Australian Dental Journal 2023; 68: 135–143

doi: 10.1111/adj.12959

Diagnostic and treatment preferences for cracked posterior

teeth
J. Fong,* A. Tan,* A. Ha,* U. Krishnan*
*The University of Queensland, School of Dentistry, Brisbane, Queensland, Australia.

ABSTRACT
Background: Longitudinal cracks in teeth are common and often present challenges in diagnosis and management. This
study investigated the preferred diagnostic process and treatment modalities for these cracked teeth.
Methods: Dentists currently registered with Dental Board of Australia and practising within Australia were invited to
complete an online Qualtrics-based survey on their perspectives on the presentations, diagnosis, and treatment prefer-
ences for cracked teeth.
Results: Of respondents, 56.8% chose to place an indirect cuspal-coverage restoration on an asymptomatic cracked vital
tooth. When the tooth was mildly cold sensitive, direct cuspal-coverage restoration was favoured (64.9%), while 36.8%
preferred placing an orthodontic band in a tooth with biting pain. Respondents had higher odds of recommending indi-
rect restoration when CAD–CAM milling was available on-site or magnification was routinely used, regardless of pre-
senting symptoms. Almost half (46.8%) preferred to extract if the tooth undergoing root canal treatment had a crack
with a 5 mm probing pocket depth. Most (71.4%) demonstrated a poor understanding of cracked tooth biomechanics.
Conclusion: Australian dentists varied in their diagnostic and treatment preferences for cracked teeth, reflecting a need
for more well-controlled clinical studies in the diagnostic process, clinical biomechanics and treatment modalities for
these teeth. © 2023 Australian Dental Association.
Keywords: Australian dentists, Cracked tooth, CAD–CAM, magnification.
Abbreviations and acronyms: ADA = Australian Dental Association; NPBRN = national practice-based research network.
(Accepted for publication 4 April 2023.)

51% of the 1297 symptomatic cases had sensitivity to

INTRODUCTION
cold alone.13 In contrast, pain on biting was the sole
A cracked tooth is the most common amongst the five symptom in only 9.3% and spontaneous pain in
types of longitudinal tooth fractures.1 It is defined as an 4.9%.13 This diagnostic ambiguity is further compli-
incomplete fracture originating from the crown and cated by the fact that many cracks are asymptom-
extending subgingivally. The prevalence of cracked atic,13,14 with minimal clinical progression.15 The
teeth varies from around 10%2 to 70%, with the high- authors are unsure how many dentists are aware of
est reported being from the North West United States this fact.
of America.3 There has also been a reported increase in The ability to visualize a break in the continuity of
incidence during the Covid 19 pandemic.4,5 Failure to the tooth structure varies on the location of the crack.
manage cracks appropriately can cause early restor- Various tools such as magnification,16 staining,17 trans-
ative failure, unstable crack propagation and progres- illumination,1 quantitative light-induced fluorescence,18
sive bacterial contamination of the crack.6,7 This can and laser19 may aid in the visualization of cracks,
lead to pulpitis, fracture necrosis or tooth loss.4,8,9 though with varying degrees of accuracy.1 These aids
Cracked teeth present a clinical challenge mainly are usually supplemented with testing individual cusps
due to the non-specificity of their symptoms.10 Earlier with FracFinderⓇ (Denbur Inc.) or Tooth SloothⓇ (Pro-
studies with low sample sizes reported common pain fessional Results Inc.) to simulate pain on biting. Few
symptoms on biting, though sensitivity to cold and clinical studies have tested these tools’ sensitivity, speci-
spontaneous pain have been reported.11,12 However, ficity, and accuracy, adding to the diagnostic challenge.
an extensive national practice-based research network The general management of cracked teeth involves
(NPBRN) involving 2858 cracked teeth revealed that immobilizing the cracked segments to prevent
© 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association. 135
This is an open access article under the terms of the Creative Commons Attribution License, which permits use,
distribution and reproduction in any medium, provided the original work is properly cited.

