Master Class Series #1

"It can be challenging to arrive at the correct diagnosis for patients in pain.  Dr. Abou-Rass presents the definitive class in the etiology, diagnosis, and treatment of tooth pain. His material on discovering tooth cracks is invaluable."

Dr. Chris Salierno
Chief Editor, Dental Economics

Course Director/Presenter

Marwan Abou-Rass DDS, MDS, Ph.D Marwan Abou-Rass DDS, MDS, PhD
Professor Emeritus,
Herman Ostrow School of Dentistry
University of Southern California

Dr. Abou-Rass brings nearly 50 years of cutting-edge innovations in the field of endodontics and dental education. He pioneered the concept of teaching molar versus central teeth as the best sequence for learning endodontic skills and developed the critical error approach to clinical performance evaluation.

In clinical endodontics, Dr. Abou-Rass has made a number of significant new concept and methodology contributions including:

  • Stressed pulp concept
  • Anti-curvature filing method
  • 4R Operational Diagnosis Protocol
  • Composite Post and Core buildup protocol
  • Endodontic Treatment Finalization Protocol
  • Interim Endodontic Therapy for native bone regeneration before implant placement

In addition to his DDS, Dr. Abou-Rass holds a Master’s degree in Dental Science in Prosthodontics, a certificate in Endodontics and a PhD., in Higher Education from the University of Pittsburgh, Pennsylvania. Dr. Abou-Rass served as Endodontic Department Chairman and Director of the Advanced Endodontic program at the University of Southern California, School of Dentistry (1971-2000). Dr. Abou-Rass moved to Riyadh, Saudi Arabia in 2000, where he directed the AEGD program at PAADI from 2000 to 2012.

Currently he is USC Professor Emeritus and publisher of Dental Economics MENA Journal and

Master Class Logo

Best Practices In Cracked Teeth Management
13.5 hours of advanced academic & clinical education

The Dental Academy of Continuing Education is pleased to announce our new Master Class educational series. This series will provide dental professionals with a higher level of education. This series will concentrate on teaching today's dentists and dental hygienists the procedures and techniques that can only be taught by skilled practitioners.

Our first Master Class series was created by Dr. Marwan Abou-Rass. He has been involved in teaching and practicing endodontics for almost 50 years. Dr. Abou-Rass has developed these highly clinical courses especially for the Master Class series. These courses are rich with endodontic-oriented content relevant to every dental professional.

This 5-Part Master Class series has been developed to help clinicians better understand, diagnose, and treat the cracked tooth problem.

The detection and diagnosis of the TSC is perhaps the most difficult aspect in the management of the cracked, fissured and fractured teeth in dental practice. In this five parts series the 4Rs operational diagnosis protocol(4RsOD) is used as a best dental diagnosis practice.

The protocol was specifically developed to remedy the shortcomings of the conventional Endodontic diagnosis tests.

The protocol helps the clinician to use the skills of: hearing, seeing and acting to accurately learn the patient problem.

The(4Rs OD) protocol provides the clinician with multidisciplinary, systematic approach for collecting, analyzing, and synthesizing the examination data into diagnostic, treatment planning, and prognostic decisions.

The 4Rs OD consists of the followings assessment tests:

R1: Report of the patient assessment
A key assessment step which require the patient to document his or her chief complaint and pain history details. The Patient Pain Profile developed in this step is essential to help the doctor in selecting the best radiographs to obtain and the most appropriate pulp. Periodontal or periapical tests to perform.

R2: Radiographic assessment
The 10 (ADI) Areas of Diagnostic Interest is a list of 10 diagnostic imaging interpretation guidelines. The interpretation findings will help the clinician determine the need for additional or alternative radiographs and confirm the most appropriate response testing needed.

R3: Response testing assessment
The dental pulp response to CO2 Ice is routinely performed on all teeth with pulp. Periodontal or periapical diseases or problems. Gingival, periodontal probing, alveolar socket bone sounding and fistula tracking are conducted following pulp testing and preferably under local anesthesia. Endodontically treated teeth are physically evaluated during the R4 step when the patient is anesthetized.

R4: Restorative and tooth structure assessment
Here, all the R1 & R3 subjective findings are supported or refuted through the objective findings obtained through restoration removal and/or the debridement of diseased or damaged tooth structure. R4 is the most objective and operational step of the protocol. R4 assists the clinician in determines tooth restorability, tooth structure cracks presence, treatment feasibility and alternative treatment options.

In this part of the series we will demonstrate the important role of tooth structure cracks (TSC) in dental practice. It will show how undiagnosed or misdiagnosed tooth cracks can affect or complicate endodontic, periodontic or restorative treatments outcomes.

