CAMBRA, one bite at a time: To eat the elephant of caries management, swallow after each bite

The CAMBRA philosophy can best be summed up by the World Federation of Dentistry Vision 2020-to create a world free of caries. Sounds impossible? That is exactly the crux of the change needed to implement CAMBRA, the belief that a caries-free world is possible.

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By Patti DiGangi, RDH, BS

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How do you eat an elephant? One bite at a time. We all know the saying, but we often fail to apply this lesson in our lives. If you view the elephant as one giant goal, you're setting yourself up for disappointment. Why not enjoy the bites along the way?

CAMBRA is the elephant in the room. You've read about it, and taken a course here and there that talks about it. Yet, you still don't know where to start to incorporate it routinely into your practice. So let's make it simple and take three small bites to start.

Step 1

Believe in a caries-free world

Dentistry, particularly through the efforts of a hard-working dental hygienist like you, has made amazing strides in assisting patients to become healthier. At the same time, none of us have seen a patient with "too much" health. That almost sounds silly. We know there are levels of health just as there are levels of disease. CAMBRA seeks to create higher levels of health, not just the absence of disease.

The CAMBRA philosophy can best be summed up by the World Federation of Dentistry Vision 2020-to create a caries-free world. Sounds impossible? That is exactly the crux of the change needed to implement CAMBRA, the belief that a caries-free world is possible.

CAMBRA embraces three levels of prevention:

  • Primary prevention, which means to entirely avoid the development of disease by eliminating or allaying the principal risk factors.
  • Secondary prevention means early detection at a stage at which intervention may lead either to an outright cure or to a significant reduction in damage.
  • Tertiary prevention means to reduce the risk of disease recurrence following treatment, and minimizing the risk of disease-related complications. Though we need to practice all three levels, the best prevention is primary prevention that identifies risk.

The Centers for Disease Control and Prevention provides statistics on the current state of caries infection in the United States. Their March 2015 brief shows:

  • Approximately 23% of children aged 2 to 5 years had dental caries in primary teeth.
  • Untreated tooth decay in primary teeth among children aged 2 to 8 was twice as high for Hispanic and non-Hispanic black children compared with non-Hispanic white children.
  • Among those aged 6 to 11, 27% of Hispanic children had any dental caries in permanent teeth compared with nearly 18% of non-Hispanic white and Asian children.
  • About three in five adolescents aged 12 to 19 had experienced dental caries in permanent teeth, and 15% had untreated tooth decay.
  • Caries infection is not limited to children. Another CDC study in May 2015 followed adults:
  • Among adults aged 20 to 64, 91% had dental caries and 27% had untreated tooth decay.
  • Untreated tooth decay was higher for Hispanic (36%) and non-Hispanic black (42%) adults compared with non-Hispanic white (22%) and non-Hispanic Asian (17%) adults aged 20 to 64.
  • Adults aged 20 to 39 were twice as likely to have all their teeth (67%) compared with those aged 40 to 64 (34%).
  • About one in five adults aged 65 and over had untreated tooth decay.

These statistics clearly indicate that not everyone is equally at risk for caries infections. The best way to determine who is at risk and what puts them at risk is to use specific methodologies to assess risk. One size never really fits everyone. This one bite is just a beginning.

Step 2

Create your individual scientific basis for CAMBRA CE curriculum

Internalizing the belief that a caries-free world is possible doesn't happen overnight. You have some deeply held philosophies from your education, past science, your perspectives, experiences, and self-reinforcing beliefs. These need to be unlearned or replaced with new beliefs. Replacing these beliefs can happen when you explore and learn more about the scientific basis for CAMBRA. One way to do this is to create your own CAMBRA CE curriculum.