J Fong et al.
symptoms and crack progression concurrent with ade-
quate treatment that addresses the pulpal status.20
Immobilization can be accomplished in the short term
with orthodontic banding, occlusal adjustment or
composite resin splinting, while long-term manage-
ment may be through mechanical splinting with direct
or indirect cuspal-coverage restorations.20–23 This can
result in broadly two types of treatment modalities, a
single-stage treatment where a definite restoration is
placed or a multi-stage treatment which involves an
interim phase to monitor pulpal condition.24 Although
many treatment protocols have been suggested, a
recent review highlighted the heterogeneous nature of
the existing literature and the difficulty in synthesizing
recommendations.24 This has resulted in significant
variations in treatment recommendations, as evident
in surveys carried out in Kuwait,21 Singapore25 and
the United States of America.26
To the authors0 knowledge, no studies have investi-
gated dentists’ diagnostic processes and treatment
preferences for cracked posterior teeth within Austra-
lia. This study aimed to identify the preferred diagnos-
tic method employed by Australian dentists in
diagnosing cracked teeth and their treatment prefer-
ences given various clinical scenarios.
METHODOLOGY
Survey design
This cross-sectional study involved general dentists
currently registered with the Dental Board of Austra-
lia and practising within Australia. Data were col-
lected through an online questionnaire hosted by the
Qualtrics platform. This study received ethics
approval from the University of Queensland Human
Research Ethics Committee (2021/HE002249).
The questions within the survey were developed
based on the gaps identified in surveys conducted in
other countries.21,25,26 Following the question devel-
opment, a pilot survey was conducted with multiple
registered dental practitioners. The final survey was
composed of three sections. The first section explored
participants’ demographics such as gender, experience
level, practice location, and employment sector. The
second section explored participants’ diagnostic pro-
cesses, their techniques when dealing with cracked
teeth. The third section recorded treatment choices in
response to four clinical scenarios and a question
exploring the biomechanics of cracked teeth (Fig. 1).
Clinical scenarios
Scenario 1. In this scenario, participants were shown
a clinical photograph illustrating a cracked tooth in a
mandibular second molar tooth (Fig. 1a). The text
136 © 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
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accompanying the photograph stated that the crack
was discovered after removal of an amalgam restora-
tion and that the patient had reported occasional sen-
sitivity to cold.
Scenario 2. In this scenario, the same clinical image
was used as in scenario 1. However, the reported
symptoms were changed to involve pain on biting,
mild tenderness to percussion, and occasional sensitiv-
ity to cold (Fig. 1a).
Scenario 3. In this scenario, participants were pre-
sented with a photograph of an asymptomatic man-
dibular molar exhibiting a mesiodistal crack. The
tooth was reported to be vital and the crack had been
detected after the removal of a broken amalgam resto-
ration. Clinically, this molar had a comparatively
more intact tooth structure than scenario in 1 & 2
(Fig. 1b).
Scenario 4. In this scenario, participants were
shown a clinical photograph of a maxillary first pre-
molar with asymptomatic apical periodontitis in
which root canal treatment was initiated. A crack was
present which involved the root canal and a 5 mm
pocket was associated with the crack (Fig. 1c).
Crack tooth biomechanics
This image-assisted question was designed to test the
understanding of cracked tooth biomechanics by ask-
ing practitioners to determine whether a crack pro-
gressing through coronal dentine would follow a
straight or tortuous path (Fig. 1d).
Multiple responses were allowed with certain ques-
tions to allow the option to recommend single-stage
or multi-stage treatment. Participants could also come
up with customized responses.
Study sample
Multi-level sampling was used to distribute the ques-
tionnaire to Australian dental practices. Australia was
stratified into its different states and territories. Post-
codes within each state and territory were random-
ized, listed, and each tenth postcode was selected for
inclusion in this study. These postcodes were searched
on the Australian Dental Association (ADA) Online
Dental Directory for dental practices within the corre-
sponding locations. Every fifth and tenth practice
within an included postcode was contacted by tele-
phone or email to participate in this study. If fewer
than five practices were listed in an included postcode,
then the first practice listed was contacted instead.
This process was repeated twice. The survey was also
distributed via the ADA Peer group online discussion
forum, study clubs, dental school faculty members
and dentists working in the public sector. The total
number of participants who received an invitation to
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Cracked posterior teeth

