New directions in interorganizational collaboration in dentistry: the CAMBRA Coalition model

Caries management by risk assessment (CAMBRA) represents a paradigm shift in the management of dental decay. It treats dental caries as an infectious disease that is curable and preventable. The science supporting CAMBRA has been present for quite some time; however, its clinical adoption, until recently, remained slow. This article analyzes the Western CAMBRA Coalition, a special collaboration of diverse groups of independent organizations based in the western region of the United States. This coalition, which has formed an interorganizational collaborative (IOC), has evolved over four years and has led to significant progress in the clinical adoption of CAMBRA. Theoretical perspectives of reasons and the conditions that drive organizations to collaborate will be applied to the CAMBRA model, concluding that IOCs offer great benefits in promoting CAMBRA as well as future innovations in dental treatments.     

五种龋病风险评估方法对口腔门诊患者患龋风险水平区分能力的研究

目的本研究旨在建立一种适合我国门诊病人龋风险评估体系-龋风险窗口(caries risk window,CRW)预测法,并与现有国外龋风险评估系统进行比较,评价其对门诊患者患龋风险等级区分能力和检测结果的一致性。方法选取111名门诊患者,进行临床检查和问卷调查。口腔检查包括患龋状况、口腔卫生状况、牙齿发育缺陷等;问卷调查包括饮食习惯、口腔卫生行为和就医行为。分别用五种龋风险评估方法确定个体的患龋风险等级:CRW预测法、Cariostat法、ADA龋风险评估、CAMBRA(Caries Management by Risk Assessment)、Cariogram系统。采用卡方检验比较五种方法对患者患龋风险水平的区分度;采用加权kappa比较五种方法检测结果的一致性。结果五种方法判断出龋高风险个体的比例从高到低分别是:CAMBRA(93%)、ADA(86%)、Cariogram(77%)、CRW(65%)和Cariostat(56%)。ADA和CAMBRA的一致性最高(加权kappa:0.593,P<0.05),属于中等水平。Cariogram与CAMBRA和ADA,CRW与ADA和Cariogram的一致性属于一般水平(加权kappa:0.221~0.358,P<0.05)。CRW与CAMBRA和Cariostat的一致性属于较差水平(加权kappa:0.150~0.161,P<0.05)。其它方法之间的一致性没有统计学意义。结论CRW和Cariogram对门诊患者患龋风险等级的区分能力优于CAMBRA和ADA龋风险评估方法,Cariostat居中,不同龋风险评估体系结果的一致性不高。需通过纵向研究进一步评价龋风险评估体系的准确性。     

A view from both sides

This letter to the editor is from one of the key figures in caries management by risk assessment. Dr. Featherstone brings a unique perspective to the access issue. He grew up in New Zealand and experienced care under the dental therapist provider model. His letter is included here because it complements the other articles by providing his views on CAMBRA in the context of addressing barriers to care.     

Guiding the practitioner through the caries management by risk assessment (CAMBRA) protocol

In the past, the approach for treating caries was mainly symptomatic and involved removal of caries, teeth restoration, oral hygiene instructions, and fluoride applications in cases that presented with significant disease. As the bacterial component of the disease was revealed, questions emerged concerning the significance of each strain present and intervention in the process of caries development. This article reviews the evidence that supports the implementation of the current caries risk assessment and management protocol (CAMBRA). It details the current risk factors, techniques and devices for assessing them and, interventions that should be considered in order to address the risk. The paper defines specific guidelines for managing risks related to caries. Intervention should be customized according to the risk determined for each specific patient.     

Lasers in modern caries management--part II: CAMBRA.

Part two of this series discussed the key strategies that each practice should focus on for caries management. History has proven that oral hygiene and "drilling and filling" alone will not eliminate dental caries. Chemical treatments to prevent and reverse early lesions and conservative, tooth-preserving restorative procedures when surgical intervention is necessary should be the new standard of care. Caries management by risk assessment (CAMBRA), where risk factors are "re-balanced" to that of health, is a sound strategy that is one step closer to "curative" dentistry and improving the quality of life of dental patients. The final article in this series will discuss the role that glass-ionomer materials and hard tissue lasers play in the minimally invasive restorative procedures for dental caries.     

Validity of caries risk assessment programmes in preschool children

Objectives

Various programmes have been developed for caries risk assessment (CRA). Nevertheless, scientific evidence on their validity is lacking. This study aimed to compare the validity of 4 CRA programmes (CAT, CAMBRA, Cariogram, and NUS-CRA) in predicting early childhood caries.

