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Case Report
Adult rampant caries: A clinical
report
Shanti Varghese, Vinaya Bhat1, Lekshmy S Devi2
Departments of Prosthodontics and 2Conservative Dentistry, Noorul Islam College of Dental Sciences (Kerala
University), Aralumoodu, Trivandrum, Kerala, 1Department of Prosthodontics, AB Shetty Memorial Institute of
Dental Sciences (NITTE University), Mangalore, Karnataka, India

ABSTRACT

Rampant caries has been predominantly observed in young teenagers, with a few occurrences
in children and adults. Oral environment imbalances in the presence of pro-caries factors like
reduced salivary flow and reduced tooth remineralization response have been attributed as the
causative factors. The prognosis of the treatment depends upon the age of the patient, extent
of decay, co-operation of the patient, and the patients motivation toward dental treatment.
This clinical report describes a comprehensive treatment approach involved in rehabilitating
a patient presenting with adult rampant caries.

Key words: Adult rampant caries, oral imbalances, rampant caries

Introduction dental visits included uneventful extractions

Address for correspondence:
Dr. Shanti Varghese,
Department of Prosthodontics, Noorul
Islam College of Dental Sciences,
Aralumoodu, PO Neyattinkara,
Trivandrum - 695 123, Kerala, India.
E-mail:shantivrghs02@yahoo.com
Date of Submission: 21-05-2013
Date of Acceptance: 23-01-2014
Access this article online
Website:
www.indjos.com
DOI:
10.4103/0976-6944.176388
Quick Response Code:
Rampant caries has been defined by Massler[1]
as a suddenly appearing, widespread, rapid
burrowing type of caries, resulting in early
involvement of the pulp and affecting
those teeth usually regarded as immune to
ordinary decay. Its predominant occurrence
in young teenagers with a rare predilection
for children and adults has been observed.
Pre-etiologic factors have been attributed
to emotional imbalance leading to excessive
craving for sweets and snacks that is quite
common in adolescents, reduced salivary
flow, and a reduced tooth remineralization
response.
Case Report
A healthy 28-year-old female patient
presented to the Department of
Prosthodontics with complaints of
unaesthetic appearance due to decayed
teeth. Evaluation of patients medical history
revealed that the patient was in good health
with no evident signs or symptoms of any
systemic disease. Past dental history revealed
that she had noticed a sudden onset and
rapid decay of all the remaining teeth after
her first pregnancy (about 2years ago)which
were apparently previously sound. Routine
of the severely damaged and non-restorable
teeth. The patient reported no pain or
discomfort. She was accustomed to chewing
almost toothless.
Extraoral clinical findings demonstrated
asymptomatic temporomandibular joints,
muscles of mastication, muscles of facial
expression, and associated nonpalpable
lymph nodes. Mandibular range of motion
was in acceptable limits. Facial appearance
did not show any noticeable signs of
a collapsedo cclusal vertical dimension
(OVD) [Figure1].
Intraoral clinical findings demonstrated
partial edentulism, root stumps # 31, 32,
41, full veneer crown # 11, and an uneven
occlusal plane. Anterior teeth were affected
by soft, burrowing caries till the free gingival
level. Soft tissue and periodontal examination
demonstrated generalized mild gingivitis
with mild bleeding on probing [Figure 2a
and b]. No mobility or periodontal pockets
were elicited on any of the remaining teeth.
Radiographic examination demonstrated
healthy roots with adequate root length,
adequate periodontal and bone support,
and a favorable bony trabecular pattern
[Figure3].

