Rampant Caries

Rampant caries is sudden, rapidly progressing decay that involves many teeth at once, including surfaces that are usually resistant such as the lower incisors, and that reaches the pulp in a short time.

It is seen in children and adolescents with heavy sugar exposure, and in adults after loss of saliva or with a change in drugs, diet or habits. It is distinct from slow chronic decay and from early childhood caries of the first years, and it needs a search for an underlying cause.

Pathophysiology. A sustained fall in plaque pH from frequent sugars, together with little or no salivary buffering and clearance, leads to continuous demineralisation that outpaces remineralisation.

Common causes are hyposalivation (head and neck radiotherapy, Sjögren syndrome, drugs with anticholinergic action, uncontrolled diabetes), frequent sugar containing medicines and drinks, stimulant misuse and chronic vomiting or reflux with acid exposure. Radiation caries begins at the cervical margin and encircles the tooth.

Multiple new cavities within months, with cervical, incisal and smooth surface involvement, brown or black discoloured crowns, tooth sensitivity, pain, broken crowns and abscesses. Dry mouth, a sticky mouth, burning, difficulty swallowing dry food and sore lips point to hyposalivation.

Take a full medication list (including sugary syrups), sugar and drink frequency, vomiting, substance use, and past radiotherapy. Teeth may fracture at the cervical margin after radiotherapy.

Facial swelling, trismus, fever, dysphagia and airway symptoms need urgent assessment for spreading infection.

• Full charting of caries and bitewing radiographs, with periapical or panoramic views for pulp and periapical involvement.
• Salivary flow: unstimulated flow under 0.1 mL/min and stimulated flow under 0.7 mL/min mark hyposalivation.
• Tests for the cause: HbA1c, full blood count and ferritin, thyroid function, coeliac serology, anti-Ro and anti-La antibodies and rheumatoid factor if Sjögren syndrome is possible, and screening for eating disorder, reflux and substance use.
• Diet diary over 3 days and drug review.
• Plaque and Streptococcus mutans and lactobacillus tests are optional and add little.

Differential diagnosis.

• Early childhood caries
• Dental erosion from acid exposure
• Amelogenesis imperfecta and dentinogenesis imperfecta
• Molar incisor hypomineralisation
• Radiation related tooth fracture without caries
• Attrition and abfraction lesions
• Staining and developmental defects

• Remove or reduce the cause: change sugary medicines to sugar free forms with the prescriber, reduce the frequency of sugars to meal times, treat reflux and vomiting, and support substance misuse treatment.
• High fluoride toothpaste 5000 ppm brushed twice daily in people aged 16 years and over, spitting and not rinsing, with a 0.05% fluoride mouthwash at a different time of the day. In younger children use toothpaste with 1450 ppm fluoride.
• Fluoride varnish 5% sodium fluoride (22 600 ppm) every 3 months to all teeth, with silver diamine fluoride 38% to arrest cavitated lesions, accepting black staining.
• Fluoride gel 1.1% sodium fluoride applied in a custom tray for 5 minutes daily in radiotherapy patients, lifelong.
• Hyposalivation: sugar free gum or lozenges, saliva substitutes, frequent water sips, review of drugs, and pilocarpine 5 mg orally three times daily with meals (maximum 30 mg daily; 5 mg twice daily in hepatic impairment) in residual gland function. Avoid in uncontrolled asthma, narrow angle glaucoma and severe cardiovascular disease, and with beta blockers.
• Restore with glass ionomer or resin modified glass ionomer, which release fluoride, and use root canal treatment or extraction for pulp involvement. In young patients, stainless steel crowns are durable.
• Antibiotics only for spreading infection: amoxicillin 500 mg orally three times daily for 5 days (reduce to 500 mg every 12 hours at eGFR 10 to 30), or clarithromycin 500 mg twice daily if penicillin allergic.
• Avoid extractions in irradiated bone without specialist planning because of osteoradionecrosis.

Special groups. Adolescents with eating disorders need rinsing with a neutral fluoride rinse (and not brushing) after vomiting, and joint care with the mental health team. Children need weight based dosing and fluoride safety checks.

Monitoring. Review every 3 months until lesions arrest, then every 3 to 6 months. Recheck salivary flow, diet and plaque control.

Referral and escalation. Refer to restorative or paediatric dentistry for extensive disease, and to oral medicine, rheumatology or endocrinology to treat the underlying cause. Emergency referral for facial swelling, airway risk or sepsis.