778november 2007

cda j ournal , vol 35 , n

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How to Integrate
CAMBRA into
Private Practice
v. kim kutsch, dmd; graeme milicich, bds; william domb, dmd;
max anderson, dds; and ed zinman, dds, jd
Carics risk asscssmcnt, or thc man
agcmcnt o carics by risk asscssmcnt,
rcprcscnts an cvidcnccbascd approach
to managing dcntal carics. A challcngc
or dcntal practitioncrs intcgrating ncw
scicntic implications into clinical practicc
is idcntiying thc practical and stratcgic
stcps ncccssary to accomplish that task.
Kcy tools that hclp thc dcntist and thc
dcntal tcam intcgratc CAMBRA into thcir
cxisting practiccs arc rccommcndcd.
Traditional dcntistry has not always
adcquatcly controllcd carics by its prcdomi
nantly surgical approach. Only trcating
cxisting carics rcstorativcly may not
prcvcnt a liclong continuation o a chronic
discasc statc that ultimatcly contributcs to
rccurrcnt carics ncccssitating additional
surgical intcrvcntions.
r
Conscqucntly, a
working group has rccxamincd our
procssions approach to prcvcnting and
managing carics.
.
CAMBRA, carics
abstractThe traditional dentistry approach treated the disease with a limited
surgical strategy aimed at removing carious lesions on teeth. Today, the dental
profession is refocusing its eorts to include risk assessment with evidence-based
diagnosis while also treating the biolm component of the disease. While there is
compelling science to support CAMBRA, there are fewer articles with practical direction
regarding how to integrate CAMBRA diagnostics and treatment into clinical practice,
which this article addresses.
A
clinicians ability to succcss
ully intcgratc any ncw mcth
odology or tcchnology into an
cxisting dcntal practicc may
rcquirc a changc in somc, i
not all, o thc cxisting systcms. Tc dcn
tistowncrmanagcr who cxplains CAM
BRA bcncts (through cducation) to thc
dcntal occ tcam will gain thcir support
and acilitatc a smooth transition. Tc
authors cxaminc thc dicrcnt rcquirc
mcnts o cach mcmbcr o thc dcntal tcam
to succcssully intcgratc carics risk as
scssmcnt into an cxisting dcntal practicc.
Tcrc is amplc scicntic rcscarch
to support carics risk asscssmcnt as
a prudcnt approach to trcating, and
morc importantly, prcvcnting dcn
tal carics. Succcssul implcmcntation
rcquircs cducation and support o thc
dcntal tcam and subscqucnt cducation
o paticnts about CAMBRA bcncts.
authors
V. Kim Kutsch, dmd, is in
clinical practice in Albany,
Ore.
Graeme Milicich, bds, is in
clinical practice, Anglesea
Clinic Dental Care, in
Hamilton, New Zealand.
William C. Domb, dmd,
is in clinical practice in
Upland, Calif.
Max Anderson, dds, ms,
med, is with Anderson
Dental Consulting in
Sequim, Wash.
Edwin J. Zinman, dds, jd,
is with the Law Oces of
Edwin J. Zinman, in San
Francisco.
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cda j ournal , vol 35 , n

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november 2 007 779
managcmcnt by risk asscssmcnt, is a
rationalc that cxamincs carics conccntra
tion in a particular paticnt, thcn plans a
mcasurcd trcatmcnt bascd on thc indi
vidual nccds o thc paticnt.

In hcalth, thc oral biolm is a divcrsc

and complcx community o about cc di
crcnt bactcrial spccics in any individual
paticnt. \hcn dcsirablc bactcria domi
natc thc oral biolm, thcrc is a hcalthy
cquilibrium. Tis biolm scrvcs many
positivc unctions, including balancing
thc dcmincralizationrcmincralization
cyclcs o cnamcl, and standing as thc
rst linc o dccnsc against pathogcns.

Cariogcnic bactcria arc known to bc incc
tious and transmittablc.

Most childrcn
acquirc thcsc bactcria during thc rst
cw months o lic rom thcir primary
carcgivcr. Typically thcsc cariogcnic
bactcria rcprcscnt lcss than r pcrccnt o
thc oral biolm. Howcvcr, undcr ccrtain
conditions, a hcalthy biolm can bc trans
ormcd into a discascd statc. Cariogcnic
bactcria thcn thrivc and prolicratc into a
much highcr pcrccntagc o thc biolm.

Carics risk actors which includc

cariogcnic biolm, poor dict, saliva
production, mcdications, abscncc o
uoridcs, and inadcquatc homccarc arc
summarizcd in Fcathcrstonc ct al. in last
months issuc.
/
Mctabolism o carbohy
dratcs by cariogcnic bactcria rcsults in
acid production. Tis lowcrs thc pH o thc
biolm, which inhibits many commcn
sal organisms. \hcn compoundcd with
othcr risk actors, thc acidic pH bccomcs
thc sclcction prcssurc that rcsults in an
ovcrabundancc o acidogcnic organisms.
