Dental News - What’s new in CAMBRA?

Search Dental Tribune

What’s new in CAMBRA?

Shirley Gutkowski, RDH, BSDH, FACE
Shirley Gutkowski, USA

Shirley Gutkowski, USA

Wed. 6 April 2011

save

As you may know, CAMBRA stands for Caries Management By Risk Assessment. It doesn’t sound new or innovative for most clinicians because we believe we practice this way. Clinicians believe that they practice this protocol by looking into the mouth, seeing debris (the risk) and telling patients that they need to brush or floss to remove the soft deposits that have accumulated on the teeth (caries management).

This strategy worked for a long time. We can see it work by the declining edentulous rate. Somehow, over time, the focus of treating caries has shifted to repairing caries lesions — the ones caused by the bacterial infection. This is akin to treating diabetes complications by amputating gangrenous appendages and calling it treatment.

Prevention is not really hitting all the high points, and this is partly because of confusing dental language.

Bacteria cause holes in the teeth, and CAMBRA impresses this idea on students by reducing quotas for drilling and filling and increasing the requirements for managing the disease. The requirement for saliva testing, bacterial testing and treatments that center on cariology receive more emphasis. Even today, some schools do not teach cariology as a separate class, but introduce bits and parts of cariology into other classes.

The CAMBRA dental students of today elevate the patients’ risk profile into a diagnostic tool to help launch a treatment plan that doesn’t center on surgically altering teeth and placing prosthetics in an effort to reestablish the biological dimensions of the tooth.

It’s a difficult undertaking. The dentists employed to manage the student clinic are of the surgical mindset, filling the holes in the teeth. When the new CAMBRA graduates are released into the public, they are often at odds with their employers.

The traditional dentist removes the infected part of the tooth, never really dealing with the cause of the damage. The current thought is that there’s no money in risk management.

The national board exams also do not reflect the CAMBRA focus on caries control protocols.

The Western CAMBRA meeting this past year focused on continually refining the language of dentistry and finding ways to reflect this educational model in the board exams. Dr. M. Fontana led a committee in the Cariology Special Interest Group (now a Section) on terminology at the American Dental Educators Association (ADEA). Together with other interested parties, the group created a “standardization of dental terms” to be used in dental programs. The glossary is published in Dental Clinics of North America, August 2010 (Dent Clin N Am 54 (2010) 423–440).

Over the past five years or so, these issues — of clinical instructor’s focus and standardizing dental language — are being ironed out at the schools. The liaison between CAMBRA and the dental examining boards has been working too. Requirements for drilling still far outweigh the requirements for including caries management recommendations, or even considering caries risk when establishing recall intervals.

While the idea of CAMBRA is working its way into the stream of traditional dentistry, the CAMBRA team is working on getting on top of the cause to educate dental and dental hygiene students about the management of caries and going beyond damage control. Language drives clarity and change.

What’s interesting about the language change is the list of words to be retired. Words such as “watch.” Watch has never been a technical term. The word “watch” in the context of caries management has traditionally been used to monitor an area. Without further treatment, “watch” really described passivity on the part of the practitioner to wait until the area had progressed to the point of cavitating and needing a restoration of some kind.

In the recent past (Dec. 2010), the FDA again addressed the safety of amalgam as a restorative for diseased enamel. The salient point that was never addressed, the elephant in the room, was that rebalancing the oral pH and providing the missing components of saliva, thus forfeiting the reasons for the amalgam in the first place, could treat many of these lesions.

Following are some of the important glossary terms from Dental Clinics of North America. These definitions are quoted from the entry: Defining Dental Caries for 2010 and Beyond. References for the definitions can be found in the source for the following summary.

Caries process

The caries process is the dynamic sequence of biofilm-tooth interaction that can occur over time on and within a tooth surface.

This process involves a shift in the balance between protective factors (that aid in remineralization) and destructive factors (that aid in demineralization) in favor of demineralization of the tooth structure over time. The process can be arrested at any time.

Demineralization

Demineralization is the loss of calcified material from the structure of the tooth. This chemical process can be biofilm mediated (i.e., caries) or chemically mediated (i.e., erosion) from exogenous or endogenous sources of acid (e.g., from the diet, environment or stomach).

Caries lesion/carious lesion

A caries/carious lesion is a detectable change in the tooth structure that results from the biofilm-tooth interaction occurring due to the disease caries. It is the clinical manifestation (sign) of the caries process. “People have dental caries, teeth have caries lesions.”

Although attempts have been made in the literature to separate the term “caries lesion” from “carious lesion” (and in some cases to deprecate the term carious) — in some instances the latter is being used to refer to an “active” lesion — we find that applying those distinctions to everyday practice can be confusing, and thus we suggest that both terms can continue to be used interchangeably.

Caries lesion severity

This is the stage of lesion progression along the spectrum of net mineral loss, from the initial loss at a molecular level to total tissue destruction.

