journal of the california dental association nov 2007

7/29/2019 Journal of the California Dental Association Nov 2007

http://slidepdf.com/reader/full/journal-of-the-california-dental-association-nov-2007 1/41

JournalN O V E M B E R

Role of RDHs, RDAs,

Oce Sta

Inuencing Change

Consensus Statement

( !)

( )

Caries riskassessment

Douglas A. Young, DDS, MS, MBA;

John D.B. Feather stone, MSc, PhD;

and Jon R. Roth, MS, CAE



d e p a r t m e n t s

The Associate Editor/Journalism and the Sanctity of Science

Impressions

Case Study/Wrongful Termination and Workers’ Compensation

Dr. Bob/Heavy Pondering on Light

features

Ci MgM by ik M – PCiio’ gi

An introduction to the issue.

Duglas A. Yug, DDS, MS, MBA; Jh D.B. Fathst, MSc, PhD; ad J R. Rth, MS, CAE

How o ig CMb io Piv PCiC

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.

V. Ki Kutsch, DMD; Ga Milicich, BDS; Willia D, DMD; Max Ads, DDS; ad Ed Zia DDS, JD

H ol o l Hygii, i oiC i CMb

The role of the dental team in Caries Management By Risk Assessment is critical to successful patient outcomes. This

article will evaluate the role of the clinical and administrative staff in maintaining a practice with a focus on disease

prevention and management.

Shily Gutkwski, RDH, BSDH; Di Gg, RDH, MPH; Ja Casy, RDH, DDS; Aa Nls, CDA, RDA, MA;

ad Duglas A. Yug, DDS, MBA, MS

iky bi: ilCig PoPl o CHg

This paper described numerous theories and approaches that can be used to positively influence the behavior of patients

and dental health care workers so they actively engage the CAMBRA process.

Buc Plti, PhD, MBA; Philip Wisti, PhD; ad Richad Fdkid, DMD, MA

Co M Ci MgM by ik M: iMPlMio

gili o PP o ol HlH

This sis ccluds with a cssus dcut adptd y hudds f dtal xpts, acadic sachs,

pactitis, ad dtal gaizatis that suaizs th ai picipls ad cliical applicati f CAMBRA.

Duglas A. Yug, DDS, MS, MBA; Jh D.B. Fathst, MSc, PhD; J R. Rth, MS, CAE; Max Ads, DDS, MS,

Md; Jaaa Auti-Gld, DDS, PhD; Gd J. Chists, DDS, MSD, PhD; Maghita Ftaa, DDS, PhD; V. Ki

Kutsch, DMD; Mathild (Tilly) C. Pts, DMD, PhD; Richad J. Sis, DDS, MS; ad Mak S. Wlff, DDS, PhD

7 6 1

765

770

822

777

778

786

794

799

CDA Jual

Vlu 35, Nu 11

n o v e m b e r 2 0 0 7Jual



c d a j o u r n a l , v o l 3 5 , n º 1 1

n o v e m b e r 2 0 0 7 76 1

Assoc. Editor

Jourlim h ciy of cicsteven a. gd, dds

ine. Tat is the number o den-

tal publications that arrived on

my desk the rst two days o

this week. Te variety o these

publications is as noteworthy

as the volume: three association journals,including this one, and another with two

supplements; a popular publication ea-

turing a reprinting o online discussionsor “threads,” and a tabloid-style esthet-

ics “journal” so large that it served as a

convenient older to carry all the others

home to their nal destination (either theshel or the city o Santa Monica recycling

bin). Te inormation contained therein

is beyond the assimilation o all but the

most reakishly gited and bored readers.Now more than ever dentists must be

selective in what they read.Te sheer existence o so many publi-

cations is a testament to the importanceo the printed word in the dissemination

o inormation within our proession.

I a publication arrives on our desk, be

certain that someone somewhere is read-ing it, even i we are not. Te popularity

o dental journalism is not new. Long

beore the days o dental mega-meet-

ings, multimedia presentations, the DVDeducational series, and online continuing

education courses, scientic-based dentalknowledge was primarily passed on

through our journals.It did not take long or manuactur-

ers and others with a or-prot interest

to recognize the potential or marketing

their goods through our proession’spublications. Te American College o

Dentists recognized the adverse inu-

ence commercial interests were having

on our proessional scientic publica-tions and elt the situation had reached a

crisis. In response, the college conceived

an organization known as the American

Association o Dental Editors. Te year

was 1931. Seventy-six years later, many in our proession eel we are still acing

a crisis with regard to commercialism in

dental journalism.

We are a proession grounded in sci-ence; and, as such, we rely on evidence

that has withstood the rigors o thescientic process in order to make clinical

decisions. Tese decisions directly aectthe health o our patients. When you

connect the dots, the line between our

proession’s journals and the oral health

o the public is a short and direct one.Tus, the importance o the reliability o

the inormation they contain cannot be

overstated.

We accept that there are proessionalpublications heavily tied to the dental

industry. Tese are oten extremely valuable to clinicians and enjoyable to

read. Tere are times, however, when wedemand to know that our inormation is

completely unbiased.

We are disappointed when we look to

a published article or reliable, unbiasedscientic clinical inormation and we nd

that the study has been unded by a or-

prot entity. We are not surprised when

the study reaches a avorable conclusionabout a product or technique that directly

benets this entity. It is disturbing when

we learn the author o the study has

received some orm o nancial remu-

neration rom the company in question.But what is even more disturbing is when

these connections are not clear to us. Tis

link between science and selling in our

dental publications is oten murky anddifcult to dissect. Yes, when we discover

this link it is disturbing. When we don’t, itcan be outright dangerous.

As this issue o the Journal goes topress, the AADE is preparing or its an-

nual meeting, which is held just prior to

the American Dental Association Annual

Session. Te current president o the AADE is John O’Keee, esteemed editor

o the Journal of the Canadian Dental

Association. During his presidency, he

has devoted his eorts to addressing theissue o commercialism in dental journal-

ism. It is our hope that at their meetingthis year, the AADE will take concrete

steps to curb the inuence o commer-cialism in our scientic journals. Some

have suggested a categorization o dental

publications based on their relationship

with commercial entities. Tis catego-rization would need to be clearly and

prominently displayed to the readers in

order or the publication to maintain

AADE recognition status. Te thoughtis that i the publication you are read-

N

We rely on evidence that has withstood the

rigors of the scientific process in order to

make clinical decisions.



76 2 n o v e m b e r 2 0 0 7


Address commens, leters, and quesionso he edior a [email protected].

ing carries the AADE logo on its insidecover, you will be able to nd a statement

identiying whether or not any o the

published studies contained within are

connected in any way to commercial in-terests. Tose interested in the proceed-

ings o this meeting or other activities

o our organization o dental editors are

welcome to visit www.dentaleditors.org.