8

Lcmincralization sucicnt to causc cavi
tation is a sign o thc undcrlying discasc.
CAMBRA cxamincs thc carious biolm
and its potcntial or rclcasing its varicty
o bioacids that, unlcss ncutralizcd, can
cvcntually dcstroy tooth structurc.
\hilc it is important to rcstorc
tccth, it is critical to addrcss corrcct
ing thc biolm imbalancc and othcr
prcdisposing actors to bc succcssul in
trcating thc sourcc o carious lcsions.
\hcn rcstoring ncw cavitics, wc should
bc asking oursclvcs, \hat am I do
ing to hclp thc paticnt prcvcnt morc
cavitics rom orming` Appropriatcly,
thcn, CAMBRA has bccn continually
gaining ground in scicntic rcscarch,
dcntal cducation, and privatc practicc.
nccd rcstorativc proccdurcs. CAMBRA
docs not climinatc thc nccd or lcsion or
tooth rcpair. Howcvcr, othcr tactics may
bc introduccd that rcducc thc numbcr o
rcstorativc intcrvcntions whcn paticnts
can bc cmpowcrcd to rcbalancc thcir own
oral cquilibrium and rcmincralizc tooth
damagc. Tcn, dcpcnding on asscsscd
risk actors, paticnts should bc rccxam
incd at rcasonablc rcqucncics to rcvicw
potcntial changcs in thcir risk actors.
Tis can involvc saliva tcsting, dict rcvicw,
quantication o acidogcnic bactcrial
lcvcls, bucring capacity and thc likc.
CAMBRA, in this scnsc, is a ormalization
o many tcchniqucs o carics control uscd
by dcntists or considcrablc timc (rccr to
RamosComcz ct al., Fcathcrstonc ct al.,
and cnson ct al., in last months issuc or
dctails o thc rccommcndcd proccdurcs).
Being the Leader
First, thc tcam lcadcr is dctcrmincd
and this pcrson must bc vcry clcar and rc
alistic about thc goals. Tc authors rccom
mcnd thc CAMBRA tcam lcadcr providc
writtcn CAMBRA goals and mcthodology,
and sharc thcm with thc tcam. Coals
should bc concisc, concrctc, and casy or
tcam mcmbcrs to undcrstand and implc
mcnt. Somc goals may rcquirc thc acquisi
tion o ncw skills, knowlcdgc, or matcri
als. In thc casc o CAMBRA, it rcquircs an
undcrstanding o thc cariogcnic biolm,
how to propcrly diagnosc, trcat, monitor,
and mcasurc trcatmcnt outcomcs, i.c.,
CAMBRA courscs or thc dcntal tcam
should bc considcrcd along with train
ing vidcos and manuals. Standardizcd
carics risk asscssmcnt orms arc uscul,
along with somc mctric to gaugc bactcrial
load. \hat antibactcrials andor rcmin
cralization products arc availablc` \hat
paticnt cducation matcrials arc on hand`
Oncc thc practicc apprcciatcs CAM
BRA goals and bcncts, it can dcsign
Implementation Strategies
\hilc thcrc arc a numbcr o valid
scicntic rcasons to implcmcnt CAMBRA
into privatc practicc, including cthical,
lcgal and standard o carc issucs, thc
most important rcason is paticnt bcnct,
which is our primary obligation. CAM
BRA convcrsion in privatc practicc docs
not happcn ovcrnight. Carics managc
mcnt by risk asscssmcnt rcprcscnts a
signicant changc in mindsct. how wc
cxaminc and prioritizc trcating carics
discasc. Implcmcnting CAMBRA a
ccts all systcms in thc practicc, rom
schcduling and ccs to diagnostics,
trcatmcnt, and paticnt cducation.
CAMBRAs goal is to cducatc and
motivatc paticnts to improvc thcir
bchaviors and givc thcm stratcgics to
attain and maintain a hcalthy biobalancc
in thcir mouth. Many paticnts will still
caries management
by risk assessment
represents a significant
change in mindset: how
we examine and prioritize
treating caries disease.
780november 2007
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thc pathway rom thc prcscnt position
to accomplish thc uturc goal. As with
any planning proccss, it is a good idca to
cstablish a timclinc with intcrmcdiatc
milcstoncs. Lcciding which tcam mcmbcr
is rcsponsiblc or cach stcp is important.
Lo not arbitrarily dcsignatc a pcrson to
do a stcp without cducation. Also, idcntiy
who will monitor and mcasurc thc prog
rcss on a timcly basis. Considcr implc
mcnting a rcward systcm or both thc
intcrmcdiatc proccss as wcll as nal stcps.