Methods

A total of 544 children aged 3 years underwent oral examination and biological tests (saliva flow rate, salivary buffering capacity and abundance of cariogenic bacteria mutans Streptococci and Lactobacilli). Their parents completed a questionnaire. Children's caries risk was predicted using the 4 study programmes without biological tests (screening mode) and with biological tests (comprehensive mode). After 12 months, caries increment in 485 (89%) children was recorded and compared with the baseline risk predictions.

Results

Reasoning-based programmes (CAT and CAMBRA screening) had high sensitivity (≥93.8%) but low specificity (≤43.6%) in predicting caries in children. CAMBRA comprehensive assessment reached a better balance (sensitivity/specificity of 83.7%/62.9%). Algorithm-based programmes (Cariogram and NUS-CRA) generated better predictions. The sensitivity/specificity of NUS-CRA screening and comprehensive models were 73.6%/84.7% and 78.1%/85.3%, respectively, higher than those of the Cariogram screening (62.9%/77.9%) and comprehensive assessment (64.6%/78.5%). NUS-CRA comprehensive model met the criteria for a useful CRA tool (sensitivity + specificity ≥ 160%), while its screening model approached that target.

Conclusions

Our results supported algorithm-based approach of caries risk modelling and the usefulness of NUS-CRA in identifying children susceptible to caries.

Clinical significance

This prospective study provided evidence for practitioners to select tools for assessing children's caries risk, so that prevention measures can be tailored and treatment plan can be optimised.     

A Best Practices Approach to Caries Management

Caries management by risk assessment represents best practices and is an evidence-based model that focuses on treating and preventing disease at the patient level rather than a surgical/restorative approach at the tooth level.BackgroundDental caries is a multifactorial, biofilm and pH mediated disease that affects people of all ages and disproportionally affects certain populations at epidemic proportions. Simply restoring cavitated teeth does nothing to resolve the disease. At the heart of the CAMBRA philiosphy is identifying the patient's unique risk level for future caries disease. This can be done by completing a caries risk assessment (CRA). Several easy to use CRA questionnaires are available. Once the patient's unique risk level has been determined, preventive and therapeutic interventions, based on the specific risk level, can then be implemented.MethodsLandmark publications, original research, and systematic reviews are analyzed and reviewed to form the basis for this shift in patient care related to caries disease.ConclusionsCaries management by risk assessment has emerged as the new paradigm in patient care and represents an evidence-based, best practices approach with the potential for significant advantages over traditional methods.     

How to integrate CAMBRA into private practice

The 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 efforts to include risk assessment with evidence-based diagnosis while also treating the biofilm 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.     

龋病防治的临床难度评估

龋病是发生于牙体硬组织的慢性感染性疾病,具有发病率高、治疗率低等特点,严重危害口腔和全身健康。加强和完善龋病的规范化治疗是全人群、全生命周期龋病管理面临的关键问题。因此,在龋病诊断和分类的基础上,建立龋病防治临床难度评估系统,主要包括龋病风险评估和龋病治疗难度评估,可为龋病管理提供有效的依据。本文围绕龋病防治难度评估系统,从龋病的诊断和分类、龋病风险评估和龋病治疗难度评估等龋病防治临床管理的重要组成部分进行归纳与阐述。     

Risky business: influencing people to change

The evolution of prevention methods represents a positive development of significant value. Managing the behavioral components of prevention is crucial to create buy-in by staff and patients. Numerous recommendations for successful implementation of CAMBRA are cited. It is important for dentists to establish which option works best with each employee, and for the dental care team to do the same with each patient in the practice.     

The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults

In the absence of effective caries preventive methods, operative care became established as the means for caries control in general practice. Water fluoridation resulted in a declining caries incidence which decreased further following the advent of fluoridated toothpaste. The challenge today is to develop a non-invasive model of practice that will sustain a low level of primary caries experience in the younger generation and reduce risk of caries experience in the older generations. The Caries Management System is a ten step non-invasive strategy to arrest and remineralize early lesions. The governing principle of this system is that caries management must include consideration of the patient at risk, the status of each lesion, patient management, clinical management and monitoring. Both dental caries risk and treatment are managed according to a set of protocols that are applied at various steps throughout patient consultation and treatment. The anticipated outcome of implementing the Caries Management System in general dental practice is reduction in caries incidence and increased patient satisfaction. Since the attainment and maintenance of oral health is determined mainly by controlling both caries and periodontal disease, the implementation of the Caries Management System in general practice will promote both outcomes.     

