Accepted Manuscript A Best Practices Approach to Caries Management Michelle Hurlbutt, RDH, MSDH Douglas A. Young, DDS, EdD, MBA, MS PII:
S1532-3382(14)00060-8
DOI:
10.1016/j.jebdp.2014.03.006
Reference:
YMED 947
To appear in:
The Journal of Evidence-Based Dental Practice
Please cite this article as: Hurlbutt M, Young DA, A Best Practices Approach to Caries Management, The Journal of Evidence-Based Dental Practice (2014), doi: 10.1016/j.jebdp.2014.03.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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A Best Practices Approach to Caries Management
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Michelle Hurlbutt, RDH, MSDH Associate Professor, Department of Dental Hygiene Loma Linda University School of Dentistry 11092 Anderson Street Loma Linda, CA 92350 [email protected]
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Douglas A. Young, DDS, EdD, MBA, MS Professor,Department of Dental Practice University of the Pacific, Arthur A. Dugoni School of Dentistry 2155 Webster St. Suite 400 San Francisco, CA 94115 dyoung@ pacific.edu
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Abstract
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BACKGROUND. Dental caries is a multifactorial, biofilm and pH mediated disease that affects people of all ages and disproportionally affects certain populations at epidemic proportions. Simply restoring cavitated teeth does nothing to resolve the disease. At the heart of the CAMBRA philiosphy is identifying the patient’s unique risk level for future caries disease. This can be done by completing a caries risk assessment (CRA). Several easy to use CRA questionnaires are available. Once the patient’s unique risk level has been determined, preventive and therapeutic interventions, based on the specific risk level, can then be implemented. METHODS. Landmark publications, original research, and systematic reviews are analyzed and reviewed to form the basis for this shift in patient care related to caries disease.
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CONCLUSIONS. Caries management by risk assessment has emerged as the new paradigm in patient care and represents an evidence-based, best practices approach with the potential for significant advantages over traditional methods
A Best Practices Approach to Caries Management Introduction
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Great advances in knowledge about dental caries have been realized over the last century, yet this disease remains one of the most common seen in America. In the United States, the prevalence of caries disease remains persistently high, especially among young children and
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selected populations. Data from the most recently analyzed national survey, the 2005-2008 National Health and Nutrition Examination Survey (NHANES), unveiled that one in five people
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had untreated dental caries and 75% of the population had at least one restoration.1 Almost 23% of people aged 65 and older were edentulous and dental caries varied significantly by race, ethnicity, and poverty level for all age groups. Children of color continued to have more caries experience and less exposure to preventive interventions such as sealants; approximately one in four children, aged 3–5 and 6–9 years, living in poverty, had untreated carious lesions.2 Even with the knowledge of caries prevention and treatment, caries disease continues to disproportionately burden the population and remains a significant problem for both children and
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adults. This problem may be grossly underestimated considering that caries experience was typically measured by decayed-missing-filled teeth (DMFT) or decayed-missing-filled surfaces
and ignores the earlier stages of caries disease (non-cavitated lesions).
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(DMFS), which reflect the very late stages of caries disease when visible cavitation was present
The typical method in treating dental caries remains focused on tooth restoration as it was a century ago. Most dentists continue to rely on a surgical-restorative approach where the
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carious lesion is identified, removed, and a restoration is placed. This approach has resulted in the gradual accumulation of restored tooth surfaces; because all restorations have a limited
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clinical life, the surgical-restorative model promotes increased restoration size or more invasive procedures over time. It is estimated that over two-thirds of all restorative treatments are performed on previously restored teeth, with recurrent carious lesions reported as the predominant cause.3 In addition, recent research demonstrated that restoring teeth alone does not
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stop the disease or future tooth decay.4 It can be argued that the manner in which this disease has been managed represents a public health failure on the part of oral health care providers. Dental Caries
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It is well understood that dental caries disease is preventable and can be arrested.5,6 Caries disease is a consequence of a shift in the homeostatic balance of the resident microflora
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due to a change in local environmental conditions (such as pH), which favor the growth of cariogenic pathogens.7,8 If the cariogenic bacteria present in the plaque biofilm continue to produce acid, the plaque pH falls to an acidic range where dissolution of the carbonated hydroxyapatite mineral (demineralization) of the enamel surface may lead to a carious lesion. Under normal physiological conditions, saliva neutralizes the acid attack and provides supersaturation of calcium and phosphate ions and when combined with fluoride will have a
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good chance of slowing or halting caries disease via the remineralization process. Therefore, it is the local chemistry, at any given tooth site, that determines whether the plaque biofilm will create enough acid to result in demineralization and cause visible changes to the tooth site
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(carious lesions).