Idcntiying thc challcngcs and
barricrs to accomplishing cach
milcstonc is also o grcat usc.
n
How much will it cost`
n
\hat spacc will bc ncccssary`
n
\hat matcrials will wc usc`
n
How long bcorc wc arc ablc to
implcmcnt CAMBRA or all paticnts`
n
How will this acct all o thc
occ systcms alrcady in placc`
n
\ho will bc doing thc ini
tial carics risk asscssmcnt`
Implcmcnting CAMBRA is an op
portunity or bcncting paticnts and
our procssion. Probably thc grcatcst
challcngc is thc paradigm shit in thc
dcntists mindsct. Lcntists wcrc traincd
to drill rst and ask qucstions latcr. Tcy
wcrc instructcd in thc rst wcck o dcntal
school that dcntal carics is an incctious
bactcrial discasc and thcn, instantly, a
dcntal drill was placcd in thcir hands.
Tc practicc o CAMBRA changcs this
approach to. Ask qucstions rst, ollow up
with morc qucstions, nd out why you arc
drilling, gurc out how to avoid drilling
in thc uturc, and thcn drill only what
is minimally ncccssary. Finally, monitor
and mcasurc your trcatmcnt outcomcs.
The Role of the Dental Team
CAMBRA can only bc succcssully
intcgratcd into a practicc i thc cntirc
dcntal tcam undcrstands and supports
this mcthodology. Iikc any othcr changc
in thc dcntal practicc, CAMBRA will
not succccd without thc support o thc
cntirc dcntal tcam. Pclticr, \cinstcin,
and Frcdckind discuss bchavioral changc
in morc dctail in this issuc. Communi
cation and cducation arc vital kcys to
succcss. Tc dcntist should spcnd timc
with thcir tcam studying thc scicntic
basis o dcntal carics and thcn ocusing
on thc paticnt bcncts o CAMBRA.
also an cxccllcnt rcsourcc or articlcs
on carics risk asscssmcnt. Additional
inormation can bc gathcrcd by attcnding
local or statc C.F. programs ocuscd on
CAMBRA. Taking thc cntirc dcntal tcam
to thcsc programs is an cxccllcnt oppor
tunity to updatc thc CAMBRA tcam.
Oncc thc tcam undcrstands and
supports thc goal, cach mcmbcr can
contributc to thc road map dcsign by
idcntiying how CAMBRA will impact
thcir rcsponsibilitics and what changcs
arc nccdcd. Tis will crcatc somc ncw
challcngcs, as tcam mcmbcrs cvaluatc
how thcy can incorporatc morc scrviccs
into a limitcd amount o timc. In many
occs, thc majority o thc CAMBRA
cducation, risk asscssmcnt, bactc
rial tcsting, and trcatmcnt monitoring
occurs in thc hygicnc opcratory. Tis
may placc ncw dcmands on thc dutics
and schcduling o both thc hygicnist
and dcntal assistants. Fvcry practicc
will solvc thcsc changcs as appropri
atc or thc individual practicc. Many o
thcsc issucs arc discusscd by Cutkowski
ct al. in this issuc o thc Journal.
It is important during thc implc
mcntation to havc rcqucnt ccdback
and cvaluatc succcsscs or dclays. Hav
ing thc cntirc tcam solvc thcsc issucs is
critical or succcss. It is also important to
sharc paticnt succcss storics as a group.
Nothing takcs thc car and drcad out o
changcs likc hcaring about thc dicrcnccs
wc arc making in paticnts livcs. Addrcss
and solvc issucs, but succcss comcs rom
kccping thc tcam ocuscd on thc goal.
Sincc our goal is to ultimatcly improvc
thc dcntal hcalth o our paticnts, wc nccd
ncw bcnchmarks to mcasurc our succcss.
Tc dcntal procssion has always uscd
thc no cavitics as a gold standard or
thc mcasurcmcnt o hcalth. But a paticnt
with high risk actors and no cavitics
is in rcality a paticnt with a discasc that
Sta mcctings can bc uscd to discuss thc
cvidcncc and thc approach to CAMBRA
as thc standard o carc. Onc mcasurc
o succcss in this cducation proccss o
your tcam is to cnd thc scssion with
a show o hands to How many would
likc thcir own childrcn or lovcd oncs
trcatcd in this ashion` I cvcryonc
raiscs thcir hand, thcn your ncxt qucs
tion should bc \hy thcn shouldnt wc
trcat all our paticnts thc way wc would
trcat our own lovcd oncs` Isnt this thc
typc o practicc you want to dcvclop`
Tcrc arc many rcsourccs or CAM
BRAs scicntic oundation. Prcvious
issucs o thc Journal of the California
Dental Association ocuscd on this topic
in Fcbruary and March .cc, and arc
pcrmancntly archivcd in thcir cntircty on
thc CLA Foundation \cb sitc at www.
cdaoundation.orgjournal. PubMcd is
cambra can only
be successfully
integrated into a
practice if the entire
dental team
understands and supports
this methodology.