Fig. 1 (a) Same image used for both scenario 1 & 2: Scenario 1: Symptomatic cracked tooth with cold sensitivity. Scenario 2: Symptomatic cracked tooth
with cold sensitivity, biting pain and tenderness to percussion (b) Scenario 3: Asymptomatic cracked tooth incidentally discovered during restoration
replacement (c) Scenario 4: Asymptomatic apical periodontitis in a cracked tooth with a 5 mm distal probing defect discovered during root canal treatment
(d) Hypothetical scenario investigating crack progression under tension in dentine where respondents asked to choose between image (a) or image (b)

partake in the study and the response rate could not
be calculated as multiple platforms and methods were
used to source participants.
Statistical analysis
The data were transferred from Qualtrics and ana-
lysed in the statistical software Jamovi (Version 1.6,
The Jamovi project (2021)). After incomplete
responses were removed 171 responses were available
for the final analysis. Qualitative data, such as com-
ments by study participants, was read and catego-
rized. Due to ’crown’ being a prevalent chosen option
within the written responses of Scenarios 1 and 2,
these responses were removed from the ’other’ cate-
gory, and ’crown’ and ’indirect onlay’ were clustered
into ’indirect restorations’ for analytical purposes.
Within Scenarios 1 and 2, the selection of ’direct
cuspal-coverage restoration’, ’indirect restorations’,
’root canal treatment’, ’extraction’, or the selection of
both ’direct cuspal-coverage restoration’ and ’indirect
restoration’ together were classified as single-stage
treatment. All other selections were classified as multi-
stage treatment. Within Scenario 3, indirect restora-
tion placement, such as the placement of indirect
onlays and crowns, was clustered to aid analysis.
The custom responses were analysed for themes,
but none were identified. Hence, no further mixed-
method analysis was performed, and appropriate
descriptive statistics were used to manage the quanti-
tative data. Associations between demographic vari-
ables and treatment choices were assessed using
Pearson’s Chi-Squared test and Fischer’s Exact test.
© 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
For scenarios 1, 2 and 3, the odds ratio at 95% confi-
dence interval was calculated for demographic factors
as the predictor variable and indirect restoration as
the outcome variable. A similar analysis was per-
formed for scenario 4 with extraction as the outcome
variable.
RESULTS
Demographics
One hundred and seventy-one completed responses
were included in this study (Table 1). Most partici-
pants received their qualifications in Australia
(79.5%) and practised in the private sector (87.7%).
Routine use of magnification was common (77.8%),
and nearly a third had access to onsite CAD–CAM
milling (31.0%).
Diagnostic process
Almost all participants (95.4%) selected pain on bit-
ing as the symptom which made them suspect the
presence of a cracked tooth (Fig. 2), whilst sensitivity
to cold was selected by approximately half of respon-
dents (55.3%). Preference towards dependence on a
single symptom versus various combinations of symp-
toms is depicted in Fig. 2. Around 96.5% would use a
symptom replicator such as a FracFinderⓇ (Denbur
Inc.) or Tooth SloothⓇ (Professional Results Inc.) as
the primary diagnostic aid for the identification of a
cracked tooth. In comparison, half of the participants
also used transillumination (57.7%).
137
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J Fong et al.

