Reconnecting Practicing Hygienists with the Nation's Leading Educators and Researchers.

Managing the Risk of Caries

New horizons for dental hygiene in caries risk assessment and management (CAMBRA).

Coming in 2009!

This is the first in a three part series that will continue into 2009. The second installment will cover how to use the CAMBRA tools in the office. The third part offers advice on how to get a skeptical dentist on board with the CAMBRA approach.

Dental caries is the most common chronic disease of children in the United States.1 It remains a significant oral health problem world wide for both children and adults.2 The traditional mantra of “brush, floss, and avoid sugar” to prevent caries has proven unsuccessful in reducing the incidence of this preventable malady.

Current science in the modern management of dental caries suggests a clear focus on the elimination of the infectious agent and the remineralization of noncavitated lesions, as well as minimally invasive restorative approaches when necessary.3 This is the essence of managing caries risk, which, if practiced by all clinicians, could effectively reduce active caries in the population. The dental profession has shifted away from a pure surgical approach in favor of more preventive and curative clinical protocols.4 This rapidly evolving perspective on the treatment and prevention of dental caries requires new strategies by dental professionals if oral health is to be significantly affected. Caries management by risk assessment (CAMBRA) is an evidencebased strategy for preventive and reparative care for early dental caries that can be implemented in any dental office setting.3

The concept of prevention as the optimal method of caries reduction is not new to dental hygiene. It was this very belief that motivated Dr. Alfred Fones to develop the first dental hygiene program in 1914.5 In addition to delivering direct patient services, dental hygienists have historically provided prevention education in many forms. In spite of these efforts, dental decay remains a problem in the United States, especially in children and in dentally underserved communities.4 The United States Department of Health and Human Services statistics emphasize that “80% of caries in permanent teeth is concentrated in 25% of U.S. children.”6

Along with the periodontal health education that hygienists already provide, educating patients on minimizing caries risk is critical. The goal of CAMBRA is to educate and motivate patients to improve their behaviors and give them strategies and products to attain and maintain a healthy oral environment.7


Studies show that the microorganisms that cause caries are contagious and can be passed vertically, from parent or caregiver to child, or horizontally, between young children.8 Once risk factors are determined through the assessment process, the patients must be given strategies to reduce their caries risk.8 Drilling and filling as the sole treatment for caries are not the cure, because they do not modify the infectious biofilm causing the disease.9 Reduction of the infectious microorganisms, along with natural and chemically aided remineralization of the injured tooth surface, is proving to be the more conservative and longer lasting treatment for this disease.10

Dental schools are now beginning to integrate CAMBRA protocol into their curricula. By building on established risk assessment tools for periodontal disease, CAMBRA offers techniques that allow dental professionals to identify caries risk patterns and develop individualized treatment plans unique to each patient. In addition, improvements in restorative materials have allowed the dentist to place smaller, more conservative restorations.


Dental hygienists are the first line of defense in early caries intervention strategies. They currently perform many of the assessments and procedures used in the CAMBRA protocol. Among these steps are fluoride applications, dietary counseling, and placement of dental sealants. Fluoridated drinking water, toothpastes and rinses, calcium phosphate products, and professionally applied fluoride foams and varnishes are well-established vehicles for strengthening the tooth surfaces.11

Dental hygienists have the educational background to make dietary recommendations for caries-prone patients in an effort to maintain optimal oral pH, thereby preventing the onset of enamel demineralization. Dietary recommendations may include consuming acid-buffering dairy products, selecting xylitol as a sugar substitute, and reducing the frequent consumption of fermentable carbohydrates.12 The application of dental sealants by dental hygienists is a highly effective means of preventing pit and fissure caries.13

The ethical question must be raised that if dentistry, including dental hygiene, is to continue to treat the disease of dental caries, then the profession must do so using a current evidencebased approach to guide their clinical protocol. Over the last 2 decades, science has revealed that the caries process and its treatment are more complex than can be managed by the traditional model alone.


The evidence-based approach of CAMBRA includes assessing risk and, when necessary, repairing early damage using remineralization and or minimally invasive restorative techniques. In contrast to conventional management, this more contemporary model emphasizes the whole disease process, not just the cavitated end-stage lesion. Figure 1 depicts the imbalance often discovered in caries prone patients when disease indicators and risk factors outweigh protective factors. As shown in Figure 2, assessing risk for caries is based on questions that the dental hygienist asks at each appointment. The clinician must consider disease indicators and biological risk factors when assessing the degree of risk. Protective factors, listed in Figure 2, add therapeutic and preventive modalities that can decrease risk. Simply put, depending on a patient’s current risk level for caries development, recommendations should be made that are designed to reduce, eliminate, or reverse the caries.

