20 Tips on CAMBRA
Effectively Treating Dental Caries
V. Kim Kutsch, DMD

Dental Caries
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. Dental caries is a complex interaction of bacterial, dietary, behavioral, environmental, socio-economic, and physiological factors. It is a biofilm disease that includes numerous bacteria. The point for practitioners is instead of focusing or targeting one or two bacterial species in their therapy, they should look at treating the biofilm dysfunction, which is driven by prolonged periods of low pH.

Treatment
To effectively treat dental caries, the teeth must be restored to function and the dental biofilm behavior needs to be corrected to health. Dentists have traditionally spent the majority of their clinical time actively treating and restoring the serious damage caused by dental caries. Cosmetic dentists have added the focus of making these repairs with tooth-colored materials. They provide services that range from complete restoration of the caries-ravaged smile to elective cosmetic services for the healthy smile. For the patient with active dental caries, the greater the extent of the disease and restorative need, the greater the risk of restoration failure due to recurring decay. The cosmetic dentist can provide excellent esthetic care with predictable treatment outcomes by addressing and correcting the caries biofilm disease, in addition to adhering to a careful esthetic restorative plan.

  1. Caries management by risk assessment (CAMBRA) is a standard of care that includes early risk assessment and diagnosis of the caries disease process and then
    Figure 1: Any elective cosmetic dental procedure can be performed with confidence for a patient with a healthy smile.
    Figure 2: Patients at risk for or with active dental caries must have the biofilm dysfunction treated, as well as cosmetic restorations to ensure a predictable and successful long-term outcome.
    Figure 3: Patients with xerostomia represent a special risk, with unique needs related to their therapeutic strategies.
    treatment with minimally invasive procedures.
  2. The best approach to CAMBRA is to create a system within your practice to identify and treat patients at risk for dental caries.
  3. Involve and educate your dental team about caries risk assessment and have them help develop the system, from appointment scheduling to fees.
  4. The most successful CAMBRA system is simple for the team to implement. CAMBRA starts with risk assessment followed by diagnosis and then development of treatment strategies.
  5. Start with a standardized caries risk assessment form that is used for all patients in the practice. Several standardized caries risk assessment (CRA) forms are available. The CRA form has been clinically validated by Dr. John Featherstone at the University of California, San Francisco. 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 (Fig 2), the real intent of the CRA form is not to identify these patients, but rather to 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, counseling should be directed to the behaviors that can be modified and provide therapeutic strategies to overcome the risk factors that cannot be modified by behavioral counseling. Consider 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 an endpoint to therapy. Adenosine triphosphate bioluminescence is a rapid, simple, accurate chair-side biometric test that involves just 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 varnish.5 At-risk patients should receive an immediate fluoride varnish and then on a regular basis every three months until they are healthy. Fluoride varnish provides excellent fluoride retention, causes less discomfort, and achieves greater patient compliance.6,7
  11. Other fluoride products belong in your therapeutic plan. Consider adding fluoride toothpaste, rinse, or gels as appropriate for your patient’s individual needs.
  12. Antimicrobial agents provide a bacterial load reduction and give the commensal bacterial an opportunity to re-establish control of the biofilm. Chlorhexidine has been a standard antimicrobial agent, although it has little activity on Lactobacillus. Sodium hypochlorite in an oral rinse works as a rapid broad-spectrum antimicrobial agent. 
  13. Xylitol, a five-carbon, naturally-occurring sugar alcohol, is a proven anti-caries agent. The cariogenic bacteria ingest the xylitol, cannot metabolize it, and expend energy to expel it from their cells. Xylitol is known to potentiate even small amounts of fluoride.
  14. It makes sense to correct the biofilm pH dysfunction by creating pH strategies and frequently using products that neutralize the biofilm. This drives remineralization and also selects for healthy commensal bacteria in the biofilm. 
  15. Dietary counseling plays an important role for many patients at high risk for caries. Frequent snacking results in periods of low pH, contributing to dental caries dysfunction of the biofilm.
  16. Many risk factors cannot be modified by counseling. Patients on multiple medications often experience medication-induced xerostomia, and the low saliva volume reduces their ability to neutralize their mouth following eating, increasing their caries risk.
  17. Saliva is already supersaturated with calcium phosphate, hydroxyl apatite and fluor-apatite, but the xerostomic patient does not have enough saliva to begin with, so it makes sense to add a form of calcium phosphate supplement to their oral hygiene regimen (Fig 3).
  18. Probiotics are products that have bacteria added to them to help influence the bacterial mix of the biofilm. While many of the probiotic bacteria being used are aciduric, this approach may have anti-caries potential in the future. 
  19. It is important to keep the treatment regimen simple for patients; a complicated regimen may well result in non-compliance and ultimate failure.
  20. For patients at risk for caries, it is important to provide recare appointments at three-month intervals to reevaluate them; and to provide ongoing counseling and supportive care to create a healthy smile and keep them cavity-free.  
     

References

  1. Kutsch VK, Kutsch CL, Nelson BC. A clinical look at CAMBRA. DPR. 2007 Aug;41(8):62-7.
  2. Takahashi N, Nyvad B. Caries ecology revisited: microbial dynamics and the caries process. Caries Research. 2008; 42(6):409-18.
  3. Palmer CA, Kent R, Loo CY, Hughes CV, Stutius E, Pradhan N, Dahlan M, Kanasi E, Arevalo Vasquez SS, Tanner AC. Diet and caries-associated bacteria in severe early childhood caries. J Dent Res. 2010 Nov;89(11):1224-9.
  4. Domejean-Orliaquet S, Gansky SA, Featherstone JD. Caries risk assessment in an educational environment. J Dent Educ. 2006 Dec;70(12):1346-54.
  5. Azarpazhooh A, Main PA. Fluoride varnish in the prevention of dental caries in children and adolescents: a systematic review. J Can Dent Assoc. 2008 Feb;74(1):73-9.
  6. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Dent Educ. 2007 Mar;71(3):393-402.
  7. Quock RL, Warren-Morris DP. Fluoride varnish: the top choice for professionally applied fluoride. Tex Dent J. 2010 Aug;127(8):749-59.