Table 1. Demographic characteristics of respondents Table 1 (continued)

Counts (%) Counts (%)
Gender More than 60% 2 (1.2)
Female 88 (51.5) Removal of the entire crack prior to
Male 82 (48.0) restoration (all other factors
Other or unspecified 1 (0.6) being favourable)
Country of dental qualification Removes the entire crack 77 (45.0%)
Australia 136 (79.5) Does not remove the entire crack 94 (55.0%)
New Zealand 3 (1.8)
Other 32 (18.7) *Only respondents who selected "yes" to the previous question were
State of practice able to answer, resulting in the percentage not totalling to 100.
QLD 79 (46.2)
NSW 33 (19.3)
ACT 1 (0.6)
VIC 26 (15.2) Clinical scenarios
SA 14 (8.2)
NT 0 (0) Treatment preferences in relation to different scenar-
TAS 1 (0.6) ios are presented in Table 2.
WA 17 (9.9) Scenario 1. Approximately two-thirds (65.3%) of
Type of practice*
Private sector 150 (87.7) the dentists indicated that placement of a direct
Public health services 32 (18.7) cuspal-coverage composite resin would be their
Academic 9 (5.3) recommended treatment option. However, nearly half
Other 4 (2.3)
Location of practice (54.1%) chose to provide an indirect cuspal-coverage
Metropolitan zone 114 (66.7) restoration. Dentists with CAD–CAM milling units
(Population of ≥100 000) had 3.77 times higher odds of recommending indirect
Rural zone (Population of 5001–99 999) 54 (31.6)
Remote zone (Population of ≤5000) 3 (1.8) restoration. Those who used magnification had 2.90
Qualification times higher odds of preferring indirect restoration
General dentist 167 (97.7) (Table 3). For this scenario participants were allowed
Specialist 4 (2.3)
Years of experience to select multiple options as transitioning to more
0–5 years 55 (32.2) definitive procedures was possible with this scenario.
5–10 years 31 (18.1) Further details of single-stage treatment versus multi-
10–20 years 24 (14.0)
More than 20 years 61 (35.7) stage treatment for scenarios 1 and 2 are depicted in
Routine use of magnification Table 2. The decision to place an orthodontic band
Yes 133 (77.8) and interim resin modified glassionomer cement
No 38 (22.2)
Type of magnification* (RMGIC) restoration was less common (20.6%) and
2.59 loupes 58 (33.9) was not associated with any demographic factor.
3.09 loupes 24 (14.0) Scenario 2. Participants were allowed to select mul-
Loupes with magnification of 3.59 or more 45 (26.3)
Microscope 6 (3.5) tiple options as transitioning to more definitive proce-
Routine marking of occlusal contacts before dures was possible with this scenario (Table 2).
placement of restoration However, when presented with additional symptoms,
Yes 34 (19.9)
No 137 (80.1) compared to scenario 1, fewer dentists indicated they
Increase in incidence of cracked teeth would place a direct cuspal-coverage composite resin
in the last 2 years (48.2%) or indirect cuspal-coverage restoration
Yes 69 (40.4)
No 60 (35.1) (38.8%), and more would place an orthodontic band
Not sure 42 (24.6) and interim RMGIC restoration (36.5%). In addition,
Availability of in-office CAD-CAM milling an association between treatment preferences and
Yes 53 (31.0)
No 118 (69.0) demographic factors revealed that if the dentist had
Indirect cuspal-coverage restorations access to the CAD–CAM milling unit, the odds of
placed due to cracks placing an indirect restoration were 2.65 times higher.
0–20% 47 (27.5)
20–40% 47 (27.5) A similar association was noted with use of magnifica-
40–60% 31 (18.1) tion (OR 2.42).
More than 60% 27 (15.8) Scenario 3. The most common treatment option
I do not place 19 (11.1)
Percentage of cracked teeth referred selected was an indirect restoration (53.8%) which
to a prosthodontist or endodontist was similar to scenario 1. The key difference with sce-
0–20% 143 (83.6) nario 1 & 2 were that there was no recommendation
20–40% 18 (10.5)
40–60% 8 (4.7) for the placement of orthodontic bands when the
tooth was asymptomatic. Indirect restorations had
(continued) 5.19 times higher odds of being chosen when CAD–