Dental caries can be considered an imbalance in the demineralization-remineralization process favoring demineralization. Although acid-generating bacteria present in plaque biofilm
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are often considered the etiologic agents, dental caries is also influenced by dietary and host factors. The caries process is dependent upon the interaction of protective and pathologic factors
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in saliva and plaque biofilm as well as the balance between the cariogenic and noncariogenic microbial populations that reside in saliva. The caries balance/imbalance model is one way to visualize the multi-factorial nature of the caries process just described (Figure 1).9 This model illustrates the factors contributing to caries disease and the dynamic interaction of the biofilm
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with the oral environment. This balance or imbalance amongst disease indicators, risk factors, and protective factors determines whether dental caries is arrested, reversed, or progresses. The key to caries management and disease prevention lies with modifying the behavior of
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complex dental biofilm as well as transforming factors to favor health. 6, 10, 11 This evidencedbased approach represents a major paradigm shift away from the surgical-restorative model and
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although embraced by dental education, is still in the process of evolution.12-14 There is less acceptance of this ‘best practices’ approach to dental caries disease identification and prevention among mainstream dental practices than in the education arena, with the most frequent adherents being younger, more recently-graduated dentists.15, 16 Oral healthcare providers need to acknowledge that the procedure-oriented practice of simply removing and restoring the carious lesion has not resulted in successful resolution of
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caries disease across a lifetime. This is an after-the-fact irreversible repair approach that does not address the complex nature of caries disease and is no longer grounded in evidence. Modern caries management includes a more patient-centered, evidence-based approach to determine an
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individual’s unique risk for caries disease and more targeted treatment and preventive therapies to be implemented. This approach fits perfectly within dental hygiene practice because dental
within their scope of dental hygiene practice. Evidence-Based Caries Management
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hygienists actively promote evidence-based oral disease prevention and disease management
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Evidence-based practice differs from traditional practice in that it requires the incorporation of the highest levels of research evidence available to help guide decisions rather than treating all patients alike regardless of their underlying disease indicators or risk factors. Levels of evidence refer to a hierarchy of research study designs and are often used to determine
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the strength of the evidence being reviewed. Most consider a systematic review and metaanalyses as providing the strongest support, followed by randomized clinical trials. The wisdom of restricting decisions or the willingness to change clinical technique solely on the highest levels
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of evidence is being questioned with regard to caries management. This is because as the complexity of caries disease continues to be elucidated, there may not be a systematic review or
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randomized clinical trial available which addresses a specific clinical decision for a particular patient. There are often several variables that need to be addressed simultaneously to effectively treat a patient’s multiple risk factors, which would be problematic with randomized clinical trials (and thus systematic reviews) since these study designs usually focus on few variables to minimize confounding factors. A study design that is gaining popularity is outcomes-based research from dental practice based research networks (BPRNs). PBRNs are unique research
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models where a network of private practices interested in conducting practice-based research jointly apply the scientific method to ‘everyday’ issues in the delivery of oral healthcare. The absence of high levels of evidence, does not necessarily mean an intervention or
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method of care will not be beneficial to the patient. Evidence-based caries management requires the practitioner to seek out and interpret the best available scientific research to fill the void when the highest levels of evidence (randomized clinical trials and systematic reviews) are
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lacking. When faced with choosing products or treatment modalities that do not have high levels of evidence, practitioners should carefully weigh the benefits and risks for their patients (Figure
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2).When implementing an evidence-based approach related to caries management, practitioners should remember that research alone is not sufficient to resolve a clinical problem. The practitioner’s experience and judgment as well as the patient’s preferences, values, and unique needs should also be considered.17
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Caries Management by Risk Assessment
When scientific evidence for caries management is limited, the practitioner is left with two choices: 1) continue using the traditional restorative-only approach involving irreversible
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procedures or, 2) use tooth preserving risk-based caries management strategies that decrease caries risk factors and increase caries protective factors using the best scientific evidence
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available. The latter option reflects best practices and is being proposed to the profession for adoption as a process of care and practice philosophy termed caries management by risk assessment (CAMBRA).18
CAMBRA relies on preventing or treating the cause of dental caries at the earliest of stages, rather than waiting for irreversible damage to the teeth. Teeth undergo constant demineralization and remineralization, 24 hours of the day. The clinical goal is to help the
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patient modify factors to offset the challenges that allow for demineralization to prevail over remineralization. By collecting information about the patient’s unique caries balance, a practitioner can assess the risk of future demineralization based on weighing all the disease
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indicators and risk factors against existing protective factors. Implementation of CAMBRA into clinical practice involves four components ( Table 1). Hard Tissue Examination
Once the practitioner gathers information through review of the patient’s unique history,
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a comprehensive hard tissue examination is conducted before the risk assessment. The best predictor of future caries disease is previous caries experience or current carious lesions,
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including white spot lesions. 19-22 The CAMBRA philosophy advocates the detection of the carious lesion at the earliest possible stage so the process can be halted or arrested. The accurate detection and diagnosis of non-cavitated carious lesions, should be a high priority. The most commonly used method for detecting carious lesions is visual-tactile inspection. This type of
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examination has limitations, as research has demonstrated a high ability of clinicians to correctly identify sound tooth surface sites but a low ability to correctly identify carious lesion sites, especially sites demonstrating early stages of caries activity.23, 24 The CAMBRA process of care
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suggests that practitioners should evaluate for indicators of disease such as white spots on smooth surfaces, restorations placed within the last three years as a result of active caries disease
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or restorations placed within the last year for re-care patients and frank cavities, carious lesions that are cavitated.9 In addition, practitioners should utilize radiographs to determine the presence of approximal enamel or dentin lesions. A positive response to any of these disease indicators would place the patient at risk for dental caries disease. The next step is to apply the information gained through the hard tissue examination to a caries risk assessment (CRA) to guide the practitioner in clinical decision making.