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Varghese, etal.: Adult rampant caries
Figure 1: Extraoral preoperative view
a b
Figure 2: (a) Intraoral preoperative view; (b) intraoral preoperative
view in occlusion
Figure 3: Preoperative radiograph
According to M. M. Houses[2] classification of mental
attitude, the patient exhibited a very co-operative and
understanding attitude within the philosophical category.
Diagnostic impressions were made with alginate (alginoplast;
Heraeus Kulzer, South Bend, IN, USA) and diagnostic casts
obtained with typeIII dental stone (Labstone; Kalabhai
Karson, Mumbai, India). The patient was diagnosed as
ClassIV partial edentulism according to the Prosthodontic
Diagnostic index.[3]
An interdisciplinary approach was sought based upon
the clinical findings, examination of diagnostic casts, and
radiographs. Asequential treatment plan was framed out.
A detailed treatment plan was presented to the patient
Indian Journal of Oral Sciences Vol. 7 Issue 1 Jan-Apr 2016
that included the alternatives, benefits, and limitations of
each treatment. The patient opted for rehabilitation with
a fixed prosthesis. On obtaining consent from the patient,
treatment was initiated.
Phase I treatment sequence
The aim of this treatment phase was to remove caries
and arrest its progression as much as possible followed by
restoration of the dentition to optimal crown height and
form. The first line of treatment involved psychological
counseling and motivation of the patient followed by
diet assessment and counseling. Meticulous oral hygiene
maintenance was emphasized.
Root stumps # 31, 32, and 41 which were otherwise
considered hopeless were extracted
Full-mouth oral prophylaxis was done. Oral hygiene
instructions and follow-up were emphasized
Root canal treatment for # 12, 13, 21, 22, 23, 34, 35, 43,
and 44 was executed
Pre-fabricated dowels and core were done for # 12, 21,
22, 34, 35, 43, and 44 using pre-fabricated gold-tapered
dowels (Dental Conical Screw O Posts; Nordin, Swiss
dental products, Bangalore, India of distinction) and
light-cured composite (Nexcomp A3; Confident Sales
India Pvt, Bangalore, India) for the core buildup
Posterior teeth attacked by caries were restored with
posterior composites (Dentsply composite resin
Esthet-X flow; Dentsply, Trivandrum, India)
Crown lengthening was done for # 27, 38, 35, 34, 43,
and 44.
Phase II treatment sequence
The goal of this treatment sequence was to perform a
diagnostic wax-up and fabricate provisional restorations
which would be worn for 610 weeks so as to evaluate
esthetics, form, function, and patients tolerance of a 4-mm
increase in vertical dimension.
In order to evaluate the existing physiologic rest position
(PRP), OVD, and interocclusal distance (IOD), a
diagnostic mounting on a semi-adjustable articulator
was done
Impressions were made in stock trays using alginate
(alginoplast; Heraeus Kulzer) and casts obtained with
type III dental stone (Labstone; Kalabhai Karson).
Maxillary cast was mounted on a Hanau semi-
adjustable articulator (Hanau Wide Vue; Water Pik,
Fort Collins, CO, USA) using a face-bow transfer
(Hanau Spring-bow model # 182-8; Water Pik
technologies, CO, USA.). With the help of a centric
relation record at the existing OVD, mandibular cast
was mounted.
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Varghese, etal.: Adult rampant caries
The patients IOD was determined by taking the
difference between the PRP and OVD. [4] Ridge
parallelism was also taken as a guide to establish the
OVD. IOD was determined at 9mm. It was decided to
restore 4mm of the lost OVD, so as to avoid a long
face
A diagnostic wax-up was done.[5] The plane of occlusion
was made parallel to the interarch plane and was also
dictated by tooth # 11. Amutually protected occlusal
scheme was given, so as to prevent the destruction of
the new prosthesis[6]
The diagnostic wax-up was used as a template in the
fabrication of provisional restorations
Tooth preparation was done for metal ceramic crowns
Gingival tissues were retracted and definitive impressions
made with polyvinylsiloxane (Reprosil; Dentsply, USA).
Interocclusal records were made. Maxillary cast was
mounted using a face-bow transfer and mandibular cast
with centric relation record
Provisional crowns were made from the diagnostic
wax-up template and provisionally cemented with zinc
phosphate cement zinc phosphate cement; Harvard,
Germany)
The provisionals were worn for 8weeks with periodic
recalls to evaluate esthetics, form, function, and patients
tolerance of a 4-mm increase in vertical dimension
On the occasion of a review 2weeks later, the patient
expressed a need for a reduced tooth size and alteration
in tooth shape. She also noticed a slight tilt in the cant of
the maxillary anteriors. Diagnostic wax-up was modified
accordingly, and the provisionals were refabricated
and worn for the rest of the period. The patient was
asymptomatic and expressed satisfaction on subsequent
reviews.
Phase III treatment sequence
The goal of this treatment phase was to definitively restore
the dentition with metal ceramic fixed prosthesis after
Figure 4: Intraoral post-restorative view
44
the response with the use of provisionals was considered
satisfactory.
The provisionals were removed and a full-mouth oral
prophylaxis was done. Oral hygiene instructions were
re-emphasized. Signs of caries attack were not noticed
Gingival tissues were retracted and definitive impressions
made with polyvinylsiloxane (Reprosil; Dentsply, USA).
Interocclusal records were remade and mounted. With
the aid of the diagnostic wax-up, fixed prosthesis was
fabricated. After trial and patients approval, permanent
cementation was done with glass ionomer cement (GC
