CAMBRA: The New Model for Managing Caries

CAMBRA: The New Model for Managing CariesThe dental caries experience and the management of dental caries incidences are the focus of Caries Management by Risk Assessment or CAMBRA.

The CAMBRA approach was proposed by a group of experts based on scientific literature as a means of caries risk assessment through disease indicators, risk factors and protective factors to determine the associated clinical protocols or interventions.1,2 Because the primary purpose of CAMBRA is to assess the patient’s risk for caries and to determine appropriate preventive and therapeutic approaches, the dental hygienist can be the key dental team member responsible for the creation, implementation and evaluation of CAMBRA.

CAMBRA Assessment Tool
The caries assessment tool was developed in formats for use by dental providers for patients age 0 to 5 and patients age 6 through adult. The assessment tool is a part of an overall approach to prevent and treat the caries infection and is composed of the following sections:1

  • Caries disease indicators– low SES (socioeconomic status); development problems; and presence of cavities, white spots, and restorations placed in the previous 3 years
  • Caries risk factors – type and quantity of Mutans streptococci (MS) and lactobacilli(LB); visible plaque; exposed roots; saliva reducing factors and inadequate saliva flow; frequent snacks; deep pits and fissures; and orthodontic appliances
  • Caries protective factors– systemic and topical fluoride sources; adequate saliva flow; and regular use of chlorhexidine, xylitol, and calcium and phosphate paste
  • Clinical examination – presence of white spots, decalcification, restorations, and plaque; and bacterial culture and saliva flow tests

From the Caries Risk Assessment Tool to Continuing Care
After the caries risk assessment tool has been used to determine the patients risk level, the next step is to develop a preventive and therapeutic treatment plan. The following is a summary of the CAMBRA clinical guidelines.

  1. Caregiver/parent or patient answers the questions on the risk assessment form
  2. Determine the overall caries risk as low, moderate, high or extreme
    • Low risk – no dental lesions, no visible plaque, optimal fluoride, regular dental care
    • Moderate risk – dental lesion in previous 12 months, visible plaque, suboptimal fluoride, irregular dental care
    • High risk – one or more cavitated lesions, visible plaque, suboptimal fluoride, no dental care, high bacterial challenge, impaired saliva, medications, frequent snacking
    • Extreme risk – high risk patient with special needs or severe hyposalivation
  3. Perform bacteria and saliva testing as indicated by risk level
  4. Determine the plan for caries intervention and prevention
    • Patients age 0 to 5 – consider the following for the caregiver and patient based on risk level: saliva and bacterial testing; antibacterials; fluoride consumption, use, and professional application of fluoride varnish; frequency of radiographs; frequency of periodic examinations; oral hygiene instructions; xylitol and/or baking soda; sealants; and existing lesions.3
    • Patients age 6 through adult – consider the following based on patient risk level: frequency of radiographs; frequency of caries recall examinations; oral hygiene instructions; saliva and bacterial testing; antibacterials such as chlorhexidine and xylitol; fluoride use and professional application of fluoride varnish; pH control; calcium and phosphate; and sealants.4
  5. Discuss home care recommendations based on risk level
  6. Provide follow-up care and reassess risk level

The Dental Team Approach
CAMBRA protocols are more likely to result in successful patient outcomes when the entire dental team including the office staff, dental assistants, dental hygienists and dentists are involved and supportive.5 Each team member is therefore required to have foundational knowledge and communication skills which take the evidence-basis for CAMBRA to patients of all demographics. Additionally, team members need to be familiar with the variety of preventive and therapeutic products available today. The following TEAM steps were developed to create a systematic approach to CAMBRA for the dental team:

Step 1 – Topics to discuss include

  • The “caries balance” which focuses on the need to assess, manage, and treat the disease indicators, risk factors, and protective factors.1,6-7
  • Bacterial transmission – vertical transmission from mother or caregiver to child and horizontal transmission from person to person.8
  • Medicine issues specifically related to pH and sugar levels in oral suspensions and lozenges.
  • Snack and beverage issues related to frequency and levels of pH and sugar.