138 © 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
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Cracked posterior teeth

Fig. 2 Comparison of symptoms associated with cracked teeth reported in this survey (a) with that of actual clinical presentation in NPBRN database (b.
Hilton 2018). (a) represents distribution according to symptoms that raise suspicion of cracked teeth among the respondents. The green area represents
responses that were solely pain on biting (35.9% (61)), the purple area represents responses that were solely sensitivity to cold (0.6% (1)), the red area
represents sensitivity to heat and pain on biting, while the overlap between the purple and red represents all three symptoms. (b) Represents symptoms of
cracked teeth based on NPBRN (Reprinted with permission, Hilton 2018). Key differences are in sole symptoms.

CAM milling was available and 3.27 times higher
odds when magnification was routinely used (Table 3).
Direct cuspal-coverage restoration was much less
commonly used (26.9%).
Scenario 4. Almost half of the dentists elected to
extract (46.8%), which had 2.65 times higher odds if
magnification was routinely used and 1.75 times
higher odds if CAD–CAM milling was available,
although the latter result was not statistically signifi-
cant. Dentists practicing within a metropolitan region
had lower odds (0.41 OR) in recommending extrac-
tion in scenario 4 (Table 3).
Question on cracked tooth biomechanics. Most
dentists (71.4%) selected the wrong answer and con-
sidered that the crack would proceed in a straight line
with no consideration to toughening mechanisms of
dentine. However, there were no significant associa-
tions between poor biomechanical understanding and
demographic factors.
DISCUSSION
This study has provided valuable insights into the
diagnostic and treatment choices of Australian dentists
for cracked posterior teeth.
Demographics
That most respondents were employed in private prac-
tice and received their dental qualification from Aus-
tralia is consistent with data reported within national
statistics.27,28 The gender distribution of our sample
was also similar to the national dental board registry.
© 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
Diagnostic process and methods
Awareness of the symptoms that indicate the presence
of a crack in a tooth is critical for timely diagnosis.
Sensitivity to cold and biting pain have been shown to
be expected in symptomatic cracked teeth, though
there is some degree of overlap with other symp-
toms.12,14,29,30 Interestingly, a third of the respondents
considered pain on biting to be the sole symptom of
cracked teeth, which contradicts the NPBRN reports
based on a large sample size of such teeth.13 Only one
respondent (0.6%) would consider the presence of a
cracked tooth if sensitivity to cold was the only chief
complaint. This is despite the fact that 51% of the
1297 symptomatic patients based on NPBRN pre-
sented with sensitivity to cold alone.13 The overlap of
sensitivity to cold with a variety of other common
conditions, such as non-carious cervical abrasion, den-
tin hypersensitivity, dental caries and defective resto-
ration, may be the reason for the low suspicion of
cracked teeth. Of historical note, Cameron in his orig-
inal publication on cracked teeth in 1964 suggested
that unexplained sensitivity to cold was an important
diagnostic feature of cracked teeth. Of importance is
that, cracked teeth have been associated with undiag-
nosed diffuse long-standing pain of more than 3
months without the presence of sensitivity to cold or
pain on biting.31 Hence cracked teeth can have a
range of presentations and should be in the differen-
tial diagnosis, particularly with unexplained sensitivity
to cold or long-standing diffuse orofacial pain.
Regarding the aids used for diagnosing cracked
teeth, pain on biting replicators such as FracFinderⓇ
139
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J Fong et al.

