Rampant caries: What it is and what it isn’t

Dear Sir,Although the term “rampant caries” is not well definedand its usage has varied over time, the terminology is stillcommonly used, particularly in public healthcare settings,to inform triaging of individuals and the correspondingpathways and waitlist priority. Hence, here we provide asuccinct but thorough account of this condition.

1 HISTORICAL PERSPECTIVE

The term “rampant caries” was first coined in the early1920s to describe the severe tooth decay that was com-mon in children from poor families. 1 In the 1940s and1950s, there was a significant increase in the prevalence ofearly childhood caries (ECC, often presenting with “ram-pant” pattern) in the United States, and later this trendexpanded worldwide. This was thought to be due to theintroduction of sweetened baby formulas, the increasedpopularity of bottle feeding and the use of sweetenedpacifiers.2,3 In the following decades, the term “rampantcaries” became more widely used to describe the typi-cal pattern of severe tooth decay that was seen in bothchildren and adults. In the 1980s and 1990s, the termwas also employed to describe the tooth decay that wasseen in people with other medical conditions, such as dia-betes or HIV/AIDS and in people from low socioeconomicbackgrounds.4 In the 2000s, rampant caries have beenincreasingly reported in illicit drug users. For example, theterm methamphetamine-induced caries has been adoptedto describe the rampant caries often found in metham-phetamine users, which is also called “meth mouth”.5Rampant caries are also prevalent in adults with specialneeds, including individuals with disabilities, mental ill-ness, homelessness, and incarceration.6,7 It is thereforeimportant to address this unmet dental need from a publichealth perspective.

2 EPIDEMIOLOGY OF RAMPANTCARIES

Due to the lack of unanimous definition of rampant caries,it is extremely difficult to collect accurate epidemiological data, as most studies available in the literature focuson EEC. However, while all rampant caries arising duringchildhood are ECC, only some ECC are in fact rampant.Importantly, when cavities develop in children youngerthan 3 years, the condition is called severe early child-hood caries (S-ECC).8 The term S-ECC has been widelyused in children with “atypical,” “progressive,” ’’acute,“or ”rampant’’ pattern of dental caries, 9,10 suggesting thatcaries may be referred to as “rampant” when progressionis particularly aggressive.A study in Saudi Arabia reported that rampant carieswere diagnosed in 34% of children,11 whereas the preva-lence of ECC was 73%. In this study, rampant caries weredefined as caries affecting smooth surfaces of two or moremaxillary incisors, in agreement with previously publishedresearch.12 Earlier studies from other geographical areasreported similar rates of rampant caries in children.13,14A large cross-sectional study in South Africa revealedthat the prevalence of rampant caries in preschool chil-dren varied dramatically according to the definition used.15Specifically, based on the presence of caries on (a) the labialsurface of at least one incisor tooth, or (b) at least two max-illary incisors, and secondly, (c) a dmft value of 5 or more,or (d) 10 or more, the prevalence of “rampant caries” was11.4%, 8.6%, 28.9%, and 5.4%, respectively.14 Thus, it is clearthat the prevalence of rampant caries change based on thedifferent diagnostic criteria used.For rampant caries in adolescents and adults, the epi-demiological data are even more scant 16,17 and rely mostlyon small case series. In general, its prevalence is consideredto be relatively low, 4 yet it affects individuals with specialneeds at a higher rate. 17

3 DIAGNOSIS OF RAMPANT CARIES

There are a number of risk factors to consider when mak-ing a diagnosis of rampant caries.18–21 With few exceptions,these risk factors disproportionately impact individualswith special oral health care needs and include low socio-economic status, poor oral hygiene, diet, certain medicalconditions, certain medications (such as antidepressantsand antipsychotics), and genetic predisposition.

The key diagnostic elements focus on the followingcriteria: (1) the number and type of teeth affected; (2)the surfaces of the teeth that are involved; (3) the sever-ity of the decay; (4) the rate at which the decay isprogressing; (5) the patient’s age and/or overall healthstatus.Rampant dental caries in adults characteristically man-ifest on the outer and inner surfaces of premolars andmolars, as well as the adjacent surfaces of mandibularincisors. Adults with rampant dental caries often exhibitmultiple carious lesions located at the cervical area of theirteeth. The pattern of rampant caries in “meth mouth” isdistinctive in that, initially, it tends to start near the gumsand involves the buccal smooth surface of the posteriorteeth and the interproximal space of the anterior teeth, pro-gressing to complete destruction of the coronal portion ofthe tooth.22 Additionally, extensive cavities can be foundon the biting surfaces and the sides of the teeth. Notably,in older individuals with gum recession, root caries are aprevalent issue.

4 TREATMENT OF RAMPANT CARIES

Treatment typically involves a combination of restora-tive dentistry and preventive care. Restorative dentistryprocedures may include fillings, crowns, and root canaltreatments. Preventive care measures may include educa-tion on oral hygiene, diet, and the risks of rampant caries.23In some cases, patients with rampant caries may also needto be treated for underlying medical conditions, such asdiabetes or HIV/AIDS, or drug addiction.22,24–25A valuable approach to rampant caries encompasses themanagement of patients with high caries risk and/or highcaries activity, also referred to as Rampant Caries ControlProgram or RCCP, 26 and involves three phases: an emergency phase, a corrective phase if/when necessary, andmaintenance phases (Table 1).

5 MODERN USE OF THE TERM“RAMPANT CARIES” AND PROPOSEDDEFINITION

The consensus report from a workshop organized byORCA and the Cariology Research Group of the IADR,published in 2020, did not reach the agreed-upon consen-sus threshold of 80% for the definition of rampant caries,as it was considered an “historic term”.27 However, in theauthors’ opinion, it would be useful to retain this term froma public health and equity of care standpoint.From an operative perspective, our definition of “ram-pant” caries based on a single dental inspection includesdental caries affecting:1. two or more maxillary incisors in children and adoles-cents2. five or more teeth (or 15% of teeth in partially edentu-lous patients) including at least two teeth with carieson smooth surfaces, in adults from at risk groups

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interests.

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasetswere generated or analysed during the current study.

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