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Case Report
Adult rampant caries: A clinical
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


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

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

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Varghese, etal.: Adult rampant caries

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

Figure 1: Extraoral preoperative view
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
a b
dental products, Bangalore, India of distinction) and
light-cured composite (Nexcomp A3; Confident Sales
Figure 2: (a) Intraoral preoperative view; (b) intraoral preoperative
view in occlusion 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
Figure 3: Preoperative radiograph esthetics, form, function, and patients tolerance of a 4-mm
increase in vertical dimension.
According to M. M. Houses[2] classification of mental
attitude, the patient exhibited a very co-operative and In order to evaluate the existing physiologic rest position
understanding attitude within the philosophical category. (PRP), OVD, and interocclusal distance (IOD), a
diagnostic mounting on a semi-adjustable articulator
Diagnostic impressions were made with alginate (alginoplast; was done
Heraeus Kulzer, South Bend, IN, USA) and diagnostic casts Impressions were made in stock trays using alginate
obtained with typeIII dental stone (Labstone; Kalabhai (alginoplast; Heraeus Kulzer) and casts obtained with
Karson, Mumbai, India). The patient was diagnosed as type III dental stone (Labstone; Kalabhai Karson).
ClassIV partial edentulism according to the Prosthodontic Maxillary cast was mounted on a Hanau semi-
Diagnostic index.[3] adjustable articulator (Hanau Wide Vue; Water Pik,
Fort Collins, CO, USA) using a face-bow transfer
An interdisciplinary approach was sought based upon (Hanau Spring-bow model # 182-8; Water Pik
the clinical findings, examination of diagnostic casts, and technologies, CO, USA.). With the help of a centric
radiographs. Asequential treatment plan was framed out. relation record at the existing OVD, mandibular cast
A detailed treatment plan was presented to the patient was mounted.

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Varghese, etal.: Adult rampant caries

The patients IOD was determined by taking the the response with the use of provisionals was considered
difference between the PRP and OVD. [4] Ridge satisfactory.
parallelism was also taken as a guide to establish the
OVD. IOD was determined at 9mm. It was decided to The provisionals were removed and a full-mouth oral
restore 4mm of the lost OVD, so as to avoid a long prophylaxis was done. Oral hygiene instructions were
face re-emphasized. Signs of caries attack were not noticed
A diagnostic wax-up was done.[5] The plane of occlusion Gingival tissues were retracted and definitive impressions
was made parallel to the interarch plane and was also made with polyvinylsiloxane (Reprosil; Dentsply, USA).
dictated by tooth # 11. Amutually protected occlusal Interocclusal records were remade and mounted. With
scheme was given, so as to prevent the destruction of the aid of the diagnostic wax-up, fixed prosthesis was
the new prosthesis[6] fabricated. After trial and patients approval, permanent
The diagnostic wax-up was used as a template in the cementation was done with glass ionomer cement (GC
fabrication of provisional restorations Fuji I; GC Corporation, Tokyo, Japan). The patient
Tooth preparation was done for metal ceramic crowns was recalled for the insertion of an occlusal splint
Gingival tissues were retracted and definitive impressions [Figures4 and 5]
made with polyvinylsiloxane (Reprosil; Dentsply, USA). Impressions of the completed restoration were
made with polyvinylsiloxane for the fabrication of a
Interocclusal records were made. Maxillary cast was
heat-activated clear acrylic occlusal splint. It was inserted
mounted using a face-bow transfer and mandibular cast
and instructions were given for maintenance and wear
with centric relation record
at night
Provisional crowns were made from the diagnostic
Oral hygiene instructions were revised and re-emphasized.
wax-up template and provisionally cemented with zinc
Patient was demonstrated and instructed on the use of
phosphate cement zinc phosphate cement; Harvard, floss threaders under the fixed partial denture. Also,
Germany) instructions for a periodic 6-month recall were given.
The provisionals were worn for 8weeks with periodic
recalls to evaluate esthetics, form, function, and patients Discussion
tolerance of a 4-mm increase in vertical dimension
On the occasion of a review 2weeks later, the patient Massler[1] has defined rampant caries as a suddenly
expressed a need for a reduced tooth size and alteration appearing, widespread, rapid burrowing type of caries,
in tooth shape. She also noticed a slight tilt in the cant of resulting in early involvement of the pulp and affecting
the maxillary anteriors. Diagnostic wax-up was modified those teeth usually regarded as immune to ordinary decay.
accordingly, and the provisionals were refabricated A sudden onset and progression of this disease has been
and worn for the rest of the period. The patient was attributed to a definite oral environment imbalance; and in
asymptomatic and expressed satisfaction on subsequent the presence of pro-caries factors, the disease accelerates
reviews. to be uncontrollable. Hence, it has been termed rampant
Phase III treatment sequence
The goal of this treatment phase was to definitively restore In 1966, Winter[7] termed rampant caries as caries of
the dentition with metal ceramic fixed prosthesis after acute onset involving many or all teeth in areas that are
not susceptible and is associated with rapid destruction