The program includes detailed histories of 4 substandard endodontically treated that were retreated and restored by general practitioners, and specialists. Either through case history progression or restoration removal, the 4 teeth were found having TSC.

Because of the retrospective nature of the analysis, it was impossible to determine whether the cracks were present prior to treatment and were missed, initiated or propagated during the treatment. What is important in this regard is to focus on the role of the cracks and their effect on the treatment outcome.

After a lengthy history of treatment, retreatment, recall and follow-ups, the 4 teeth were extracted and became teaching cases. each case is retrospectively analyzed its story and history is presented in the webinar.

The webinar presentation is organized to sharpen the dental professionals diagnostic skills, specifically increase their awareness to search for hidden line cracks concealed under crowns and large restorations. Especially Amalgam restorations in teeth planned for full crowns or full coverage restoration.

The lessons learned from these 4 teaching cases, have generated many guiding principles. Here are 3 examples:

  • Never do endodontic treatment or retreatment through defective or a mediocre crown.
  • The crown or the bridge dentists work hard to save is often the cause of the endodontic or periodontic problem.
  • Endodontic surgery is not a substitute for standard endodontic treatment or retreatment.

Clinical management of cracked teeth in dental practice is an area replete with misunderstanding and misinformation. First, the literature lacks prospective studies and clinically useful universal definitions. Second, although cracked teeth problems vary significantly in diagnosis, treatment and prognosis. The literature terminology does not specifically differentiate between “Fractured teeth”, “Cracked teeth”, “Cracked Tooth Syndrome”, “Green stick fractures” and “Incomplete coronal fractures”.

The author’s 3x3 Tooth Structure Cracks (TSC) classification, grouped the various terminologies which relate to the cracked or fractured teeth problems, under one term “Tooth Cracks”. Then defined and classified the “cracks” according to their anatomic, physical and pathologic characteristics.

Physically, “Tooth Cracks” are classified into:

  • Line Cracks
  • Fissure Cracks
  • Fracture Cracks

Anatomically, “Tooth Cracks” are classified into:

  • Marginal Ridges
  • Grooves
  • Surfaces

Pathologically, “Tooth Cracks “are classified into:

  • Contributory
  • Noncontributory
  • Partially Contributory

The webinar presentation shows how to differentiate between the harmless “noncontributory crack” and the harmful “contributory crack”.

Contributory cracks cause reversible and irreversible pulpitis, pulp calcification, pulp necrosis, periapical and periradicular lesions. On the other hand, noncontributory cracks could be microscopically visible microcracks or clinically visible line. These cracks remain at the early initiation or development stages for years. They remain still and stationery, cause no pulpal or periodontal pathology as long as they are not pressured, and stressed by new forces or loads. Forces such as root filling condensation or traumatic fitting of a post.

Updated information about the etiology and initiation mechanism of tooth cracks is presented focusing on:

  • Abusive restorative procedures that cause coronal cracks
  • Abusive mechanical endodontic procedures that cause radicular cracks
  • Abusive post placement procedures
  • Dental occlusion factors

Part IV of the series focuses on how to apply the information learned in Part I, II and III of the cracked teeth master class series into clinical patient care.

The 4R Operational Diagnosis protocol is used in the diagnosis of the presented seven symptomatic cracked teeth cases, therefore each of the cases will include the 4R protocol findings profiles for:

  1. Patient Pain
  2. Ten Areas of Diagnostic Interest radiographic interpretation
  3. Pulp response
  4. Periodontal response
  5. Crown structure
  6. Pulp chamber content
  7. Canal content

A common diagnostic imaging finding in posterior cracked teeth, is pulp chamber opacity. Pulp Stones, denticles and calcific chamber recession are considered cardinal signs of the pathology commonly called pulpal calcification. the opacity is principally observed in unrestored, posterior cracked teeth or teeth with defective restorations, chronic caries and bacterial leakage.

Pulp calcification has detrimental effects on the dental pulp recovery from injury abilities and response to testing stimuli. Furthermore, it is known to complicate the endodontic treatment procedures. Because of its importance as diagnostic and the treatment risk factor, a special segment on the of pulpal calcification is featured in the introduction.

The 7-cases reviewed in the webinar represent an excellent sampling of the symptomatic cracked teeth cases encountered in general dental practices. Dr. Abou-Rass explains his guiding principles, clinical and biological rationales used in the treatment of each case.

