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 of 1999- 2002 recorded that 21% of the children and 23% of adults had dental caries in the permanent dentition. Ten percent of adults had untreated root caries. ⁽¹⁾ 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 decay”.²

Most affected patients develop five or more lesions a year.^3,4 There is high probability that permanent teeth will be affected in those who had rampant caries in primary dentition, unless successful preventive measures were implemented.⁵ Rampant Caries is rare in adults. After adolescence, sudden onset of caries has been reported that some major alteration occurred in patient’s oral environment or diet.

In adults, rampant caries occurs due to frequent consumption of cariogenic diet. The carious lesions appear typically on buccal and lingual surfaces of premolars and molars as well as proximal and labial surfaces of mandibular incisors.⁶ In adults, the disease is often associated with reduction in salivary flow rate. Occasionally, salivary gland hypofunction results from the use of antisialogogic drugs or impaired emotional states.⁷ Multiple cervical carious lesions are typical features of adult rampant dental caries along with extensive occlusal and proximal cavities may also be present. Especially in elders with gingival recession, root caries are prominent.

There is ample literature on rampant dental caries in children. But the literature on management of this condition in adults is very minimal.^2,5,7 We, therefore, present here a rare case report emphasizing on salient clinical features, diagnosis and elaborate multidisciplinary management approach.

DESCRIPTION OF THE CASE

A 31 year old adult male 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 hesitated to smile and lacked self confidence. He presented with both aesthetic and functional impairment of his oral health.

History of illness revealed that decay of his teeth started around 10 years back for which he did not undergo any treatment. Diet analysis was performed and it was noted that he had the habit of frequent consumption of tea and biscuits in between meals for frequency of 12-15 times a day. He brushed once a day in the morning. He did not practice any other forms of oral hygiene measures. Patient was well nourished. 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&B). 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: Patient was asked to chew paraffin before breakfast to collect saliva. The specimen was shaken and after that 0.1 cc of sample was withdrawn. Samples (diluted and undiluted) were then spread evenly over a Rogosa’s SL agar plate. After incubation for 4 days, the number of lactobacillus colonies were counted. Number of organisms were more than 10,000 suggesting marked caries activity.

Saliva flow test; Salivary flow rate was assessed 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 adult rampant caries was made. The nature of disease, the time duration required for treatment as well as the total cost of the treatment were 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

1. Emergency phase: Oral prophylaxis was done followed by caries stabilization by removal of caries and provisional restoration of all carious teeth with glass ionomer cement. Root stumps were extracted. Patient was advised on maintaining oral hygiene followed by home and professional fluoride treatment.

2. 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 apicaly repositioned flap with osseous recontouring was considered in relation with 13,12,11,21,22 and 23 to increase crown length to achieve biologic width of 2mm. (Fig.C)

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.D). Core build up was done with composite(Fig.E). 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, 45 in mandibular arch. Aesthetics, over jet, over bite was established & canine guided occlusion was achieved(Fig. F)

3) Maintenance phase: Dietary counseling and oral hygiene instructions - Patient was educated and motivated to reduce frequency of sucrose consumption between meals. He was advised to restrict consumption of sugar containing foods and beverages 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 the term rampant caries should be used whenever caries occurs at the rate of 10 or more new lesions a year. Daniel (1954) believes the distinguishing characteristics of rampant caries are the involvement of proximal surface of the mandibular anterior teeth and appearance of cervical type of caries.8 Sucrose is thought to be more likely to be the main etiological factor for rampant caries. Other causative factors of rampant caries observed in children and adults with rampant caries are emotional disturbances, repressed emotions and fears, failures, stress against a home situation, inferiority complex, and continuous general tension and anxiety.⁹

An emotional disturbance may initiate an unusual craving for sweets or the habit of snacking. Decreased salivary flow leads to decreased caries resistance caused by impaired remineralization.¹⁰ The early loss of teeth may result in reduction in masticatory efficiency, decrease in vertical dimension, esthetic-functional problems such as malocclusion, space loss. Unaesthetic appearance of teeth leads to psychological problems that can interfere in the personality and behavior of the patient.¹¹

The Lactobacillus count quantitatively measures the number of lactobacilli present in 1ml of salivary sample (CFU/ml). It measures the caries risk. According to Granath et al. it is a better criterion than the salivary count of Streptococus mutans. Lactobacillus count is directly proportional to caries. The higher the DMF index, higher is the number of samples harbouring high Lactobacillus count. There exists a strong correlation between the Lactobacillus count and the presence of root caries in adults.¹²

Post is used as an anchor placed in the tooth root following a root canal treatment to strengthen the tooth and to retain 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. When a tooth is used as an abutment, crown preparation will further decrease fracture resistance.¹³ 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 necessitate 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 recommended.¹⁴

Ferrule is defined as a circumferential area of axial dentin superior to the preferential bevel, should have a height of 1.5 to 2.5mm.¹⁵ Prefabricated radix fiber posts with resin composite core were the strongest post core systems.⁽¹⁶⁾ If destruction of the teeth makes a sufficient ferrule difficult to achieve, a surgical crown lengthening can be done. 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 success.¹⁷

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.