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nove mber 2007 781
hasnt manicstcd carics signs or symp
toms yct. In addition, a paticnt that cur
rcntly has no cavitics docsnt ncccssarily
mcan thcy arc at low risk or uturc carics.
Enlightening Experience
Tcrc is no substitutc or a rsthand
cxpcricncc. Tc dcntist should ollow
through thc CAMBRA proccss as a paticnt
in thc occ. Tcn, cach tcam mcmbcr
should go through thc proccss as wcll.
Tis may bc an cnlightcning cxpcricncc
or thc individual tcam mcmbcrs, as
thcy may pcrsonally discovcr unknown
risk actors or risky bactcrial loads. In
a dclicatc biobalancc o dcntal hcalth
cquilibrium, it may takc only tiny changcs
to crcatc scrious issucs in what othcr
wisc appcarcd to bc a hcalthy mouth.
Fvcry dcntist has had cxpcricncc with
thc highrisk paticnt, young or old, with
scrious dccay issucs. And cvcry practicc
has paticnts who havc bccn dccayrcc
or ycars. Its thc group in bctwccn that
rcprcscnts thc grcatcst diagnostic chal
lcngc. Paticnts who comc along with littlc
cvidcncc o discasc or long pcriods may
suddcnly dcvclop multiplc ncw cavitics.
Tcsc paticnts potcntially bcnct thc
most rom CAMBRA. It is casy to idcntiy
thc highrisk, high carics activc paticnts,
and also thc lowrisk, low carics activc
paticnts. Howcvcr, thc paticnts who arc at
risk with no apparcnt signs o thc discasc
arc thc oncs CAMBRA hclps to idcntiy
and bcnct with carics risk rcduction.
At a sta mccting, thc dcntal tcam
should practicc lling out thc carics
risk asscssmcnt orms and doing thc
bactcrial tcsting. Fach can practicc how
thcy will cxplain CAMBRA bcncts to
paticnts. Communicating ncw idcas
comortably and compctcntly gcncr
ally rcquircs somc practicc and rolc
play. It also prcscnts an opportunity to
practicc answcring thc paticnts rc
qucntly askcd qucstions as ollows.
n
\hy do I gct cavitics`
n
I brush and oss, docsnt that
prcvcnt any cavitics`
n
How do you dctcrminc my carics
risk` Is thc trcatmcnt cxpcnsivc`
n
I I havc thc carics discasc, should
othcr mcmbcrs o my houschold bc tcstcd
too`
n
\hy hasnt anybody cxplaincd this
to mc bcorc`
ing organizations that currcntly practicc
CAMBRA providcs valuablc inormation
on what idcas hclpcd thc proccss and
what hurdlcs thc dcntal tcam ovcrcamc.
Usc cstablishcd nctworks and rcsourccs
such as thc \orld Congrcss o Minimally
Invasivc Lcntistry or support and advicc.
n
www.cdaoundation.orgjournal
n
www.rstoralhcalth.org
n
www.adca.orgLMSScctions
dcault.htm
n
www.aapd.org
n
www.icdas.org
n
www.midcntistry.org
n
www.wcmid.com
Educating the Patients
Oncc thc cntirc tcam undcrstands and
is rcady to implcmcnt CAMBRA, it is timc
to cducatc your paticnts. A pcrsonal lcttcr
cxplaining thc CAMBRA bcncts is a grcat
way to brcak thc ncws to cvcrybody at thc
samc timc. Put it in your ncwslcttcr or on
your \cb sitc and advisc your paticnts to
look and lcarn. Fxpcricncc rcportcd rom a
numbcr o occs has shown that this is a
vcry ccctivc way to dclivcr dctailcd inor
mation bccausc most paticnts do rcad your
ncwslcttcrs. Somc practiccs havc dcvclopcd
brochurcs cxplaining CAMBRA. Tcsc arc
mailcd with a covcr lcttcr to thc paticnt
basc. Also providc paticnts with a brochurc
at thc ront dcsk whcn thcy arrivc or thcir
appointmcnt. Fxplain thc cvolving changc
in thc practiccs progrcssivc improvcmcnts
with thc latcst scicntic tcchnology and
carics studics. Ict thcm know what to cx
pcct on thcir ncxt visit. Tc morc inormcd
basic inormation you can providc in thcsc
ormats, thc lcss chairtimc you will nccd
to spcnd cxplaining CAMBRA to thcm.
Also, thc inormation you advisc in
thc opcratory will rcinorcc what thcy
rcad carlicr. A simplc oncpagc dcscrip
tion o thc carics proccss dcsigncd or
childrcn and adults is includcd at thc cnd
Bccausc CAMBRA is prctty straightor
ward and logical, thc most rcqucntly askcd
qucstion sccms to bc \hy hasnt anybody
told mc this bcorc` Tc sta can givc
cach othcr immcdiatc ccdback during thc
proccss. How did thc cxpcricncc ccl` \as
thcrc cnough inormation` Lid it makc
scnsc` \as it comortablc` Tis sccnario
givcs cvcrybody a rsthand cxpcricncc
as a paticnt. It also givcs cvcrybody a
chancc to practicc in a sac and comort
ablc cnvironmcnt thc ncw languagc and
communication skills that thc changcs will
rcquirc. Tcy will bc morc condcnt and
thc program will bc morc succcssul as a
rcsult o taking thc timc to practicc.
