Multidisciplinary Management Of Adult Rampant Dental Caries - A Rare Case Report

INTRODUCTION

In spite of the worldwide decline in dental caries rates, there persists a segment of the population who are still ravaged by the disease. The National Health and Nutrition Examination Survey for 1999-2002 recorded that 21% of children and 23% of adults had untreated dental caries in the permanent dentition. Ten percent of adults had untreated root caries¹ .The most accepted definition of adult rampant caries as given by Massler (1945) as “a suddenly appearing, widespread, rapidly borrowing type of caries, resulting in early involvement of the pulp and affecting those teeth usually regarded as immune to ordinary decay²” .

Most affected patients develop five or more lesions a year^3,4 .It has been suggested that there is a high probability that permanent teeth will be affected in those who suffer from the disease in the primary dentition, unless successful preventive measures were implemented⁵ .Rampant Caries is rare in adults. Sudden onset after adolescence show that some major alteration has occurred in patient's oral environment or diet.

In young adults, rampant caries may result from frequent consumption of cariogenic diet, such as cakes, chocolates and sugar-sweetened carbonated drinks. The carious lesions appear typically on buccal and lingual surfaces of premolars and molars as well as proximal and labial surfaces of mandibular incisors⁶. In adults, the disease is often associated with salivary gland hypofunction, due to irradiation of the head and neck region⁵ . Occasionally, salivary gland hypofunction results from the use of antisialogogic drugs or impaired emotional states.⁷ Multiple cervical carious lesions are typical, although extensive occlusal and proximal cavities may also be present. Where there has been gingival recession, root caries may be seen, especially in the elderly.

There is considerable literature on rampant caries in children^{2, 5, 7} but little appears to have been written on the management of this condition in adults. We, therefore, present here a rare case report with the aim of highlighting the characteristic features in clinical presentation and management of patients with multidisciplinary approach.

CASE REPORT

A 31 year old male patient presented to the Department of Conservative Dentistry and Endodontics with the chief complaint of poor appearance due to discoloration and breakdown of his entire dentition. The appearance of his teeth had a significant impact on both social and psychological aspects of his life. His oral condition had affected his quality of life by impairing physical and social functioning as well as his self esteem. He avoided smiling and lacked self confidence. He presented with both aesthetic and functional impairment of his oral health.

History revealed that decay of his teeth started around 10 years back for which he did not seek any treatment. Diet analysis was performed and it was noted that he had the habit of frequent intake of sugars (tea and biscuits) in between meals for frequency of 12-15 times a day. He used to brush once a day in the morning and practiced no other forms of oral hygiene measures. Patient was well nourished. On clinical and radiographic examination (OPG) revealed rampant caries involving interproximal and cervical surfaces and involving the pulp. Multiple teeth were decayed to the level of alveolar crest (Fig A). On electric pulp testing 11, 12, 13, 14, 21, 22, 23, 33, 34, 35, 36, 43, and 44 were nonvital. Root stumps were present in relation to15, 24, 25, 27, 37 and 48.

Lactobacillus colony count test; Saliva was collected by chewing paraffin before breakfast. The specimen was vigorously shaken and after that 0.1 cc of sample was withdrawn. Dilute and undiluted samples were then spread evenly over a rogosa's SL agar plate. The plate is incubated for 4 days and number of lactobacillus colonies that developed were counted . Number of organisms were more than 10,000 suggesting marked caries activity.

Saliva flow test: Salivary flow rate was determined by collecting paraffin stimulated saliva in a test tube over 5 minutes. Viscous saliva with decreased flow rate was noted relating to increased caries susceptibility.

Final diagnosis of rampant caries was made. The nature of disease, the time duration required for treatment as well as the total cost of the treatment was explained to the patient. Patient consent was obtained and treatment plan was executed.

The treatment plan was basically divided into 1) Emergency phase, 2) Corrective phase and 3) Maintenance phases.

Emergency phase

Oral prophylaxis done followed by caries stabilization by excavation of caries and provisional restoration of all carious teeth with glass ionomer cement to improve his appearance. Root stumps were extracted. Patient was advised on maintaining oral hygiene followed by home and professional fluoride treatment.