Science and commercialism do not

mix, and it is imperative the proession o dentistry continues to challenge those who

seek to poison the sanctity o pure scien-

tic knowledge with pursuit o prot.




n o v e m b e r 2 0 0 7 6

Impressions

nnues n 7 8

bt o!b pa rees

Tere are numerous reasons or people

to kick their tobacco habit, most impor-tantly improved health, and multiple ways

to quit. And it’s never been easier. And just in time or the annual Great American

Smokeout scheduled or Nov. 15.

Te Caliornia Smokers’ Helpline,

which celebrates its 15th anniversary this year and is unded by tobacco taxes, is a

condential telephone program that helps

smokers quit. According to the Helpline’s

brochure, it has been scientically proven,

in randomized trials, that a telephone

quitline works.1

In a research study o more than 3,000

smokers, it was ound that people who

receive counseling are twice as likely toquit or good compared with those who

embark on this daunting task alone, ac-

cording to Helpline.

“Dental proessionals are in a unique

D a n H u b i g

Ofce Trash May Compromise Dental PatientsDi ig g wih hi k whh

i i ii i i i h .

P y w ii i ig

g ’ h i hgh h y, h Journal of

the Philadelphia County Dental Society ih wig i i

Ai-J i.

Aiiy, h t y iii wh

ii ii w i i h ih hi

, hi, iig g hi g h

Ri-Ai, Wg’, CVS ii, i iy,

hi ii gig i ii.

I h i y ii,

y i. Di h k wih hi

i whh i i ii i i i h ,

ig h ig i i h Journal.



6 6 n o v e m b e r 2 0 0 7


n e m e r 0 7 m p r e s s n s

the study. In the year between the ex-aminations, 7 percent o control subjects

developed symptoms in the MJ versus34 percent o study subjects.

Te M joint is one o the mostcomplex joints in the body. Any problem

that prevents this system o muscles,

ligaments, discs and bones rom working

together properly may result in a painulMJ disorder.

When the patients reported having

symptoms in the MJ either beore or

ater their accidents, or both, authors

evaluated symptoms, including MJ pain,

locking, and clicking. Tey also askedpatients to rate their pain intensity and

report the degree that symptoms inter-

ered with their daily lives, including sleepdisturbances, use o pain relievers, and

the need to take sick leave.

“One in three people who are exposed

to whiplash trauma, which induces necksymptoms, is at risk o developing delayed

MJ pain and dysunction during the year

ater the accident,” said the researchers.

y F cci viciOne-third o those exposed to whip-

lash trauma are at risk o developingdelayed MJ symptoms that may

require treatment. According to research

published in the

August issue o

the Journal of the

American Dental

Association, re-

searchers at Umeå

University, Sweden,

studied short- and long-

term temporomandibular joint pain and dysunction in 60 patients

in hospital emergency rooms directly

ater they were involved in a rear-end carcollisions. Tose patients were evaluated

a year later.

Te incidence o new symptoms o

MJ pain, dysunction or both betweenthe initial examination and ollow-up

was ve times higher in subjects than in

uninjured control subjects, according to

T N D y

A i , y h i iwi h i

h Pi Ei Mi Sy. Di wh i hi y k

i ii h y i i i hy hw hy

hi i.

Th ADA Sy C i h Sy Cii I kig ,

i qi i ig h i. I i h y

qi i, ii, g, i, i i.

Si h y h

U.S.

i, h wh i h

y g f

h h i

h wihi h wk

i.

Di wih qi

ih y h h ADA

Sy C --.

D. lch N w Cc

A wealth o useul inormation on

dental careers now awaits students at

ADA.org.

Te ADA recently launched a new Web

resource with compre-hensive career inorma-

tion or those thinkingabout becoming a dentist,

dental assistant, dental hygienist, or

dental lab tech.

At www.ada .org/goto/careers, you’ ll ind resources such as “10 Great

Reasons to Be A Dentist,” research

topics that make dentistry an exciting

career or the 21st century, the “CollegeFreshman-Senior imeline” (pertain-

ing to the timing o applying to dentalschool), inormation on diversiying the

proession and inancing dental educa-tion and more. “A Day in the Lie” are

testimonials in which dental students,

practicing dentists and dental school

proessors talk about what goes on dur-ing a typical day.

For more inormation on careers, con-

tact Beverly Skoog, coordinator, Career

Guidance, (800) 621-8099, ext. 2390.




n o v e m b e r 2 0 0 7 6

y D C Fi:Th Di Mj g

In a rst or the Army Dental Corps,

three dentists have recently served asmajor general at the same time.

“Te act that the Army had threedentists serving at the rank o major

general is testimony to the distinct leader-ship skills, character, and proessionalism

inherent in our soldier-clinician dentists,”

said Maj. Gen. Russell Czerw, current

dental corps chie. “ oday’s Army dentistis ingrained with the Army values and

warrior ethos, those characteristics which

are critical to the success o the Army now

and in the uture.”Maj. Gen. Joseph G.

Webb, Jr., his immediatepredecessor as dental corps

chie, was the rst dentalof cer to command an Army

medical center. He later

headed the dental corps or

nearly our years throughJuly 10, 2006, as the Army

mounted a dental tness

initiative or rst-term

soldiers and oered a loan

ic- ch Mi

Hoping to help people have a better

grasp o the mechanics and undamentalnature o evidence-based dentistry, Fran-

cesco Chiappelli, PhD, Division o Oral

Biology and Medicine, University o Cali-ornia, Los Angeles, School o Dentistry,

put together the Manual of Evidence-Based

Research for the Health Sciences.

Te manual may be helpul to stu-dents, scientists, clinicians, policymakers,

and industry product developers enabling

them to have access to all o the parts and

complexities associated with evaluatingand applying inormation using the tools

and concepts that have become associatedwith evidence-based dentistry, according

to a press release.opics in the book range rom the un-

damentals, such as an overview, research

and ethical concerns; practicum; issues

about methodology; and research orgeriatric populations, just to name a ew.

For more details, including the cost and

purchasing the book, contact Dr. Chiap-

pelli at [email protected].

up mn me e ns

repayment plan to dental of cers. An oral

pathologist, Webb was scheduled to retire

Sept. 1.

Maj. Gen. Ronald Silverman, U.S. Army reservist who has a private prac-

tice in civilian lie, is the highest rankingmedical of cer in Iraq and the rst dentist

to command all medical operations in acombat zone.

“Te best way to describe it is to say

I run the world’s largest trauma center

spread out over seven hospitals andthousands o miles,” Silverman told the

ADA News.

All three are association members.

2 0 0 7

N. 2-Dc. 1 ic cy o Mxici iy h i,

Chic, ..

2 0 0 8

My 1-4 CD i ciiic i, hi, -CD-MIl (232-4), c..

J 22-2 Fyi Di cii Mi, h lk Th, (12) 23-21,

yii.c.

. 12-14 CD F ciiic i, Fcic, -CD-MIl (232-4), c..

oc. 1-1 ic D cii 14h i, i, Tx, ..To have an event included on this list of nonprofit association continuing education meetings, please send the information

to Upcoming Meetings, CDA Journal, 1201 K St., 16th Floor, Sacramento, CA 95814 or fax the information to 916-554-5962.



