CASE CHALLENGE – RAMPANT CARIES

Newsletter No. 6

Caries

COLGATE CARIES CONTROL PROGRAMA joint program by Colgate Oral Care and Adelaide University

Medical history■ No major relevant medical problems.

■ Currently not taking any medications.

■ Patient is a smoker.

Oral Examination■ Caries was present on some anterior and

posterior teeth (Figure 1).

■ There were no symptoms of pulpitis, but strongreaction to cold (dentinal pain).

■ Teeth were all stained and covered in debris andplaque.

■ Gums were red and swollen, but no pocketing orloss of attachment was found therefore,generalised gingivitis was diagnosed.

■ Salivary flow was normal (stimulated flowrate=1.4mL/min - just outside normal range;resting pH=6.5; stimulated pH=7.9 - normal).

Social HistoryThe patient, currently employed as a factory worker,left home at age 17 and since then has beenmoving frequently, in and out of work, sharingaccommodation with other young people in similarcircumstances. He didn't look after himself andlived on soft drinks and junk foods for the pastcouple of years. He said he wanted to 'get himselftogether' and was very keen for his front teeth to besaved, but he said he could not stand injections.

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

U

U U

U

Figure 1Patient’s caries chart

KeyDecayed surface AmAg U Missing/Unerupted

Rig

ht

Left

■ PATIENT’S DETAILS:

A 19-year old male who hadnot visited a dentist sinceprimary school. The patientpresented with grosslycarious maxillary anteriorsand complained that teethwere very sensitive totemperature, touch andacidic foods and beverages.The sensitivity was sosevere that the patient wasunable to brush his teeth forthe last few months.

Dental HistoryFour restorations were placed when at primaryschool and patient had experienced considerablepain during the procedure. The local anaesthesiagiven before the procedure had not worked and wasvery painful. He had avoided dental visits since andhad developed an extreme fear of injections anddrilling.

DietCurrently a very unhealthy and unbalanced diet. Hedrinks over three litres of sugared soft drink that hesips throughout the day. His meals are irregular andusually based on junk food. The amount andfrequency of sugared drinks were identified as themajor dietary cariogenic factor in this case.

Fluoride ExposureFluoride exposure was not investigated but patientadmitted to not brushing for a few months.

Risk AssessmentBased on oral examination that revealed many teethwith active decay, presence of dietary risk factors aswell as insufficient fluoride exposure, patient wasclassified as a high caries risk patient.

Management plan1. Relief of pain.

2. Discuss dietary problem with patient.

3. Cover decayed buccal surfaces with fluoridecontaining temporary restorations usingatraumatic technique.

4. Topical fluoride treatment and weekly self-application of 0.2% NaF mouthrinses.

5. Recommend six monthly reviews until thecariogenic factors are reduced andremineralization balance restored.

Outcome of preventivecounselling

The patient did not seem motivated enough tocontrol the cariogenic dietary factors, despite thelong-term dental consequences being explained. Allhe seemed to be interested in was to have the frontteeth fixed.

The patient understood the role his diet played inhis teeth problems and agreed to try to replace thesoft drinks with artificially sweetened drinks and toreduce the frequency of drinking them. As animmediate measure, the patient was urged toconcentrate on toothbrushing and was advised touse a high fluoride concentration toothpaste(5000ppm) after every meal.

Grossly decayed buccal surfaces of many teeth showing various stages of caries activity.

Figure 2

Some of thefluoride productsavailable

Your preferred fluoride product for this case management and why?

Why would you use it

Why wouldn’t you use it

Professional fluoride applications

Low-fluorideconcentration rinses

Higher-fluorideconcentration rinses

Fluoride gels/foams

High-fluorideconcentration toothpaste

Fluoride tablets

Further informationcan be obtained from the

Dental Practice Education Research UnitDental School

Adelaide University, South Australia 5005

Phone (08) 8303 5438 • Toll free 1800 805 738 • Fax (08) 8303 4858Email dperu@adelaide.edu.au • Website//www.adelaide.edu.au/socprev-dent/dperu

He was also told to use the 'brush no rinse'technique to ensure the prolonged topical effect offluoridated toothpaste.

Because of concern about the patient's motivationno other additional fluoride vehicles were employed.The approach to firstly place temporary (glassionomer) fillings to protect pulp, stabilise, and toreverse some of the damages was explained to thepatient. After some hesitation regarding additionalcost, the patient recognised the long-term benefit ofsuch an approach and consented to the treatment plan.

Over a number of visits all initial temporaryconservative treatment was completed. During eachof those visits brushing and dietary issues werediscussed and motivation built up. It was alsorevealed that he was interested in the appearance ofhis front teeth for social reasons, but he alsorealised that the preventive methods he wasadopting were helping all of his teeth and not justthe front ones. As the treatment progressed, he becamefree of pain in his front teeth and his appearanceimproved. He has changed his mind and requested thathis back teeth receive the same treatment.

Six month monitoringvisit

The patient had successfully changed to mostlydrinking artificially sweetened soft drinks andreduced their frequency and amount. The patientreported that he follows the recommended brushingregime, but he finds it difficult to brush during theday (while at work) therefore he stopped doing thissome time ago. All the recently placed temporaryrestorations remained intact and there were no signsof new lesions. There was also no sensitivity to coldor brushing reported. The patient has also askedwhether he could have his front teeth fixed withdifferent material to further improve theirappearance. As caries risk factors appeared to bereduced and balance tipped away from decay andtowards health all six upper front teeth were filledwith a LCR to match the colour of patient's teeth.Patient was happy and agreed to a further six-monthreview. He was also advised that although at thatstage, all other temporary restorations were sound,the material was not very strong and the restorationsshould be replaced within the next six months.

Twelve month monitoringvisit

Oral examination revealed that oral hygiene was stillgood, otherwise little change had occurred with onlysome of the temporary restorations showing signs ofwear. It was decided that patient can stop using thehigh fluoride toothpaste and go back to using aregular (1000ppm) toothpaste. Due to financialconstrains (patient at that stage had becomeunemployed) only some of the posterior temporaryrestorations were replaced and patient was advisedof the availability of government dental services.Also for the same financial reason the patient wasnot keen on further review appointments. He saidthat when he was in a better financial position hewould return for a check-up.

■ Understanding a patient's

motivation for seeking

dental care, incorporating

that knowledge into a

strategy for a desirable

behavioural change, and

providing adequate and easy

to understand dental

messages will help a patient

to achieve a better oral

health outcomes.