CAMBRA and water fluoridation collect supportive evidence, but what really stems the tide on caries?
By Diana Macri, RDH, BSDH, MSEd, AADH
Faculty in colleges and universities continuously strive to engage students in the process of critical thinking. There are many definitions for this term but, generally, the idea is to engage in thinking that is purposeful, focused, systematic, and designed to solve problems. In dentistry and dental hygiene, students are taught the process of evidence-based decision making, which entails the thinker breaking down the process into steps to seek and analyze higher levels of evidence and make decisions based on those findings. In the case of dental caries—a scourge on dentistry if ever there was one—this process is failing, as evidenced by the preposterous rate of decay: 91% of American adults (ages 20 to 64) have experienced dental decay,1 and 3.5 billion globally have caries.2
Dentistry’s consistent method of controlling this pandemic has been to utilize fluoride in every possible way. No method has received more attention than community water fluoridation, touted as one of the greatest public health inventions of all time.3 Throughout my dental career of 30-plus years, I’ve supported community water fluoridation and still do. However, my support—and the support of others—has not been enough to control the rate of caries among our patients.
Concerns over the safety of community water systems drive many to avoid drinking tap water. These concerns are not unfounded. The crisis in Flint, Michigan, has brought to the forefront the reality that water systems can become polluted, causing a myriad of disorders that cause severe developmental abnormalities and death.4 Additionally, the deleterious effects of fluoride consumption continue to be a topic of discussion and research. A 2006 report from the National Research Council found, among other things, that
• “fluoride might be associated with alterations in reproductive hormones, fertility, and Down’s syndrome”;
• IQ scores for children consuming fluoridated water at levels between 2 to 4 mg/L were lower than those of children consuming fluoridated water at levels between 0.4 to 1 mg/L; and
• fluoride inhibits the activity of cholinesterases, including acetylcholinesterase (an enzyme that catalyzes the breakdown of acetylcholine, which is important for mental stability and memory retrieval).5
It is understandable, then, that parents are concerned enough about the effects of fluoride consumption that they prefer their children drink bottled water (which rarely contains fluoride) instead of tap water.
Some American children have ingested excessive fluoride as evidenced by the increase in enamel fluorosis. In 1986 to 1987, 22.6% of adolescents aged 12 to 15 had dental fluorosis. In 1999 to 2004, that number jumped to 40.7%.6 Interestingly, children with fluorosis experience high levels of dental decay.7
Finally, many people substitute other beverages for water. The Institutes of Medicine reports that 80% of Americans’ hydration needs are met by intake of fluids (including beverages sweetened with sugar) and 20% is met through food consumption.8
A better way
Is there a better way to help our patients combat dental decay? This question was explored by Dr. John Featherstone and his colleagues over 20 years ago. Their research led to the creation of caries management by risk assessment, known as CAMBRA. (For an informative discussion of CAMBRA and caries risk management, see the October 2007 issue of the Journal of the California Dental Association.)
Dentists and dental hygienists graduating from programs within the last 10 years are familiar with this system, which entails the practitioner conducting a thorough clinical and health history assessment to determine the dental decay risk factors present. Practitioners then make patient-specific recommendations, respecting the patient’s autonomy and values, to tip the scales in favor of remineralization, reduce the presence of risk factors, or both.
There is a plethora of evidence proving CAMBRA’s efficacy in controlled research environments, but recently the Practice Based Research Network published the findings of their study in “the real world.”9 Researchers recruited 21 dentists and over 400 participants. After receiving training, the dentists provided restorative treatment and applied the CAMBRA techniques to an intervention group. At the end of the two-year study, both the intervention and control groups had lower percentages of high-risk patients, but the percentage of high risk patients in the intervention was significantly lower than the control group (25% versus 53.8%).
Dentists and dental hygienists have been slow to adopt CAMBRA into their practice. Studies have shown there is a lack of knowledge and application of evidence-based approaches among these professionals:
• Only 63% of dentists air dry a surface in order to diagnose caries.10
• Approximately one third of California dental hygienists (a very progressive state regarding dental hygiene practice) reported no familiarity with the term CAMBRA.11
• Only 44% of Maryland dental hygienists correctly identified that the quantity of sugar consumed is less important than frequency of consumption.12
• The AAPD recommendation that a child’s first dental visit should be by age one is “not common knowledge” among dentists.13
So, what we have here is an evidence-based approach to caries prevention which, coincidentally, costs the public nothing, has no unknown side effects, and also supports the adoption of healthy habits that contribute to quality of life and longevity. This aligns perfectly with the central mission of the profession of dental hygiene, which is primarily focused on disease prevention, and at least one of the goals of the American Dental Association: to improve the oral health of the public.
Would our patients be better served if we targeted the culprit more directly? Would we see a better return on investment if we focused our considerable resources (energy, money, and time) on reducing the amount of sugar Americans consume as opposed to incorporating fluoride into what they ingest?
Diana Macri, RDH, BSDH, MSEd, AADH, is an assistant professor at Hostos Community College in New York City. She can be contacted at
1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and tooth loss in adults in the United States, 2011–2012. Hyattsville, MD: National Center for Health Statistics; 2015. NCHS Data Brief 197.
2. Kassebaum NJ, Smith AGC, Bernabé E, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990–2015: a systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res. 2017;96(4):380-387. doi: 10.1177/0022034517693566.
3. Community water fluoridation. American Public Health Association website. https://www.apha.org/fluoridation.
4. Philip A, Sims E, Houston J, Konieczny R. 63 million Americans exposed to unsafe drinking water. USA Today website. https://www.usatoday.com/story/news/2017/08/14/63-million-americans-exposed-unsafe-drinking-water/564278001/. Published August 14, 2017. Updated August 15, 2017.
5. National Research Council of the National Academies. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. Washington, D.C.: National Academies Press; 2007.
6. Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental fluorosis in the United States, 1999-2004. Hyattsville, MD: National Center for Health Statistics; 2010. NCHS Data Brief 53.
7. Jiménez-Farfán MD, Hernández-Guerrero JC, Juárez-López LA, Jacinto-Alemán LF, de la Fuente-Hernández J. Fluoride consumption and its impact on oral health. Int J Environ Res Public Health. 2011 Jan;8(1):148-60. doi: 10.3390/ijerph8010148.
8. Institute of Medicine of the National Academies. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, D.C.: National Academies Press; 2005.
9. Rechmann P, Jue B, Santo W, Rechmann BMT, Featherstone JDB. Calibration of dentists for caries management by risk assessment research in a practice based research network - CAMBRA PBRN. BMC Oral Health. 2018;18(1):2.
10. Norton WE, Funkhouser E, Makhija SK, et al. Concordance between clinical practice and published evidence: findings from the National Dental Practice-Based Research Network. J Am Dent Assoc. 2014;145(1):22-31.
11. Urban RA, Rowe DJ. Knowledge, attitudes and practices of dental hygienists regarding caries management by risk assessment. J Dent Hyg. 2015 Feb;89(1):55-62.
12. Clovis JB, Horowitz AM, Kleinman DV, Wang MQ, Massey M. Maryland dental hygienists’ knowledge, opinions and practices regarding dental caries prevention and early detection. J Dent Hyg. 2012;86(4):292-305.
13. Horowitz AM, Kleinman DV, Child W, Radice SD, Maybury C. Perceptions of dental hygienists and dentists about preventing early childhood caries: A qualitative study. J Dent Hyg. 2017;91(4):29-36.