What is the protocol for treating cracked tooth syndrome, especially on a "hot" tooth?

Cracked tooth syndrome is something that we see quite often in our practice. It’s usually very painful and there is constant acute pain. The first thing that we normally do is we try to assess how bad the crack is. If the crack is so bad that the tooth has split into two, and there’s no way to salvage the tooth, then the treatment for such a scenario would be to extract the tooth.

However, if the crack is actually not too bad and there’s enough tooth structure left, we normally would start by commencing root canal treatment to remove the inflamed nerves inside the tooth. And after doing the root canal treatment, it’s very common to continue with a crown.

Since we’re talking about a hot tooth, a hot tooth is a nightmare for both dentists and patients because it means that the tooth is very inflamed and very difficult to anaesthetise. So for teeth like that, whether you need extraction or root canal treatment, the problem is you can’t be sure if you can anaesthetise the root completely.

There are a few ways you can get around it. One is premedication, that helps a lot -- you need to start on anti-inflammatories medication like Arcoxia and Ibuprofen. Because local anaesthetic doesn’t anaesthetise all the nerves, so those medications will take care of those nerves. Sometimes we put patients on steroids as well, just a very short course to get rid of inflammation. And then very often we give a lot of local anaesthetics and wait. If you wait long enough, like 30 minutes, especially for lower molars which are very difficult to numb, the success rate of anaesthesia goes up a lot.

Those are some of the ways. If the patient is very stressed out and anxious because they’re in pain, maybe their pain threshold is low, sedation will definitely help with that. There are different ways of sedating the patient.

In our practice, it’s quite common to do IV sedation, so the patient is completely knocked out and doesn't remember what happened. For lighter cases we can use laughing gas, which means no injections, or even oral sedation like diazepam, just to help the patient relax. But you still need to have a local anaesthetic.

Those are the ways to deal with a hot tooth. Because once you can numb the patient, then you can go ahead with any procedure. The problem is when the patient is not numb, then everyone is stressed out because as you’re working you’ll be waiting for the patient to jump and the patient is waiting for the pain. It’s just a very vicious cycle that tends to stress out the dentists, the staff, and the patients.