Tcrc arc numcrous occs that havc
alrcady succcssully intcgratcd CAM
BRA into thcir daily practiccs. You dont
havc to ncccssarily rcinvcnt thc whccl.
Contacting a CAMBRA collcaguc or join
the patients who
are at risk with no
apparent signs of the
disease are the ones
CAMBRA helps to identify
and benefit with caries
risk reduction.
782november 2007
a logical goal
in the CAMBRA
conversation with the
patient is for them to
understand that just treating
their cavities will not
prevent future disease.
o thc dcscription o carics risk asscss
mcnt by Fcathcrstonc ct al. in this issuc.
Tus, chairtimc can bc ccctivcly dcvotcd
to answcring qucstions rathcr than bcgin
ning CAMBRA cducation at ground zcro.
Providc thc cxtra timc or cducation
and communication with thc paticnts.
Try to schcdulc and allow or thc cw
morc minutcs it will rcquirc to cxplain
CAMBRA to thcm, and always answcr
thcir qucstions. Tc bcnct o having thc
cntirc tcam supporting thc philosophy
changc is thcy will hcar it rom morc
than onc pcrson and tcnd to rcquirc lcss
o thc dcntists dircct timc in cducation.
Howcvcr, thc most ccctivc mcssagc still
has to originatc rom thc dcntist. Tis
is how wc arc changing and hcrc is why
is thc doctors obligation. A logical goal
in thc CAMBRA convcrsation with thc
paticnt is or thcm to undcrstand that
just trcating thcir cavitics will not prcvcnt
uturc discasc. Also, cavitics arc only
undcrlying signs and symptoms o thc
carics bactcrial incction proccss. Paticnts
nccd to undcrstand that this biolm
incction must bc diagnoscd and trcatcd
as a discasc proccss. Tcy also nccd to
lcarn and undcrstand thc conccpt o thc
balancc bctwccn hcalth and discasc and
thc pathologic actors vcrsus thc protcc
tivc actors. \ith propcr cducational
background, paticnts should bc ablc to
hclp idcntiy any changcs in thcir risk
rcduction actors during uturc visits.
I thc paticnts dcsirc additional
inormation, dircct thcm to thc CLA
Foundation \cb sitc at www.cdaounda
tion.org, or othcr cariology \cb sitcs on
thc Intcrnct. A couplc o abstracts rom
PubMcd arc hclpul to support particular
idcas about carics risk asscssmcnt. Sclcct
thc abstracts that convcy thc kcy points
you want your paticnts to undcrstand.
Lownload thcsc abstracts as documcnt
lcs, and thcn boldacc and undcrlinc
thc signicant scntcnccs you want to
makc surc thcy rcad and undcrstand. Tc
documcnts can bc printcd in \ord ormat
and givcn to thc paticnt to takc homc.
Your paticnts can orward CAMBRA
rom your \cb sitc to othcr ricnds and
amily, which is a provcn practicc buildcr.
Intcrnctsavvy paticnts may bc intcr
cstcd in acccssing PubMcd dircctly. Tc
morc undcrstanding and valid inorma
Undcrtrcatmcnt occurs whcn a clinician
systcmatically providcs nontrcatmcnt or
lcssthanoptimal trcatmcnt o cxisting
pathology. Tis would includc ailurc to
diagnosc thc paticnts carics risk status.
Tc conscqucncc o undcrtrcatmcnt is
rccurring carics and potcntial loss o morc
tooth structurc and or tccth. Prcviously,
thc ratc o progrcssion o dcntal car
ics madc conscrvativc dccisions highly
qucstionablc. Today with thc lowcr carics
incidcncc and rcduction in carics progrcs
sion, surgical intcrvcntions nccd to bc
minimal in all but thc most aggrcssivc
dcntal carics situations, thc cavitation.
In thc CAMBRA paradigm, cvcn a small
cavitation is a vcry scrious sign o carics
imbalancc. As part o thcir risk asscss
mcnt protocol, dcntists nccd to cvaluatc
thc rcqucncy o rccall or cach paticnt. I
thc dcntal tcam has cvaluatcd thc paticnt
as a high carics probability paticnt, thcn
prophylactic prcvcntivc thcrapics and
othcr principlcs idcnticd in this journal
should bc implcmcntcd (cnson ct al.
and Spolsky ct al., prcvious issuc). Tis
rcduccs thc possibility o undcrtrcatmcnt.
