1. Introduction to CAMBRA
Job Corps Health and Wellness Webinar
June 30, 2010

2. Presenters Pamela Alston, DDS, MPP
Job Corps Principal Dental Consultant, Humanitas, Inc.
Keri Cassinelli, BS, RDH
Dental Hygienist, Sierra Nevada Job Corps Center

3. Continuing Education Information
“This activity has been planned and implemented in accordance with the standards of the Academy of General Dentistry Program Approval for Continuing Education (PACE) through the joint program provider approval of the National Dental Association and Humanitas, Inc. The National Dental Association is approved for awarding FAGD/MAGD credit.”
CE Partners
National Dental Association
Humanitas, Inc.

4. CAMBRA Caries Management By Risk Assessment Scientifically proven
Evidence based
Patient specific

5. Prevalence of Caries 77.9% of 17 years olds have dental caries
Low socioeconomic status increases risk
Source: U.S. Department of Health and Human Service. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

6. Introduction to CAMBRA—Caries Management by Risk Assessment
“What am I doing to help the students prevent more cavities from forming?”

7. Treating Carious Lesions vs. Treating the Cause of Carious Lesions
Failure to treat the cause of the caries lesions is like lathering dirty dishes and putting them in greasy rinse water. You’ll just have to lather them again.

8. Topics Caries balance and imbalance Caries risk assessments
Therapeutic regimens
Student self-responsibility
JC oral health & wellness team-members’ responsibility

9. Agenda
Pre-test
CAMBRA
Discussion
Post-test
Webinar evaluation

10. Learning Objectives
After participating in this webinar, the participant should be able to:
Understand the role of caries risk assessment in prevention
Understand how caries is an infectious disease in which the balance between cariogenic oral biofilm and the tooth becomes compromised
Describe the components of the CAMBRA approach
Put all of the learning objectives on one slide.

11. CAMBRA Principles Modification of the oral flora to favor health
Patient education and informed participation
Remineralization
Minimal operative intervention

12. Definitions
Dental caries—an infectious disease leading to loss of mineralized tissue in the tooth structure
Risk assessment—determining the risk for tooth decay in the future
Caries balance—balance among disease indicators, risk factors, and protective factors
Caries management—altering the balance between caries pathological and protective factors

13. Job Corps Priority Classification System of Lesions
Priority 1 or 2
Source: Andréa Ferreira Zandoná and Domenick T. Zero, “Diagnostic Tools for Early Caries Detection,” JADA, 2006, 137(12); , Copyright © 2006 American Dental Association. All rights reserved. Reprinted by permission.

14. CAMBRA Clinical Study Featherstone JDB, Gansky SA, et al.
A randomized clinical trial of caries management by risk assessment.
Caries Res 39:295 (Abstract #25), 2005

15. CAMBRA Clinical Study Conclusions
The Caries Balance concept is confirmed
Fluoride alone cannot overcome a high bacterial challenge
Restorations don’t reduce bacterial loading
Chemical therapy markedly reduces level of new caries

16. Biofilm
Due to time constraints and the broad topic matter we are covering today. It is my intent to briefly cover what biofilms are and their role in the carious process.
Dental Plaque

17. What are biofilms?
“Biofilms are communities of micro-organisms encased within an extra cellular polymeric slime (Eps) matrix living on surfaces.”(1)
Biofilms form when bacteria are exposed to a wet surface.

18. Where do we see biofilms?
They are everywhere! We see them on kitchen surfaces, bathrooms, fish tanks, coffee mugs, and in our mouth.
Dental plaque is a form of biofilm.

20.
Film sequence by Dr. Wenyuan UCLA, provided by Dr. V. Kim Kutsch

21. Bioflims and Carious Lesions
How do biofilms lead to cavitation?
Should be lesions?

22. Low pH
This is the most important fact to understand. Without an acidic environment (pH of 4.8 and lower) there would be no demineralization and cavitation.