The cases are as follows:

Case #1 Successful Conservative Treatment of a Cracked Tooth with Symptomatic Reversible Pulpitis
Case #2 Unsuccessful Conservative Treatment of a Cracked Tooth with Symptomatic Reversible Pulpitis
Case #3 Cracked Tooth with Symptomatic Irreversible Pulpitis
Case #4 Cracked Tooth with Symptomatic Early Apical Periodontitis or Apical Abscess
Case #5 Cracked Tooth with Symptomatic Chronic Apical Periodontitis without Isolated Periodontal Pocket (IPP)
Case #6 Cracked Tooth with Symptomatic Chronic Apical Periodontitis with Isolated Periodontal Pocket. (None Contributory TSC)
Case #7 Cracked Tooth with Symptomatic Chronic Apical Periodontitis with Isolated Periodontal Pocket. (Contributory TSC)

In the introduction of the program, the author reveals an alarming 24%-60% global prevalence of Apical lesions in teeth with inadequate root canal treatment. The literature’s histopathologic term used in describing these lesions is Apical Periodontitis. (AP). The statistics are alarming because the “Standard Normal” prevalence of Apical lesions in endodontically untreated teeth is 1½% - 7%.

This program stands for the management of teeth with substandard endodontic treatment failures because of the evidence-based relationship between abusive endodontic treatment, and root structure cracks initiation and propagation. Abusive endodontic treatment is one form and a principal cause of substandard endodontic treatment. More on this relationship discussed in part III of the master class series.

The program is composed of seven chapters planned to include the most clinically relevant facets of the inadequate or sub-standard endodontic treatment.

Chapter One Tells the story of misdiagnosing of a failing substandard endodontic treatment as periodontitis. Analyzes the complications and shows the importance of proper diagnostic investigation.
Chapter Two Review of the current definitions and terminology used in describing endodontic apical translucencies.
Chapter Three Discuss the most important studies on the factors influencing endodontic treatment success or failure.
Chapter Four Identify the factors, materials, methods and clinical practices that promote quality treatment, prevent, and heal Apical Periodontitis.
Chapter Five Examine the factors, materials, methods and clinical practices that result in substandard endodontic treatment and development of Apical Periodontitis.
Chapter Six How to use the 4ROD protocol to investigate substandard endodontic procedures, identify the cause of the failure and rule-out cracks.
Chapter Seven Introduces nonsurgical and surgical interim endodontic therapy to eliminate large Apical Periodontitis Infections, regenerate native bone and prepare the sites of hopelessly fractured teeth for implant placement.

Pulpal necrosis and substandard endodontic treatment are the principal causes of Apical Periodontitis. Mechanical root canal preparation is an integral part of modern endodontic practice. The improper use of mechanical or manual endodontic instruments causes root canal ledging, stripping, perforating and instrument breakage. These errors cause incomplete root filling which is the leading cause of substandard endodontic treatment outcomes. Collectively about 80% of endodontic treatment failures are contributed to root canal preparation errors.

To correct canal preparation errors, the clinician uses manual, mechanical tools and gadgets to bypass a root canal ledge or broken instrument. The generated forces associated with these attempts may initiate within the root canal surfaces micro cracks or propagate existing ones. The clinical complications of these cracks usually manifest months or years following endodontic treatment and post placement completion.

Therefore, regardless of the patient signs and symptoms, the radiographic diagnosis of a tooth with substandard endodontic treatment, should be considered a dental treatment risk factor. The clinician should investigate the tooth when considering endodontic retreatment or plan to use the previous root canal filling as a foundation for a post placement or new restoration.

Chapter 6 outlines the procedural protocol to follow when treating patients with substandard endodontically treated teeth. The clinician’s objectives are:

  1. Establish a doctor–patient relationship based on considerate interaction especially when the patient is unaware of having an iatrogenic dental problem.
  2. Identify and correct the cause of the substandard treatment.
  3. Rule out the presence of line cracks in the pulp chamber or the clinical crown before endodontic or restorative retreatment.
  4. Prevent tooth crack propagation thru changing the treatment protocol to atraumatic endodontic and restorative retreatment.

The program contains advanced specialty knowledge that enhances the clinician diagnostic and treatment skills. The general practitioners need such knowledge because they perform 72%- 88% of endodontic treatments services provided in the USA and Canada.

Chapter five discusses the role of the dental school as an important influencing factor in resolving the problem of substandard endodontic treatment. Endodontic curricula must have additional instructional hours’ time. Need to focus on more relevant content presented by full-time endodontic faculty committed only to the undergraduate curriculum and advanced continuing education courses to the general practitioners.

This program offers concepts, methods and guiding principles based on evidence, and tested clinical practices. The goal is to enhance the clinicians understanding of endodontic treatment diagnostics and the relationship between endodontic treatment and tooth structure cracks.