10 Tips For CAMBRA Beginners

by Dr. V Kim Kutsch

Every day I go into my office and try to do something to show that I treat people better; better than the guy down the road and better than I treated people yesterday or last year. As doctors we have the power and privilege to help patients realize new things about their oral health and help them achieve things they never thought possible. In all my years of trying daily to treat people better, I believe that CAMBRA, or caries management by risk assessment, is one of the best ways we can fulfill that promise each and every day. If you have dabbled in CAMBRA but don’t yet have a standard protocol, or if you have not ever tried implementing the philosophy, but want to, this post is for you.

The Basics

Dental caries is a bacterial biofilm mediated disease with known disease indicators and risk factors. It is a disease that results from prolonged episodes of low pH in dental biofilm that selects for cariogenic pathogens and favors demineralization. The end result is net mineral loss and cavitation of the teeth. Originally considered a disease of the two primary pathogens Mutans streptococci and Lactobacillus, recent biofilm science has expanded this disease model to include numerous pathogens in a biofilm community. To effectively treat dental caries, the teeth must be restored to function and the dental biofilm behavior needs to be corrected to health.

Ten Things to Know About CAMBRA

1. 1. CAMBRA is a standard of care that has 3 defining characteristics: early risk assessment, diagnosis of the caries disease process, and then treatment with minimally invasive procedures.
2. CAMBRA should be a regular system within your practice to identify and treat patients at risk for dental caries.
3. CAMBRA programs that work well involve a team educated on caries risk assessment. The team should help develop the system, from appointment scheduling to procedure fees.
4. The most successful CAMBRA system is simple for the team to implement. If it is not simple, it won’t work. CAMBRA starts with risk assessment followed by diagnosis and then development of treatment strategies.
5. It is best to start with a standardized caries risk assessment form for all patients in the practice. Several standardized caries risk assessments (CRA) forms are available. The California Dental Association Journal’s form has been clinically validated by Dr. John Featherstone at UCSF¹. Use a simple form that provides the information you need to make an accurate assessment.
6. While it is easy to identify the patient with obvious caries lesions, the real intent of the caries risk assessment is not to identify these patients, but rather discover why they have cavities. What risk factors are contributing to their disease state, and what factors can be modified?
7. Once the risk factors have been identified, then practitioners can hone in their counseling to the behaviors that can be changed while also providing therapeutic strategies (products) to overcome the risk factors that cannot be modified. Think about it like creating a balance between risk factors and protective factors that re-establishes a healthy biofilm and a healthy mouth.
8. Use a biometric to screen for at risk patients, measure progress and provide a surrogate endpoint to therapy. Adenosine Triphosphate or ATP bioluminescence is a rapid, simple, accurate chair side biometric test that involves a swab and a meter.
9. Direct your treatment strategies at the biofilm dysfunction. By correcting the biofilm, you re-establish a healthy balance of the remineralization and demineralization resulting in healthy maintenance of tooth mineral.
10.  The best immediate anti-caries therapy is the use of fluoride varnish². At risk patients should receive an immediate fluoride varnish and then on a regular basis every 3 months until they are healthy. Fluoride varnish provides the best fluoride substantivity and requires the least patient participation^3,4.

References
1. Domejean-Orliaquet S, Gansky SA, Featherstone JD. Caries risk assessment in an educational environment. J Dent Educ December 2006. 70(12):1346-54
2. Azarpazhooh A, Main PA. Fluoride varnish in the prevention of dental caries in children and adolescents: a systematic review. J Can Dent Assoc. February 2008. 74(1):73-9.
3. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Dent Educ. March 2007. 71(3):393-402.
4. Quock RL, Warren-Morris DP. Fluoride varnish: the top choice for professionally applied fluoride. Tex Dent J August 2010. 127(8):749-59.