23. What Creates a Lower pH?
Initial changes in environment due to any one factor: saliva flow decreases, poor diet, or poor homecare, can lead to an acidic pH in the mouth.

24. Demineralization
Anaerobic, acid-producing bacteria in plaque biofilm produce and increase amount of acid due to fermentation, causing the pH of the biofilm to lower and demineralization to occur.
Once demineralization occurs, hydroxy and fluorapatite become unstable in the tooth and are leached out. Bacteria enter the tooth and a cavity is born.

25. Bacteria No one particular bacteria species causes carious lesions.
“Good biofilm bacteria” have been found to adapt and produce acid once the pH drops as well.

26. The Caries Balance Protective Factors Pathological Factors
Saliva flow and
components
Fluoride - remineralization
Antibacterials -
chlorhexidine, xylitol, new?
Pathological Factors
Acid-producing bacteria
Frequent eating/drinking
of fermentable carbohydrates
Sub-normal saliva flow and
function
Caries
No Caries
Featherstone, Comm Dent Oral Epidemiol, 1999

27. The Caries Imbalance Protective Risk Factors Factors
Saliva
Fluoride, Ca, P
Antibacterials
Risk Factors
Acidogenic
Bacteria
Frequent
carbohydrates
Sub-normal saliva
Disease Indicators
Cavities/dentin
Enamel lesions
Restorations < 3 yr
White spots
Caries Progression
No Caries
Featherstone, Young, Wolff, 2007

28. CAMBRA Assessment Tool
Caries disease factors (Exam)
Caries risk factors (Interview)
Caries protective factors (Interview)
Caries risk level
Bacteria and saliva testing
Treatment plan for caries intervention and prevention

29. Caries Risk Assessment Tool
Caries risk factors (Interview)
Caries protective factors (Interview)
Caries disease factors (Exam)
Caries risk level
Bacteria and saliva testing
Treatment plan for caries intervention and prevention

30. Build Rapport Be sensitive Be culturally appropriate Show respect
Remain non-judgmental and friendly
Give positive reinforcement

31. Caries Risk Assessment Tool
Caries risk factors (Interview)
Caries protective factors (Interview)
Caries disease factors (Exam)
Caries risk level
Bacteria and saliva testing
Treatment plan for caries intervention and prevention

32. Job Corps Priority Classification System of Lesions
Priority 1 or 2
Source: Zandona AF, Zero DT. Diagnostic tools for early caries detection. JADA 2006;137(12); Copyright © 2006 American Dental Association. All rights reserved. Reproduced by permission.

33. Caries Risk Assessment Tool
Caries risk factors (Interview)
Caries protective factors (Interview)
Caries disease factors (Exam)
Caries risk level
Bacteria and saliva testing
Treatment plan for caries intervention and prevention

34. Caries Risk Assessment Tool
Caries risk factors (Interview)
Caries protective factors (Interview)
Caries disease factors (Exam)
Caries risk level
Bacteria and saliva testing
Treatment plan for caries intervention and prevention

35. Caries Risk Assessment Tool
Caries risk factors (Interview)
Caries protective factors (Interview)
Caries disease factors (Exam)
Caries risk level
Bacteria and saliva testing
Treatment plan for caries intervention and prevention

38. Self-Management Vital Behaviors
What are two vital behaviors that you feel will help you avoid signs of caries disease?
Why did you pick these two vital behaviors?
What can you see getting in the way of making these vital behaviors habits?
What are some ideas you have to overcome those obstacles?
How will you feel when your vital behaviors become habits?

40. Effectiveness of Therapeutics
Source: Andréa Ferreira Zandoná and Domenick T. Zero, “Diagnostic Tools for Early Caries Detection,” JADA, 2006, 137(12); , Copyright © 2006 American Dental Association. All rights reserved. Reprinted by permission.