This involves elements of both the extent of the lesion in a pulpal direction (i.e., proximity to the dento-enamel junction and pulp) and the mineral loss in volume terms. Noncavitated and cavitated lesions are, for example, two specific stages of lesion severity.

Noncavitated lesion (a.k.a. incipient lesion, initial lesion, an early lesion or white-spot lesion)

A noncavitated lesion is a caries/carious lesion whose surface appears macroscopically intact. In other words, it is a caries lesion without visual evidence of cavitation.

This lesion is still potentially reversible by chemical means or arrestable by chemical or mechanical means.

White-spot lesion

This is a noncavitated caries/carious lesion that has reached the stage where the net subsurface mineral loss has produced changes in the optical properties of enamel, such that these are visibly detectable as a loss of translucency, resulting in a white appearance of the enamel surface.

However, it must be noted that although initial lesions appear as a white, opaque change to the naked eye, not all white-spot lesions are either initial (beginning lesions) or incipient, as they may be present for many years and may involve enamel and/or dentin.

Brown-spot lesion

A brown-spot lesion is a noncavitated caries/carious lesion that has reached the stage where the net subsurface mineral loss — in conjunction with the acquisition of intrinsic or exogenous pigments — has produced changes in the optical properties of enamel, such that these are visibly detectable as a loss of translucency and a brown discoloration, resulting in a brown appearance of the enamel surface.

Microcavity/microcavitation

This is a caries/carious lesion with a surface that has lost its original contour/integrity, without visually distinct cavity formation. This may take the form of localized “widening” of the enamel fissure morphology beyond its original features within an initial enamel lesion, and/or a very small cavity with no detectable dentine at the base.

Caries lesion activity (net progression toward demineralization)

The summation of the dynamics of the caries process resulting in the net loss of mineral over time from a caries lesion (i.e., there is active lesion progression).

Active caries lesion

A caries lesion from which, over a specified period of time, there is net mineral loss, that is, the lesion is progressing. Criteria include visual appearance, tactile feeling and potential for plaque accumulation.

Lesion is likely active when surface of enamel is whitish/yellowish opaque and chalky (with loss of luster); feels rough when the tip of the probe is moved gently across the surface.

Lesion is in a plaque stagnation area, that is, pits and fissures, near the gingival and approximal surface below the contact point.

In dentin, lesion is likely active when the dentin is soft or leathery on gently probing. The term active caries should be avoided and replaced by active caries lesion.

Arrested or inactive caries lesion

A lesion that is not undergoing net mineral loss, that is, the caries process in a specific lesion is no longer progressing. It is a scar of past disease activity.

Clinical observations to be taken into consideration for assessing caries lesion activity include visual appearance, tactile feeling and potential for plaque accumulation.

Lesion is likely inactive when surface of enamel is whitish, evidence of lesion arrest but also one or more of other definite changes, including increased mineral concentration (remineralization), increased radiodensity, decreased size of white-spot lesions, increased hardness of the surface and increased surface sheen compared with a previous matte surface texture.

For the day-to-day clinician some of this sounds like an academic exercise. Attention to the details in terminology for even a week can make very positive changes in the practice and healthier patients will emerge.

Obsolete hygiene terms

‘Caries free’
This term has frequently been used when referring to assessments made (of either individuals or groups) even where the diagnostic threshold employed has been at the “dentine or worse” level, ignoring all grades of initial lesion that may also be present. The term should now be avoided and more precise terms used.

‘Active caries’
This term was used to mean any lesion that had penetrated into dentine. The more modern definitions (e.g., active caries lesion) should now be used.

‘Radiation caries’
Caries lesions of the cervical regions of the teeth, incisal edges and cusp tips secondary to hyposalivation, induced by radiation therapy to the head and neck.

‘Watch’
This is a term sometimes used to indicate early, white-spot lesions in either smooth or occlusal surfaces. The term is used to either indicate uncertainty regarding the state of activity of the lesion or to indicate uncertainty as to whether it is actually a caries lesion to begin with.

As it is not a diagnostic term, it cannot lead to any management decision; the decision not to do anything or just “watch” should be eliminated from our choices of treatment.

The term may have previously been used as a way to delay restorative intervention for sites that we were unsure about when we did not have many treatment options for these earlier stages of the disease.

However, with the availability of better detection methods and noninvasive interventions, it is necessary to avoid using this term and make the best possible diagnostic call at any one point in time. Instead of watching over time, we should be monitoring the effect of our therapies and treatments on the lesions we are following.

About the author

Shirley Gutkowski, RDH, BSDH, FACE, is an international speaker, and award-winning writer, with a focus on minimal intervention dental hygiene. She also publishes in nursing journals. Gutkowski is co-creator of Adopt A Nursing Home, a board member and fellow of ACE, and a member of the World Congress of Minimally Invasive Dentistry. Gutkowski is co-director of CareerFusion, a retreat for clinicians interested in evolving their clinical career. You may reach her at crosslinkpresent@aol.com.

Leave a Reply

Your email address will not be published. Required fields are marked *

advertisement
advertisement