Overtreatment occurs whcn intcrvcn
tions arc unjusticd or too aggrcssivc or
thc clinical situation. Tc goal o mini
mally invasivc dcntistry is to prcscrvc
thc maximum amount o hcalthy dcntal
tissucs. An cxamplc o this conscrvativc
MIL philosophy is thc usc o air abra
sion, hard tissuc lascrs, or ultrasmall
burs to vcry conscrvativcly clcan or opcn
a qucstionablc ssurc to scc whats in
thcrc bascd on thc ICLAS codcs and
thc protocols outlincd by cnson ct al.
in last months issuc rathcr than blindly
rcstoring thc tooth with amalgam or
compositc. Tc conscqucnccs o ovcr
trcatmcnt arc wcll charactcrizcd as thc
rcstorationrcrcstoration cyclc. Any
cutting o tooth structurc wcakcns thc
tooth and should bc avoidcd i possiblc.
tion a paticnt has, thc bcttcr is thcir
capability to choosc wisc hcalth carc dcci
sions or thcmsclvcs. CAMBRA inormcd
paticnts arc grcat CAMBRA ambassadors
who advisc othcrs o your improvcd and
modcrn approach to carics control and
prcvcntion.
Undertreatment and
Overtreatment Issues
Incipicnt lcsions that do not pcnctratc
through thc tooths cnamcl and into
dcntin arc candidatcs or conscrvativc,
noninvasivc thcrapy likc rcmincraliza
tion, dcntal scalants, and othcr prcvcn
tivc mcasurcs. Rcstoring tccth without
rcgard to carics risk and omission o thc
chcmorcparativc and prcvcntativc phascs
o thcrapy is somctimcs callcd undertreat-
ment bccausc paticnts arc only gctting
thc rcstorativc phasc o trcatmcnt.
i n t e g r at i n g c a mb r a
cda j ournal , vol 35 , n

1 1
november 2007 783
focusing on
caries damage when
CAMBRA
does not intervene
stops short of
reversing
the carious process.
Proper Documentation
All vc Caliornia dcntal schools
practicc and tcach carics risk asscssmcnt
or CAMBRA as a standard o carc on
paticnts trcatcd in thcir clinics. Argu
ably, CAMBRA is thc currcnt standard o
carc. Standard o carc dcbatcs arc popular
among dcntists with cvcrybody wcigh
ing in with opinions. Tc purposc o this
papcr is not to rcsolvc thosc issucs but
rathcr to addrcss currcnt knowlcdgc and
scicncc. \hcn cxamining thc risks and
thc bcncts o practicing CAMBRA, im
plcmcnting this philosophy into thc dcn
tal practicc rcduccs thc carics risk or thc
paticnt and thc lcgal risk or thc dcntist.
Practicing CAMBRA rcquircs propcr
documcntation. In thc paticnts chart,
thc dcntist should havc a standardizcd
carics risk asscssmcnt orm (RamosCo
mcz ct al., Fcathcrstonc ct al., prcvious
issuc), and thcn routincly includc di
agnosis, any bactcrial tcsting or moni
toring, trcatmcnt rccommcndations,
trcatmcnt outcomcs and rccarc plans. It
is important to rccord accuratcly, simply,
and routincly to makc surc all chart
cntrics arc consistcnt. I thc paticnt
dcclincs carics trcatmcnt in addition
to any rcstorations, it is important to
rccord that paticnt dcclination in thc
chart notcs as wcll. Tc paticnts should
bc making thcir trcatmcnt dccisions
with a ully inormcd conscnt. Consc
qucntly, cducation about thc bcncts
o CAMBRA is now rcquircd or an
adcquatc inormcd conscnt, cxplain
ing CAMBRA ABCs, which includc
altcrnativcs, bcncts and conscqucnccs
o nonCAMBRA implcmcntation.
Tcrc arc numcrous orms availablc
to rccord your asscssmcnt rcsults as
prcviously notcd. Tc authors suggcst
kccping things as simplc as possiblc. Tc
orms prcscntcd or childrcn agc c ycars
by RamosComcz ct al. and thosc or
agc and oldcr Fcathcrstonc ct al. in thc
prcvious issuc arc thc most scicntically
validatcd to datc. Tc choicc o orms is
not as important as having a orm. Tis
dccision might bcst bc madc with your
tcam, gctting thcir input on which orm
would work bcst. It is bcst to scparatc
thc spccial situation or childrcn agc
c rom childrcn agc through adult.
\hilc scalants and uoridc trcatmcnts
wcrc somctimcs covcrcd, thc ocus has too
otcn disrcgardcd prcvcntivc trcatmcnts.