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Caries Risk Assessment Decision making related to caries disease can be as complex as the disease itself. The concept of using risk assessment to identify the danger for developing or progressing caries
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disease has been discussed in dentistry since the late 1980s.25, 26 Risk assessment is a process that is used to characterize and quantify the likelihood of adverse events occurring in the
immediate future. Caries risk assessment (CRA) can be described as a formalized process that
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involves an analysis of the probability that the number, size, or activity of carious lesions will change over a specified period of time.5 The concept is straightforward, those patients who will
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most likely develop dental caries or carious lesions in the near future are identified, followed by a determination of what is causing the problems and providing those individuals with appropriate preventive and therapeutic measures to arrest the disease. An ideal CRA system should not only be easy to use, but have high validity and reliability, as determined by research. Although there
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is no statistically valid and reliable method of CRA to date, the use of a structured system to assess the caries risk level will be helpful to the practitioner in determining a patient’s expected caries experience over a period of time as well as the likelihood of new carious lesions
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developing or existing carious lesions progressing.27 An individualized treatment plan can then be created based on the patient’s risk level and evidence based preventive and therapeutic
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interventions are then implemented. It is important to note that re-evaluation of the patient’s risk level should be routinely conducted, with those patients at higher risk needing re-evaluation much sooner than those at low risk. Although CRA has been investigated since the early 1990s,28-30 clinical acceptance was not well promoted or popularized until over a decade later.31-35 It has been reported that only 14% of dentists use a CRA in determining their patient’s caries risk, with the majority of oral
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healthcare providers assessing their patient’s caries risk through their clinical observation and experience. This may, in part, be due to the fact that there is not one universally accepted CRA system.. CAMBRA requires the practitioner to select a CRA system and follow the instructions.
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There are a number of patient specific instruments or questionnaires that are easily available to practitioners to use in conducting a CRA including a California Dental Association (CDA) CRA form, an American Dental Association (ADA) CRA form, an American Academy of Pediatric
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Dentistry (AAPD) form, and the Cariogram, a computerized program. There are also industry forms and computerized and cell application programs available. References for these
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computerized and cell application programs are provided later in this paper. The classification of high and low risk varies between these different systems but the factors of caries experience, salivary flow, presence of plaque biofilm, exposure to fluoride, and diet, as well as general health considerations, are present in all current CRA systems.
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CDA CRA
One of the first CRA forms published for clinical use was based on the CAMBRA philosophy of care and the best available evidence at that time.36 This form, referred to as the
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California Dental Association (CDA) CRA form because it was originally published in the CDA Journal in 2003, was subsequently modified and improved by a national working group who
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supports the CAMBRA process of care and republished in 200737 and again in 2013.9 This CRA questionnaire includes a total of 24 items including disease indicators, pathological risk factors, and protective factors, to evaluate and assist practitioners in identifying whether a patient over six years of age is at low, moderate, high, or extreme risk for caries disease. This form is reproduced in Table 2. Practitioners are advised to complete the CRA by circling the “yes” answers and then to visualize how the responses affect the caries balance at the bottom of the
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form. Low risk indicates there is little risk of caries disease in the near future (a year or two), providing no major deleterious changes are seen. High risk indicates a high likelihood of new carious lesions in the near future and if hyposalivation or major salivary dysfunction is present,
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the risk level automatically moves up to extreme risk. If there is doubt between low and high risk, then the practitioner is advised to classify the patient as moderate risk.9
A retrospective study to evaluate the validity of the CDA CRA (6>) and to determine its
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predictive value for future caries was conducted in 2011 from analyzing patient chart data
received from a California dental school that uses the form in their clinic.38 It was found that
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88% of extreme risk patients and 69.3% of high risk patients were correctly identified using the form and developed new carious lesions by their first follow up examination. The authors concluded the CDA CRA was helpful in screening adult patients who are at high or extreme risk of developing further carious lesions. Currently, that dental school prescribes CAMBRA-based
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products based upon the assessed risk level. A similar CDA CRA form was developed for young children and published in 200739 and slightly revised and republished in 201140 using 20 factors to identify low, moderate, or high risk patients five years and under. There have been no
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published studies on the caries predictability using this instrument. Evidence-based clinical guidelines based on caries risk levels were published in 2007 and updated in 2013, 9, 41 with the
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pediatric protocols (6) and child (0-6) CRA forms in 2009 and updated them in 2011 to be fillable forms that can be downloaded from the ADA website.42, 43 The ADA forms use 19 factors associated with caries in evaluating patients over six years of age and 14 factors for children 0-5 years of age to determine a low, moderate, or high risk level.
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Practitioners are instructed to check the conditions that apply in each of the three columns that represent low, moderate, or high risk and then based on the number of checks, make a decision as to what the final caries risk level is. The ADA emphasizes that the clinical judgment of the
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dentist allows for a change of the patient’s risk level based on a review of this form. There are no published ADA clinical guidelines related to caries management or published studies on the caries predictability using this tool.
