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The caries management by risk assessment (CAMBRA) philosophy is built on the understanding that
dental caries is a disease initiated by a complex
biofilm (rather than any one pathogen), which
changes dynamically with its environment and the
local chemistry of the tooth site, pellicle, and saliva.
This is in stark contrast to the classic medical
model of one pathogen-one disease, thus, rather
than focusing on the elimination of any one pathogen, caries management must determine which of
many factors is causing the expression of disease
and takes corrective action. For purposes of this
paper, the phrase caries management by risk
assessment or CAMBRA will be used to describe
this risk-based approach to prevent, reverse and,
when necessary, repair damage to teeth using minimally invasive methodologies (1). CAMBRA is not
a trade name for products or a company, nor is it a
caries risk assessment (CRA) form, it is a concept
for managing dental caries and its manifestations.
In its simplest form, it means (i) assessing the risk
for future caries lesions, (ii) reducing the pathological factors, (iii) enhancing the protective factors,
doi: 10.1111/cdoe.12031
and (iv) minimally invasive restorative care resulting in control of the disease.
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Not indicated
(optional for
primary prevention
of at risk deep pits
and fissures)
Sealants are
recommended per
ICDAS code (see
Table 3) for
secondary
prevention
Low risk
OTC fluoride
toothpaste used
bid
OTC fluoride
toothpaste used
bid. 0.05% NaF
rinse bid.
Varnish applied
every 46
months
5000 ppm
toothpaste used
od or bid. 0.05%
NaF rinse bid.
Varnish applied
every 34
months
Not indicated
Xylitol therapy 23
times/day for a total
daily dose of 610 g
If patient has high
levels of acidogenic
bacteria then treating
with the following
agents it must be
understood that the
evidence is very limited
for antibacterials and
pH neutralization, such
as chlorhexidine,
sodium hypochlorite,
povidine iodine,
essential oils, per
manufacturer s
instructions. Retest
bacterial load test in
1 month, discuss and
motivate patient, and
repeat as needed
Saliva testing is
optional or may be
done for purposes
of baseline records
Measure resting and
stimulated flow and
pH especially if
hyposalivation is
suspected
Objective
measurement of
acidogenic bacterial
load via culturing
or direct
measurement of
plaque ATP
Consider supplementing
if topical fluoride alone
is not effective
Required if xerostomia is
three present
Recession or sensitive
roots may indicate
need for
supplementation
Fluoride (topical)
Antibacterials
Saliva
Encourage healthy
dietary habits, low
frequency of
fermentable
carbohydrates,
adequate protein
intake and effective
oral hygiene
practices using
motivational
interviewing
techniques.
Substitute xylitol
for sucrose
Effective lifestyle
habits
Every 46
months
Every 34
months
Every 1824
months
Every 618
months
Every 3 months
Every 6 months
Every 2436
months
Every
6 months
until no new
caries
lesions
Recare
Radiographs
Patients with one (or more) cavitated lesion(s) are high risk patients. Patients with one (or more) cavitated lesion(s) and hyposalivation are extreme risk patients. All restorative work to be done with the minimally invasive philosophy in mind. Existing smooth surface lesions that do not significantly penetrate the DEJ and are not cavitated
should be treated chemically not surgically. For extreme risk patients with multiple cavitations, some choose to use caries control procedures with glass ionomer materials
until caries progression is halted and/or reversed followed my more permanent restorative care. Patients with appliances (RPDs, Orthodontics) require excellent oral
hygiene together with intensive fluoride therapy (e.g. high fluoride toothpaste and fluoride varnish every 3 months). If antibacterial therapy is tried, it should be done in
conjunction with fluoride therapy (and every attempt be made not to interfere with the fluoride intervention). A 1 month initial treatment evaluation may be helpful for
positive reinforcement. Patients must maintain good oral hygiene (a powered toothbrush may be helpful to high and extreme risk patients). A diet low in frequency of fermentable carbohydrates is recommended. It is important to know the amount of xylitol in the product being recommended. Xylitol products should contain 100% xylitol
(daily dosages of 610 g/day for antimicrobial effects) and pose extreme health risks to family pets, especially dogs.
Extreme risk
High risk
Moderate risk
Sealants
All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined
to enemel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of
the preparation in dentin and the preparation extends to a second surface (note: the second surface does not have to be
in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel
is immature, or where fissure preparation is not desired, or where rubber damn isolation is not practical. Patients should
be given a choice in sealant placement and material selection.
b
Patients with one (or more) cavitated lesion(s) are high risk patients.
c
Patients with one (or more) cavitated lesion(s) and xerostomia are extreme risk patients.
Adapted from Jenson et al. (11).
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EXTENT
Initial caries management stage
(non-surgical approach)
OCCLUSAL SITE
ICDAS code 0
ICDAS code 1
ICDAS code 2
ICDAS code 3
ICDAS code 4
ICDAS code 5
Severe caries
management
stage
(conventional
restorative
approach)
ICDAS code 6
Radiographic E0
****
Management
Minimally invasive
restoration probable
(but not absolute) based
on lesion progression,
regression, or tooth
separaon.
Non-cavitated lesions
Inacve
Acve
FACIAL/LINGUAL
SITE
(shiny, smooth)
Radiographic E1
Radiographic D1
(outer 1/3 dentin)
Radiographic D2
(middle 1/3 dentin)
(matt, rough)
Non-cavitated lesions
Management
Acve white or brown spot lesions
receive chemical therapies based on
caries risk assessment (CRA).