6 n o v e m b e r 2 0 0 7


n e m e r 0 7 m p r e s s n s

position to intervene with patients,” saidWalter Silverman, partner development

coordinator with the Caliornia Smokers’Helpline. “Receiving dental care in the

clinic provides a teachable moment andoten boosts motivation to quit smoking.

Intervention is as simple as implementing

a system to: Ask patients i they smoke;

advise smokers it is in the best interest o their health to quit; and reer them to the

Helpline at (800) NO BUS.”

Tis ast and easy technique is pro-

moted nationally by the Smoking Cessa-

tion Leadership Center, added Silverman.

Once callers contact the Helpline,they will be asked a series o questions

to establish their needs. Tey are oered

options or services such as materi-als and/or counseling. I they choose

counseling, they may begin immediate

counseling or schedule an appointed

time. Te rst counseling session isapproximately 40 minutes, according

to Helpline materials. Te counselor

will provide as many as ve additional

counseling sessions, set at a certaintime, ollowing the rst counseling

session. Out-o-state residents can alsoaccess quitline services by calling (800)

QUI-NOW.Helpline counselors, who have

bachelor’s and master’s degrees, have

backgrounds in health-related elds,

social work, or psychology. o become acounselor, all have completed a 48-hour

in-house training program, a one-month

apprenticeship at the Helpline center,

and trained ully on empirically validatedprotocol. Overseeing all the clinical work

is a licensed psychologist.While Helpline does not provide

nicotine replacement therapy or othercessations medications that are FDA-

approved, the organization works with

Medicare, Medi-Cal, and county health

enrollees to use their benets. County health programs and Medi-Cal provide

ree pharmacotherapy or those enrollees

who participate in behavior-modication,

such as Helpline, and who also have aprescription rom their physician. Some

pharmacotherapy is covered by Medi-care, and it also reimburses or provider

counseling. And you can’t beat the cost: ree to

Caliornia residents, whether they are cur-rently smoking, have quit already, or want

inormation to help a relative or riend

kick their habit. Since the Helpline’s

creation in 1992, an estimated 430,000people living in the Golden State have re-

ceived help via the telephone quitline. Te

average daily call volume is 250, according

to the Helpline. At the moment, there are

more ex-smokers than current users in

Caliornia.Services include over-the-phone

counseling and quitting materials, reer-

ral to local programs on tobacco cessa-tion, and sel-help materials. Clients

who request counseling receive up to six

sessions with a counselor on a proac-

tive basis. Service hours are 7 a.m. to9 p.m. Monday through Friday; and 9

a.m. to 1 p.m. Saturday. For those who

call ater hours, or i lines are busy, the

Helpline has a 24-hour voice mail service.Tey may leave a message or listen to

automated messages about the use o quitting aids and the benets o tobacco

cessation, or example.Tere are services available in English,

Cantonese, Korean, Mandarin, Spanish,

DD/Y, and Vietnamese. Additionally,

there are specialized services availableor teens, pregnant women, and tobacco

users.

Funded by tobacco taxes, through the

state’s Department o Health and First 5Caliornia, Helpline operates out o the

Moores Cancer Center located at the Uni-versity o Caliornia, San Diego.

Te Web site or Caliornia Smokers’Helpline is www.nobutts.org. Free promo-

tional materials are available to providers

to distribute to their patients. Providers

simply call the outreach department at(858) 300-1010 or go to the Web site.

ref erenes1. Zh S-H, A CM, , Ei -w -

i h qii k. N Engl J Med

4:8-9, .

us , nnued fr m 7 5

“Ii i

i

ii

y :

k i i hy

k; i k

i i i h i

hi hh

qi; h

h Hi

() No bTT.”

aer serman




n o v e m b e r 2 0 0 7 6 9

Honors

Paul Glassman, DDS,

MA, MBA

Dvid lunt, DDS, Nhig,Ci., h i -

y h Fyig Di Ai-

i. F i 96 i

wh i,

hi i ig

h k i.

Aiiy, h gizi -

i h hi i-

i ii y

w iig i

ig i

hh i.

Pu Gssmn, DDS, Ma,

Mba, G, Ci., -

i i

ii hgy,

i A Ei

i G Diy Uiiy

h Pif, Ah A. Dgi

Sh Diy, i hSi C Diy Aii

S K Aw.

Th w, h ii’

high, y giz

iii ig “x-

y hi ii

h hh

wih i .”

G, i

h Si C Diy Ai-

i, h i wih h

i gizi

y.

Gurminder Sidhu, DDS, MS,

S Fi, h -

i h ii i

i i-

gy i Pif Sh

Diy.

Di cx y oH

Te Occupational Saety and Health

Administration’s disaster and storm

resources include hurricane-specic

inormation or employers conductingresponse and recovery operations.

A Web-based hurricane eMatrix at

www.osha.gov incorporates occupational

hazards inormation, observations, recom-mendations, and data OSHA has gathered

in responding to hurricanes Katrina, Rita,and Wilma and oers as guidance on OSHA

standards or uture disaster response.For more inormation about preparing

or and recovering rom disasters, see the

Disaster Planning and Recovery content

area, www.osha.gov.



0 n o v e m b e r 2 0 0 7


wg Tii wk’ Cpi:Fiig py wih

op Ci

her right oot when she tripped over

boxes in the storage room doorway. A

sta person called the dentist and askedher to return to the of ce immediately.

When she arrived, she instructed Ms.Smith to go to the emergency room, but

Ms. Smith reused. Even though theinjury was bothering her, Ms. Smith did

not seek medical care until one week

later. Radiographs indicated no racture,

and her physician diagnosed bruisingto the right oot but did not prescribe

medication or therapy or her oot.

Ms. Smith returned to her physician

at the end o June or back, knee, andoot pain. She underwent physical therapy

or one month. At that time, Ms. Smithdetermined the therapy was not helping

and elected to stop treatment. During her August perormance review, Ms. Smith

presented the dentist with a disability

note rom her physician stating she would

need extended time o or her nonworkrelated injury. Te note did not indicate

a return to work date. Te employee

manual stated, “Employees must put

all requests or time o work in writingindicating the start and end dates.” Even

ormer employee led a

lawsuit against a dentist al-

leging wrongul terminationwhen the dentist red her

ater she opened a workers’compensation claim. Te dentist claimed

she red the employee due to poor per-ormance and excessive absenteeism.

A dentist hired Sally Smith as an of ce

manager on Sept. 9, 2002. Over the next

year, the dentist noted several job-relatedissues including insurance billing mis-

takes and generally, poor job perormance

in Ms. Smith’s personnel le. On May 12,

2003, Ms. Smith hit her right knee againsta piece o wood underneath the counter-

top o her desk. Te dentist and anotheremployee saw the injury happen. Ms.

Smith did not seek medical attention un-til May 16 when her knee became sti and

painul. Her physician diagnosed trauma

to her right knee and prescribed Celebrex.

Ms. Smith did not take any time o work.wo weeks later, on May 30, Ms.

