Put the Plan into Action

In 2007 the philosophy of caries management by risk assessment (CAMBRA) was introduced, providing dental professionals with a systematic approach to caries management.^1-3 The CAMBRA protocol includes a questionnaire that is used to assess caries risk. Risk factors are then assigned a numeric value based on severity of risk.

CAMBRA also includes bacteriologic tests and pH measurements of resting and stimulated saliva. When the numeric values of these tests are added together, the number corresponds to a specific risk category. Once assigned to a risk category, the patient is treated according to the guidelines for his or her specific category.^2,4 Caries risk reduction product choices are reviewed and discussed with patient.³ CAMBRA recommendations are all appropriate, but in order to establish a successful caries management program within a private practice setting, some modifications may be necessary.

IMPLEMENTATION

Our office began using CAMBRA protocols in 2007. Initially all attempts were made to replicate the original recommendations, however, we faced some significant challenges (see Table 1).
Because dental hygienists see patients frequently throughout the year, they are well suited to lead a caries management program. Most dental hygienists have approximately 45 minutes to 1 hour with each patient. As such, dental hygienists may not have enough time to complete the CAMBRA risk assessment documents and tests; educate the patient about the findings; gain consent for and then perform bacterial, salivary, and pH tests; and provide therapies.

Although dental hygienists have many responsibilities during initial and recare appointments, they can perform multiple risk assessments and review risk reduction protocols while performing an exam and prophylaxis. For instance, a review of the patient’s health history at the initial appointment and all recare appointments will reveal whether a patient is taking any xerostomia-inducing medications.

Clinical observations on the amount and quality of saliva, degree of bacterial plaque, and review of enamel and root surface conditions during the prophylaxis may indicate an increased risk of caries. There is generally adequate time for questions about diet, ooral-related habits, and possible infectious contact. Although formal testing of bacteria, salivary flow, and pH are appropriate, these tests can be time consuming and expensive. In a private practice setting, dental hygienists can routinely perform risk assessments through clinical examination and verbal questioning, and then use formal testing on those patients who are at extremely high risk of caries.

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TABLE 1. CHALLENGES ENCOUNTERED WHEN TRYING TO IMPLEMENT CAMBRA PROTOCOLS INTO PRIVATE PRACTICE.

• Time to complete the risk assessment handout/questionnaire.
• Limited evaluation of risk factors.
• Expense and time required for various bacterial, salivary, and pH tests.
• Compliance of patients with the many recommended products.
• Compliance/coordination of clinical office staff.
• Ineffectiveness of the products if used improperly.
• Cost of the recommended products.

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Dental hygienists play the primary role in our CAMBRA system, although each clinical staff member must be properly trained in order to augment implementation and promote success of the program. Dental assistants provide an important liaison between patients and clinicians because they enhance communication, aide in documentation, and provide support related to proper risk reduction procedures.

The dentist’s role is focused on diagnosis. The dentist diagnoses carious lesions and evaluates the degree of incipient lesions and overall condition of existing restorations based on clinical inspection and radiographic interpretation. These examinations are required at all initial and recare appointments. As attempts are made to reverse incipient carious lesions, an examination by the dentist is required approximately 4 weeks after the initial diagnosis.

ADDITIONAL RISK FACTOR EVALUATION

Numerous risk factors may predispose a patient to dental caries. The CAMBRA protocol suggests a variety of risk factors that, when compounded, place a patient into a specific risk category.⁴ We found that additional risk factors and alternative methods of risk assessment may provide a more accurate caries risk assessment. Table 2 lists the CAMBRA recommendations, with our modifications noted in italics.

Patients with removable partial dentures (RPDs) most commonly experience caries in the area of the guide plane or minor connector/clasps of the chrome-cobalt framework.^5,6 As such, we recommend these patients be placed in the high risk category (or extreme high risk category depending on other risk factors) and placed on a frequent recare schedule. Patients with extensive restorative therapy often have a history of dental destruction. Independent of other risk factors, these patients should be considered at high risk of dental caries. The condition and age of existing restorations should be documented to facilitate accurate monitoring.^7,8

When a restoration is placed, the margin between the restorative material and sound tooth structure is susceptible to caries because material shrinkage and marginal disparity are inevitable. Initial anecdotal observation revealed ineffective results following treatment with risk reduction protocols on open margin restorations. A systematic review of the literature suggested that 50% of all restorations last between 10 years and 20 years.⁹ This research shows that both the placement of restorations and a history of existing restorations place patients at a greater risk of caries.¹⁰ As a result, we modified the original risk assessment protocol to include the presence of six or more existing restorations as an indicator of high risk (or extreme high risk, dependent on other risk factors) for future caries incidence. This risk is independent of the date the restorations were placed.