儿童龋病分级管理

儿童龋病分级管理模式是指通过临床检查与问卷调查,将儿童分为不同的患龋风险等级,并进行相应的个性化、精细化管理,以期达到降低儿童龋病患病率的目的。近年来,尽管我国卫生行政部门在儿童龋病防治方面投入了大量的人力和物力,但收效甚微。根据第四次全国口腔健康流行病学调查结果显示,我国儿童龋病患龋率仍处于较高水平。目前,国内已有不少文献对儿童龋病的风险评估进行了研究,但对其后的管理模式尚未有文献探讨。而国外已有文献对儿童龋病的管理模式进行了讨论,并且有些地区已将龋病分级管理的部分步骤应用于实践。文章将对儿童龋病分级管理模式进行论述,以期为我国儿童龋病的管理提供借鉴。     

应用微创理念构建老年龋病防治方案（二）

微创牙科治疗（MID）是一种全新的齿科医学理念,着眼于疾病的早发现、早诊断、早治疗,强调病症早期的微创（甚至分子水平）治疗以及发生不可逆性损伤时以患者为本的治疗方案。依据MID理念构建的老年龋病防治方案是着眼于改善口腔微环境、降低患龋风险,终止甚至逆转龋病进程,必须进行手术治疗时尽量减轻患者疼痛的综合性防治体系。应用MID理念构建的老年龋病防治方案包括对蚀损、磨损、脱矿、猛性冠根龋、残根、继发龋（冠和其他修复体周围）、龈下龋,唾液腺机能障碍、高菌斑水平、牙龈肿胀出血,治疗时隔湿困难等老年人常见的口内情况,以及伴有行为障碍等全身疾病的老年龋病患者进行系统、完善的治疗。本文主要阐述了MID在老年龋病修复方面的应用,包括在去龋、窝洞预备,生物性修复材料的选择,蚀损和磨损的治疗,隔湿困难患者的治疗以及活髓保存技术中的应用。     

基于慢性疾病管理理念的重度低龄儿童龋管理方法

重度低龄儿童龋是威胁中国儿童口腔健康的主要疾病。目前中国龋病治疗的主要手段是充填修复,对重度低龄儿童龋患者,充填修复具有患儿难配合、新发龋多、经济及医疗负担重等局限之处。随着对龋病病因学和疾病过程的深入理解,学界提出了基于慢性疾病管理思路的龋病管理模式,通过对致龋因子和保护因子的干预来改善口腔环境,由单纯的去除龋坏组织转向控制龋病的疾病进程,由此来改善龋病的治疗效果。本文以龋病的慢性疾病管理方法及国外本专业学术组织发布的指南进行回顾综述,为中国重度低龄儿童龋防治提供参考。     

Dental caries process.

The boundaries of caries diagnosis and caries intervention are changing. Dentists currently use visual, tactical, and radiographic information to detect relatively advanced changes in the dental hard tissues. The clinical management of dental caries has been primarily directed at the treatment of the consequences of the disease process by placing restorations and not at curing the disease. Using emerging technology, dentists will be able to detect incipient dental caries (demineralization) at an earlier stage than the clinically visible white spot. Dental caries is a dynamic process, which in its early stages is reversible and even in its more advanced stages can be arrested. The widespread use of fluoride has dramatically reduced the prevalence of dental caries and the rate of the progression of carious lesions. These changes permit dentists to adopt more conservative management strategies directed at the prevention and cure of dental caries.     

应用微创理念构建老年龋病防治方案（一）

随着我国步入老龄化社会，老年人口占总人口的比例逐步升高。近年来，随着老年口腔医学的不断发展与普及，我国老年人口内存留牙数不断增多，过去患龋率较低和需行大面积修复治疗的老年人群的龋病发生率有所提高，口腔医生在老年龋病防治工作中面临新的挑战。微创牙科治疗（MID）是一种全新的齿科医学理念，着眼于疾病的早发现、早诊断、早治疗，强调病症早期的微创（甚至分子水平）治疗以及发生不可逆性损伤时以患者为本的治疗方案。本文主要阐述了MID理念在老年龋病预防中的应用，主要内容包括患龋风险评估、龋病早期诊断（未形成龋洞前）、促进牙体外部和窝洞内部的再矿化，体现了MID在老年龋病早期诊断、早期治疗以及控制龋病进程中的重要作用。     