Smith told coworkers she ell while com-

ing out o the of ce’s storage area. Since

she ell during the lunch hour, therewere no witnesses. She said she injured

a s e s t u d

O q, h

Journal f

TDIC -

y, whh

y

y f

y .

Ah y TDIC

y,

h

w -

f , w

h y y

h .




n o v e m b e r 2 0 0 7 1

though the dentist reminded her o thepolicy, Ms. Smith reused to do this.

Ms. Smith led a workers’ compen-

sation claim during the third week o

her leave o absence. She alleged shehurt her right knee on May 12, 2003,

had back problems that started ater

the May 30 all, and cumulative trauma

injuries to her neck, back, and shoulders

since she began working or the den-tist in 2002. Ater the ourth week, the

dentist terminated Ms. Smith or poor

perormance and excessive absences.Subsequently, Ms. Smith led a wrongul

termination claim alleging retaliation or

ling the workers’ compensation claim.

Dig DicvyIt is important to realize a workers’

compensation claim is separate rom the

wrongul termination claim. Each claimhas its own insurance coverage. How-

ever, each insurance carrier has accessto the other’s investigation inorma-

tion and oten share inormation whiledeending the same policyholder. Since

the dentist had the Employment Prac-

tices Liability Insurance endorsement,

DIC initiated an investigation intothe wrongul termination allegation.

Te investigation revealed Ms.

Smith had been in a car accident in

1986, which injured her neck. Accord-ing to testimony given at the workers’

compensation deposition, Ms. Smithreported complete recovery rom that

injury. She claimed that she rst no-ticed problems with her neck, back and

shoulders ater her May 30, 2003, all.

Te extent o her injuries was ques-

tionable. Reports rom several physiciansrevealed diering diagnosis and treatment

recommendations. Her actions also contra-

dicted her allegations. While she claimed

her right knee continued to bother her atershe hit it on May 12, she never requested

time o work. Additionally, Ms. Smith

sought treatment one week ater her alleged

all in the storage room when she claimedshe hurt her right oot on May 30. Even

though she reused the dentist’s suggestion

to go to the emergency room that day, thedentist should have completed an incident

report addressing this all and the steps she

took to oer medical care to Ms. Smith.

Ms. Smith’s employee le noted thatapproximately one month ater she start-

ing working or the dentist, Ms. Smith

requested our days o. She wrote a letter

to the dentist saying she was gettingmigraine headaches due to stress at work

and amily issues. Te letter also claimedthat the dentist was not allowing her to

complete her duties as the ofce man-ager by not permitting her to discipline

two employees. Furthermore, there were

several entries where the dentist noted

Ms. Smith taking unapproved time o.Ms. Smith’s employee le contained

several entries including the August 2003

perormance evaluation, which noted:nHer poor job perormance,nMany patients had not received a bill

since February, andn An inquiry regarding the inconsistency

in the decrease in ofce earnings when thedaily schedule was busier than ever.

Tere is no record o Ms. Smith’s

response. Te dentist placed Ms.

Smith on probation pending an im-provement in her job perormance.

Ms. Smith went to a doctor’s ap-

pointment mid-August. She returned

with a note rom her physician statingshe would have to take time o, but

oered no timeline. She picked up hercheck and returned her ofce key to the

dentist without an explanation on Aug.

25. Te dentist terminated Ms. Smith, in

writing, on Sept. 4 stating the termina-tion was due to excessive absenteeism,

poor job perormance, and numer-

ous errors and omissions that aected

the practice. Te dentist attached Ms.

Smith nal paycheck to the letter.With the documentation the dentist

took during Ms. Smith’s employment,

DIC argued the merits o the wrongultermination allegation. Ms. Smith’s lack o

perormance and ailure to ulll her job

requirements supported the dentist’s deci-

sion to terminate her employment. How-ever, the timing o the termination did

aect the case outcome. Since it occurred

shortly ater Ms. Smith led the work-

ers’ compensation claim, it appeared thedentist was retaliating against Ms. Smith.

Te case ended up settling or a smallamount due to the dentist’s consistent

entries regarding Ms. Smith’s poorperormance.

l l

at an e earn frm reen

ts ase?

Workplace injuries and incident reports

Providing immediate access to a

physician provides the injured employeeneeded care and lessens the possibil-

ity o urther harm. It also providesdocumentation as to the extent o the

injury. Delaying treatment may exacer-

bate the injury exposing the dentist to

continued risk. Document and reportto your workers’ compensation car-

rier all employee injuries whether or

not they sought medical attention.

Similar to the documentation in pa-tient charts, proper documentation o an

I

z w’

f

h wf

.



n o v e m b e r 2 0 0 7


incident can be an excellent deense to aworkers’ compensation or general liability

lawsuit. Complete a report when patients,

sta, or visitors are involved in an inci-

dent that has caused injury, loss, or dam-age to them or their personal property.

Tis includes incidents where no obvious

injury occurred. Te person completing

the report should be the individual who

witnessed or is the most amiliar withthe incident. Te report should include:nTe date, time and location o the

incident. Factually explain what happenedbut do not include a judgment as to the

cause o the incident or the extent o any

injuries.n A brie description o the incident,

including injuries.nNames o witnesses along with their

contact inormation.n All action taken, including whether

medical services were needed. I so, by

whom. Also, note whether medicalservices were oered and denied by the

injured party.nTe signature o the injured party, i

possible.

File the report in a readily accessible

older separate rom the personnel leand give a copy to the injured person.

Workers’ compensation insurance is

a ederal requirement; however, some

states opt or requirements that are morestringent. o nd i your state ollows

ederal or state requirements, go to www.dol.gov/esa/owcp_org.htm or work-

ers’ compensation inormation or ask your workers’ compensation carrier.

In this case, the dentist should have

lled out incident reports ater Ms. Smith

hit her knee and again ater she claimedto have allen in the storage room. Both

reports would have documented the

dentist’s inquiry about medical care and

Ms. Smith’s reusal. Further, when anemployee suers a work injury, seeking

medical care should not be an option.

Some employees may want to go to theirown physician. Tis may or may not be

acceptable to your workers’ compensation

carrier. Contact your carrier to discussor set an appointment or a medical

evaluation. Tis evaluation memorial-

izes the injury and its extent, which

discourages the employee rom addingurther injuries onto a uture claim.

Employee Manual

Te dentist had a current employeemanual that detailed the of ce’s policies and

procedures. It emphasized that employ-ment in the of ce was “at-will” and either

party may terminate employment at any time. In the event the dentist terminates the

employee, the dentist must pay all wages

earned by the employee on the nal day

o employment. Te manual also detailedthat employees were expected to arrive at

the of ce at their scheduled time and gave

instructions about what to do in the event

the employee was sick or late to work. Tedentist’s policy stated employees must sub-

mit requests or leaves o absence in writing.Except in the case o accident or illness,

employees were to give two months notice i they required an extended leave o absence.

Personnel Records

Te dentist kept excellent person-nel records on all o her employees.

She regularly gave perormance evalu-

ations and counseled employees who

were not ullling their employmentobligations. Te les also reected

recognition awards she gave employ-ees who were doing their jobs well.