guidelines on CRA and
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The AAPD first published its
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AAPD CRA
Management that included forms (0-5 and ≥ 6) for dental
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professionals as well as clinical guidelines in 2006 and revised this document in 2010, 2011, and 2013.44 The AAPD also has a CRA form that is promoted for use by physicians and non-dentists for 0-3 years of age. The AAPD CRA uses 14 factors to evaluate for low, moderate, or high risk
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classification in children. The AAPD promotes the use of their clinical guidelines that provide evidence-based preventive and treatment recommendations based on the risk level determined by
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the use of the AAPD CRA form. A published study on this instrument found although the predictive value was low, once the confounding influence of socio-economic status was removed from the statistical analysis, this instrument’s accuracy improved.45 Cariogram
The Cariogram was developed in Sweden in 2003 by dental faculty at the Malmö University and is a computerized version of a CRA.46 The program evaluates data according to its built-in algorithm and presents the results as a color-coded pie-diagram that represents five
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different groups of factors related to dental caries (Figure 3). This software will calculate the actual chance to avoid new cavities as well as offers some guidance in reducing the risk for developing new caries disease. As with other CRA systems, the authors of this database
studies that validate this system for children 47, 48 and elderly adults.49 Caries Interventions and Therapy
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emphasize that it should not replace the judgment of the dental professional. There are published
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Best practices dictate that once the practitioner has identified the patient’s caries risk (low, moderate, high and extreme), a therapeutic and/or preventive plan is implemented. An
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evidence-based, individualized plan is presented to the patient that also includes the practitioner’s expertise and the patient’s unique wants and needs. As discussed previously, clinical intervention protocols have been developed based on research and caries risk levels. An example of clinical guidelines based on risk levels can be found in Table 3. CAMBRA also
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emphasizes minimally invasive restorative care when cavitated carious lesions are present.9, 41 High level research supporting the CAMBRA philosophy of care is emerging. One randomized clinical trial demonstrated the use of the CAMBRA model.4 In this study the test
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group used caries risk assessment, based on salivary fluoride levels and bacterial load (MS and LB cultures) to drive treatment decisions using a 0.12% chlorhexidine gluconate antibacterial
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rinse and/or a 0.05% NaF topical fluoride rinse. The test group lowered mean caries increment by 24% compared to the control group which used a traditional restorative only approach (no risk assessment or chemical based treatments were not employed) With respect to specific treatments and prevention for caries disease, high level research exists for only topical fluoride, including toothpastes, mouth rinses, gels or varnish50, 51 pit and fissure sealants52 and perhaps to some extent, conservative caries removal.53, 54 All other treatment modalities and products have
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less or lower levels of evidence and practitioners are advised to use them to supplement (rather than replace) those with higher levels of evidence and to appraise the literature to determine whether the use of those agents would benefit the patient. The practitioner must also assist the
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patient in modification of behaviors that favor oral health. Conclusion
Best practices are an evolving approach to exceptional patient care and CAMBRA offers
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dental professionals the ability to apply the most clinically relevant, research-based and helpful interventions to real-life practice. The use of a CRA to guide the decision-making process
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supports this new evidence-based model to caries management that emphasizes a targeted approach to caries prevention and early, minimally invasive tooth preserving treatment. It is well understood that the cornerstone of dental hygiene practice rests with prevention and control of oral diseases. Dental hygienists are educated in oral disease detection and with
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dental hygiene diagnosis legal in some but not all states, they are responsible for recognizing disease indicators, risk factors, and protective factors related to dental caries. Dental hygienists actively promote the use of preventive and therapeutic methods for the treatment and prevention
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of dental caries and are well equipped to coordinate and conduct the CRA and implement strategies that will reduce the patient’s risk.
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The key to widespread adoption of CAMBRA philosophy lies in a team approach concept where each member of the oral health care team is involved and understands that every team member has a role: the front office staff member may introduce the patient to the CRA form in the reception area and is responsible for knowing the various billing codes attached to CAMBRA; the dental assistant may assist in gathering data necessary for the completion of the CRA form and educate the patient on various strategies; the dentist and dental hygienist will
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quarterback the prevention and treatment as well patient motivation for self-care. CAMBRA has emerged as the new paradigm in patient care and represents a patient-centered, best practices
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approach with the potential for significant advantages over traditional methods.
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Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, Makela M, et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev 2013;3:CD001830. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006;3:CD003808. Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc 2008;139(6):705-12.
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Table 1
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CAMBRA- Components for Clinical Practice
Patient interview to review the health, dental, and social history to gather information related to dental caries disease
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Hard tissue examination and charting to identify location, severity and activity of carious lesions
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Caries risk assessment utilizing data gathered from the patient histories and examination
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Evidence-based treatment and prevention plan based on the patient’s risk level
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Figure 1: Caries Balance/Imbalance
. TABLE 2. Caries Risk Assessment Form for Ages 6 Years Through Adult
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CHART #: DATE: Is this (please circle) Baseline or Recall
Disease Indicators (Any one YES signifies likely “High Risk” and to do a bacteria load test**) New/Progressing visible cavitations or radiolucencies into dentin New/Progressing approximal enamel Lesions by radiograph New/Active White spots on smooth surfaces Restoration for caries lesion in the last 3 years (only for initial CRA exam)
YES = CIRCLE YES
YES = CIRCLE
YES YES YES
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Risk Factors (Biological predisposing factors) MS and LB both medium or high (by culture or ATP bioluminescence **) Visible heavy plaque on teeth Frequent snack (> 3x daily between meals) Deep pits and fissures Recreational drug use Inadequate saliva flow by observation or measurement (**If measured note the flow rate below) Saliva reducing factors (medications/radiation/systemic) Exposed roots Orthodontic appliances
YES= CIRCLE
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Patient Name: Assessment Date:
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YES YES YES YES YES YES YES YES YES
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Protective Factors YES 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 months YES 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) ** 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/#:
Date:
LOW
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Table 3: SAFER Protocol: An Example of clinical guidelines based on caries risk for patients 6 years through adult.
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Note: 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, the use of caries control procedures with glass ionomer materials until caries progression is halted and/or reversed may be used and followed with more permanent restorative care. Patients at risk with appliances (RPDs, Orthodontics) require excellent oral hygiene together with intensive fluoride therapy (e.g. high fluoride toothpaste and fluoride varnish every 3 mos). 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 for 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 6-10 gr/day for antimicrobial effects)
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Figure 2. Guidelines to follow when high level evidence is not an option
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S1532-3382(14)00060-8
DOI:
10.1016/j.jebdp.2014.03.006
Reference:
YMED 947
To appear in:
The Journal of Evidence-Based Dental Practice
Please cite this article as: Hurlbutt M, Young DA, A Best Practices Approach to Caries Management, The Journal of Evidence-Based Dental Practice (2014), doi: 10.1016/j.jebdp.2014.03.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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A Best Practices Approach to Caries Management
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Michelle Hurlbutt, RDH, MSDH Associate Professor, Department of Dental Hygiene Loma Linda University School of Dentistry 11092 Anderson Street Loma Linda, CA 92350 [email protected]
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Douglas A. Young, DDS, EdD, MBA, MS Professor,Department of Dental Practice University of the Pacific, Arthur A. Dugoni School of Dentistry 2155 Webster St. Suite 400 San Francisco, CA 94115 dyoung@ pacific.edu
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Abstract
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BACKGROUND. Dental caries is a multifactorial, biofilm and pH mediated disease that affects people of all ages and disproportionally affects certain populations at epidemic proportions. Simply restoring cavitated teeth does nothing to resolve the disease. At the heart of the CAMBRA philiosphy is identifying the patient’s unique risk level for future caries disease. This can be done by completing a caries risk assessment (CRA). Several easy to use CRA questionnaires are available. Once the patient’s unique risk level has been determined, preventive and therapeutic interventions, based on the specific risk level, can then be implemented. METHODS. Landmark publications, original research, and systematic reviews are analyzed and reviewed to form the basis for this shift in patient care related to caries disease.
