1. Implementation of CAMBRA into Clinical Practice
Karan Bershaw, MS, RDH
Dental Hygiene Clinician, Berkeley, CA

3. CAMBRA Caries Risk Assessment
Implemented during:
Dental hygiene care (existing client)
Comprehensive exam (new client)

4. Dental Hygiene Process of Care
Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
I thought the Dental hygiene process of care from Darby & Walsh provides a familiar framework for implementing CAMBRA into our DH care appointments
(Darby & Walsh, 2015)

5. North Berkeley Dental Arts Caries Risk Assessment
RISK LEVEL
BACTERIAL TEST
s. mutans & l. bacillus 10n/ml
ROOT EXPOSURE
DECAY
SALIVA FLOW
PLAQUE INDEX
FERMENTABLE CARBOHYDRATE SNACKS
APPLIANCES
LOW
3,3 No
None
>1.6ml/min.
<1
MODERATE
4,4
Yes
Interprox. radiolucency/
decalcified spots
Root
Surface Discoloration
1.6 ml/min.
<2
HIGH
5,4
5,5
1+ in dentin
<2pts>
1 soft or 1-2 Leather-like leasions on root surface <2pts>
ml/min.
2-3
2-3/day
VERY HIGH
6.5
6,6
2+ active
<3pts>
2+ Lesions on root surface
<0.7 ml/min. 3
3+/day
This CRA is adapted from and simplified from a compilation of dental schools risk assessment forms. It was designed to save time by circling what caries risk factors are relevant to client. Every box is worth 1 point, except these specific boxes, you need 5 pts to determine the caries risk. They are given more points due to the impact they have on the clients caries risk. This is filled out for the initial caries risk assessment.
*5 pts needed to determine caries risk

6. Caries Risk Assessment
DATE
CULTURE
s. mutans/
l. bacillus
PLAQUE INDEX
TREATMENT RECOMMENDATIONS
TREATMENT COMPLETION
MONITORING SITES
This the back side and is used for updates, notes, treatment and sites that are being monitored.

7. Dental Hygiene Process of Care
Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
I will start with Assessment
(Darby & Walsh, 2015)

8. Chart Assessment
Incorporate existing data from client chart to fill in the caries risk assessment
Like most of us, I start my morning by going through the charts prior to seeing clients. If the client does not have a caries risk assessment in his or her chart than I try to get that completed during their appointment. I start by gathering information that already exist in the client chart.

9. Chart Assessment Review health history:
Oral side effects of medications
Reduced salivary flow
Health conditions that could hinder the clients ability to perform effective homecare

10. Chart Assessment Disease indicators Restorations White spot lesions
Incipient lesions (watch)
Reasons for treatment, e.g. dental caries, fractures
Frequency of dental caries

11. Chart Assessment Caries risk factors:
Review periodontal charting for recession
Review previous oral hygiene instructions and recommendations for improvement in plaque control

12. Chart Assessment 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?

13. 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
With this I gaging their motivation and capability of compliance

14. This is a great visual aid in educating the client about caries.
(Featherstone, et.al., 2007 p. 705)

15. 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
If the primary care provider has had active decay then I would probably do a salivary culture on them and put them on the CAMBRA protocol for a high risk client. This is where a dental asisstant can help with time. They could do the culture on the care provider while I continue with the client.

16. Intraoral Assessment
Detect relevant data related to disease indicators and risk factors

17. Intraoral Assessment Saliva Assessments Salivary flow rate
Culture s. mutans and l. bacillus (new client or baseline culture for existing client)

18. 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

19. Intraoral Assessment
Examination of teeth to determine the location and severity of decalcifications and possible carious lesions

20. Dental Hygiene Process of Care
Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
(Darby & Walsh, 2015)

21. Determine Caries Risk Level (“Diagnosis”)
Use evidence-based decision making to determine a client’s caries risk
Low
Moderate
High
Extreme

22. CAMBRA Case 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?

23. North Berkeley Dental Arts Caries Risk Assessment
RISK LEVEL
BACTERIAL TEST
s. mutans & l. bacillus 10n/ml
ROOT EXPOSURE
DECAY
SALIVA FLOW
PLAQUE INDEX
FERMENTABLE CARBOHYDRATE SNACKS
APPLIANCES
LOW
3,3 No
None
>1.6ml/min.
<1
MODERATE
4,4
Yes
Interprox. radiolucency/
decalcified spots
Root
Surface Discoloration
1.6 ml/min.
<2
HIGH
5,4
5,5
1+ in dentin
<2pts>
1 soft or 1-2 Leather-like leasions on root surface <2pts>
ml/min.
2-3
2-3/day
VERY HIGH
6.5
6,6
2+ active
<3pts>
2+ Lesions on root surface
<0.7 ml/min. 3
3+/day
This CRA is adapted from and simplified from a compilation of dental schools risk assessment forms. It was designed to save time by circling what caries risk factors are relevant to client. Every box is worth 1 point, except these specific boxes, you need 5 pts to determine the caries risk. They are given more points due to the impact they have on the clients caries risk. This is filled out for the initial caries risk assessment.
*5 pts needed to determine caries risk

24. Caries Risk Assessment
DATE
CULTURE
s. mutans/
l. bacillus
PLAQUE INDEX
TREATMENT RECOMMENDATIONS
TREATMENT COMPLETION
MONITORING SITES
 6, 5
 < 2
 TAKE BWX 1/YEAR
3-4 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

25. Dental Hygiene Process of Care
Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
(Darby & Walsh, 2015)

26. Planning & Implementation
Design an evidence-based therapy appropriate for the client’s caries risk

27. 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

28. Planning & Implementation
My proposed treatment for Scarlett
Chlorhexidine rinse for 1 week/month, client may receive monthly reminder via text or
MI Paste – low salivary flow
3-4 month recall interval for dental hygiene care appointment
I would increase the frequency of DH recall, due to the reduced salivary flow and bacterial challenge. Just as you would for a client at higher risk for periodontal disease.

29. 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

30. 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

31. Dental Hygiene Process of Care
Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
(Darby & Walsh, 2015)

32. 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

33. 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

34. Dental Hygiene Process of Care
Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
(Darby & Walsh, 2015)

35. Documentation
Document client’s caries risk

36. 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
We will be adding an additional disease risk form to the chart to better follow a client’s risk for oral disease

37. 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)

38. 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

39. Motivation of Hygienists
Knowledge 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

40. 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

41. 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.

42. References
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.
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.
Hurlbutt, M (2011). CAMBRA Best practices in dental caries management. RDH 31:
CRT ® Bacteria:
Colgate ®:
GC America: MI Paste™:
Scott S, Fierce Conversations. (2004) New York, New York: Berkeley.