Among other things, Ms. Smith’s le

reected the extent o her unexcused

absenteeism and tardiness, ailure toproduce satisactory quantity and qual-

ity work, attending to personal aairs

during of ce hours, and ailure to ollow

of ce policies. Tis documentation sup-

ported Ms. Smith’s termination andwould have been suf cient justica-

tion or her termination had she not

led a workers’ compensation claim.

Workers’ Compensation

Te timing o Ms. Smith’s termina-

tion is the real issue in this case. Tedentist should have written a letter to

Ms. Smith accepting her resignation when

she voluntarily turned in her of ce key.

Unortunately, she terminated Ms. Smithater Ms. Smith opened a workers’ com-

pensation claim. It appears the dentistretaliated against Ms. Smith because she

opened the claim. It is illegal to termi-nate an employee in retaliation o or to

avoid a workers’ compensation claim.

Workers’ compensation law allows

employees to seek medical care wheninjured while perorming job duties.

Tey have a right to medical care and the

employer has an obligation to provide

it. Because o this obligation to providemedical care, it stands to reason that

employers will be diligent in providinga sae working environment or their

employees and avoid workplace injuries.Do not terminate an employee who

is out on a workers’ compensation claim.

Contact your workers’ compensation

carrier or an employment attorney orassistance with perormance issues

o employees who have open or ac-

tive workers’ compensation claims.— jaime davenport

tdic risk management analst

a s e s t u d

ase stud, ntnued fr m 772

I

y

f

w’

.




n o v e m b e r 2 0 0 7

allocation, the inherent complexity o

the process, and the inuence o third-

party payers on patient acceptance.Dr. Young; John D.B. Featherstone,

MSc, PhD; Jon R. Roth, MS, CAE; Dr.

Anderson; Jaana Autio-Gold, DDS, PhD;

Gordon J. Christensen, DDS, MSD, PhD;Margherita Fontana, DDS, PhD; Dr.

Kutsch; Mathilde (illy) C. Peters, DMD,PhD; Richard J. Simonsen, DDS, MS; and

Mark S. Wol, DDS, PhD, complete thisseries with a consensus document adopted

by hundreds o dental experts, academic

researchers, practitioners, and dental

organizations that summarizes the mainprinciples and clinical application o

CAMBRA.

ast month we reviewed the updated CAMBRA as-

sessment tools or children age 0-5, children age

6 through adult, as well as the latest products inthe marketplace that can assist practitioners with

incorporating CAMBRA into their practices.

In Part 2 o this series, we will look through the lens o

practicing dentists who are using CAMBRA in their of ces,how to establish nancially viable models or CAMBRA adop-

tion, as well as how to enlist the rest o the dental team andpatients into the benets o the CAMBRA approach to care.

V. Kim Kutsch, DMD; Graeme Milicich, BDS; Max Ander-son, DDS, MS, MEd; Edwin J. Zinman, DDS, JD; and William

C. Domb, DMD, begin with a discussion regarding the impor-

tance o the dentist owner/manager detailing the CAMBRA

benets to the dental of ce team and patients in order toacilitate a smooth transition. Te authors examine the dier-

ent requirements o each member o the dental team to inte-

grate caries risk assessment into an existing dental practice.

Shirley Gutkowski, RDH, BSDH; Debi Gerger, RDH,MPH; Jean Creasey, RDH, DDS; Anna Nelson, CDA,

RDA, MA; and Douglas A. Young, DDS, MS, MBA, pres-ent inormation relating to the role o the dental team

in CAMBRA as a critical component to successul pa-tient outcomes. Proper appointment scheduling, diag-

nostics, and data gathering, as well as implementation

o noninvasive or minimally invasive procedures can be

the responsibility o all members o the dental team.Bruce Peltier, PhD, MBA; Philip Weinstein, PhD; and Rich-

ard Fredekind, DMD, MA, discuss managing the behavioral

components o prevention as crucial to creating buy-in by both

dental team members and patients. Challenges to successulimplementation o CAMBRA include such issues as resource

n v e m e r 0 7 i n t r d u c t i n

guest editors

Dog . yog, dds,

ms, ma,

D-

D P

Uy

Pf, A A D

S Dy,

S F.

Joh D.b. Fho,

msc, pd, ,

Uy C,

S F, S

Dy, -

D

P R-

D S

UCSF.

Jo . oh, ms, cae,

x

C D A-

F.

C My Rk A

douglas a. oung, dds, ms, mba; john d.b. eatherstone, msc, phd; and jon r. roth, ms, cae

— a p r a c t i t i n e r ’ s u i d e

CDA Foundation will host a

live Web cast featuring Drs. John D.B.

Featherstone and Douglas A. Young,along with authors from last month’s

issue and this month’s Journal, from to

p.m. Dec. . Participants will be able to

submit questions on the topics covered in

these issues for answers during the Web

cast. This course is sponsored by the CDA

Foundation through its grant from First

California, and is approved to confer two

C.E. credits. To register for the event, go to:

cdafoundation.org or firstoralhealth.org.

l



77 n o v e m b e r 2 0 0 7


H ICMb iPi Pcicv. kim kutsch, dmd; graeme milicich, bds; illiam domb, dmd;max anderson, dds; and ed inman, dds, jd

Caries risk assessment, or the man-agement o caries by risk assessment,

represents an evidence-based approach

to managing dental caries. A challenge

or dental practitioners integrating newscientic implications into clinical practice

is identiying the practical and strategic

steps necessary to accomplish that task.

Key tools that help the dentist and thedental team integrate CAMBRA into their

existing practices are recommended.raditional dentistry has not always

adequately controlled caries by its predomi-nantly surgical approach. Only treating

existing caries restoratively may not

prevent a lielong continuation o a chronic

disease state that ultimately contributes torecurrent caries necessitating additional

surgical interventions.1 Consequently, a

working group has re-examined our

proession’s approach to preventing andmanaging caries.2 CAMBRA, caries

a st ra t T y pp w y . Ty,

p w -

w f p . W

p pp CAMBRA, w w p

w CAMBRA p,

w .

clinician’s ability to success-ully integrate any new meth-

odology or technology into an

existing dental practice may

require a change in some, i not all, o the existing systems. Te den-

tist-owner/manager who explains CAM-

BRA benets (through education) to the

dental ofce team will gain their supportand acilitate a smooth transition. Te

authors examine the dierent require-ments o each member o the dental team

to successully integrate caries risk as-sessment into an existing dental practice.

Tere is ample scientic research

to support caries risk assessment as

a prudent approach to treating, andmore importantly, preventing den-

tal caries. Successul implementation

requires education and support o the

dental team and subsequent educationo patients about CAMBRA benets.

authors

v. ki kch, dmd,

p Ay,

O.

g Miicich, ds,

p, A

C D C,

H, Nw Z.

wii C. D, dmd,

p

Up, C.