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CONCLUSIONS. Caries management by risk assessment has emerged as the new paradigm in patient care and represents an evidence-based, best practices approach with the potential for significant advantages over traditional methods
A Best Practices Approach to Caries Management Introduction
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Great advances in knowledge about dental caries have been realized over the last century, yet this disease remains one of the most common seen in America. In the United States, the prevalence of caries disease remains persistently high, especially among young children and
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selected populations. Data from the most recently analyzed national survey, the 2005-2008 National Health and Nutrition Examination Survey (NHANES), unveiled that one in five people
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had untreated dental caries and 75% of the population had at least one restoration.1 Almost 23% of people aged 65 and older were edentulous and dental caries varied significantly by race, ethnicity, and poverty level for all age groups. Children of color continued to have more caries experience and less exposure to preventive interventions such as sealants; approximately one in four children, aged 3–5 and 6–9 years, living in poverty, had untreated carious lesions.2 Even with the knowledge of caries prevention and treatment, caries disease continues to disproportionately burden the population and remains a significant problem for both children and
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adults. This problem may be grossly underestimated considering that caries experience was typically measured by decayed-missing-filled teeth (DMFT) or decayed-missing-filled surfaces
and ignores the earlier stages of caries disease (non-cavitated lesions).
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(DMFS), which reflect the very late stages of caries disease when visible cavitation was present
The typical method in treating dental caries remains focused on tooth restoration as it was a century ago. Most dentists continue to rely on a surgical-restorative approach where the
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carious lesion is identified, removed, and a restoration is placed. This approach has resulted in the gradual accumulation of restored tooth surfaces; because all restorations have a limited
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clinical life, the surgical-restorative model promotes increased restoration size or more invasive procedures over time. It is estimated that over two-thirds of all restorative treatments are performed on previously restored teeth, with recurrent carious lesions reported as the predominant cause.3 In addition, recent research demonstrated that restoring teeth alone does not
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stop the disease or future tooth decay.4 It can be argued that the manner in which this disease has been managed represents a public health failure on the part of oral health care providers. Dental Caries
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It is well understood that dental caries disease is preventable and can be arrested.5,6 Caries disease is a consequence of a shift in the homeostatic balance of the resident microflora
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due to a change in local environmental conditions (such as pH), which favor the growth of cariogenic pathogens.7,8 If the cariogenic bacteria present in the plaque biofilm continue to produce acid, the plaque pH falls to an acidic range where dissolution of the carbonated hydroxyapatite mineral (demineralization) of the enamel surface may lead to a carious lesion. Under normal physiological conditions, saliva neutralizes the acid attack and provides supersaturation of calcium and phosphate ions and when combined with fluoride will have a
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good chance of slowing or halting caries disease via the remineralization process. Therefore, it is the local chemistry, at any given tooth site, that determines whether the plaque biofilm will create enough acid to result in demineralization and cause visible changes to the tooth site
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(carious lesions).
Dental caries can be considered an imbalance in the demineralization-remineralization process favoring demineralization. Although acid-generating bacteria present in plaque biofilm
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are often considered the etiologic agents, dental caries is also influenced by dietary and host factors. The caries process is dependent upon the interaction of protective and pathologic factors
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in saliva and plaque biofilm as well as the balance between the cariogenic and noncariogenic microbial populations that reside in saliva. The caries balance/imbalance model is one way to visualize the multi-factorial nature of the caries process just described (Figure 1).9 This model illustrates the factors contributing to caries disease and the dynamic interaction of the biofilm
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with the oral environment. This balance or imbalance amongst disease indicators, risk factors, and protective factors determines whether dental caries is arrested, reversed, or progresses. The key to caries management and disease prevention lies with modifying the behavior of
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complex dental biofilm as well as transforming factors to favor health. 6, 10, 11 This evidencedbased approach represents a major paradigm shift away from the surgical-restorative model and
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although embraced by dental education, is still in the process of evolution.12-14 There is less acceptance of this ‘best practices’ approach to dental caries disease identification and prevention among mainstream dental practices than in the education arena, with the most frequent adherents being younger, more recently-graduated dentists.15, 16 Oral healthcare providers need to acknowledge that the procedure-oriented practice of simply removing and restoring the carious lesion has not resulted in successful resolution of
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caries disease across a lifetime. This is an after-the-fact irreversible repair approach that does not address the complex nature of caries disease and is no longer grounded in evidence. Modern caries management includes a more patient-centered, evidence-based approach to determine an
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individual’s unique risk for caries disease and more targeted treatment and preventive therapies to be implemented. This approach fits perfectly within dental hygiene practice because dental
within their scope of dental hygiene practice. Evidence-Based Caries Management
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hygienists actively promote evidence-based oral disease prevention and disease management
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Evidence-based practice differs from traditional practice in that it requires the incorporation of the highest levels of research evidence available to help guide decisions rather than treating all patients alike regardless of their underlying disease indicators or risk factors. Levels of evidence refer to a hierarchy of research study designs and are often used to determine
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the strength of the evidence being reviewed. Most consider a systematic review and metaanalyses as providing the strongest support, followed by randomized clinical trials. The wisdom of restricting decisions or the willingness to change clinical technique solely on the highest levels
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of evidence is being questioned with regard to caries management. This is because as the complexity of caries disease continues to be elucidated, there may not be a systematic review or
