Caries Management By Risk Assessment

(CAMBRA)
And Fluoride Intervention

Khalida Mustafa
BDS MFDS (RCSED) UK MFD (RCSI) Ireland
PG certificate- Restorative Dentistry -UK
What is CAMBRA APPROACH

Paradigm shift Management of Dental caries

Rechmann, P(2018)
Why CAMBRA
Dental Caries: a multifactorial disease, not solely bacterial

Increased cariogenic
bacteria (Streptococcus
RISK FACTORS

mutans /Lactobacillus)

Reduced level of
Cariogenic Saliva (Dry
carbohydra mouth)
te diet
Dental
caries
Taditional vs Cambra

Traditional Management Cambra Approach

Focus on Treatment- Tooth level Focus on Prevention –Patient centered

Detect Identifying Risk Factors

Drill Caries Risk Assessment

Fill Predict Risk Level

Objective- CAMBRA

❖ Prevent new carious lesions.

❖ Reverse early non-cavitated lesions through remineralization (Non-
invasive approach)
Background

➢ Developed in 2007 by researchers and dental experts at UCSF.

Featherstone, J.D.(2007)

➢ Based on a 6-year retrospective study (Domejean) and a 2-year

randomized controlled study (Rechmann) Rechmann, P.(2018)

➢ Clinical guidelines updated and published in the California Dental

Association Journal by John D.B. Featherstone (2019).

➢ Utilizes a practical tool: Caries Risk Assessment (CRA) form to assist

practitioners in everyday practice.
How CAMBRA works in practice

1. Assess Caries Risk: Use Caries Risk Assessment (CRA) form.

2. Predict Risk Level: Apply the caries balance concept.

3. Preventive Intervention: Tailor treatment based on risk.

4. Monitor: Regular follow-up to ensure compliance and adjust care.

1-Caries Risk
Assessment Form
(CRA)- Aged 6 Years
Through Adults-
updated
Featherstone JD(2019)
2-Predicting Risk Score ( Caries Balance/Imbalance)

Caries risk level is outweighed between biological risk factors and protective factors.
Patient is categorised into low,medium,high,extreme high risk Featherstone, J.D., 2007.
Risk Level
Low Risk Moderate Risk High Risk Extreme Risk
Between low-risk and One or more disease Hyposalivation(dry
No disease indicators high-risk indicators present mouth)

Very few risk factors No caries indicator Risk factors outweigh Disease indicators
the protective factors. may or may not be
Uses fluoride Exposed root surfaces present
toothpaste twice a day
Uses fluoride Saliva flow can be
toothpaste once a day observed or measured
–the chairside

Normal level : 1ml/mt

Critical level :<.5ml/mt
Featherstone, J.D., 2007
3-Preventive Treatment Recommendation
Low Risk Moderate Risk High Risk Extreme Risk
➢ OTC toothpaste with ➢ Prescribed 5000 ppm ➢ Prescribed 5000 ppm
flouride (1000- fluoride toothpaste 2x F toothpaste
➢ Over the counter(OTC) 1450ppm F) 2x daily daily(if available) 2Xdaily(if available)
fluoride toothpaste (1000 Or
ppm F) 2x daily ➢ OTC fluoride ➢ Alternative regimen of ➢ 5%NaF varnish at first
mouthwash(.05%NaF) 1450ppm F 2x daily visit and every4- 6
, once daily months
- Fluoride mouth rinse-
➢ Dietary counseling (.05%) daily ➢ Xylitol(plant based
natural gum) for
➢ Patient education in - Fluoride varnish at first salivation- (limited
Modifying behavior visit and at recall visits evidence)

➢ Antibacterial Therapy ➢ Baking soda rinse(2tsf

chlorhexidine rinse in 250 ml of water)
(0.12%)once daily (1
week/month)
Featherstone, J.D., 2007
4-Monitoring

Follow-up visits are crucial to re-evaluate the risk level and patient
compliance

● High Risk:
○ Follow-up every 4-6 months
● Moderate Risk:
○ Follow-up every 6-8 months
● Low Risk:
○ Follow-up every 12-24 months
Key facts of Fluoride

➢ Fluoride is strongly negatively charged and quickly binds to

hydroxyapatite crystal
➢ Works more effectively at the tooth surface interface than during the
development of tooth Limeback, H., 1999.
➢ Fluorapatite crystals are least soluble in acid (critical pH 4.5)
➢ Low fluoride levels (0.03–0.05 mg/L in saliva) support
remineralization, but higher levels are necessary for high-risk patients
Featherstone, J.D.B., 2009.
➢ Systemic fluoride (drinking water) has minimal effect on post-erupted
teeth Limeback, H., 1999.
Emerging Research on Fluoride safe dose