Figure 4: Intraoral post-restorative view Figure 5: Post-restorative radiograph

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Varghese, etal.: Adult rampant caries

of the crowns with frequent involvement of the dental The fabrication of provisionals with the aid of a diagnostic
pulp. wax-up always serves as an evaluation phase for the patient,
dentist, and the technician. It helps in determining the
Rampant caries has been predominantly observed in young required amount of tooth preparation, tooth inclination,
teenagers, with a few occurrences in children and adults. occlusal plane, vertical dimension, occlusion, esthetics, and
Prognostic factors have been attributed to emotional muscular harmony.[15]
imbalance leading to an excessive craving for sweets and
snacks (quite common in adolescents), reduced salivary A mutually protected occlusal scheme was given. It has
flow, and a reduced tooth remineralization response. been defined by the Glossary of Prosthodontic Terms[20]
as an occlusal scheme in which the posterior teeth prevent
Three major hypotheses have been proposed as the excessive contact of the anterior teeth in maximum
etiology of dental caries: the specific plaque hypothesis intercuspation and the anterior teeth disengage the
by Loesche, [8] the nonspecific plaque hypothesis by posterior teeth in all mandibular excursions.[19]
Theilade, [9] and the ecological plaque hypothesis by
Marsch.[10] The specific plaque hypothesis emphasizes the Declaration of patient consent
active involvement of Streptococcus mutans and Streptococcus The authors certify that they have obtained all appropriate
sobrinus in dental caries. The nonspecific plaque hypothesis patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
stresses the overall activity of the total plaque microflora
other clinical information to be reported in the journal.
which is inclusive of other bacterial species also. The
The patients understand that their names and initials will
ecological plaque hypothesis suggests that caries is due to
not be published and due efforts will be made to conceal
a microfloral imbalance brought about by a definite oral
their identity, but anonymity cannot be guaranteed.
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 1. Massler JN. Tee-age caries. JDent Child 1945;12;57-64.
composition. 2. Gamer S, Tuch R, Garcia LT. House mental classification revisited:
Intersection of particular patient types and particular dentistsneeds.
JProsthet Dent 2003;89:297-302.
The prognosis of the treatment depends upon the age
3. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR,Koumjian JH,
and co-operation of the patient, extent of decay, and et al. Classification system for partial edentulism. JProsthodont 2002;11:181-
the patients motivation toward dental treatment. Chu 93.
and Zhang[12] suggested minimal intervention dentistry 4. Toolson LB, Smith DE. Clinical measurement and evaluation of vertical
as a new approach for the management of caries in dimension. JProsthet Dent 1982;47:236-41.
5. Yu A, Lee H. Awax guide to measure the amount of occlusal reduction
older patients. It involves early diagnosis and treatment, during tooth preparation in fixed prosthodontics. J Prosthet Dent
improving the oral ecological balance, reducing the caries 2010;103:256-7.
risk, reversing the dental caries, and minimal surgical 6. Standlee JP, Caputo AA, Ralph JP. Stress transfer to the mandible during
intervention procedures. anterior guidance and group function eccentric movements. JProsthet
Dent 1979;41:35-9.
7. Arathy R. Principles and practice of pedodontics. 1st ed. New Delhi:
The first line of treatment was to arrest the progression Jaypee Brothers Medical publishers; 2012. p. 139-41.
of the disease by psychological counseling and motivation 8. Loesche WJ. The specific plaque hypothesis and the antimicrobial
of the patient followed by diet assessment and counseling. treatment of periodontal disease. Dent Update 1992;19:68, 70-2, 74.
Meticulous oral hygiene maintenance was emphasized. 9. Theilade E. The non-specific theory in microbial etiology of inflammatory
periodontal diseases. JClin Periodontol 1986;13:905-11.
Dentition had to be debrided of caries and restored. 10. Marsh PD. Microbial ecology of dental plaque and its significance in
health and disease. Adv Dent Res 1994;8:263-71.
Treatment options included adhesive restorations,[13,14] 11. Aas JA, Griffen AL, Dardis SR, Lee AM, Olsen I, Dewhirst FE, et al.
overdentures,[15] occlusal overlay splint,[16,17] removable Bacteria of dental caries in primary and permanent teeth in children
partial denture.[18] FPD, or crowns and implants.[19] Due and young adults. JClin Microbial 2008;46;1407-17.
12. Chu BF, Zhang Y, Liu HC. Minimal intervention dentistry: Avision of
to the reduced amount of available tooth structure, an caries management for older patients. II. Hua Xi Kou Qiang Yi Xue Za
increased facial height, and patients economic constraints, Zhi 2010;28;9-12.
restoration of the entire dentition with metal ceramic 13. Soares CJ, Pizi EC, Fonseca RB, Martins LR, Neto AJ. Direct restoration
crowns and FPD was chosen. An increase in vertical of worn maxillary anterior teeth with a combination of composite resin
materials: Acase report. JEsthet Restor Dent 2005;17:85-92.
dimension of 4 mm was required to provide adequate 14. Robinson S, Nixon PJ, Gahan MJ, Chan MF. Techniques for restoring
restorative space without further increasing the facial worn anterior teeth with direct composite resin. Dent Update
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15. Goud A, Deshpande S. Prosthodontic rehabilitation of dentinogenesis worn teeth. JProsthet Dent 2004;91:210-4.
imperfecta. Contemp Clin Dent 2011;2:138-41. 19. Bencharit S, Schardt-Sacco D, Border MB, Barbaro CP. Full mouth
16. Koksal T, Dikbas I, Kazaoglu E. Alternative restorative approach for rehabilitation with implant-supported prostheses for severe periodontitis:
treatment of patient with extremely worn dentition. NY State Dent J Acase report. Open Dent J 2010;4:165-71.
2009;75:52-5. 20. The glossary of prosthodontic terms. J Prosthet Dent 2005;94:10-92.
17. Song MY, Park JM, Park EJ. Full mouth rehabilitation of the patient
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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.
18. Ganddini MR, Al-Mardini M, Graser GN, Almog D. Maxillary and
Source of Support: Nil, Conflict of Interest: None declared
mandibular overlay removable partial dentures for the restoration of

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