CAMBRA: Best Practices in Dental Caries Management A Peer-Reviewed Publication Written by Michelle Hurlbutt, RDH, MSDH

The current approach to dental caries focuses on modifying and correcting factors to favor oral health. Caries management by risk assessment (CAMBRA) is an evidence-based approach to preventing or treating dental caries at the earliest stages. Caries protective factors are biologic or therapeutic measures that can be used to prevent or arrest the pathologic challenges posed by the caries risk factors. Best practices dictate that once the clinician has identified the patient’s caries risk (low, moderate, high or extreme), a therapeutic and/or preventive plan should be implemented. Motivating patients to adhere to recommendations from their dental professionals is also an important aspect in achieving successful outcomes in caries management. Along with fluoride, new products are available to assist clinicians with noninvasive management strategies. Introduction Dental caries is the most common oral disease seen in dentistry despite advancements in science, and continues to be a worldwide health concern.1 According to the National Health and Nutrition Examination Survey (1999-2004), dental caries continues to affect a large number of Americans in all age groups, with carious lesions in primary teeth increasing among children aged 2-5 years.2 This survey revealed that 42% of children aged 2-11 have had carious lesions in their primary teeth and 21% of children aged 6-11 have had carious lesions in their permanent dentition. Approximately 59% of adolescents aged 12-19 have experienced dental caries, and by adulthood (aged 20-75+) well over 92% of those surveyed have experienced dental caries in their permanent dentition. This suggests that the population of individuals susceptible to carious lesions and dental caries continues to expand with increased age. The management of this disease continues to be a challenge and requires dental professionals to acknowledge that simply removing or restoring the carious lesion will not change the unhealthy plaque biofilm that contributes to this disease state. Historically, dentistry has approached dental caries disease management through a surgical-restorative approach that can lead to several lifetime replacement procedures, resulting in an increased restoration size or more invasive procedures over time. It is estimated that 71% of all restorative treatments are performed on previously restored teeth, with recurrent carious lesions as a predominant cause.3 This demonstrates that although the carious lesion was repaired, the dental caries disease was not fully treated, because the actual cause and risk factors were not adequately resolved. Current science has determined that the key to dental caries treatment and disease prevention lies with modifying and correcting the complex dental biofilm and transforming oral factors to favor health.4-6 This can be accomplished through a best-practices approach that decreases caries risk factors, increases caries protective factors and is the basis for caries management by risk assessment (CAMBRA). The CAMBRA philosophy was first introduced nearly a decade ago when an unofficial group called the Western CAMBRA Coalition was formed that included stakeholders from education, research, industry, governmental agencies and private practitioners based in the western region of the United States.7 A consensus conference was held that same year, resulting in two entire issues of the Journal of the California Dental Association (February and March 2003) dedicated to the scientific literature on CAMBRA. Sharing of information among dental schools quickly led to all Western dental schools teaching the principles of CAMBRA. In 2007, another two issues of the Journal of the California Dental Association (October and November 2007) were devoted to the clinical implementation of CAMBRA, including clinical practice protocols. All four issues can be accessed by the public and downloaded, without charge, at www. cdafoundation.org/journal. As the CAMBRA philosophy grew in popularity, a Central CAMBRA Coalition and an Eastern CAMBRA Coalition were formed, and together with the Western CAMBRA Coalition they served as a catalyst to establish a Cariology Section within the American Dental Education Association (ADEA) and to have the core principles of CAMBRA adopted as official policy in dental education. CAMBRA Principles Caries management by risk assessment (CAMBRA) is an evidence-based approach to preventing or treating the cause of dental caries at the earliest stages rather than waiting for irreversible damage to the teeth. This philosophy requires an understanding that dental caries is an infectious bacterial biofilm disease that is expressed in a predominantly pathologic oral environment.8 Science suggests this disease is the consequence of a shift in the homeostatic balance of the resident microflora due to a change in local environmental conditions (such as pH) that favor the growth of cariogenic pathogens.9-10 Although acid-generating bacteria present in plaque biofilm are often considered the etiologic agents, dental caries is multifactorial since it is also influenced by lifestyle and host factors.6 In the simplest of descriptions, dental caries disease is a result of these acid-producing