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Implementation of

CAMBRA into Clinical

PracticeKaran Bershaw, MS, RDH

Dental Hygiene Clinician, Berkeley, CA

karanrdh@gmail.com

www.karanbershaw.com

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CAMBRACaries Risk Assessment

Implemented during:

Dental hygiene care (existing client)

Comprehensive exam (new client)

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Assessment

Diagnosis

Planning

Implementation

Evaluation

Documentation

Dental Hygiene Process of Care

(Darby & Walsh, 2015)

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RISK LEVEL

BACTERIAL TEST

s. mutans & l. bacillus

10n/ml

ROOT EXPOSURE

DECAYSALIVA FLOW

PLAQUE INDEX

FERMENTABLE CARBOHYDRATE

SNACKSAPPLIANCES

LOW 3,3 No None>1.6ml/

min.<1 <1 No

MODERATE 4,4 Yes

Interprox. radiolucency/

decalcified spots

RootSurface

Discoloration1.6 ml/min. <2 <2 No

HIGH5,45,5

Yes1+ in dentin

<2pts>

1 soft or 1-2 Leather-like

leasions on root surface <2pts>

0.7-1.6 ml/min.

2-3 2-3/day Yes

VERY HIGH6.56,6

Yes2+ active<3pts>

2+ Lesions on root surface

<3pts>

<0.7 ml/min.<2pts>

3 3+/day Yes

North Berkeley Dental ArtsCaries Risk Assessment

*5 pts needed to determine caries risk

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Caries Risk Assessment

DATECULTURE

s. mutans/l. bacillus

PLAQUE INDEX

TREATMENT RECOMMENDATIONS TREATMENT COMPLETION MONITORING SITES

           

           

           

           

           

           

           

           

           

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Assessment

Diagnosis

Planning

Implementation

Evaluation

Documentation

Dental Hygiene Process of Care

(Darby & Walsh, 2015)

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Chart Assessment

Incorporate existing data from client chart to fill in the caries risk assessment

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Review health history:

Oral side effects of medications

Reduced salivary flow

Health conditions that could hinder the clients ability to perform effective homecare

Chart Assessment

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Disease indicators

Restorations

White spot lesions

Incipient lesions (watch)

Reasons for treatment, e.g. dental caries, fractures

Frequency of dental caries

Chart Assessment

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Chart Assessment

Caries risk factors:

Review periodontal charting for recession

Review previous oral hygiene instructions and recommendations for improvement in plaque control

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Radiographs

Review for existing dentistry Frequency taken based on previous dental treatment:

Would I recommend increasing the interval?

Would I recommend decreasing the interval?

Would I recommend keeping it the same?

Chart Assessment

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Chairside Assessment

Client interview to review the health, dental and social histories and gather information related to food and snack choices.

Within this interview I introduce CAMBRA and the use of the caries risk assessment form as a preventive tool the office is using to better assess and improve oral health

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(Featherstone, et.al., 2007 p. 705)

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Chairside Assessment

If the client is a child, then I would interview the care giver about the child’s health and dental history

If the primary care giver has had active decay in the last 12 months, we assume the child is at high risk for dental caries

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Intraoral Assessment

Detect relevant data related to disease indicators and risk factors

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Intraoral Assessment

Saliva Assessments

Salivary flow rate

Culture s. mutans and l. bacillus (new client or baseline culture for existing client)

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Intraoral Assessment

Plaque index

Disclose for visual clarification

Client oral hygiene educational tool

Take a photo for baseline visual record and use to compare at future appointments

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Intraoral Assessment

Examination of teeth to determine the location and severity of decalcifications and possible carious lesions

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Assessment

Diagnosis

Planning

Implementation

Evaluation

Documentation

Dental Hygiene Process of Care

(Darby & Walsh, 2015)

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Determine Caries Risk Level (“Diagnosis”)

Use evidence-based decision making to determine a client’s caries risk

Low Moderate High Extreme

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CAMBRACase Scenario

Scarlett is a 65 year old healthy female, but has reduced salivary flow.  She has generalized moderate recession with 2 non-soft root lesions on posterior teeth. She has a very high culture reading (6, 5), moderate plaque index and snacks infrequently . In your opinion, what is Scarlett’s caries risk?

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RISK LEVEL

BACTERIAL TEST

s. mutans & l. bacillus

10n/ml

ROOT EXPOSURE

DECAYSALIVA FLOW

PLAQUE INDEX

FERMENTABLE CARBOHYDRATE

SNACKSAPPLIANCES

LOW 3,3 No None>1.6ml/

min.<1 <1 No

MODERATE 4,4 Yes

Interprox. radiolucency/

decalcified spots

RootSurface

Discoloration1.6 ml/min. <2 <2 No

HIGH5,45,5

Yes1+ in dentin

<2pts>

1 soft or 1-2 Leather-like

leasions on root surface <2pts>

0.7-1.6 ml/min.