Step 2 – Essential CAMBRA supplies include

  • CAMBRA form to determine patient risk level
  • Products to treat the caries infection
    • Fluorides – OTC and prescription toothpastes, 0.2% and 0.05% sodium fluoride rinse, CariFree maintenance rinse, 5% sodium fluoride varnish
    • Sealants – resin-based or glass ionomer
    • Saliva tests – Caries Risk Test (CRT) bacteria, CRT buffer
    • Bacteria tests – Caries Risk Test (CRT) bacteria, CariScreen Caries Susceptibility Test
    • Xylitol – Epic, Spry, Omni Theragum, Ice Breakers Cubes
    • Buffering products – sodium bicarbonate toothpastes and gum, CariFree boost breath spray, DenClude, ProClude
    • Chlorhexidine gluconate – Peridex, Periogard
    • Iodine – Betadine
    • ACP – Prospec MI Paste and MI Paste Plus, NovaMin
    • Detection technology – DIAGNOdent, DiaLUX Probe, Caries ID, LOGICON Caries Detector Software
    • Palliative products for xerostomia – Salivart, Optimoist, Biotene
    • Probiotics

Step 3 – patient at a time includes

  • Role play CAMBRA conversations with coworkers
  • Work to implement CAMBRA one patient at a time
  • Be clear on which steps of CAMBRA each team member can legally provide

Step 4 – Monetary reimbursement includes

  • Organizing for success
  • Educate the entire dental team about CAMBRA
  • Choose a coordinator for implementation
  • Organize forms, codes, procedures, and billing

Standard of care is defined as what a reasonably prudent dental provider should be doing under the same or similar circumstances. Over a dozen dental negligence cases have gone through litigation where the dentists did not practice caries risk assessment and management.Today, risk assessment and disease management are considered standard of care, and therefore an ethical and legal requirement for today’s dental providers. The CAMBRA approach is a scientifically proven, evidence-based approach to the assessment, prevention, and treatment of dental caries that is patient specific.

References

  1. Featherstone, J.D.B., Domejean-Orliaguet, S., Jenson, L., Wolff, M., & Young, D.A. (2007). Caries risk assessment in practice for age 6 through adult. Journal of the California Dental Association,35(10), 703-713.
  2. Featherstone, J.D., Adair, S.M., Anderson, M.H., Berkowitz, R.J., Bird, W.F., Crall, J.J., Den Besten, P.K., Donly, K.J., Glassman, P., Milgrom, P., Roth, J.R., Snow, R., & Stewart, R.E. (2003). Caries management by risk assessment: consensus statement, April 2002. Journal of the California Dental Association,31(3), 257-269.
  3. Ramos-Gomez, F.J., Crall, J., Gansky, S.A., Slayton, R.L., & Featherstone, J.D. (2007). Caries risk assessment appropriate for the age 1 visit (infants and toddlers). Journal of the California Dental Association,35(10), 687-702.
  4. Jenson, L., Budenz, A.W., Featherstone, J.D.B., Ramos-Gomez, F.J., Spolsky, V.W., & Young, D.A. (2007). Clinical protocol for caries management by risk assessment. Journal of the California Dental Association,35(11), 714-723.
  5. Gutkowski, S., Gerger, D., Creasey, J., Nelson, A., & Young, D.A. (2007). The role of dental hygienists, assistants, and office staff in CAMBRA. Journal of the California Dental Association,35(11), 786-789, 792-793.
  6. Featherstone, J.D. (2006). Caries prevention and reversal based on the caries balance. Pediatric Dentistry,28(2), 128-132.
  7. Featherstone, J.D.B. (2006). Delivery challenges for fluoride, chlorhexidine, and xylitol. BMC Oral Health,6(Supp 1), S8.
  8. American Academy of Pediatrics Policy Statement. (2003, May). Oral health risk assessment timing and establishment of the dental home. Pediatrics,111(5), 1113-1116.
  9. Spaeth, D. (2003, July). Surprise, a new standard of care. Dental Practice Report. Retrieved November 2, 2008.

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