Table 2. Treatment preferences for single or multi- well-controlled studies examining the effectiveness of
stage treatment, and combinations of treatment pref- transillumination as a diagnostic tool, particularly at
erences within Scenarios 1 and 2 the false positive results associated with transillumination.
Counts
(%) Association between demographics and treatment
Scenario 1 choices
Single-stage treatment 135 (78.9)
Direct cuspal-coverage restoration only 53 (31.0) The association with the provision of indirect restora-
Direct and indirect cuspal-coverage restoration* 42 (24.6) tion and availability of CAD–CAM milling was con-
Indirect cuspal-coverage restoration only 35 (20.5)
Extraction only 3 (1.8)
sistent in scenarios 1–4. This may be due to the
Single-stage treatments not otherwise included 2 (1.2) ability to provide faster stabilization of the cracked
Multi-stage treatment 36 (21.1) segments with current bonding techniques and the
Orthodontic band with interim RMGIC only 12 (7.0)
Orthodontic band with interim RMGIC, and indirect 8 (4.7)
bracing effect offered by indirect cuspal coverage res-
cuspal-coverage restoration torations.33 Some practitioners believe that immediate
Orthodontic band with interim RMGIC, direct and 6 (3.5) dentin sealing, performed before indirect cuspal over-
indirect cuspal-coverage restoration*
Orthodontic band with interim RMGIC, and direct 6 (3.5)
lay, would limit bacterial penetration and crack prop-
cuspal-coverage restoration agation.33 Prevention of tooth fracture has been
Multi-stage treatments not otherwise included 4 (2.3) reported as a reason for the provision of a single
Scenario 2
Single-stage treatment 98 (57.3)
crown in NPBRN reports, which could also be the
Direct cuspal-coverage restoration only 38 (22.2) reason why indirect restorations were preferred in this
Indirect cuspal-coverage restoration only 24 (14.0) survey.34 The relationship with magnification use may
Direct and indirect cuspal-coverage restoration* 19 (11.1)
Root canal treatment 7 (4.1)
be more nuanced as, anecdotally, magnification is of
Extraction 6 (3.5) great benefit in the identification of cracks.16 These
Single-stage treatments not otherwise included 4 (2.3) observations indicate that treatment preferences are
Multi-stage treatment 73 (42.7)
Orthodontic band with interim RMGIC only 36 (21.1)
significantly affected by local factors in individual
Orthodontic band with interim RMGIC, direct and 8 (4.7) practice.
indirect cuspal-coverage restoration*
Orthodontic band with interim RMGIC, and direct 8 (4.7)
cuspal-coverage restoration Symptoms, structural loss and treatment decisions
Orthodontic band with interim RMGIC, and indirect 6 (3.5)
cuspal-coverage restoration
(Scenario 1, 2 & 3)
Root canal treatment, direct and indirect cuspal- 4 (2.3)
coverage restoration*
The presence or absence of symptoms seems to be a
Multi-stage treatments not otherwise included 11 (6.4) significant determinant among the respondents in
choosing definitive single-stage treatment. Generally, a
RMGIC = resin modified glassionomer cement.
*This result indicates respondents that selected both direct cuspal- multi-stage approach, such as placement of an ortho-
coverage restoration and indirect cuspal-coverage restoration. This dontic band was chosen in the symptomatic cracked
result does not combine the results of respondents that made a sin- tooth as suggested in a recent review.24 On the other
gle selection of either direct cuspal-coverage restoration or indirect
cuspal-coverage restoration. hand, more definitive treatment, such as indirect
cuspal-coverage was preferred for an asymptomatic
cracked tooth. These findings reflect those of the
or Tooth SloothⓇ were the most popular, while pain NPBRN reports that cited presence of symptoms as a
on biting was the most frequent symptom that made reason to commence restorative treatment.14 The
the respondents suspect a crack in tooth. Of note is choice of direct cuspal coverage in both scenarios 1
that in a Korean study29 on symptomatic cracked (68.9%) & 2 (48.0%) is supported by the literature
teeth with pain on biting only 82% were positive for both as an interim and as a long-term measure.35
bite test. An Australian study involving cracked teeth The treatment decision in cracked teeth appeared to
referred to an endodontic practice involved a high be more influenced by symptoms rather than by the
number of pain on biting symptoms, may not repre- amount of remaining tooth structure. This is evident
sent the presentation in general dental practice.30 Fur- by the reduction in choice of direct cuspal coverage
ther, even in the latter study, only 10% had pain on restorations (26.9%) in scenario 3 despite there being
biting as the sole symptom and the majority (81%) more tooth structure when compared to the other two
were in combination with sensitivity to cold, heat or scenarios. The choice of indirect restoration by
both.30 around half the dentists in scenario 3 was similar to
Transillumination was the second most preferred the reports from the USA, where 44% of the crowns
diagnostic aid in this survey. Transillumination can were placed purportedly to prevent complete frac-
demonstrate blockage of light transmission due to ture.36 The lack of symptoms coupled with a vital
cracks or deep fissure.1,22,32 However, there are no pulp probably may have given dentists more
140 © 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
 18347819, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12959 by Cochrane Peru, Wiley Online Library on [18/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Cracked posterior teeth