Tobacco use decreases the amount of saliva produced in the oral cavity as well as its quality.^11,12 Among tobacco users, the pH buffering capacity of saliva is altered and the oral environment tends to be more acidic, which increases the risk of caries.¹¹ Tobacco users also tend to have higher levels of Lactobacilli and Streptococcus mutans.¹² A study conducted over 4 years with more than 300,000 subjects found that tobacco users were at increased risk of caries.¹³ We modified the original risk assessments to include smoking/smokeless tobacco use as an indicator of high caries risk. In addition to providing risk reduction protocols, patient education related to tobacco cessation is customized and support is offered.

At the age of 60 years, decay rates increase to higher than those of adolescents who grew up without the benefits of fluoride in the water supply.¹⁴ Older adults tend to have several caries risk factors, such as: xerostomia related to medication use or systemic conditions; a large amount of previously restored teeth; recession; fixed or removal partial dentures; diets high in sugars/carbohydrates with frequent snacking; and difficulty performing adequate home care.^14-16

The oral cavity does not necessarily become more dry with age.¹⁵ Xerostomia is often related to commonly diagnosed diseases. Undergoing chemotherapy or head and neck radiation, rheumatoid arthritis, diabetes, hypertension, anxiety, depression, Sjögren’s syndrome, and lupus can induce xerostomia.^14-16 Medication use, however, is the main cause. More than 400 medications list xerostomia as a side effect.¹⁵ Antihypertensives, antidepressants, analgesics, diuretics, decongestants, and antihistamines are common medications that can induce xerostomia.¹⁵ We modified the risk assessment profile to include age (60 years and older) as a high risk factor for caries (or extreme risk if other risk factors are present). In these cases, patient education is provided and risk reduction therapies are offered.

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Table 2. CAMBRA RECOMMENDATIONS FOR CARIES RISK ASSESSMENT WITH AUTHORS’ MODIFICATIONS IN ITALICS.

• Caries incidence within 3 years
• Incipient caries/demineralization
• Xerostomia
• Poor oral hygiene
• Deep pits and fissures
• Recession
• Diet high in carbohydrates/sugars
• Recreational drug use
• Orthodontics
• Nonfluoridated drinking water during childhood
• Removable partial dentures
• History of extensive prosthodontic or restorative therapy
• Older than 60 years
• Smoking
• Infectious contact

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Caries-causing bacteria are easily transmitted by close contact with infected saliva. It is estimated that most people have S. mutans within their oral cavity, despite not being born with this bacterium.^17,18 If a patient is at a low to moderate risk of caries but an immediate family member has active caries, the patient’s risk of tooth decay increases.¹⁸ Questioning the patient about his or her family’s recent caries history is prudent.^1,2,4 Additionally, the patient should be asked about social practices, such as sharing drinks or utensils when eating. Although patients can’t be expected to eliminate all contact with the saliva of others, dental professionals must educate patients about the importance of minimizing contact with infected saliva. Patients who have constant contact with infected saliva should be moved into a high risk category in order to more effectively prevent the disease.

RISK REDUCTION

The use of CAMBRA risk reduction protocols did not reduce the incidence of caries among patients in our practice. The costs of the products recommended by the CAMBRA protocol were substantial to both patients and dental offices. Prescriptions for products were routinely arranged for patients, however, they were infrequently filled. Protocols were also difficult for patients and clinicians to follow due to the number of products recommended and the different instructions for use.

Following a literature review, product evaluation with manufacturer representatives, and consultations with patients and clinical staff, we made modifications to our risk reduction protocols. Table 3 provides an overview of our modified CAMBRA protocol.

MODIFIED RISK REDUCTION THERAPIES

Fluoride cannot remineralize tooth structure without the presence of calcium and phosphate.^19,20 Decreases in salivary quality and quantity can negatively affect a patient’s calcium and phosphate levels.¹⁹ We decided to enhance the role of fluoride by recommending professionally-dispensed 1.1% NaFl2 toothpaste that also contains calcium phosphate to all high and extremely high risk patients.^21,22 We found that dispensing the toothpaste within the dental office vs providing a prescription increased patient compliance.

Additionally, this toothpaste reduced the need for multiple products that contained the ingredients separately, subsequently reducing the overall cost and risk of chemical interaction. Fluoride varnishes that include calcium and phosphate are also recommended to all patients in all risk categories.

An examination of the evidence related to chlorhexidine’s efficacy proved inconclusive.^23,24 Many studies suggest that chlorhexidine is not highly effective in preventing caries.^23,24 In our practice, we also experienced poor patient compliance with its use. Patients complained of tooth staining, negative taste, and high cost. The most frequent complaint was about the required time separation of 2 hours between use of the 5,000 ppm fluoride toothpaste and the chlorhexidine mouthrinse.

On average, there are between 400 microbes and 700 microbes present within the oral cavity.²⁶ Chlorhexidine gluconate has nonselective antimicrobial properties, and thus controls only two of these many microbes.²⁵ The potential ramifications of bacteriostatic and bactericidal solutions are simply not known. As a result, we eliminated chlorhexidine gluconate 0.12% rinses and chlorhexidine varnish from our prevention protocol.