Mx , dds, ms,

med, w A

D C

Sq, W.

i J. Zi, dds, jd,

w Lw O

Ew J. Z, S

F.

n t e r a t n a m r a




n o v e m b e r 2 0 0 7 77 9

management by risk assessment, is a

rationale that examines caries concentra-

tion in a particular patient, then plans a

measured treatment based on the indi-vidual needs o the patient.3

In health, the oral biolm is a diverse

and complex community o about 400 di-

erent bacterial species in any individual

patient. When desirable bacteria domi-

nate the oral biolm, there is a healthy equilibrium. Tis biolm serves many

positive unctions, including balancing

the demineralization-remineralizationcycles o enamel, and standing as the

rst line o deense against pathogens.4

Cariogenic bacteria are known to be inec-

tious and transmittable.5 Most childrenacquire these bacteria during the rst

ew months o lie rom their primary

caregiver. ypically these cariogenic

bacteria represent less than 1 percent o the oral biolm. However, under certain

conditions, a healthy biolm can be trans-ormed into a diseased state. Cariogenic

bacteria then thrive and prolierate into amuch higher percentage o the biolm.6

Caries risk actors — which include

cariogenic biolm, poor diet, saliva

production, medications, absence o uorides, and inadequate homecare — are

summarized in Featherstone et al. in last

month’s issue.7 Metabolism o carbohy-

drates by cariogenic bacteria results inacid production. Tis lowers the pH o the

biolm, which inhibits many commen-sal organisms. When compounded with

other risk actors, the acidic pH becomesthe selection pressure that results in an

overabundance o acidogenic organisms.8

Demineralization suf cient to cause cavi-

tation is a sign o the underlying disease.CAMBRA examines the carious biolm

and its potential or releasing its variety

o bio-acids that, unless neutralized, can

eventually destroy tooth structure.While it is important to restore

teeth, it is critical to address correct-

ing the biolm imbalance and other

predisposing actors to be successul in

treating the source o carious lesions.When restoring new cavities, we should

be asking ourselves, “What am I do-

ing to help the patient prevent more

cavities rom orming?” Appropriately,

then, CAMBRA has been continually

gaining ground in scientic research,dental education, and private practice.

need restorative procedures. CAMBRA

does not eliminate the need or lesion or

tooth repair. However, other tactics may

be introduced that reduce the number o restorative interventions when patients

can be empowered to rebalance their own

oral equilibrium and remineralize tooth

damage. Ten, depending on assessed

risk actors, patients should be re-exam-

ined at reasonable requencies to reviewpotential changes in their risk actors.

Tis can involve saliva testing, diet review,

quantication o acidogenic bacteriallevels, buering capacity and the like.

CAMBRA, in this sense, is a ormalization

o many techniques o caries control used

by dentists or considerable time (reer toRamos-Gomez et al., Featherstone et al.,

and Jenson et al., in last month’s issue or

details o the recommended procedures).

bi h l

First, the team leader is determinedand this person must be very clear and re-

alistic about the goals. Te authors recom-mend the CAMBRA team leader provide

written CAMBRA goals and methodology,

and share them with the team. Goals

should be concise, concrete, and easy orteam members to understand and imple-

ment. Some goals may require the acquisi-

tion o new skills, knowledge, or materi-

als. In the case o CAMBRA, it requires anunderstanding o the cariogenic biolm,

how to properly diagnose, treat, monitor,and measure treatment outcomes, i.e.,

CAMBRA courses or the dental teamshould be considered along with train-

ing videos and manuals. Standardized

caries risk assessment orms are useul,

along with some metric to gauge bacterialload. What antibacterials and/or remin-

eralization products are available? What

patient education materials are on hand?

Once the practice appreciates CAM-BRA goals and benets, it can design

Ii iWhile there are a number o valid

scientic reasons to implement CAMBRA

into private practice, including ethical,legal and standard o care issues, the

most important reason is patient benet,

which is our primary obligation. CAM-

BRA conversion in private practice doesnot happen overnight. Caries manage-

ment by risk assessment represents asignicant change in mindset: how we

examine and prioritize treating cariesdisease. Implementing CAMBRA a-

ects all systems in the practice, rom

scheduling and ees to diagnostics,

treatment, and patient education.CAMBRA’s goal is to educate and

motivate patients to improve their

behaviors and give them strategies to

attain and maintain a healthy bio-balancein their mouth. Many patients will still

ares manaement

y

p

: w

w pz

.



7 0 n o v e m b e r 2 0 0 7


the pathway rom the present position

to accomplish the uture goal. As with

any planning process, it is a good idea to

establish a timeline with intermediatemilestones. Deciding which team member

is responsible or each step is important.

Do not arbitrarily designate a person to

do a step without education. Also, identiy

who will monitor and measure the prog-

ress on a timely basis. Consider imple-menting a reward system or both the

intermediate process as well as nal steps.

Identiying the challenges andbarriers to accomplishing each

milestone is also o great use:nHow much will it cost?nWhat space will be necessary?nWhat materials will we use?nHow long beore we are able to

implement CAMBRA or all patients?nHow will this aect all o the

of ce systems already in place?

nWho will be doing the ini-tial caries risk assessment?

Implementing CAMBRA is an op-portunity or beneting patients and

our proession. Probably the greatest

challenge is the paradigm shit in the

dentist’s mindset. Dentists were trainedto drill rst and ask questions later. Tey

were instructed in the rst week o dental

school that dental caries is an inectious

bacterial disease and then, instantly, adental drill was placed in their hands.

Te practice o CAMBRA changes thisapproach to: Ask questions rst; ollow up

with more questions; nd out why you aredrilling; gure out how to avoid drilling

in the uture; and then drill only what

is minimally necessary. Finally, monitor

and measure your treatment outcomes.

Th h D TCAMBRA can only be successully

integrated into a practice i the entiredental team understands and supports

this methodology. Like any other change

in the dental practice, CAMBRA will

not succeed without the support o the

entire dental team. Peltier, Weinstein,and Fredekind discuss behavioral change

in more detail in this issue. Communi-

cation and education are vital keys to

success. Te dentist should spend time

with their team studying the scientic

basis o dental caries and then ocusingon the patient benets o CAMBRA.

also an excellent resource or articles

on caries risk assessment. Additional

inormation can be gathered by attending

local or state C.E. programs ocused onCAMBRA. aking the entire dental team

to these programs is an excellent oppor-

tunity to update the CAMBRA team.

Once the team understands and

supports the goal, each member can

contribute to the road map design by identiying how CAMBRA will impact

their responsibilities and what changes

are needed. Tis will create some newchallenges, as team members evaluate

how they can incorporate more ser vices

into a limited amount o time. In many

of ces, the majority o the CAMBRA education, risk assessment, bacte-

rial testing, and treatment monitoring

occurs in the hygiene operatory. Tis

may place new demands on the dutiesand scheduling o both the hygienist

and dental assistants. Every practicewill solve these changes as appropri-

ate or the individual practice. Many o these issues are discussed by Gutkowski

et al. in this issue o the Journal.