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randomized clinical trial available which addresses a specific clinical decision for a particular patient. There are often several variables that need to be addressed simultaneously to effectively treat a patient’s multiple risk factors, which would be problematic with randomized clinical trials (and thus systematic reviews) since these study designs usually focus on few variables to minimize confounding factors. A study design that is gaining popularity is outcomes-based research from dental practice based research networks (BPRNs). PBRNs are unique research
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models where a network of private practices interested in conducting practice-based research jointly apply the scientific method to ‘everyday’ issues in the delivery of oral healthcare. The absence of high levels of evidence, does not necessarily mean an intervention or
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method of care will not be beneficial to the patient. Evidence-based caries management requires the practitioner to seek out and interpret the best available scientific research to fill the void when the highest levels of evidence (randomized clinical trials and systematic reviews) are
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lacking. When faced with choosing products or treatment modalities that do not have high levels of evidence, practitioners should carefully weigh the benefits and risks for their patients (Figure
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2).When implementing an evidence-based approach related to caries management, practitioners should remember that research alone is not sufficient to resolve a clinical problem. The practitioner’s experience and judgment as well as the patient’s preferences, values, and unique needs should also be considered.17
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Caries Management by Risk Assessment
When scientific evidence for caries management is limited, the practitioner is left with two choices: 1) continue using the traditional restorative-only approach involving irreversible
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procedures or, 2) use tooth preserving risk-based caries management strategies that decrease caries risk factors and increase caries protective factors using the best scientific evidence
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available. The latter option reflects best practices and is being proposed to the profession for adoption as a process of care and practice philosophy termed caries management by risk assessment (CAMBRA).18
CAMBRA relies on preventing or treating the cause of dental caries at the earliest of stages, rather than waiting for irreversible damage to the teeth. Teeth undergo constant demineralization and remineralization, 24 hours of the day. The clinical goal is to help the
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patient modify factors to offset the challenges that allow for demineralization to prevail over remineralization. By collecting information about the patient’s unique caries balance, a practitioner can assess the risk of future demineralization based on weighing all the disease
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indicators and risk factors against existing protective factors. Implementation of CAMBRA into clinical practice involves four components ( Table 1). Hard Tissue Examination
Once the practitioner gathers information through review of the patient’s unique history,
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a comprehensive hard tissue examination is conducted before the risk assessment. The best predictor of future caries disease is previous caries experience or current carious lesions,
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including white spot lesions. 19-22 The CAMBRA philosophy advocates the detection of the carious lesion at the earliest possible stage so the process can be halted or arrested. The accurate detection and diagnosis of non-cavitated carious lesions, should be a high priority. The most commonly used method for detecting carious lesions is visual-tactile inspection. This type of
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examination has limitations, as research has demonstrated a high ability of clinicians to correctly identify sound tooth surface sites but a low ability to correctly identify carious lesion sites, especially sites demonstrating early stages of caries activity.23, 24 The CAMBRA process of care
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suggests that practitioners should evaluate for indicators of disease such as white spots on smooth surfaces, restorations placed within the last three years as a result of active caries disease
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or restorations placed within the last year for re-care patients and frank cavities, carious lesions that are cavitated.9 In addition, practitioners should utilize radiographs to determine the presence of approximal enamel or dentin lesions. A positive response to any of these disease indicators would place the patient at risk for dental caries disease. The next step is to apply the information gained through the hard tissue examination to a caries risk assessment (CRA) to guide the practitioner in clinical decision making.
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Caries Risk Assessment Decision making related to caries disease can be as complex as the disease itself. The concept of using risk assessment to identify the danger for developing or progressing caries
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disease has been discussed in dentistry since the late 1980s.25, 26 Risk assessment is a process that is used to characterize and quantify the likelihood of adverse events occurring in the
immediate future. Caries risk assessment (CRA) can be described as a formalized process that
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involves an analysis of the probability that the number, size, or activity of carious lesions will change over a specified period of time.5 The concept is straightforward, those patients who will
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most likely develop dental caries or carious lesions in the near future are identified, followed by a determination of what is causing the problems and providing those individuals with appropriate preventive and therapeutic measures to arrest the disease. An ideal CRA system should not only be easy to use, but have high validity and reliability, as determined by research. Although there
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is no statistically valid and reliable method of CRA to date, the use of a structured system to assess the caries risk level will be helpful to the practitioner in determining a patient’s expected caries experience over a period of time as well as the likelihood of new carious lesions
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developing or existing carious lesions progressing.27 An individualized treatment plan can then be created based on the patient’s risk level and evidence based preventive and therapeutic
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interventions are then implemented. It is important to note that re-evaluation of the patient’s risk level should be routinely conducted, with those patients at higher risk needing re-evaluation much sooner than those at low risk. Although CRA has been investigated since the early 1990s,28-30 clinical acceptance was not well promoted or popularized until over a decade later.31-35 It has been reported that only 14% of dentists use a CRA in determining their patient’s caries risk, with the majority of oral
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healthcare providers assessing their patient’s caries risk through their clinical observation and experience. This may, in part, be due to the fact that there is not one universally accepted CRA system.. CAMBRA requires the practitioner to select a CRA system and follow the instructions.