The implementation of the CAMBRA assessment logically fits into the scope of practice of the dental team at the recare appointment. The CAMBRA protocol provides the opportunity for both dental hygienists and dental assistants to expand their roles and create an environment that improves the health of patients. Together, this team will be responsible for reviewing the medical history and performing the risk assessment. If a patient is at high risk for dental caries, a CAMBRA trained dental assistant can efficiently collect data from the caries risk assessment form, perform saliva testing, take radiographs and intraoral photos, and provide oral health education to the patient.7,14 The dental hygienist then proceeds with additional assessments that may include the use of a caries detection device on the occlusal surfaces of the teeth and recommendations for the use of antimicrobials, calcium phosphate products, and combination rinses.13 The collection of data is presented to the dentist for further analysis in determining therapeutic or restorative treatment.


Implementing CAMBRA into the scope of dental hygiene practice will provide individualized treatment from a risk assessment- based diagnosis and add value to the dental practice. CAMBRA supports itself financially. Many practices using CAMBRA also report increased acceptance of treatment plans after patients are caries free for first time in their lives. In other words, patients are confident that their investment in ideal restorative work will last and have a low risk of recurrent decay. As the business of dentistry becomes more complex, the dental hygienist and CAMBRA assistant can become more diversified in using their scope of practice to the fullest—generating greater revenue from the hygiene operatory.

Successful integration of CAMBRA depends on not just the dental hygienist, but on the entire team. The key to success is educating the patients and staff about the value of prevention. The dental hygiene role in clinical practice has always supported and encouraged behavior changes that will last a lifetime. Integration of CAMBRA into the dental hygiene process of care is a natural fit.7,15


A new standard of care is on the horizon for treating dental caries. Traditional methods of caries management have had limited efficacy in modifying the infectious bacterial etiology and eradicating disease. The oral health profession must rethink methodologies of caries risk management to continue its leadership in research and advocacy of treating dental caries. Integrating significant paradigm shifts in treatment philosophy and methodology can be challenging, however, research supports the rationale of the caries risk assessment as a fundamental element of contemporary clinical care. As the role of the dental hygienist continues to evolve, it is crucial to stay current on research and treatment options.


  1. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA. 2000;284:2625-2631.
  2. World Health Organization. Recommendations for preventing dental disease. Available at: nutrition/ topics/5_population_nutrient/en/index18.html. Accessed September 23, 2008.
  3. Young DA, Featherstone JDB, Roth JR, et al. Caries management by risk assessment: Implementation guidelines. J Calif Dent Assoc. 2007;35:799-805.
  4. Ramos-Gomez FJ, Crall JJ, Gansky SA, Slayton RL, Featherstone JDB. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). J Calif Dent Assoc. 2007;35:687-702. D
  5. ADHA History—Part One—Founding the Dental Hygiene Profession. Available at: Accessed September 23, 2008.
  6. Dental caries in U.S. children. Guide to Children’s Dental Care in Medicaid. Washington, DC: Department of Health and Human Services; 2004.
  7. Kutsch VK, Milicich G, Domb W, Anderson M, Zinman E. How to integrate CAMBRA into private practice. J Calif Dent Assoc. 200735: 778-785.
  8. American Academy of Pediatric Dentistry. Policy on early childhood caries: classifications, consequences, and preventive strategies. Available at: Accessed September 23, 2008.
  9. Young DA. New caries detection technologies and modern caries management: merging the strategies. General Dentistry. 2002;50:320-331.
  10. NIH Consensus Development Program. Diagonsis and management of dental caries throughout life. Available at: Accessed September 23, 2008.
  11. American Academy of Pediatric Dentistry. Policy on use of fluoride. Available at: deUse.pdf. Accessed September 23, 2008.
  12. Touger-Decker R, van Loveren C. Sugar and dental caries. Am J Clin Nutr. 2003;78(Suppl):881S-92D.
  13. Dental sealants in the prevention of tooth decay. Presented at: National Institutes of Health Consensus Development Conference Statement; 1983:4, 11.
  14. Gutkowski S, Gerger D, Creasey J, Nelson A, Young DA. The role of dental hygienists, assistants, and office staff in CAMBRA. J Calif Dent Assoc. 2007;35:786-789, 792-793.
  15. Jenson L, Budenz AW, Featherstone JDB, Gomez-Ramos FJ, Spolsky VW, Young DA. (2007). Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007;35:714-723.
  16. Featherstone JDB, Young DA, Domejean- Orliageut S, Jenson L, Wolff M. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35:703-713.

From Dimensions of Dental Hygiene. October 2008; 6(10):40,42, 44-45.

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