➢ New evidence links high fluoride exposure during pregnancy to

lower IQ scores in children Green, R., (2019)
➢ U.S. Public Health recommends 0.7 mg/L for water fluoridation to
prevent caries, reduced from the previous 1–1.2 mg/L.
➢ Fluoride now reaches teeth through multiple sources like tap
water, bottled water, beverages, and dental products, unlike earlier
when it was mainly from water fluoridation.“
➢ Careful management of topical fluoride is crucial in areas with high
fluoride levels in drinking water(>1mg/L)
➢ Kashmir's community water fluoride levels are mostly 0.24 mg/L,
with 0.92 mg/L from Dal Lake Shah, A.F., (2014).
Alternative Remineralizing agents

➢ Toothpaste containing higher conc. Calcium and phosphate are

effective in remineralization Hou, P.J(2021) and are more safe
during pregnancy

➢ GC Tooth Mousse- contains CPP-ACP(casein

phosphopeptide-Amorphous Calcium Phosphate)

➢ GC Tooth Mousse plus- With fluoride

➢ Clinpro Tooth creme- 950ppm fluoride and Tricalcium

phosphate
Conclusion
➢ CAMBRA is an effective, structured approach to controlling caries at the patient level.

➢ The Caries Risk Assessment (CRA) form helps predict and document patient risk levels.

➢ Fluoride remains a key therapeutic agent in caries prevention.

➢ Calcium and phosphate-based remineralization products are alternatives for pregnant

patients and those with high fluoride levels in drinking water (>1 mg/L).

➢ CAMBRA provides a practical way to educate and motivate patients.

➢ Integrating CAMBRA into daily practice enhances patient care and outcomes.

➢ Challenges include patient compliance and additional time for assessment

References
Almulla, H.I., King, N.M., Alnsour, H.M. and Sajnani, A.K., 2016. Fluoride content of bottled drinking waters in Qatar. Biological trace element research, 174, pp.471-476.

Featherstone, J.D., Domejean-Orliaguet, S., Jenson, L., Wolff, M. and Young, D.A., 2007. Caries risk assessment in practice for age 6 through adult. Journal of the California Dental
Association

Featherstone, J.D., 2004. The caries balance: the basis for caries management by risk assessment. Oral health & preventive dentistry, 2, pp.259-264.

Featherstone, J.D., 1999. Prevention and reversal of dental caries: role of low level fluoride. Community dentistry and oral epidemiology, 27(1), pp.31-40.

Fejerskov, O., 2004. Changing paradigms in concepts on dental caries: consequences for oral health care. Caries research, 38(3), pp.182-191
.
Featherstone, J.D.B., 2009. Remineralization, the natural caries repair process—the need for new approaches. Advances in dental research, 21(1), pp.4-7.

Green, R., Lanphear, B., Hornung, R., Flora, D., Martinez-Mier, E.A., Neufeld, R., Ayotte, P., Muckle, G. and Till, C., 2019. Association between maternal fluoride exposure during
pregnancy and IQ scores in offspring in Canada. JAMA pediatrics, 173(10), pp.940-948.

https://www.researchgate.net/publication/334401386_CAMBRAR_Caries_Management_by_Risk_Assessment_A_Comprehensive_Caries_Management_Guide_for_Dental_Profe

Hou, P.J., Lee, C.Y., Ou, K.L., Lan, W.C., Chuo, Y.C., Lin, H.Y., Chao, H.W., Huang, B.H., Saito, T., Tsai, H.Y. and Yang, T.S., 2021. Calcium release from different toothpastes after the
incorporation of tricalcium phosphate and amorphous calcium phosphate. Applied Sciences, 11(4), p.1848.

Limeback, H., 1999. A re‐examination of the pre‐eruptive and post‐eruptive mechanism of the anti‐caries effects of fluoride: is there any anti‐caries benefit from swallowing
fluoride?. Community Dentistry and Oral Epidemiology, 27(1), pp.62-71.

Rechmann, P., Kinsel, R. and Featherstone, J.D., 2018. Integrating Caries Management by Risk Assessment (CAMBRA) and Prevention Strategies Into the Contemporary Dental
Practice. Compendium of continuing education in dentistry (Jamesburg, NJ: 1995), 39(4), pp.226-233.

Rechmann, P., Jue, B., Santo, W., Rechmann, B.M. and Featherstone, J.D., 2018. Calibration of dentists for caries management by risk assessment research in a practice based
research network-CAMBRA PBRN. BMC oral health, 18, pp.1-9.

Shah,A.F; Ishrat, A., Batra, M. and Gupta, V., 2014. Fluoride in the water of Kashmir valley: a BI bevelled concern. Int J Sci Nat, 5(3), pp.443-447.
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