There are many online, written, and in-person courses. Some options include:

  • The California Dental Association offers a Practitioner's Guide to CAMBRA at no cost. (cdafoundation.org)
  • Another great resource is "CAMBRA: Best Practices in Dental Caries Management," by Michelle Hurlbutt, RDH, MSDH. (INeedCE.com)
  • Dr. John Featherstone, often considered the father of CAMBRA, offers a six-week online CAMBRA course through coursera.com.
  • RDH Under One Roof 2016 Conference this July 28-30 is a can't-miss when learning about CAMBRA. Courses include Brian Novy's "How to Eat Candy," Anne Guignon's "Exploring the Oral Microbiome," and Susan Gorman and Maria Davila will present "The Role of the Dental Hygienist in the Reduction of Early Childhood Caries." (RDHUnderOneRoof.com)

This list barely scratches the surface, yet it is a bite.

Step 3

Risk assessment forms you can start using tomorrow

This step can be added tomorrow, and there are CDT codes. Let's look at the codes to help understand why these basic risk assessment forms are an important beginning step that should not be skipped.

The American Dental Association created the caries risk assessment forms that were in the CDT 2011-2012 book. This was followed by the addition of three new caries risk assessment codes in CDT 2014. The new codes are:

  • D0601 caries risk assessment and documentation, with a finding of low risk
  • D0602 caries risk assessment and documentation, with a finding of moderate risk
  • D0603 caries risk assessment and documentation, with a finding of high risk.

"And documentation" is not in bold in the CDT book. It is done here to emphasize the importance of tangible measurement systems that can be recorded, documented, and compared. The description for all three codes is: "Using recognized assessment tools." These caries risk codes are not codes for specific treatments; they are to determine risk.

These forms can be found online and through other systems. The sidebar lists where you can download some of the basic caries risk assessment forms. (Contact me at info@pdigangi.com if you don't want to type in the link.) In addition, for iPhone and iPad users, there is an app called MyCAMBRA that can be downloaded at the iTunes store.

CariFree (CariFree.com) is a company that created an entire system for assessing risk. In addition to risk forms, they offer a very simple test with their CariScreen that measures ATP. If you remember back to the citric acid cycle, also known as the Krebs cycle, ATP stands for adenosine triphosphate and is the energy molecule in all living cells. The CariScreen provides the opportunity to measure bacterial load and biofilm activity levels as they relate to health, and it only takes a few minutes to get a tangible score.

The purpose of each of these is not to find cavities but rather to use a systematic method for assessing risk. Only when risk is identified can the correct therapies be considered. So often dental professionals think in terms of therapies. We run to "fix" something before we know what's causing and contributing to it. The best prevention is primary prevention, to entirely avoid the development of disease by eliminating or allaying the principal risk factors.

Start this bite the next time you see patients. You probably won't use it for every patient at first. These forms are not for patients to fill out. They are for you to work with patients to learn some answers. Download them and fill out a couple for yourself. Yes, that's a small bite.

So what do you believe? Is disease inevitable? Is our role to manage it? Or are you starting to believe a caries-free world might be possible? If you are beginning to believe the last statement, you cannot continue to do what you have always done, even though it has brought significant success. It has not brought enough success. It is not time to rest on the laurels of our successes.

As a philosopher once said, "I am only one, but still I am one. I cannot do everything, but still I can do something; and because I cannot do everything, I will not refuse to do the something that I can do. You can do something and you can make a difference." Take one step toward eating the elephant. RDH

Links for Caries Risk Assessment Forms

  • ADA Caries Risk Assessment Form for older than 6 years old ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx
  • ADA Caries Risk Assessment Form for ages 0-6 ada.org/~/media/ADA/Member%20Center/FIles/topics_caries_under6.ashx
  • AAPD (American Academy of Pediatric Dentistry Caries Risk Form for ages 0-3. aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf
  • CariFree Risk Assessment Form carifree.com/media/wysiwyg/CRA_Form_CTx_v8.pdf

Patti DiGangi, RDH, BS, is a certified health information technology trainer shaping the changes in our interoperable electronic health record world. Patti is an ADA Evidence Based Champion and holds publishing and speaking licenses for "Current Dental Terminology" (ADA) and SNODENT Coding. She is the author of the DentalCodeology series of bite-size books for busy people. Patti was awarded the 2014 Sunstar Award of Distinction and the 2013 Sonicare Mentor of Distinction award. Visit DentalCodeology.com for more information about her books.

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