It is important during the imple-

mentation to have requent eedbackand evaluate successes or delays. Hav-

ing the entire team solve these issues is

critical or success. It is also important to

share patient success stories as a group.Nothing takes the ear and dread out o

changes like hearing about the dierenceswe are making in patients’ lives. Address

and solve issues, but success comes romkeeping the team ocused on the goal.

Since our goal is to ultimately improve

the dental health o our patients, we need

new benchmarks to measure our success.Te dental proession has always used

the “no cavities” as a gold standard or

the measurement o health. But a patient

with high risk actors and “no cavities”is in reality a patient with a disease that

Sta meetings can be used to discuss the

evidence and the approach to CAMBRA

as the standard o care. One measure

o success in this education process o your team is to end the session with

a show o hands to “How many would

like their own children or loved ones

treated in this ashion?” I everyoneraises their hand, then your next ques-

tion should be “Why then shouldn’t wetreat all our patients the way we would

treat our own loved ones?” Isn’t this thetype o practice you want to develop?

Tere are many resources or CAM-

BRA’s scientic oundation. Previous

issues o the Journal of the California

Dental Association ocused on this topic

in February and March 2003, and are

permanently archived in their entirety on

the CDA Foundation Web site at www.cdaoundation.org/journal. PubMed is

amra an ny

y

p

pp

y.





n o v e m b e r 2 0 0 7 7 1

hasn’t maniested caries signs or symp-

toms yet. In addition, a patient that cur-

rently has “no cavities” doesn’t necessarily

mean they are at low risk or uture caries.

ihi xicTere is no substitute or a rst-hand

experience. Te dentist should ollow

through the CAMBRA process as a patient

in the of ce. Ten, each team membershould go through the process as well.

Tis may be an enlightening experience

or the individual team members, asthey may personally discover unknown

risk actors or risky bacterial loads. In

a delicate bio-balance o dental health

equilibrium, it may take only tiny changesto create serious issues in what other-

wise appeared to be a healthy mouth.

Every dentist has had experience with

the high-risk patient, young or old, withserious decay issues. And every practice

has patients who have been decay-reeor years. It’s the group in between that

represents the greatest diagnostic chal-lenge. Patients who come along with little

evidence o disease or long periods may

suddenly develop multiple new cavities.

Tese patients potentially benet themost rom CAMBRA. It is easy to identiy

the high-risk, high caries active patients,

and also the low-risk, low caries active

patients. However, the patients who are atrisk with no apparent signs o the disease

are the ones CAMBRA helps to identiy and benet with caries risk reduction.

At a sta meeting, the dental teamshould practice lling out the caries

risk assessment orms and doing the

bacterial testing. Each can practice how

they will explain CAMBRA benets topatients. Communicating new ideas

comortably and competently gener-

ally requires some practice and role

play. It also presents an opportunity topractice answering the patients’ re-

quently asked questions as ollows:nWhy do I get cavities?nI brush and oss, doesn’t that

prevent any cavities?nHow do you determine my caries

risk? Is the treatment expensive?nI I have the caries disease, should

other members o my household be tested

too?n

Why hasn’t anybody explained thisto me beore?

ing organizations that currently practice

CAMBRA provides valuable inormation

on what ideas helped the process and

what hurdles the dental team overcame.Use established networks and resources

such as the World Congress o Minimally

Invasive Dentistry or support and advice.nwww.cdaoundation.org/journalnwww.rst5oralhealth.orgn

www.adea.org/DMS/Sections/deault.htmnwww.aapd.orgnwww.icdas.orgnwww.midentistry.orgnwww.wcmid.com

ci h PiOnce the entire team understands and

is ready to implement CAMBRA, it is time

to educate your patients. A personal letter

explaining the CAMBRA benets is a greatway to break the news to everybody at the

same time. Put it in your newsletter or on your Web site and advise your patients to

look and learn. Experience reported rom anumber o of ces has shown that this is a

very eective way to deliver detailed inor-

mation because most patients do read your

newsletters. Some practices have developedbrochures explaining CAMBRA. Tese are

mailed with a cover letter to the patient

base. Also provide patients with a brochure

at the ront desk when they arrive or theirappointment. Explain the evolving change

in the practice’s progressive improvementswith the latest scientic technology and

caries studies. Let them know what to ex-pect on their next visit. Te more inormed

basic inormation you can provide in these

ormats, the less chairtime you will need

to spend explaining CAMBRA to them. Also, the inormation you advise in

the operatory will reinorce what they

read earlier. A simple one-page descrip-

tion o the caries process designed orchildren and adults is included at the end

Because CAMBRA is pretty straightor-

ward and logical, the most requently asked

question seems to be “Why hasn’t anybody

told me this beore?” Te sta can giveeach other immediate eedback during the

process. How did the experience eel? Was

there enough inormation? Did it make

sense? Was it comortable? Tis scenariogives everybody a rst-hand experience

as a patient. It also gives everybody achance to practice in a sae and comort-

able environment the new language andcommunication skills that the changes will

require. Tey will be more condent and

the program will be more successul as a

result o taking the time to practice.Tere are numerous of ces that have

already successully integrated CAM-

BRA into their daily practices. You don’t

have to necessarily reinvent the wheel.Contacting a CAMBRA colleague or join-

te patents

w

pp

CAMBRA p y

w

.



7 n o v e m b e r 2 0 0 7

a a a

CAMBRA

w

p

w

p .

o the description o caries risk assess-

ment by Featherstone et al. in this issue.

Tus, chairtime can be eectively devoted

to answering questions rather than begin-ning CAMBRA education at ground zero.

Provide the extra time or education

and communication with the patients.

ry to schedule and allow or the ew

more minutes it will require to explain

CAMBRA to them, and always answertheir questions. Te benet o having the

entire team supporting the philosophy

change is they will hear it rom morethan one person and tend to require less

o the dentist’s direct time in education.

However, the most eective message still

has to originate rom the dentist. “Tisis how we are changing and here is why”

is the doctor’s obligation. A logical goal

in the CAMBRA conversation with the

patient is or them to understand that just treating their cavities will not prevent

uture disease. Also, cavities are only underlying signs and symptoms o the

caries bacterial inection process. Patientsneed to understand that this biolm

inection must be diagnosed and treated

as a disease process. Tey also need to

learn and understand the concept o thebalance between health and disease and

the pathologic actors versus the protec-

tive actors. With proper educational

background, patients should be able tohelp identiy any changes in their risk

reduction actors during uture visits.I the patients desire additional

inormation, direct them to the CDA Foundation Web site at www.cdaounda-

tion.org, or other cariology Web sites on

the Internet. A couple o abstracts rom

PubMed are helpul to support particularideas about caries risk assessment. Select

the abstracts that convey the key points

you want your patients to understand.

Download these abstracts as documentles, and then boldace and underline

the signicant sentences you want to

make sure they read and understand. Te

documents can be printed in Word ormat

and given to the patient to take home. Your patients can orward CAMBRA

rom your Web site to other riends and

amily, which is a proven practice builder.

Internet-savvy patients may be inter-

ested in accessing PubMed directly. Te

more understanding and valid inorma-

Undertreatment occurs when a clinician

systematically provides nontreatment or

less-than-optimal treatment o existing

pathology. Tis would include ailure todiagnose the patient’s caries risk status.