Insurancc companics (and cmploycrs
who ncgotiatc thc plans) and paticnts arc
willing to pay or a lling, but not thc ull
chcmothcrapcutic thcrapy ncccssary to
dcal with thc bactcrial incction andor
to rcmincralizcrcpair whitc spot lcsions
and most importantly to prcvcnt thc ncxt
carious lcsion rom dcvcloping. Amidst
this cnvironmcnt, thc ALA Currcnt Lcntal
Tcrminology book or .cc/.cc8 contains
a ncw CLT codc or uoridc varnish as a
thcrapcutic trcatmcnt or thc modcratc to
highrisk carics paticnt. \hilc in thc past
thc dcntal procssion was in a situation
whcrc thcrc is littlc or no apparcnt valuc
placcd on many prcvcntivc proccdurcs,
thcrc is promising progrcss with ncw cc
codcs bcing addcd by thirdparty paycrs.
\hy wont my insurancc pay or
this` can bc a common complaint rom
paticnts. And, i insurancc wont pay
or prcvcntivc corts, somc paticnts
rcason that pcrhaps suggcstcd prcvcn
tivc proccdurcs arc unncccssary.
CAMBRA From an Economic
Standpoint
CAMBRA has a numbcr o procc
durcs associatcd with it that havc dircct
rclatcd ccs and cc codcs alrcady in placc.
In thc CLT /, in addition to thc normal
prcvcntion codcs or prophylaxis and
uoridc applications thcrc arc codcs or.
n
L c.. Carics Susccptibility Tcsting
n
L cr. Bactcriology Studics
n
L cr. Oral Fvaluation Paticnt
ycars, Counscling Primary Carcgivcr
n
L r.c. Topical Fluoridc Applica
tion or Tcrapcutic Mcasurcs Mod
cratc to Highrisk Carics Paticnt
Mcdical insurancc might cov
cr somc o thc diagnostic tcsts
such as salivary ow and bucr
The Economics of Prevention
Tc dcntal procssion has bccn a rolc
modcl by promoting prcvcntion via rcgu
lar carc and rccarc cxams. Onc o thc is
sucs surrounding prcvcntion has bccn thc
cconomics. Most insurancc contracts havc
covcragc or prcvcntivc carc dcsigncd or
thosc who arc at minimal or modcratc
risk. Somc paticnts arc rcluctant to spcnd
thcir own moncy on prcvcntivc scrviccs.
Conscqucntly, thc majority o traditional
dcntistry has bccn ocuscd on rcstorativc
rathcr than chcmorcparativc and prcvcn
tivc carc. Focusing on carics damagc
whcn CAMBRA docs not intcrvcnc stops
short o rcvcrsing thc carious proccss.
Historically, thc thirdparty systcms
and our own paticnts dcvclopcd a prior
ity on rcstorativc proccdurcs bccausc
dcntal carics was pandcmic and validatcd
risk asscssmcnt tools wcrc not availablc.
784novembe r 2007
cda j ournal , vol 35 , n

1 1
ing capacity mcasurcmcnts.
Somc practiccs includc thc carics risk
asscssmcnt as part o thc normal oral
cxam, but additional proccdurcs rcprc
scnt ncw and scparatc ccs. Tc mcdical
approach to trcating dcntal carics usually
involvcs bchavioral counscling dircctcd
at risk actors, ollowcd by a protocol o
antimicrobial oral carc products and somc
rcmincralization stratcgics and matcri
als. Tc monitoring o ongoing trcat
mcnt and outcomcs rcquircs additional
bactcriology tcsting. Tcsc scparatc ccs
will supplcmcnt rcstorativc carc ccs.
\hilc thc incomc gcncratcd with thc
CAMBRA proccdurcs and matcrials is low
in comparison to highcnd cosmctic pro
ccdurcs, noncthclcss practicing CAMBRA
docs gcncratc sucicnt rcvcnuc to justiy
it rom a busincss modcl. \hat is most
important is that cvcry singlc pcrson
in thc occ is absolutcly committcd to
hclping thcir paticnts bccomc hcalthy
and stay dccayrcc. \hat valuc docs
that rcprcscnt to thc paticnts` Fvcry
body must bc comortablc with charging
paticnts a cc commcnsuratc with thc
scrvicc providcd. Your occ must ap
prcciatc how important your counscl is to
your paticnts. Paticnts can bc comortablc
with your CAMBRArclatcd ccs oncc you
hclp thcm undcrstand what valuc thcy arc
rccciving. So what i a paticnts insurancc
contract will not rcimbursc or spccic
important scrviccs` Many will not covcr
implants, vcnccrs and othcr cosmctic
proccdurcs. Lo wc avoid prcscnting thcsc
proccdurcs` Lo paticnts dcclinc having
thcm donc` Pcrhaps anothcr analogy
hclps conncct with your paticnts. Advisc
that you dont havc tirc insurancc, but
whcn your tircs wcar out, do you rcplacc
thcm or thc sacty o your cntirc amily`
CAMBRA ccs may rcsult in signicant
monthly rcvcnuc as thc proccss is intcgrat
cd complctcly into thc practicc. And much
cda j ournal , vol 35 , n

1 1
november 2007 785
o CAMBRA docs not rcquirc thc prcscncc
o thc dcntist or data collcction. Paticnts
who nally managc to stabilizc thcmsclvcs
with CAMBRA intcrvcntions otcn thcn dc
cidc to undcrtakc morc complcx and nan
cially productivc rcstorativc proccdurcs, in
cluding clcctivc proccdurcs oncc ncccssary
rcstorativc trcatmcnt is rcduccd or climi
natcd. \hat cxpcricnccd CAMBRA prac
ticcs arc discovcring is that thc rcal rcason
bchind why paticnts dont havc cxpcnsivc
tooth rcplaccmcnt trcatmcnt donc is bc
causc thcy dont ccl condcnt in it lasting.