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There are a number of patient specific instruments or questionnaires that are easily available to practitioners to use in conducting a CRA including a California Dental Association (CDA) CRA form, an American Dental Association (ADA) CRA form, an American Academy of Pediatric
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Dentistry (AAPD) form, and the Cariogram, a computerized program. There are also industry forms and computerized and cell application programs available. References for these
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computerized and cell application programs are provided later in this paper. The classification of high and low risk varies between these different systems but the factors of caries experience, salivary flow, presence of plaque biofilm, exposure to fluoride, and diet, as well as general health considerations, are present in all current CRA systems.
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CDA CRA
One of the first CRA forms published for clinical use was based on the CAMBRA philosophy of care and the best available evidence at that time.36 This form, referred to as the
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California Dental Association (CDA) CRA form because it was originally published in the CDA Journal in 2003, was subsequently modified and improved by a national working group who
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supports the CAMBRA process of care and republished in 200737 and again in 2013.9 This CRA questionnaire includes a total of 24 items including disease indicators, pathological risk factors, and protective factors, to evaluate and assist practitioners in identifying whether a patient over six years of age is at low, moderate, high, or extreme risk for caries disease. This form is reproduced in Table 2. Practitioners are advised to complete the CRA by circling the “yes” answers and then to visualize how the responses affect the caries balance at the bottom of the
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form. Low risk indicates there is little risk of caries disease in the near future (a year or two), providing no major deleterious changes are seen. High risk indicates a high likelihood of new carious lesions in the near future and if hyposalivation or major salivary dysfunction is present,
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the risk level automatically moves up to extreme risk. If there is doubt between low and high risk, then the practitioner is advised to classify the patient as moderate risk.9
A retrospective study to evaluate the validity of the CDA CRA (6>) and to determine its
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predictive value for future caries was conducted in 2011 from analyzing patient chart data
received from a California dental school that uses the form in their clinic.38 It was found that
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88% of extreme risk patients and 69.3% of high risk patients were correctly identified using the form and developed new carious lesions by their first follow up examination. The authors concluded the CDA CRA was helpful in screening adult patients who are at high or extreme risk of developing further carious lesions. Currently, that dental school prescribes CAMBRA-based
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products based upon the assessed risk level. A similar CDA CRA form was developed for young children and published in 200739 and slightly revised and republished in 201140 using 20 factors to identify low, moderate, or high risk patients five years and under. There have been no
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published studies on the caries predictability using this instrument. Evidence-based clinical guidelines based on caries risk levels were published in 2007 and updated in 2013, 9, 41 with the
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pediatric protocols (6) and child (0-6) CRA forms in 2009 and updated them in 2011 to be fillable forms that can be downloaded from the ADA website.42, 43 The ADA forms use 19 factors associated with caries in evaluating patients over six years of age and 14 factors for children 0-5 years of age to determine a low, moderate, or high risk level.
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Practitioners are instructed to check the conditions that apply in each of the three columns that represent low, moderate, or high risk and then based on the number of checks, make a decision as to what the final caries risk level is. The ADA emphasizes that the clinical judgment of the
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dentist allows for a change of the patient’s risk level based on a review of this form. There are no published ADA clinical guidelines related to caries management or published studies on the caries predictability using this tool.
guidelines on CRA and
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The AAPD first published its
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AAPD CRA
Management that included forms (0-5 and ≥ 6) for dental
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professionals as well as clinical guidelines in 2006 and revised this document in 2010, 2011, and 2013.44 The AAPD also has a CRA form that is promoted for use by physicians and non-dentists for 0-3 years of age. The AAPD CRA uses 14 factors to evaluate for low, moderate, or high risk
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classification in children. The AAPD promotes the use of their clinical guidelines that provide evidence-based preventive and treatment recommendations based on the risk level determined by
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the use of the AAPD CRA form. A published study on this instrument found although the predictive value was low, once the confounding influence of socio-economic status was removed from the statistical analysis, this instrument’s accuracy improved.45 Cariogram
The Cariogram was developed in Sweden in 2003 by dental faculty at the Malmö University and is a computerized version of a CRA.46 The program evaluates data according to its built-in algorithm and presents the results as a color-coded pie-diagram that represents five
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different groups of factors related to dental caries (Figure 3). This software will calculate the actual chance to avoid new cavities as well as offers some guidance in reducing the risk for developing new caries disease. As with other CRA systems, the authors of this database
studies that validate this system for children 47, 48 and elderly adults.49 Caries Interventions and Therapy
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emphasize that it should not replace the judgment of the dental professional. There are published
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Best practices dictate that once the practitioner has identified the patient’s caries risk (low, moderate, high and extreme), a therapeutic and/or preventive plan is implemented. An
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evidence-based, individualized plan is presented to the patient that also includes the practitioner’s expertise and the patient’s unique wants and needs. As discussed previously, clinical intervention protocols have been developed based on research and caries risk levels. An example of clinical guidelines based on risk levels can be found in Table 3. CAMBRA also
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emphasizes minimally invasive restorative care when cavitated carious lesions are present.9, 41 High level research supporting the CAMBRA philosophy of care is emerging. One randomized clinical trial demonstrated the use of the CAMBRA model.4 In this study the test
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group used caries risk assessment, based on salivary fluoride levels and bacterial load (MS and LB cultures) to drive treatment decisions using a 0.12% chlorhexidine gluconate antibacterial
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rinse and/or a 0.05% NaF topical fluoride rinse. The test group lowered mean caries increment by 24% compared to the control group which used a traditional restorative only approach (no risk assessment or chemical based treatments were not employed) With respect to specific treatments and prevention for caries disease, high level research exists for only topical fluoride, including toothpastes, mouth rinses, gels or varnish50, 51 pit and fissure sealants52 and perhaps to some extent, conservative caries removal.53, 54 All other treatment modalities and products have
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less or lower levels of evidence and practitioners are advised to use them to supplement (rather than replace) those with higher levels of evidence and to appraise the literature to determine whether the use of those agents would benefit the patient. The practitioner must also assist the
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patient in modification of behaviors that favor oral health. Conclusion
Best practices are an evolving approach to exceptional patient care and CAMBRA offers
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dental professionals the ability to apply the most clinically relevant, research-based and helpful interventions to real-life practice. The use of a CRA to guide the decision-making process
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supports this new evidence-based model to caries management that emphasizes a targeted approach to caries prevention and early, minimally invasive tooth preserving treatment. It is well understood that the cornerstone of dental hygiene practice rests with prevention and control of oral diseases. Dental hygienists are educated in oral disease detection and with
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dental hygiene diagnosis legal in some but not all states, they are responsible for recognizing disease indicators, risk factors, and protective factors related to dental caries. Dental hygienists actively promote the use of preventive and therapeutic methods for the treatment and prevention
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of dental caries and are well equipped to coordinate and conduct the CRA and implement strategies that will reduce the patient’s risk.