OUTCOMES

Within 3 months of implementing these modifications, we saw encouraging results. Caries reduction in groups even at the highest risk levels was noted, and early carious lesions routinely reversed. In our most recent 2-year chart review, we had diagnosed 254 carious lesions using clinical and radiographic findings; of these 215 of the lesions appeared remineralized or stabilized.

Patients were pleased because they needed fewer dental appointments, the cost of treatment was reduced, and the discomfort associated with local anesthesia injections was eliminated.

A modified caries management program was established in our private practice and run primarily within our dental hygiene department with great success. With minimal change in their usual duties, all dental hygienists were trained to assess each patient’s risk of caries, provide risk reduction recommendations and protocols, and communicate to patients and staff through chart documentation and handouts. Quality of patient care improved and production increased with minimal effort from dentists and staff.

Through proper patient evaluation and appropriate application of evidence-based literature, we can reduce the risk of caries and promote the remineralization of carious lesions. Quality of life for all patients can be enhanced through the reduction of pain, decrease in the number of carious lesions, remineralization of carious infections, and, ultimately, the prevention of tooth destruction and tooth loss.

REFERENCES

1. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. J Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007;35:714–723.
2. 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.
3. Spolsky VW, Black BP, Jenson L. Products—old, new, and emerging. J Calif Dent Assoc. 2007;35: 724–737.
4. Young DA, Featherstone JD, Roth JR, et al. Caries management by risk assessment: implementation guidelines. J Calif Dent Assoc. 2007;35:799–805.
5. Tanaka J, Tanaka M, Kawazoe T. Logintudinal research on the oral environment of elderly wearing fixed or removable prostheses. J Prosthodont Res. 2009;53:83–88.
6. Miyamoto T, Morgano SM, Kumagai T, Jones JA, Nunn ME. Treatment history of teeth in relation to the longevity of the teeth and their restorations: outcomes of the teeth and maintained for 15 years. J Prosthet Dent. 2007;97:150–156.
7. Hickel R, Mahart J. Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent. 2001;3:45–64.
8. Goldstein GR. The longevity of direct and indirect posterior restorations is uncertain and may be affected by a number of dentist-, patient, and material-related factors. J Evid Based Dent Pract. 2010;10:30–31.
9. Downer MC, Azli NA, Bedi R, Moles DR, Setchell DJ. How long do routine dental restorations last? A systemic review. Br Dent J. 1999;187:432–439.
10. Fontana M, Ganzalez-Cabezas C. Secondary Caries and restoration replacement: an unresolved problem. Compend Contin Educ Dent. 2000;21:15–18, 21–24.
11. Parvinen T. Stimulated salivary flow rate, pH and lactobacillus and yeast concentrations in non-smokers and smokers. Scand J Dent Res. 1984;92:315–318.
12. Heintze U. Secretion rate, buffer effect and number of lactobacilli and Streptococcus mutans of whole saliva of cigarette smokers and nonsmokers. Scand J Dent Res. 1984;92:294–301.
13. Bartoloni JA, Chao SY, Martin GC, Caron GA. Dental caries risk in the U.S. Air Force. J Am Dent Assoc. 2006;137:1582–1591.
14. Ettinger R. Oral health and the aging population. J Am Dent Assoc. 2007;138:5S–6S.
15. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138(Suppl):15S–20S.
16. Stookey G. The effect of saliva on dental caries. J Am Dent Assoc. 2008;139(Suppl):11S–17S.
17. Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent. 2006;28:106–109.
18. Saarela M, von Troil-Lindén B, Torkko H, et al. Transmission of oral bacterial species between spouses. Oral Microbiol Immunol. 1993;8: 349–354.
19. Featherstone JDB. Remineralization, the natural caries repair process—the need for new approaches. Adv Dent Res. 2009;21:4–7.
20. Karlinsey R, Mackey A. Solid-state preparation and dental application of an oraganically modified calcium phosphate. J Mater Sci. 2008;44:346–349.
21. Karlinsy R, Mackey A, Stookey G. In vitro remineralization efficacy of NaF systems containing unique forms of calcium: a pilot study. J Dent. In press.
22. Karlinsey RL, Mackey AC, Stookey GK, Pfarrer AM. In vitro assessments of experimental NaF dentifrices containing a prospective calcium phosphate technology. Am J Dent. 2009;22: 180–184.
23. Twetman S. Antimicrobials in future caries control? A review with special reference to chlorhexidine treatment. Caries Res. 2004;38: 223–229.
24. Duarte AR Peres MA, Vieira RS, Ramos-Jorge ML, Modesto A. Effectiveness of two mouth rinses solutions in arresting caries lesions: a short-term clinical trial. Oral Health Prev Dent. 2008;6: 231–238.
25. Kuyyakanond T, Quesnel LB. The mechanism of action of chlorhexidine. FEMS Microbiol Lett. 1992;79:211–215.
26. Marsh PD. Dental plaque as a biofilm and microbial community-implications for health and disease. BMC Oral Health. 2005;6(Suppl 1):S14.

From Dimensions of Dental Hygiene. June 2011; 9(6): 70-73.