How to Accurately Reassess Your CAMBRA Patient
It is important to note that the 3-, 6-, and 12-month appointments are very critical tipping points for patients looking to improve their level of health and reduce their risk. The practitioner must work with the patient to determine realistic expectations based on the choices the patient makes and how that corresponds with the patient’s disease condition and long-term goals. Historically, many patients and practitioners have the impression that treatment of medical conditions is one of quick fixes with a simple pill, and the expectation of immediate results. But the oral imbalance/infection that causes dental decay is one that often begins in the patient’s first months of life and may take long periods of time to manifest and consequently can take significant time and effort to reverse. Many patients and practitioners have expectations that prescription/professional oral care products can work similarly to antibiotics given to a patient with a minor infection such as an ear infection, and if the patient is compliant with the prescription, the problem will clear up in 10–14 days. This is not the case with dental caries, a complex, multifactorial biofilm and pH specific disease.
The reality of therapy expectations for dental disease should be closer in comparison to weight loss. While it can take only a few months to put on an unhealthy amount of weight, the work and time required to lose the weight may be longer and require more time and effort. Similarly, the longer a patient has had a weight problem, the longer it may take them to reach their goals and relapse is common. Many patients and practitioners choose to wait until there are serious signs/symptoms of the problem, such as cavities, prior to making changes to behavioral risk factors or prescribing targeted oral care therapy products. The sooner patients can be identified with risk factors or a biofilm challenge prior to cavities developing, the less time and effort it will take to get the patient back into balance.
For patients looking to begin a weight loss program, there are generally three ways they can choose to move forward. They can begin an exercise program while making no dietary changes. They can make dietary changes while making no changes to their activity level. Or they can increase their level of exercise and make dietary changes. Each and every patient is different, and how they choose to attack the issue will be based on their individual issues and goals. But patients that make consistent changes over time on both sides of the equation will experience the most success.
Patients with high caries risk have the same variety of options when the goal is achieving a healthy oral balance. On one side of the equation, they can choose to make behavioral changes and reduce their risk factors while continuing their current oral care product and hygiene regimen. Another option is to make no changes to their behavioral risk factors and make changes to their hygiene regimen with prescription/professional oral care products. Ideally, patients at risk would choose to alter their oral care product and hygiene regimen as well as the modifiable behavioral risk factors associated with the disease. But behavioral studies have shown that the most successful patients choose to make one lifestyle change at a time; and it is recommended that at each stage of the 3-, 6-, and 12-month appointments, patients and practitioners choose only one area at a time to modify. During the process, based on each reassessment, they can additionally decide if more changes are necessary based on the progress made. When there are several different behaviors that should be changed, it is advisable to offer the options to the patient and let them pick the behavior they want to focus on.
Finally, patients and practitioners must be looking not only for obvious signs of progress but also for a reduction in the progression of the disease. Just as a patient who is beginning a weight loss program and has a history of gaining additional weight every month and with diet modification may at first see only a slowing of the additional weight gain, a dental patient who has had a history of high biofilm challenge may only experience a slight decrease in the elevation path of the biofilm challenge at first, or only experience a reduction in the number of new cavities they develop. Instead of developing 2 or 3 new cavities every year, they may only develop 1 new cavity. Although these patients are continuing to see progression of the disease, they are making progress and should be encouraged to continue making changes to reach their goals.
Eighteen to thirty-six months. 90+% of compliant patients see substantial progress if they continue with therapy for 36 months. Examples of progress would be reduced progression of biofilm challenge, lower decay rate or eliminated incidence of decay, lower biofilm challenge, improved soft tissue health on inspection, decrease in bleeding gums when flossing or probing, improved enamel luster, reduced plaque buildup, etc.
Again, the practitioner’s goal at the 18- to 36-month reassessments should be to identify progress of any kind, verify compliance, and if the practitioner or patient is not satisfied with the progress, increase the patient’s level of therapy. If the patient assessed is at a lower level of risk, suggest the recommended level of therapy for that new risk level and caution the patient that relapse is a possible outcome until multiple healthy appointments have been established. Therapy recommendations should be made for the next 6 months. Keep in mind during these reassessment appointments the factors influencing treatment time and results such as the amount of time the patient has had the issue; the number, frequency, and severity of risk factors; the presence and severity of symptoms; the restorative treatment plan; and the level of compliance.
Patients who, by the 36-month appointment, are still experiencing dental decay are those that were noncompliant with therapy, noncompliant with behavioral risk factor changes, patients who have gaps in their treatment regimen, or patients with a long history of severe decay or have severe and unmodifiable risk factors. Many of these patients can and will reach a level of balance with their oral health, but for some, that level of balance may be one with a reduced but still occurring level of decay or a plateaued but elevated biofilm challenge.