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The key to widespread adoption of CAMBRA philosophy lies in a team approach concept where each member of the oral health care team is involved and understands that every team member has a role: the front office staff member may introduce the patient to the CRA form in the reception area and is responsible for knowing the various billing codes attached to CAMBRA; the dental assistant may assist in gathering data necessary for the completion of the CRA form and educate the patient on various strategies; the dentist and dental hygienist will
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quarterback the prevention and treatment as well patient motivation for self-care. CAMBRA has emerged as the new paradigm in patient care and represents a patient-centered, best practices
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approach with the potential for significant advantages over traditional methods.
4.
5. 6. 7. 8. 9. 10. 11. 12.
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Dye BA, Li X, Beltran-Aguilar ED. Selected oral health indicators in the United States, 2005-2008. NCHS Data Brief 2012(96):1-8. Dye BA, Li X, Thorton-Evans G. Oral health disparities as determined by selected healthy people 2020 oral health objectives for the United States, 2009-2010. NCHS Data Brief 2012(104):1-8. Fontana M, Gonzalez-Cabezas C. Secondary caries and restoration replacement: an unresolved problem. Compend Contin Educ Dent 2000;21(1):15-8, 21-4, 26 passim; quiz 30. Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, et al. A Randomized Clinical Trial of Anticaries Therapies Targeted according to Risk Assessment (Caries Management by Risk Assessment). Caries Res 2012;46(2):118-29. Fontana M, Young DA, Wolff MS, Pitts NB, Longbottom C. Defining dental caries for 2010 and beyond. Dent Clin North Am 2010;54(3):423-40. Marsh PD. Microbiology of dental plaque biofilms and their role in oral health and caries. Dent Clin North Am 2010;54(3):441-54. Marsh PD. Microbial ecology of dental plaque and its significance in health and disease. Adv Dent Res 1994;8(2):263-71. Takahashi N, Nyvad B. Caries ecology revisited: microbial dynamics and the caries process. Caries Res 2008;42(6):409-18. Young DA FJ. Caries management by risk assessment. Community Dent Oral Epidemiol 2013;41:1–12. Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: caries management in the 21st century and beyond. J Calif Dent Assoc 2007;35(10):681-5. Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard tissue ultrastructure. Dent Clin North Am 2010;54(3):455-67. Yorty JS, Walls AT, Wearden S. Caries risk assessment/treatment programs in U.S. dental schools: an eleven-year follow-up. J Dent Educ 2011;75(1):62-7.
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Table 1
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CAMBRA- Components for Clinical Practice
Patient interview to review the health, dental, and social history to gather information related to dental caries disease
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Hard tissue examination and charting to identify location, severity and activity of carious lesions
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Caries risk assessment utilizing data gathered from the patient histories and examination
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Evidence-based treatment and prevention plan based on the patient’s risk level
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Figure 1: Caries Balance/Imbalance
. TABLE 2. Caries Risk Assessment Form for Ages 6 Years Through Adult
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CHART #: DATE: Is this (please circle) Baseline or Recall
Disease Indicators (Any one YES signifies likely “High Risk” and to do a bacteria load test**) New/Progressing visible cavitations or radiolucencies into dentin New/Progressing approximal enamel Lesions by radiograph New/Active White spots on smooth surfaces Restoration for caries lesion in the last 3 years (only for initial CRA exam)
YES = CIRCLE YES
YES = CIRCLE
YES YES YES
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Risk Factors (Biological predisposing factors) MS and LB both medium or high (by culture or ATP bioluminescence **) Visible heavy plaque on teeth Frequent snack (> 3x daily between meals) Deep pits and fissures Recreational drug use Inadequate saliva flow by observation or measurement (**If measured note the flow rate below) Saliva reducing factors (medications/radiation/systemic) Exposed roots Orthodontic appliances
YES= CIRCLE
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Patient Name: Assessment Date:
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YES YES YES YES YES YES YES YES YES
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Protective Factors YES 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 months YES 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) ** 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/#:
Date:
LOW
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Table 3: SAFER Protocol: An Example of clinical guidelines based on caries risk for patients 6 years through adult.
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Note: 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, the use of caries control procedures with glass ionomer materials until caries progression is halted and/or reversed may be used and followed with more permanent restorative care. Patients at risk with appliances (RPDs, Orthodontics) require excellent oral hygiene together with intensive fluoride therapy (e.g. high fluoride toothpaste and fluoride varnish every 3 mos). 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 for 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 6-10 gr/day for antimicrobial effects)
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Figure 2. Guidelines to follow when high level evidence is not an option
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