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February 8, 2009 | Web Exclusive Why you need to attack caries differently
“Dr Mark Germack offers a very succinct and timely overview of a big change in dentistry—the treatment of the world's most common disease, CARIES. For many practitioners this new way of using a medical model, Caries Management by Risk Assessment (CAMBRA) and minimally invasive dentistry instead of a surgical model will serve our patients well.”—Dr. Joe Whitehouse, Team Lead Evidence based dentistry has transformed the way dental professionals are trained and educated. Unfortunately, this knowledge base has not transferred to the clinical practice as quickly as many had hoped. Groups like the World Congress of Minimally Invasive Dentistry (wcmidentistry.com) work to promote scientifically based practices with an eye on clinical implementation. This article will discuss how evidence based dentistry has changed the way we diagnose and treat dental caries.
Caries is an infectious, transmissible disease process where a complex cariogenic biofilm, in the presence of an oral environment status that is more pathological than protective, leads to the demineralization and eventual cavitation of dental hard tissue. To explain this it is best to imagine our mouths as a balance scale. With the protective factors against caries (good salivary flow, neutral oral pH, low fermentable carbohydrate diet, etc.) on one side of the scale, and the destructive factors (high fermentable carbohydrate intake, low oral pH, poor saliva flow etc.) on the other side. As long as the scale is tipped in the favor of the protective factors the patient is likely to be at low risk for an active caries infection. However, if the scales are tipped in favor of the destructive factors the patient is at high risk of having active demineralization occurring. Caries Management By Risk Assessment (CAMBRA) attempts to identify how each patient’s scale is balanced, aid the clinician in developing a treatment plan, educate the patient and shift the balance in favor of the protective factors. In the November 2007 CDA journal, John Featherstone, Jon Roth, Douglas Young and colleagues helped lay out the principles of CAMBRA (available on the CDA web site at cda.org). They are:
The first and most basic step in CAMBRA is the risk assessment form. Different styles are available on many Web sites including the CDA’s, the WCMID’s, and now on the ADA Web site (ada.org). A variety of CAMBRA forms are available at http://crawcmid.notlong.com. The purpose of the risk assessment form is to allow a clear, concise, and quantitative data collection about the patient's oral status. After completion of the form the patient is categorized into a group according into low, medium or high caries risk. Depending upon the level of risk the clinician can order further tests such as salivary flow, pH, and bacterial screening to aid in diagnosis and treatment planning. Diagnosis and treatment planning are where evidenced based dentistry can truly benefit our patients. Many of us have seen those lesions that radiographically extend just to the DEJ (dentinoenamel junction). In the past many of us would have just placed a “watch” on the site and moved on. But this begs the question: What are we watching it do? If the patient has a low caries risk, it may be beneficial to our patients to identify those outliers on the risk assessment form and attempt to shift them to a more favorable position without surgical intervention (i.e. chemotherapeutics to increase salivary flow, Ca and P infusion such as GC America’s MI Paste Plus, fluoride, and lower pH). This helps give the dentist and patient a clear plan of action, a goal to obtain, and quantifiable markers of success throughout treatment.
Taking a wait and see (watch) approach is not the way to go. Measuring bacterial levels and oral pH prior to and after treatment can give the clinician and patient an idea of progress, much like how physicians measure cholesterol and blood pressure prior to therapy. This process works similarly with patients at high caries risk. They may need chemotherapeutic treatment, reevaluation, and if needed surgical caries control and glass ionomer placement. The idea of the latter is to get the caries infection under control prior to going ahead with certain restorative procedures. As we all know recurrent caries is the major reason for restoration failure. If we get infection under control, educate, and monitor the patient quantitatively, we could greatly reduce the number of recurrent lesions, saving our patients and the healthcare system considerable funds. Furthermore, it could free up more of our patients “dental dollars” for other reconstructive needs such as implants and orthodontics.
As we all know, sometimes the best ideas are never implemented in our dental offices for one reason or another. However, CAMBRA, taught at nearly every dental school in the nation, is now the standard we should strive for in private clinical practice. Implementation fails for many reasons, first and foremost because many do not like change, especially when this change is added to an already hectic workday. Education of the entire dental team is essential for any new system to work, so don’t forget this when your practice is ready to implement minimally invasive protocol into the practice. The entire office has to believe in change, understand the value to patients and the practice, and have leadership not willing to back away from decisions the moment some resistance is felt. There will always be resistance to change, no matter how minute the plans are. However, implementation of CAMBRA into the dental practice is in the best interest of the patient, and should be viewed as essential to every member of the team.
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For a closer look at the caries process and manipulating oral chemistry, see Dr. Young's article “