Fuji I; GC Corporation, Tokyo, Japan). The patient
was recalled for the insertion of an occlusal splint
[Figures4 and 5]
Impressions of the completed restoration were
made with polyvinylsiloxane for the fabrication of a
heat-activated clear acrylic occlusal splint. It was inserted
and instructions were given for maintenance and wear
at night
Oral hygiene instructions were revised and re-emphasized.
Patient was demonstrated and instructed on the use of
floss threaders under the fixed partial denture. Also,
instructions for a periodic 6-month recall were given.
Discussion
Massler[1] has defined rampant caries as a suddenly
appearing, widespread, rapid burrowing type of caries,
resulting in early involvement of the pulp and affecting
those teeth usually regarded as immune to ordinary decay.
A sudden onset and progression of this disease has been
attributed to a definite oral environment imbalance; and in
the presence of pro-caries factors, the disease accelerates
to be uncontrollable. Hence, it has been termed rampant
caries.
In 1966, Winter[7] termed rampant caries as caries of
acute onset involving many or all teeth in areas that are
not susceptible and is associated with rapid destruction
Figure 5: Post-restorative radiograph
Indian Journal of Oral Sciences Vol. 7 Issue 1 Jan-Apr 2016
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Varghese, etal.: Adult rampant caries
of the crowns with frequent involvement of the dental
pulp.
Rampant caries has been predominantly observed in young
teenagers, with a few occurrences in children and adults.
Prognostic factors have been attributed to emotional
imbalance leading to an excessive craving for sweets and
snacks (quite common in adolescents), reduced salivary
flow, and a reduced tooth remineralization response.
Three major hypotheses have been proposed as the
etiology of dental caries: the specific plaque hypothesis
by Loesche, [8] the nonspecific plaque hypothesis by
Theilade, [9] and the ecological plaque hypothesis by
Marsch.[10] The specific plaque hypothesis emphasizes the
active involvement of Streptococcus mutans and Streptococcus
sobrinus in dental caries. The nonspecific plaque hypothesis
stresses the overall activity of the total plaque microflora
which is inclusive of other bacterial species also. The
ecological plaque hypothesis suggests that caries is due to
a microfloral imbalance brought about by a definite oral
environment imbalance. Jorn [11] stated that bacterial
profiles change as caries progresses and also differ
from primary to secondary dentition. Changes in oral
ecology can result in alteration of bacterial qualities and
composition.
The prognosis of the treatment depends upon the age
and co-operation of the patient, extent of decay, and
the patients motivation toward dental treatment. Chu
and Zhang[12] suggested minimal intervention dentistry
as a new approach for the management of caries in
older patients. It involves early diagnosis and treatment,
improving the oral ecological balance, reducing the caries
risk, reversing the dental caries, and minimal surgical
intervention procedures.
The first line of treatment was to arrest the progression
of the disease by psychological counseling and motivation
of the patient followed by diet assessment and counseling.
Meticulous oral hygiene maintenance was emphasized.
Dentition had to be debrided of caries and restored.
Treatment options included adhesive restorations,[13,14]
overdentures,[15] occlusal overlay splint,[16,17] removable
partial denture.[18] FPD, or crowns and implants.[19] Due
to the reduced amount of available tooth structure, an
increased facial height, and patients economic constraints,
restoration of the entire dentition with metal ceramic
crowns and FPD was chosen. An increase in vertical
dimension of 4 mm was required to provide adequate
restorative space without further increasing the facial
height.
Indian Journal of Oral Sciences Vol. 7 Issue 1 Jan-Apr 2016
The fabrication of provisionals with the aid of a diagnostic
wax-up always serves as an evaluation phase for the patient,
dentist, and the technician. It helps in determining the
required amount of tooth preparation, tooth inclination,
occlusal plane, vertical dimension, occlusion, esthetics, and
muscular harmony.[15]
A mutually protected occlusal scheme was given. It has
been defined by the Glossary of Prosthodontic Terms[20]
as an occlusal scheme in which the posterior teeth prevent
excessive contact of the anterior teeth in maximum
intercuspation and the anterior teeth disengage the
posterior teeth in all mandibular excursions.[19]
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.
The patients understand that their names and initials will
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed.
References
1. Massler JN. Tee-age caries. JDent Child 1945;12;57-64.
2. Gamer S, Tuch R, Garcia LT. House mental classification revisited:
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JProsthet Dent 2003;89:297-302.
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4. Toolson LB, Smith DE. Clinical measurement and evaluation of vertical
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5. Yu A, Lee H. Awax guide to measure the amount of occlusal reduction
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15. Goud A, Deshpande S. Prosthodontic rehabilitation of dentinogenesis
imperfecta. Contemp Clin Dent 2011;2:138-41.
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How to cite this article: Varghese S, Bhat V, Devi LS. Adult rampant
caries: A clinical report. Indian J Oral Sci 2016;7:42-6.
Source of Support: Nil, Conflict of Interest: None declared

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