Table 3. Demographic factors and their association with the choice of indirect restoration for scenarios 1–3 and
choice of extraction for scenario 4
Odds of placing an indirect restoration Odds of extraction

Scenario 1 Scenario 2 Scenario 3 Scenario 4

Characteristic OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Gender
Male practitioner 1.17 (0.64–2.14) 1.67 (0.90–3.12) 1.22 (0.67–2.23) 1.45 (0.79–2.65)
Female Practitioner
Country of training
Trained in Australia 1.34 (0.64–2.82) 1.08 (0.50–2.33) 0.84 (0.40–1.79) 1.22 (0.58–2.58)
Trained overseas
Sector of practice
Private sector 1.10 (1.44–2.74) 1.02 (0.40-2.62) 1.33 (0.53-3.31) 0.96 (0.39-2.40)
Other sectors
Location of practice
Metropolitan practice 1.00 (0.53–1.90) 0.90 (0.47–1.72) 1.07 (0.57–2.03) 0.41** (0.21–0.79)
Regional/remote/rural practice
Routinely uses magnification
Yes 2.90** (1.37–6.17) 2.42* (1.06–5.50) 3.27** (1.52–7.04) 2.65* (1.21–5.77)
No
Routinely marks occlusal contacts
Yes 0.93 (0.44–1.97) 1.33 (0.62–2.85) 1.50 (0.70–3.24) 1.83 (0.86–3.93)
No
Has CAD–CAM onsite
Yes 3.77*** (1.83–7.78) 2.65** (1.36–5.15) 5.19*** (2.43–11.08) 1.77 (0.92–3.41)
No

CAD–CAM = Computer-assisted design – computer-assisted milling.

Bold values are statistically significant.
*P < 0.05,
**P < 0.01,
***P < 0.001.

confidence to prefer single-stage definitive treatment.24
This approach was likely driven by the circumferential
bracing effect and high success rates of cuspal cover-
age indirect restorations in cracked teeth.2,37
Root canal treatment and probing depth (Scenario 4)
There seems to be concern among Australian dentists in
the study regarding performing root canal treatment on
cracked teeth with periodontal probing defect of 5 mm.
Recent studies suggest endodontic treatment of cracked
teeth has a promising prognosis with a 5-year survival
rate ranging from 84.1% to 88%.38,39 Despite the trep-
idation, a pre-treatment periodontal pocket of less than
6 mm was associated with a 2-year survival rate of
96.8%.40 However, if the probing depth is more than
6 mm, the survival is reduced to 74%.40 Likely, prob-
ing pocket depth was not the only factor respondents
considered in their decision-making. The maxillary pre-
molar in this case vignette had an MOD preparation
which is well known to reduce the cuspal stiffness by
63%41 and further compromised when axial dentin is
removed.42 The latter is of relevance as 45% of respon-
dents would prefer to remove the entire crack resulting
in a significant compromise of axial dentin.
The fact that more Australian dentists practicing
outside of a metropolitan area would choose to
extract a cracked endodontically involved tooth
© 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
reflects the lack of specialist support in the regional
area.43 Interestingly, specialist referral would be
sought by at least 20% of respondents in such situa-
tions, the highest among all case scenarios. This
inequality of dental labour force distribution in Aus-
tralia may contribute to the extraction of more
cracked teeth. Nevertheless, extraction was preferred
by only 46%, which is still significantly less compared
to a study where 83.8% of American endodontists
chose extraction in almost similar conditions.26
Biomechanics of crack progression and removal of
entire crack (Scenario 5)
Biomechanics of crack initiation and propagation is
dependent on three major factors: material properties,
loading factors and environmental issues. Coronal
dentin, although heterogeneous with different crack
growth resistances depending on age, location (coro-
nal versus root dentin) and hydration, still demon-
strates a significant increase in resistance to
progressive crack extension compared to deeper den-
tin.44 Toughening mechanisms within dentin include
crack deflection and shielding, uncracked ligament
bridges and filled dentinal tubules causing deflection
and bridging.45 These mechanisms prevent the den-
tinal crack from travelling linearly as demonstrated in
fractographic analysis.6,45 This explains the relatively
141