Tcy havc had a lictimc o chronic miscry
with dcntal carics, and thc wholc proccss
sccms a mystcry. Most o thcsc CAMBRA
practiccs rcport an unanticipatcd incrcasc
in rcvcnuc rom prcviously dcclincd
trcatmcnt knowing trcatmcnt will last.
Anothcr considcration in thc cconom
ics o practicing CAMBRA. dircct rccr
rals rom thc practiccs cxisting paticnts.
For many paticnts, CAMBRA is a lic
changing cxpcricncc. Tcy changc rom
continuous cavitics and problcms to bcing
dccayrcc or thc rst timc in thcir livcs.
\hcn paticnts apprcciatc and undcrstand
thc biolm componcnt o dcntal carics
and cxpcricncc rst hand how to nally
control thc discasc, thcy want cvcrybody
thcy know to cxpcricncc thc samc bcn
cts. \ordomouth rccrrals havc lcd
to paticnts travcling hours just to locatc
a dcntal occ that practiccs CAMBRA.
Tc last cconomic considcration is
otcn thc unspokcn car that dcntists
arc putting thcmsclvcs out o busincss.
\hat i your paticnts rcally didnt dcvclop
ncw cavitics, what would you do` On thc
othcr hand, what i cvcry paticnt in your
practicc stoppcd dcvcloping ncw singlc
suracc lcsions and you could ocus on
complctc rcstorativc carc` I your paticnts
dccidcd to havc idcal rcstorativc dcntistry
donc, would you havc cnough timc lct
in your carccr cvcn to accomplish that`
Conclusion
Many privatc practiccs bcgan practic
ing CAMBRA a cw ycars ago, whcn thcrc
was a wcalth o scicntic inormation
and not much practical implcmcntation
tips or advicc. Tcrc wcrc no validatcd
orms, thcrc wcrc no validatcd trcatmcnt
rcgimcns or trcating thc bactcrial biolm
discasc. Tis was uncomortablc tcrri
tory or CAMBRA initiating dcntists. For
a ccntury wc havc had a oncsizctsall
approach to discasc. Surgically rcmovc
thc cavity, rcgardlcss o location, sizc, or
naturc, and rcplacc it with an amalgam
rcstoration. Now, cvcry paticnt must havc
thcir risk asscssmcnt cvaluatcd individu
ally. Fvcry paticnt is uniquc. Trcatmcnt
will nccd to bc customdcsigncd or that
individual paticnt at thc prcscnt timc.
Tcn, wc must continuc to monitor cach
paticnt to prcvcnt cvcn a lowrisk paticnt
bccoming a highrisk paticnt tomorrow.
Romc wasnt built in a day. Intcgrat
ing a signicant mcthodology changc in
a dcntal practicc rcquircs somc timc and
cort. Tc kcy is to kccp thc changcs
as simplc as possiblc, brcak it down to
small logical scqucntial stcps, and kccp
thc dcntal tcam involvcd in thc proccss.
Tc CAMBRA approach, philosophy, and
trcatmcnt will continuc to cvolvc and
changc as morc data is gathcrcd ovcr
timc, but ccrtainly this rcprcscnts thc
bcst standard o carc today. \cighing thc
risks vcrsus thc bcncts o CAMBRA or
your paticnts, it is virtually all bcnct. It
all boils down to doing thc right thing or
your paticnt. How would you want to bc
trcatcd bascd on what you now know`
Bctwccn thc dircct cconomic bcnct
and thc ncw paticnt rccrrals, CAMBRA
morc than supports itscl rom a busincss
modcl. Tc additional rcvcnuc rom thc
incrcascd rcstorativc and clcctivc trcat
mcnts gaincd by carics rcduction adds
signicantly to thc avcragc practicc. From
a purcly cconomic standpoint, CAMBRA is
dcntistrys bcst kcpt sccrct. But, nanccs
asidc, thc most important rcason to
implcmcnt CAMBRA is or thc paticnts
bcst intcrcst. Tcrc is no grcatcr rcward
than making a signicant dicrcncc in a
paticnts lic through improvcd dcntal
hcalth that lasts a lictimc. \c owc this to
our paticnts and our procssion.
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to request a printed copy of this article, please contact
V. Kim Kutsch, DMD, 2200 14th St., SE, Albany, Ore., 97322.