Documentation of a Cracked Tooth on Physical Exam
Document a cracked tooth as an "infraction" or "enamel crack" if the tooth appears intact with visible crack lines, specifying the tooth number using universal numbering system and noting whether the crack is superficial (enamel only) or extends into dentin or pulp. 1
Standardized Classification for Documentation
The American Academy of Pediatrics provides a specific classification system for documenting tooth cracks that should guide your documentation:1
Infraction (Crack)
- Document as: "Infraction of tooth #[number]" when you observe a crack or craze line in the enamel surface 1
- The tooth appears intact, but crack lines are visualized by shining a focused light source (such as an otoscope) onto the crown in an axial direction 1
- This is the most precise term for a simple crack without tooth structure loss 1
Additional Documentation Elements
Include these specific details in your documentation to guide treatment decisions:
Depth Assessment:
- Enamel only: Document as "enamel infraction" or "uncomplicated enamel fracture" if limited to enamel layer 1
- Enamel and dentin: Document as "uncomplicated crown fracture involving enamel and dentin" if dentin is exposed but pulp is not visible 1
- Pulp exposure: Document as "complicated crown fracture with pulp exposure" if pink/red pulp tissue is visible 1
Associated Findings to Document:
- Tooth mobility (present/absent and degree) 1
- Sulcular bleeding at the gum margin 1
- Tooth displacement or abnormal positioning 1
- Sensitivity to percussion or palpation 1
- Patient-reported sensitivity to temperature or air 1
Tooth Numbering System
Use the Universal Numbering System (1-32 for permanent teeth, A-T for primary teeth) to specify which tooth is affected 1
Clinical Pitfall to Avoid
Do not document simply as "broken tooth" or "fractured tooth" without specifying the type, as this lacks the precision needed for appropriate referral timing and treatment planning 2, 3. The distinction between infraction, uncomplicated fracture, and complicated fracture determines whether the patient needs same-day referral versus monitoring 3, 4.
Example Documentation
- "Infraction noted on tooth #9 (maxillary right central incisor). Crack line visible with transillumination. No mobility, no sulcular bleeding, tooth appears intact. Patient denies sensitivity."
- "Uncomplicated crown fracture of tooth #8 involving enamel and dentin. No pulp exposure visualized. Patient reports sensitivity to cold. No mobility present."