J Fong et al.
slow progression of cracks through coronal dentin
and has been clinically collaborated in NPBRN
reports where only 3% of the cracked teeth resulted
in fracture.15
Though rounding the crack tip has been suggested
in brittle materials,46 dentin is a quasi-brittle material
with significant toughening mechanism.47 Considering
the structural loss associated with removal or round-
ing of dentinal cracks, a less invasive option would be
to reduce the stress intensity at the crack tip with cus-
pal coverage, providing less steep cusps and managing
deleterious loading conditions.6,48 Though specific
biomechanical questions were not asked in other sur-
veys across the globe21,25,26 the responses generally
had limited biomechanical reasoning. This calls for
further education of dentists regarding the biomechan-
ics of crack propagation.
The study has several limitations. Firstly, the partic-
ipants belonged to a category that generally uses mag-
nification, and many had access to CAD–CAM
milling units. This may not be a reflection of an every-
day Australian general dental practice. Hence, the
views captured in this survey possibly represent those
who have access to modern technology and an interest
in cracked teeth. Secondly, the response rate of the
survey could not be calculated as multiple platforms
and methods were used to reach out to dentists. Nev-
ertheless, this study sheds some insight into the pro-
cesses and challenges in crack teeth diagnosis and
treatment and sets the focus areas for future work.
CONCLUSION
This study revealed the diagnostic process and treat-
ment choices made by Australian dentists across a
wide range of cracked teeth scenarios. It allowed us
to identify the agreements and disagreements of their
choices compared with the available literature. In
addition, the uncertainties and range of diagnostic
and treatment preferences suggest a need for a struc-
tured biomechanical approach considering all aspects
that affect cracked teeth dynamics in future studies.
ACKNOWLEDGEMENTS
The authors would like to acknowledge Prof Alex
Moule and Dr Paul Renner for their suggestions. The
clinical photographs were supplied by Dr Renner.
Open access publishing facilitated by The University
of Queensland, as part of the Wiley - The University
of Queensland agreement via the Council of Austra-
lian University Librarians.
CONFLICT OF INTEREST
We do not have any conflicts of interest to declare.
142 © 2023 The Authors. Australian Dental Journal published by John Wiley & Sons Australia, Ltd on behalf of Australian Dental Association.
18347819, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12959 by Cochrane Peru, Wiley Online Library on [18/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SUPPORTING INFORMATION
Additional Supporting Information may be found in
the online version of this article:
Appendix S1: Treatment preferences in relation to
different clinical scenarios (Unclustered data).
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Address for correspondence
Unni Krishnan
The University of Queensland
School of Dentistry
Oral Health Centre
288 Herston Rd
Qld. 4006
Australia
Email: unni.krishnan@uq.edu.au
143