Applying evidence-based dentistry to caries management in dental practice: a computerized approach

BACKGROUND: It has been suggested that dentists manage patients' treatment according to their risk of developing caries, as determined on the basis of scientific findings-an example of applying evidence-based dentistry, or EBD, to caries management. This article evaluates the barriers to adopting EBD and suggests possible outcomes for dentists and patients if new EBD caries strategies are adopted. METHODS: The author estimated the complexity of adopting EBD for a general dentist by means of flowchart analysis. He considered the ease of collecting comprehensive patient screening data, identifying risk factors and classifying risk. He examined the adequacy of conventional caries charting methods for representing the different stages and behavior of carious lesions, as well as the difficulty of producing treatment plans according to different caries risk levels. He also modeled the possible financial and organizational results of applying EBD caries management methods and increasing the use of hygienists. RESULTS: Traditional caries management strategies required only one flowchart page, while EBD needed 16 pages. Two full-time hygienists and 25 percent of a dentist's time, managing only patients at low risk of developing caries, could generate the equivalent gross income of a full-time dentist working conventionally. Adding a third hygienist and devoting 75 percent of a dentist's time to managing the remaining patients (those at medium or high risk of developing caries and periodontal disease) could gross a similar amount again. CONCLUSIONS: Changing from traditional to risk-based management of caries requires complex decision making that is unlikely to occur with paper chart methods. Computers are ideal for collecting patient screening data and automating the treatment planning process to reduce the complexity of clinical management. Conventional methods of charting caries are not suited for evidence-based caries risk management. PRACTICE IMPLICATIONS: One dentist who uses risk-based management of caries and makes efficient use of three hygienists may see a doubling of income and a fourfold increase in the practice's patient population.     

The caries balance: contributing factors and early detection

The aim of this article is to present a brief overview of the dental caries process, in particular, the management of dental caries and the role of early detection methods in the clinical management of caries.     

Caries management pathways preserve dental tissues and promote oral health

In May 2012, cariologists, dentists, representatives of dental organizations, manufacturers, and third party payers from several countries, met in Philadelphia, Pennsylvania, to define a common mission; goals and strategic approaches for caries management in the 21th century. The workshop started with an address by Mr. Stanley Bergman, CEO of Henry Schein Inc. which focused on the imperative for change in academia, clinical practice, and public health. For decades, new scientific evidence on caries and how it should be managed have been discussed among experts in the field. However, there has been some limited change, except in some Scandinavian countries, in the models of caries management and reimbursement which have been heavily skewed toward ‘drilling and filling’. There is no overall agreement on a caries' case definition or on when to surgically intervene. The participants in the workshop defined a new mission for all caries management approaches, both conventional and new. The mission of each system should be to preserve the tooth structure, and restore only when necessary. This mission marks a pivotal line for judging when to surgically intervene and when to arrest or remineralize early noncavitated lesions. Even when restorative care is necessary, the removal of hard tissues should be lesion‐focused and aim to preserve, as much as possible, sound tooth structure. Continuing management of the etiological factors of caries and the use of science‐based preventive regimens also will be required to prevent recurrence and re‐restoration. These changes have been debated for over a decade. The Caries Management Pathways includes all systems and philosophies, conventional and new, of caries management that can be used or modified to achieve the new mission. The choice of which system to use to achieve the mission of caries management is left to the users and should be based on the science supporting each approach or philosophy, experience, utility, and ease of use. This document also presents a new ‘Caries Management Cycle’ that should be followed regardless of which approach is adopted for caries prevention, detection, diagnosis, and treatment. To aid success in the adoption of the new mission, a new reimbursement system that third party payers may utilize is proposed (for use by countries other than Scandinavian countries or other countries where such systems already exist). The new reimbursement/incentive model focuses on the mission of preservation of tooth structure and outcomes of caries management. Also described, is a research agenda to revitalize research on the most important and prevalent world‐wide human disease. The alliance of major dental organizations and experts that started in Philadelphia will hopefully propel over the next months and years, a change in how caries is managed by dentists all over the world. A new mission has been defined and it is time for all oral health professionals to focus on the promotion of oral health and preservation of sound teeth rather than counting the number of surgical restorative procedures provided.