Intact teeth can also crack, though usually only in association
with increased occlusal load. The most susceptible teeth are
the premolars because moderately sized amalgams
undermine the lingual and palatal cusps in the small crowns.
Lower first molars are also prone to crack because they tend
to contain the largest restorations in the mouth.
Root-filled teeth are prone to crack but obviously could not
cause a pulpal pain. Symptoms would then only be produced
if the periodontal ligament were involved and the pain would
be well localized.
Investigations
What tests and further examinations would you perform to
identify the causative tooth? What do the results tell you?
The investigations are described in Table 11.1.
On performing these tests you discover that all the teeth
in the quadrant are vital. Biting on cotton wool on the lower
second molar provokes pain that the patient identifies as the
same as that on biting. No particular cusp can be identified
and no crack can be found.
Treatment
What would you do next? Explain why.
The path of the crack must be defined as far as possible
because this will determine treatment options. The
restoration(s) in the tooth should be removed and a further
attempt made to find the crack using transillumination and
dye as described in Table 11.1. If the crack appears to enter
the pulp or be directed towards it, root treatment will be
required.
After investigation the crack is found to run across the
mesiolingual cusp and disappear subgingivally. It does not
appear to enter the pulp.
Significance
The pain must originate from a vital tooth. It is also possible that the cracked tooth might be hypersensitive.
This could aid diagnosis though hypersensitivity to testing would not be expected in the absence of pain on
hot and cold. Vitality might also affect the choice of treatment.
May reveal a crack.
Pain indicates a cracked cusp and the causative cusp is identified.
This transmits pressure to the whole occlusal surface and forces the cusps slightly apart. Pain on biting
suggests a cracked tooth.
This is a more selective test to identify the cusp or cusps which are cracked. By placing the wedge on different
surfaces of the cusp it may be possible to tell in which direction the crack runs. There may be pain on biting
but pain which is worse on release of pressure is said to be characteristic.
To exclude the possibility of caries and to assess the feasibility of root filling the tooth should it be necessary.
The radiograph is unlikely to be of direct help in diagnosis and might not be necessary if other investigations
successfully identify the cracked cusp.
 11
55

Table 11.2Restoration options for cracked teeth
Option
No treatment
Removal of the cracked portion followed by restoration
Full or partial coverage gold indirect restoration
Full coverage bonded porcelain crown
Adhesive restoration
Porcelain inlay/onlay
CASE
Pa i n o n b i t i n g
Advantages and disadvantages
This is not an option, even if the patient is happy to put up with the pain. Cracks may propagate into the pulp, allow bacterial
contamination and devitalize the tooth.
This is unsafe. Levering of the cracked portion risks a catastrophic fracture with pulpal communication.
Many cracks are incomplete and leverage may propagate them in unpredictable directions. Just occasionally the fragment will be limited to
enamel and dentine of the crown, particularly where the tooth already contains a large restoration undermining the cusp, but even then a
deliberate fracture is not recommended.
This is the treatment of choice. The preparation should finish supragingivally wherever possible. Gold is malleable and allows some plastic
deformation which is not possible with ceramics or composites which are more brittle. Full occlusal coverage is needed to protect the tooth
from further damage and a casting can provide some splinting, reducing the potential for further cracks.
Full coverage with porcelain bonded to metal has the advantage of a better appearance but the ceramic is brittle. This disadvantage may be
offset by using an adhesive to lute the crown. There is then the potential for the crack to be sealed by the infiltrating cement.
In theory an adhesive restoration would cement the crack together and prevent movement of the two fragments. However, on curing,
adhesive materials undergo polymerization shrinkage which places further stress on the crack and may propagate it further.
These suffer the same disadvantages of metal fused to porcelain crowns.

What are the treatment options for restoring cracked teeth?
What are their advantages and disadvantages?
These are listed in Table 11.2.
Suppose you had been unable to identify the causative
If the cracked portion had already been broken off at
presentation and the pulp were not involved, what
restoration options would have been open to you?
Assuming no second crack were present, this would present a
simple choice. One of the methods described in Table 11.2
could be used and this would have the advantage that
further cracks would be prevented. In view of the history
of bruxism this might be an appropriate option.
However, most cracks are single and it would also be possible
to adopt a more conservative approach and restore with a
composite and a dentine bonding agent or a sandwich
restoration. The latter uses a glass ionomer to replace the
dentine and a composite to replace the enamel. An amalgam
restoration is also simple and highly effective. Both these
would require the cusp to be reduced in height to reduce
the occlusal load.
tooth using the methods described above. What would
you try next?
Sometimes it is difficult to identify a crack. The pain is poorly
localized and a first step would be to repeat the whole
procedure on the upper molars and premolars in case the
patient has incorrectly localized the pain.
If no crack is identified, the restorations must be removed
from any further teeth that appear to be likely causes. Finally,
the most suspect tooth may have a tight fitting copper band
or orthodontic band cemented around it. This can be left in
position for several weeks to see whether the pain is
abolished, and is a particularly useful test when the pain is
felt infrequently.
This page intentionally left blank