41. Role of Therapeutics

42. Balancing the pH issue pH positive products of 6.8 or greater Xylitol
Combat xeristomia
Keeping biofilm bacterial levels in check

43. Role of Health Education

44. “Not everything faced can be changed,
but nothing can be changed until it is faced.”
-James Baldwin, writer and novelist
I love this quote. I think this gives a good perspective of what we are doing with Cambra. In 2000, Mourandian noted in the JAMA, Dental caries is the most common chronic childhood disease. 5X more prevalent than childhood asthma. Education is our best chance of promoting prevention. 44

45. Role of Health Education
Understanding their sense of “self”
What is their dental I.Q.?
How do they view the dental profession?
Be an active participant on campus 45

46. Understanding Their Sense of “Self”
These students are acutely aware of what they don’t have. Loss of teeth and replacement with bridge work, flippers, dentures, or even implants is seen not only as physically diminishing, but as placing them at the very bottom of the socio-economic totem pole.

47. What is Their Dental I.Q.? Do they understand basic oral hygiene?
Have them demonstrate their homecare skills. Understanding the environment from which they came. If they moved a lot, lived on the streets, or had a history of substance abuse, oral hygiene was most likely not a taught skill or priority.
Be careful of dental jargon.
Words like plaque, tarter, calculus, periodontal disease, or root canal, are all foreign to the majority of Job Corps population.

48. How Do They View the Dental Profession?
Many of our students have never been to a dental practice, are from foreign countries, or sought cheap quick fixes that yielded poor results. In other words, they are terrified of us.
This will result in broken appointments, miscommunication, and lack of compliance. All efforts should be made to promote a safe and compassionate environment.

49. Be an Active Participant on Campus
Classrooms
Keep information simple, understandable, and impactful.
Walk the campus grounds
This allows students to see you outside the clinic, and ask questions in a non- clinical setting.
Participate in other campus programs
At my center I lecture in weight management class, diabetes clinics, tobacco cessation programs, etc. Always relating dentistry to the field I am participating in.
Host motivational speakers
Gruen Von Behrens with the help of local sponsors recently visited our campus and spoke about the effects of tobacco use.
Use Stem wall for plumbing student with fractured root of #7.
I understand we are on limited budgets, but many communities have programs willing to sponsor youth programs. 49

50. References
Center for Genomic Sciences, West Penn Allagheny Health Systems.
Marsh, P.D. “Dental Plaque as a Biofilm and a Microbial Community- Implications for Health and Disease.” BMC Oral Health (Suppl 1) : 514.
Marquis, M.E. “Oxygen Metabolism, Oxidative Stress and Acid-Base Physiology of Dental Plaque Biofilms.” Journal of Industrial Microbiology. Vol 15. p
Young, Douglas A., et al. “Curing the Silent Epidemic: Caries Management in the 21st Century and Beyond.” CDA. Vol 35, 10. p
Nield-Gehrig, Jill S. “Dental Plaque Biofilms.”
Frutiger, Anna. “Dental Plaque Biofilms.”
Garcia-Godoy, Franklin and Hicks, John M. “Maintaining the Integrity of the Enamel Surface: The Role of Dental Biofilm, Saliva and Preventive Agents in Enamel Demineralization and Remineralization.” JADA. 2008; 139;2S-34S
Kutsch, V. Kim, and Milicich, Graeme. “Understanding the Biofilm Battle.” downloads. html. Recorded June 2, 2009.

51. References
Young, Douglas A. DDS, MS, MBA; Featherstone, MSc, PhD, John DB; Roth, Jon R. MS, CAE; et al, “Consensus Statement Caries Management by Risk Assessment: Implementation Guidelines.” Journal of the California Dental Association, Vol 35, Number 11, p 799
Peltier, Bruce, PhD, MBA; Weinstein, Phillip, PhD; and Fredekind, Richard, DMD, MA, “Risky Business: Influencing People to Change,” CDA Journal, Vol 35, No 11, p
Patel, Seena, BS, MPH; Bay, Curtis R. PhD; Glick, Michael DMD, “A systematic review of dental recall intervals and incidence of dental caries,” JADA, Vol 141, May 2010

52. How does the CAMBRA approach fit into Job Corps?