Diagnosis: the difficult part!

A 20-year-old male patient reported to the SEGi Oral Health Center for routine dental examination. On clinical examination, composite restoration was observed in the maxillary left first molar confined to distal aspect of the occlusal surface. A BPE (Basic Periodontal Examination) score of 4 was recorded for the maxillary left posterior sextant. An isolated deep periodontal pocket of 10 mm was recorded at the distopalatal area (Figure 1). The patient provided a history of persistent pus discharge from the buccal mucosal surface of the same region. An intra-oral periapical (IOPA) radiograph showed a J-shaped radiolucency around the palatal root of the left maxillary first molar (Figure 2). Interestingly, a closer analysis of the radiograph showed a fine fracture line running from the restoration and terminating at the coronal aspect of the pulp chamber (Figure 2). No fracture lines were observed extending from the floor of the pulp chamber and on any of the root surfaces. A further examination using transillumination revealed a fracture line was at the palatal aspect of the tooth extending gingivally and involving the disto-palatal cusp of the tooth. The presence of pus discharge on the buccal surface could point towards a spiral pocket communicating through the pocket on the palatal aspect of the tooth. A diagnosis of vertical root fracture was made based on the isolated periodontal pocket, J-shaped radiolucency, and persistent pus discharge from the buccal mucosal surface and the fine fracture line running beneath the restoration at the disto-palatal aspect of the tooth. A surprising feature in this case is the absence of heavy restoration, caries and/or trauma from occlusion in the involved tooth. A further enquiry with regards to the patient's past dental treatment history revealed a history of trauma to the involved tooth during extraction of the premolar as part of orthodontic treatment. This could have been the initiator of a possible minor and/or partial crack in the tooth progressing to full vertical fracture. The patient was advised to have the involved tooth extracted and referred to the unit of oral surgery.

This case underlines the importance of basic clinical, periodontal and radiographic examination in correctly identifying and diagnosing such entities in clinics, which are not only occasionally observed but are also challenging to diagnose and are easily missed by busy clinicians.¹ This translates into failed and repeated treatment cycles, mounting frustration of patients and pressure of completion on clinicians. It also highlights the variable clinical expression of the same clinical entity, ie vertical root fracture, making its early diagnosis management difficult and tricky.² Thus not only clinical experience but also sound subject knowledge is equally important to understand and identify the specific clinical signs and symptoms that indicate a specific diagnosis.³