Corrective phase

a)Endodontic phase : Root canal treatment of 18 affected teeth (14,13,12,11,21,22,23, 24, 36,35,34,33,32,42,43,44,45 and 46) performed.

b) Periodontal phase : Crown lenghthening by api c a ly r epositioned flap with oss eous recontouring was considered in relation with 13,12,11,21,22 and 23 to increase crown length to achieve biologic width of 2mm (Fig B).

c) Reconstructive phase : Gutta percha removal for post preparation was accomplished with Gates Glidden drills followed by refining of the canal space using the drills provided in Radix fiber post system. A minimal apical seal of 5mm of gutta percha filling was retained in the apical root portion. The posts were marked to the length to project into the core and cut with diamond disc. The root canals were etched, bonded and dual cure resin injected into the canal and post was placed to precut depth. Eleven fiber posts were placement in relation to 14,13,12,11,21,22,23,24,34,35 and 44 was performed (Fig C). Core build up was done with composite. This was performed in duration of one and half month.

d)Prosthetic rehabilitation : After the post & core build up for 14,13,12,11,21, 22,23,24,34,35,44, posterior teeth contact was maintained & crown preparations were carried out depending on the height and thickness of the remaining dentin, a minimum 2mm of ferrule was maintained. Porcelain fused metal bridges (PFM) were placed for 14,15,16, 13,12,11,21,22,23 and for 24,25,26,27,28 on maxillary arch. In mandibular arch PFM bridges extended for 36, 37, 38 and cantilever bridge was placed involving 45 46 to replace 47. Separate crowns were placed on 34, 35, 44, and 45 in mandibular arch. Aesthetics, over jet, over bite was established & Canine guided occlusion was achieved (Fig D).

Maintenance phase

Dietary counseling and oral hygiene instructions - Patient was educated to reduce the frequency of sucrose consumption especially between meals and consumption of sugar containing foods and beverages to be restricted to meal times. Proper brushing technique demonstrated to the patient using articulated models of dental arches and brush. Use of fluoridated tooth paste and mouthwash recommended. Patient recalled after three months.

DISCUSSION

Some believe that the term rampant caries should be applied to a caries rate of 10 or more new lesions per year. Daniel (1954) believes the distinguishing characteristics of rampant caries are the involvement of proximal surface of the lower anterior teeth and development of cervical type of caries. Sucrose is thought to be more likely to cause rampant caries than glucose, fructose, sorbitol, hydrogenated starch and starch. Other causative factors of rampant caries observed in children and adults with rampant caries are emotional disturbances, repressed emotions and fears, dissatisfaction with achievement, rebellion against a home situation, a feeling of inferiority, a traumatic school of experience and continuous general tension and anxiety⁹.

An emotional disturbance may initiate an unusual craving for sweets or the habit of snacking due to decreased salivary flow, decreased caries resistance caused by impaired remine ralization¹⁰ . The early loss of teeth may result in reduced masticatory efficiency, loss of vertical dimension, esthetic-functional problems such as malocclusion, space loss, and psychological problems that can interfere in the personality and behavior of the patient¹¹.

The Lactobacillus count represents the number of lactobacilli present in 1ml of saliva (CFU/ml). It is used to evaluate the carious risk. For Granath et al. , it is a better criterion than the saliva rate of Streptococus mutans. Astrong correlation has been established between the Lactobacillus count and caries, the higher the DMF index, the higher the number of children harbouring a high Lactobacillus count. Some studies have also been carried out in adults in order to investigate the link salivary lactobacilli / root caries. Results have shown a strong correlation between the Lactobacillus count and the presence of this kind of carious lesion¹².

Post is used as an anchor placed in the tooth root following a root canal to strengthen the tooth and help hold a crown in place. In cases where only 1 cavity wall remains, the core material has little or no effect on the fracture resistance of endodontically treated teeth. If tooth has to be used as an abutment for fixed or removable partial dentures, crown preparation will further decrease, fracture resistance¹³.If all axial walls of the cavity remain and have a thickness greater than 1mm it is not necessary to insert post. Loss of 1 or 2 cavity walls does not necessarily require the insertion of post as the remaining hard tissue provides enough surface for use of cores using adhesive systems. In cases where only 1 cavity wall remains or in cases with no cavity walls the core material has little or no effect on the fracture resistance and use of posts is recommended¹⁴.

The ferrule effect has a great influence on fracture resistance. Ferrule is defined as a circumferential area of axial dentin superior to the preferential bevel, should have a height of 1.5 to 2.5mm¹⁵. Prefabricated radix fiber posts with resin composite core were the strongest post core systems¹⁶. If deep destruction of the teeth renders a sufficient ferrule impossible, a surgical crown lengthening can be performed. This provides a crown ferrule resulting in reduction of static load failure. An endodontically treated tooth used as abutment post insertion has a significant positive treatment success¹⁷.

CONCLUSION

The rampant dental caries poses esthetic, functional ,and psychologic problems. Treatment requires motivation and assurance to patient as well as cooperation of the patient as it requires lot of time and is expensive. Proper diagnosis, treatment planning and systematic execution of the protocol will result in excellent clinical results. There is limited documentation over the incidence and nature of adult rampant caries because of its very rare occurrence.