Management of a High Caries-Risk Patient

Management of a High Caries-Risk Patient

CASE REPORT No. 01 : Managing a Teenager With High Caries Risk & A Severely Broken-Down Molar

Introduction

Adolescents often present with unique dental challenges—dietary freedom, irregular dental attendance, and lifestyle changes can lead to sudden spikes in caries.
This case highlights the management of a 16-year-old student who reported with multiple carious lesions, including one severely destroyed mandibular molar associated with a draining sinus.

This blog outlines diagnosis, investigations, treatment sequencing, preventive strategies, and long-term considerations for stabilizing such a patient.

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Patient Background

• Age: 16 years
• Occupation: College student
• General Health: Fit and healthy
• Chief Concern: “A filling came out on my lower right side and the tooth feels sharp.”

History of Present Complaint

The patient reported that a filling placed over a year ago had dislodged. He previously sought urgent care for toothache triggered by hot and cold foods but never returned for full treatment. After moving residence, he discontinued dental follow-up.

He reports no current pain, except irritation from the sharp tooth edge.

Extraoral Examination

• No swelling
• No palpable lymph nodes
• TMJ function normal
• General appearance healthy (Insert Image Placeholder Here)
  ➡ [Space for Photo]

Intraoral Examination

Findings:

• Oral hygiene: fair
• Gingivitis present in isolated areas
• Lower right first molar (46) severely carious with a draining buccal sinus
• Adjacent second molar (47) showing a small occlusal cavity
• All other teeth appear intact
• Third molars not visible clinically

(Insert Image of 46 clinical presentation)
➡ [Space for Figure: Clinical Photo]

Vitality Testing

• 46: No response to cold/EPT
• All other teeth: Normal vital responses
• Interpretation: 46 is non-vital and likely the source of infection

Radiographic Assessment

Recommended Views:

1. Bitewings
   • Detect hidden proximal/occlusal caries
   • Evaluate extent of lesions in all molars
2. Periapical (Paralleling Technique)
   • Assess the pulp involvement
   • Confirm apical pathology
   • Plan endodontic access or extraction
3. OPG (Optional)
   • General overview
   • Check for third molars

(Insert Bitewing & Periapical Radiographs Here)
➡ [Space for Radiographs]

Radiographic Interpretation

• Extensive caries in 46 invading the pulp chamber
• Complete loss of mesial wall; tooth has tilted mesially
• Periapical radiolucencies on both roots (larger on mesial)
• Loss of lamina dura around furcation
• Bitewings confirm occlusal caries in multiple molars

Diagnoses

Primary Diagnosis

✔ Non-vital mandibular right first molar (46) with a chronic periapical abscess

Secondary Diagnoses

✔ Generalized high caries risk
✔ Early occlusal lesions in multiple molars
✔ Dietary risk factors suspected

Treatment Prioritization

1️⃣ Immediate Phase

• Caries removal from 46
• Establish access for drainage
• Irrigate with NaOCl
• Place a strong temporary restoration
  • Needed to stabilize tooth
  • Prevent further structural loss
  • Allow rubber dam isolation for future RCT

2️⃣ Stabilization Phase

• Remove active caries in all molars
• Restore with temporary materials quadrant-wise
• Prevent progression to pulp exposure

3️⃣ Preventive Phase

• Full diet analysis
• Oral hygiene instruction
• Fluoride measures
• Behaviour modification

4️⃣ Definitive Restorative Phase

• RCT + core build-up on 46
• Hybrid GIC/composite restorations in other molars
• Crown or long-term indirect restoration may be needed on 46

Temporary Restoration Options

Material	Features	Ideal Use
Zinc oxide–eugenol	Easy, bactericidal, weak	Temporary coverage with low occlusal load
Cavit/Coltosol	Self-sealing, good strength	Endo access cavities
Polycarboxylate cement	Adhesive, durable	Poor retention cavities, rubber dam support
Glass Ionomer	Adhesive, fluoride release, durable	Heavily broken-down teeth, base for composite

Why Was This One Molar Destroyed So Quickly?

Possible reasons:

• Previous large restoration undermined cusps
• Marginal leakage due to poor sealing
• Caries not fully removed earlier
• Rapid progression in a diet high in fermentable carbohydrates

Ensuring Complete Caries Removal

• Remove all soft dentine at DEJ
• Hard, stained dentine may be left near pulp if sealed well
• Beware large pulp chambers in teenagers
• If symptoms of pulpitis emerge → consider elective RCT

Preventive Priority: Dietary Analysis

The most important intervention is:

🔸 Accurate 4-Day Diet Analysis

Because restricting sugar frequency is far more effective than OHI or fluoride alone.

Lifestyle considerations:
Teens often consume:

• Sweetened drinks
• Frequent snacks
• High-carb budget foods
• Irregular meals
• Sweet drinks during late-night study sessions

DIETARY CHART (You Will Add Later)

➡ [Insert Dietary Chart Placeholder]

Analysing the Patient’s Diet

When reviewing the 4-day diary:

• Highlight sugary foods
• Count sugar attacks per day
• Note timing (bedtime sugars dangerous)
• Identify hidden sugars (cereals, sauces, biscuits)
• Classify food consistency (sticky, retentive, slow-clearance)

Likely causes for this patient:
✔ Excess sweetened drinks
✔ Frequent snacking
✔ Multiple daily sugar exposures
✔ Poor clearance foods

Dietary Advice (Based on Health-Belief Model)

Key recommendations:

• Reduce sugar frequency rather than total elimination
• Reserve sugary foods for mealtimes only
• Replace snacks with safer options (nuts, cheese, sugar-free gum)
• Switch to sugar-free drinks
• Use fluoride toothpaste + weekly fluoride rinse
• Avoid sugary drinks before bed
• Finish meals with water, gum, or cheese

Definitive Restoration Plan

For 46 (Non-vital Molar):

• Complete RCT
• Place deep core build-up
• Consider cuspal coverage (crown)

Long-term issues:

• Mesial drift & tilting may cause food impaction
• Risk of distal caries on 45
• Crown may improve contour but orthodontic uprighting is the ideal solution

For Other Molars:

• Remove all caries
• Restore using:
  • Radiopaque GIC base
  • Composite overlay
• Preserve maximum tooth structure

(Insert Post-operative Radiograph Placeholder)
➡ [Space for Figure: Post-Op X-ray]

Why Not Extract the Tooth?

Extraction may be valid but not ideal because:

• Teenager has multiple molar lesions—preservation is important
• Replacement options (bridge, implant) are costly
• Space may affect occlusion long-term
• Patient wishes to save the tooth

Conclusion

This case demonstrates how quickly a previously healthy dentition can deteriorate due to dietary habits, lack of follow-up, and hidden occlusal caries. Successful management requires:
✔ Immediate stabilization
✔ Full-mouth caries control
✔ Prevention-driven behaviour change
✔ Well-planned definitive restorations

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