A scientifically based approach comprising a tooth-decay risk assessment, aggressive preventive measures, and conservative restorations can dramatically reduce decay in community dental practices, according to the University of California San Francisco (UCSF) School of Dentistry. These findings, which support earlier research demonstrating the positive results of the assessment and treatment method in a university setting, may transform dental care for high-risk patients at a lower cost for both patients and dental clinics, the researchers report.
“We put the 2012 UCSF clinical study into the real world and showed it works,” said Peter Rechmann, DMD, PhD, lead author and professor of preventive and restorative dental sciences at the UCSF School of Dentistry. “The patients at high caries risk who used prescription products went down significantly over time in their risk level. Those in the control group also reduced their risk to a lesser degree simply by using over-the-counter products that also protect teeth and affect the bacteria.”
In 2013, senior author and UCSF School of Dentistry distinguished professor of preventive and restorative dental sciences John Featherstone, PhD, MSc, launched Caries Management by Risk Assessment (CAMBRA) for preventing and treating dental caries at its earliest stages. Dentists who use CAMBRA obtain the patient’s dental and medical history and conduct a clinical exam to assess caries early enough to reverse or halt progression and to determine caries risk factors.
These risk factors include acid-producing bacteria, frequent consumption of fermentable carbohydrates (snacking), and abnormally low saliva flow and function. From this assessment, the dentist uses behavioral approaches and chemical treatments to optimize protective factors. The treatment plan typically incorporates remineralization through the use of fluoride and/or antibacterial therapies such as chlorhexidine and xylitol, minimally invasive restorative procedures to conserve tooth structure, and regular follow-up with the patient.
The authors published their initial validation of CAMBRA in 2006, followed by more data in 2011, 2012, 2015, and 2016. Since then, more than half of the dental schools in the United States have adopted it as part of their curriculum. The authors said that now that it has been shown to be effective in a non-academic clinical setting, there also is potential for insurance companies to reimburse CAMBRA and other preventive therapies for adults, lowering patient costs while increasing profits for dental practices.
The latest study recruited 17 dentists in private practice and three in community clinics to participate in a two-year CAMBRA trial of 460 patients between the ages of 12 and 65 years, with 239 in a CAMBRA group and 221 in a control group. In the CAMBRA group, high-risk patients received prescription fluoride toothpaste, chlorhexidine antibacterial rinse, xylitol mints, and fluoride varnish. The control group received regular fluoride toothpaste, an assumed inactive mouth rinse, sorbitol candies, and a non-fluoride varnish.
Follow-up visits occurred at six, 12, 18, and 24 months, and new caries lesions or changes in caries risk level were recorded. Overall, a significantly greater percentage of high-risk participants were classified at lower risk after receiving CAMBRA preventive therapies. Dental decay was low in both groups.
Among 137 intervention and 105 control patients initially identified as high risk for caries, only a quarter remained at high risk in the CAMBRA group at 24 months, while 54% of the control group did. Of the 93 intervention and 99 control low-risk participants, most remained at low risk, indicating that the assessment correctly identifies who is at risk for caries.
According to the researchers, the risk reduction among the control group may have been caused by the fluoride toothpaste enhancing tooth repair, as well as the mouth rinse enhancing saliva flow and having bactericidal effects. While not as significant as the CAMBRA group in this study, the risk level of these patients dropped more dramatically over time than for those in the 2012 UCSF CAMBRA study.
“It was surprising to see the benefits gained by the control group,” said Rechmann. “More research is needed to see if the products and treatment administered to this group function in the way we speculate, and, if so, they might be made easily available to dental patients. Doing so can change the whole picture of caries control”
Among the study limitations, the researchers noted a high study attrition of 65%, which partly may have contributed to observed declines in risk level at each subsequent recall visit. The study, “The Evidence for Caries Management by Risk Assessment (CAMBRA®),” was published by Advances in Dental Research.
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