2-3 2-3/day Yes

VERY HIGH6.56,6

Yes2+ active<3pts>

2+ Lesions on root surface

<3pts>

<0.7 ml/min.<2pts>

3 3+/day Yes

North Berkeley Dental ArtsCaries Risk Assessment

*5 pts needed to determine caries risk

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Caries Risk Assessment

DATECULTURE

s. mutans/l. bacillus

PLAQUE INDEX

TREATMENT RECOMMENDATIONS TREATMENT COMPLETIONMONITORING

SITES

   6, 5  < 2  TAKE BWX 1/YEAR3-4 MONTH RECALL

SILVER FLUORIDE (AgF) ON MONITORED SITES AT DH APPT (arrest)

#3 B#19 B

      CHLORHEXIDINE DAILY FOR 1 WEEK/MONTH

USE AgF ON POSTERIOR ROOT SURFACES FOR PREVENTION

 

      BRUSH 2X DAY WITH PREVIDENT

FM FLUORIDE VARNISH AT DH APPT

 

      XYLITOL GUM AT LEAST 6 G/DAY

   

      MI PASTE    

           

           

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Assessment

Diagnosis

Planning

Implementation

Evaluation

Documentation

Dental Hygiene Process of Care

(Darby & Walsh, 2015)

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Planning & Implementation

Design an evidence-based therapy appropriate for the client’s caries risk

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Planning & Implementation

My proposed treatment for Scarlett

Oral hygiene instruction for better plaque control – mechanically displace the biofilm

Recommend gum or candies sweetened with 100% xylitol (6-10 g/day)

5000 ppm toothpaste 2x day

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Planning & Implementation

My proposed treatment for Scarlett

Chlorhexidine rinse for 1 week/month, client may receive monthly reminder via text or email

MI Paste – low salivary flow

3-4 month recall interval for dental hygiene care appointment

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Planning & Implementation

My proposed treatment for Scarlett

Professionally applied AgF (silver fluoride) on the incipient lesions for arrest and all posterior root surfaces for prevention, in conjunction with full mouth fluoride varnish at the 3-4 month dental hygiene care appointment

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Products We Dispense from North Berkeley Dental Arts

Prevident 5000

Prevident 5000 for dry mouth

MI Paste (ACP & CCP) e.g. Recaldent

Chlorhexidine rinse

Chlorhexidine rinse without alcohol

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Assessment

Diagnosis

Planning

Implementation

Evaluation

Documentation

Dental Hygiene Process of Care

(Darby & Walsh, 2015)

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Evaluation

Subsequent dental hygiene care appointments

Review caries risk assessment with Scarlett

Oral hygiene instructions

Health changes

Rescore plaque index

AgF on incipient lesions and posterior root surfaces, followed with full mouth varnish

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Evaluation

Subsequent dental hygiene care appointments

Review the use of dispensed products

5000ppm toothpaste

Chlorhexidine rinse 1 week/month

Note any changes in monitored sites

Consider need for modification of treatment

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Assessment

Diagnosis

Planning

Implementation

Evaluation

Documentation

Dental Hygiene Process of Care

(Darby & Walsh, 2015)

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Documentation

Document client’s caries risk

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Documentation

Paper chart

Caries risk assessment form in chart (blue card stock)

Add client’s caries risk to route slip

Future electronic chart

We will add pop-up alert

Add caries risk to the schedule

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Motivation of Our Dental Team

Started with the Dentist

Standard of care

CAMBRA prepares the practice for the coming changes in dentistry

Clients appreciate prevention focused oral care, treat the infection, not just the signs & symptoms

Value added service (benefit to client & practice)

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Motivation of Dental Assistants and Administrative Staff

Knowledge is key

Lunch & learn to start the CAMBRA education process

Basics of Biofilm Role of pH Demineralization & Remineralization Products dispensed from office

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Motivation of HygienistsKnowledge is key

Reviewed CAMBRA guidelines to ensure comprehension and achieve buy-in

Requested recommendations for modifications of guidelines and caries risk assessment form

Reviewed products used during the dental hygiene care appointment & products dispensed

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Current State of CAMBRA at North Berkeley Dental Arts

Knowledge is key

Review and update knowledge

A form to improve communication of client’s disease risk status to insure continuity of care

Dental team recommendations or improvements to be made to CAMBRA protocols

What’s working well & address what’s not

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Conclusion

CAMBRA is a dental practice philosophy. By initiating broad implementation of CAMBRA, our dental team has a renewed enthusiasm for helping our clients achieve optimum oral health. As you can see from my presentation today there are many ways to implement CAMBRA and it’s ever-evolving.

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References1. Darby, M.L. & Walsh, M. Dental Hygiene Diagnosis. In Dental Hygiene Theory and

Practice (4th ed.). Editors Darby, M.L. & Walsh, M. (2015). St-Louis, Missouri: Saunders Elsevier.

2. Featherstone JD, Domejean-Orliaguet S, Jensen L, et al: Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 35:703, 2007.

3. Hurlbutt, M (2011). CAMBRA Best practices in dental caries management. RDH 31:95-108.

4. CRT ® Bacteria: www.ivoclarvivadent.com/en/products/.../crt-bacteria

5. Colgate ®: www.colgateprofessional.com/products/colgate-prevident-5000

6. GC America: MI Paste™: www.gcamerica.com/products/preventive/MI_paste

7. Scott S, Fierce Conversations. (2004) New York, New York: Berkeley.

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