Minimally invasive
restoraon
Lesion activity assessment (adapted from Kim Ekstrand) (Parameters in red indicate activity; in black, no activity) Initial caries risk status: high, moderate, or low; Visual appearance: cavitation/shadow, whitish, or brownish; Location of
the lesion: plaque stagnation area, natural, or not; Tactile feeling: rough enamel/soft dentin, or smooth enamel/hard
dentin; Gingival status (if the lesion is located near the gingiva): inflammation, bleeding on probing, or no inflammation,
no bleeding on probing; surface luster: matt, shiny; Plaque: sticky, not sticky; Age of the lesion: <3 years, >3 years.
a
All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined
to enamel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of
the preparation in dentin and the preparation extends to a second surface (Note: the second surface does not have to be
in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel
is immature, or where fissure preparation is not desired, or where rubber dam isolation is not practical. Patients should
be given a choice in sealant placement and material selection.
b
Patients with one (or more) cavitated lesion(s) are high risk patients.
c
Patients with one (or more) cavitated lesion(s) and xerostomia and/or hyposalivation are extreme risk patients.
d
Notations system used here: on bitewing radiographs as E1 (outer of enamel), E2 (inner of enamel), D1 (outer 1/3
of dentin), D2 (middle 1/3 of dentin), or D3 (inner 1/3 of dentin) and note the progression/regression from previous
radiographs if possible #33.
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7.
8.
Summary
Dental caries is a complex multifactorial disease
that cannot be controlled by restoration alone
(8). A CRA is a way to predict risk of future
disease, but it is also a systematic way to identify factors that are out of balance that could
lead to demineralization on a susceptible patient.
To assist the clinician in assessing caries risk,
several forms and procedures are in existence, of
which one form and one example protocol was
used in this paper to illustrate the science of caries management by risk assessment, CAMBRA.
CAMBRA is not a trade name for products or a
company, nor is it a CRA form, it is a concept
for managing dental caries and its manifestations. In its simplest form it means (i) assessing
the risk for future cries lesions, (ii) reducing the
pathological factors, (iii) enhancing the protective
factors, and (iv) minimally invasive restorative
care resulting in control of the disease.
9.
10.
11.
12.
13.
14.
15.
References
1. Young DA, Featherstone JD, Roth JR, Anderson M,
Autio-Gold J, Christensen GJ et al. Caries management by risk assessment: implementation guidelines.
J Calif Dent Assoc 2007;35:799805.
2. Featherstone JD, Domejean-Orliaguet S, Jenson L,
Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc
2007;35:7037, 103.
3. Featherstone JD. The caries balance: contributing factors and early detection. J Calif Dent Assoc
2003;31:12933.
4. Featherstone JD. Prevention and reversal of dental
caries: role of low level fluoride. Community Dent
Oral Epidemiol 1999;27:3140.
5. Domejean-Orliaguet S, Gansky SA, Featherstone JD.
Caries risk assessment in an educational environment. J Dent Educ 2006;70:134654.
6. Domejean S, White JM, Featherstone JD. Validation
of the cda cambra caries risk assessment a six-year
16.
17.
18.
19.
20.
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Appendix
Appendix 1. Caries risk assessment form for ages 6 years through adult. Adapted from Featherstone JD et al. (2)
Patient Name:
Assessment Date:
CHART #:
DATE:
Is this (please circle) Baseline or Recall
YES =
CIRCLE
YES
YES =
CIRCLE
YES=
CIRCLE
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Protective Factors
Lives/work/school fluoridated community
YES
Fluoride toothpaste at least once daily
YES
Fluoride toothpaste at least 2x daily
YES
Fluoride mouthrinse (0.05% NaF) daily
YES
5000 ppm F fluoride toothpaste daily
YES
Fluoride varnish in last 6 months
YES
Office F topical in last 6 months
YES
Chlorhexidine prescribed/used one week each of last 6
YES
months
Xylitol gum/lozenges 4x daily last 6 months
YES
Calcium and phosphate paste during last 6 months
YES
Adequate saliva flow (> 1 ml/min stimulated)
YES
** Biofilm Assessment: ATP bioluminescence: _______ or culture MS:_______LB:_______
Stimulated Salivary Flow Rate:_______ ml/min. Stimulated pH______ Date: _________
Resting Salivary Flow Rate: _______ ml/min. Resting pH ________ Date: _________
Buffering Capacity test:______________Consistency of resting saliva: thick-stringy-ropey vs watery
VISUALIZE CARIES BALANCE
(Use circled indicators/factors above)
(EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION)
CARIES RISK ASSESSMENT (CIRCLE):
EXTREME HIGH
MODERATE
Doctor signature/#:
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LOW
Date:
bad bacteria that cause tooth decay and can be useful in patients at high risk for tooth decay.
Fluorides. Fluorides help to make the tooth more
resistant to being dissolved by the bacterial acids.
Fluorides are available from a variety of sources
such as drinking water, toothpaste, over-the-counter rinses, and products prescribed by your dentist
such as brush-on gels or high-fluoride toothpastes
used at home or gels, foams, and varnishes applied
in the dental office. Daily use is very important to
help protect against the acid attacks.
Factors favorable for remineralization. Calcium and
phosphate at the proper pH is necessary for tooth
repair. Normally, this is carried out by your saliva
but when you have a lack of saliva (dry mouth) or
when fluoride alone is not effective, you may consider supplementing with calcium/phosphate and
acid-neutralizing products.
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