Te consequence o undertreatment is

recurring caries and potential loss o more

tooth structure and /or teeth. Previously,

the rate o progression o dental car-

ies made conservative decisions highly questionable. oday with the lower caries

incidence and reduction in caries progres-

sion, surgical interventions need to beminimal in all but the most aggressive

dental caries situations, the cavitation.

In the CAMBRA paradigm, even a small

cavitation is a very serious sign o cariesimbalance. As part o their risk assess-

ment protocol, dentists need to evaluate

the requency o recall or each patient. I

the dental team has evaluated the patientas a high caries probability patient, then

prophylactic preventive therapies andother principles identied in this journal

should be implemented (Jenson et al.and Spolsky et al., previous issue). Tis

reduces the possibility o undertreatment.Overtreatment occurs when interven-

tions are unjustied or too aggressive orthe clinical situation. Te goal o mini-

mally invasive dentistry is to preserve

the maximum amount o healthy dental

tissues. An example o this conservativeMID philosophy is the use o air abra-

sion, hard tissue lasers, or ultra-smallburs to very conservatively clean or open

a questionable ssure to “see what’s inthere” based on the ICDAS codes and

the protocols outlined by Jenson et al.

in last month’s issue rather than blindly

restoring the tooth with amalgam orcomposite. Te consequences o over-

treatment are well characterized as the

“restoration/rerestoration cycle.” Any

cutting o tooth structure weakens thetooth and should be avoided i possible.

tion a patient has, the better is their

capability to choose wise health care deci-

sions or themselves. CAMBRA inormed

patients are great CAMBRA ambassadorswho advise others o your improved and

modern approach to caries control and

prevention.

o IIncipient lesions that do not penetrate

through the tooth’s enamel and intodentin are candidates or conservative,

noninvasive therapy like remineraliza-

tion, dental sealants, and other preven-

tive measures. Restoring teeth withoutregard to caries risk and omission o the

chemo-reparative and preventative phases

o therapy is sometimes called undertreat-

ment because patients are only gettingthe restorative phase o treatment.





n o v e m b e r 2 0 0 7 7

fusn n

w

CAMBRA

p

p.

P Dci All ve Caliornia dental schools

practice and teach caries risk assessment

or CAMBRA as a standard o care onpatients treated in their clinics. Argu-

ably, CAMBRA is the current standard o

care. Standard o care debates are popular

among dentists with everybody weigh-

ing in with opinions. Te purpose o this

paper is not to resolve those issues butrather to address current knowledge and

science. When examining the risks and

the benets o practicing CAMBRA, im-plementing this philosophy into the den-

tal practice reduces the caries risk or the

patient and the legal risk or the dentist.

Practicing CAMBRA requires properdocumentation. In the patient’s chart,

the dentist should have a standardized

caries risk assessment orm (Ramos-Go-

mez et al., Featherstone et al., previousissue), and then routinely include di-

agnosis, any bacterial testing or moni-toring, treatment recommendations,

treatment outcomes and recare plans. Itis important to record accurately, simply,

and routinely to make sure all chart

entries are consistent. I the patient

declines caries treatment in additionto any restorations, it is important to

record that patient declination in the

chart notes as well. Te patients should

be making their treatment decisionswith a ully inormed consent. Conse-

quently, education about the benetso CAMBRA is now required or an

adequate inormed consent, explain-ing CAMBRA ABCs, which include

alternatives, benets and consequences

o non-CAMBRA implementation.

Tere are numerous orms availableto record your assessment results as

previously noted. Te authors suggest

keeping things as simple as possible. Te

orms presented or children age 0-5 yearsby Ramos-Gomez et al. and those or

age 6 and older Featherstone et al. in the

previous issue are the most scientically

validated to date. Te choice o orms is

not as important as having a orm. Tisdecision might best be made with your

team, getting their input on which orm

would work best. It is best to separate

the special situation or children age

0-5 rom children age 6 through adult.

While sealants and uoride treatments

were sometimes covered, the ocus has too

oten disregarded preventive treatments.

Insurance companies (and employerswho negotiate the plans) and patients are

willing to pay or a lling, but not the ull

chemotherapeutic therapy necessary to

deal with the bacterial inection and/or

to remineralize/repair white spot lesions

and most importantly to prevent the nextcarious lesion rom developing. Amidst

this environment, the ADA Current Dental

erminology book or 2007/2008 containsa new CD code or uoride varnish as a

therapeutic treatment or the moderate- to

high-risk caries patient. While in the past

the dental proession was in a situationwhere there is little or no apparent value

placed on many preventive procedures,

there is promising progress with new ee

codes being added by third-party payers.“Why won’t my insurance pay or

this?” can be a common complaint rompatients. And, i insurance won’t pay

or preventive eorts, some patientsreason that perhaps suggested preven-

tive procedures are unnecessary.

CMb F cici

CAMBRA has a number o proce-

dures associated with it that have direct

related ees and ee codes already in place.In the CD 7, in addition to the normal

prevention codes or prophylaxis anduoride applications there are codes or:nD 0425: Caries Susceptibility estingnD 0415: Bacteriology StudiesnD 0145: Oral Evaluation Patient <3

years, Counseling Primary CaregivernD 1206: opical Fluoride Applica-

tion or Terapeutic Measures Mod-

erate to High-risk Caries Patient

Medical insurance might cov-

er some o the diagnostic testssuch as salivary ow and buer-

Th cic PiTe dental proession has been a role

model by promoting prevention via regu-

lar care and recare exams. One o the is-sues surrounding prevention has been the

economics. Most insurance contracts have

coverage or preventive care designed or

those who are at minimal or moderaterisk. Some patients are reluctant to spend

their own money on preventive services.Consequently, the majority o traditional

dentistry has been ocused on restorativerather than chemo-reparative and preven-

tive care. Focusing on caries damage

when CAMBRA does not intervene stops

short o reversing the carious process.Historically, the third-party systems

and our own patients developed a prior-

ity on restorative procedures because

dental caries was pandemic and validatedrisk assessment tools were not available.



7 n o v e m b e r 2 0 0 7


ing capacity measurements.

Some practices include the caries risk

assessment as part o the normal oral

exam, but additional procedures repre-sent new and separate ees. Te medical

approach to treating dental caries usually

involves behavioral counseling directed

at risk actors, ollowed by a protocol o

antimicrobial oral care products and some

remineralization strategies and materi-als. Te monitoring o ongoing treat-

ment and outcomes requires additional

bacteriology testing. Tese separate eeswill supplement restorative care ees.

While the income generated with the

CAMBRA procedures and materials is low

in comparison to high-end cosmetic pro-cedures, nonetheless practicing CAMBRA

does generate sufcient revenue to justiy

it rom a business model. What is most

important is that every single personin the ofce is absolutely committed to

helping their patients become healthy and stay decay-ree. What value does

that represent to the patients? Every-body must be comortable with charging

patients a ee commensurate with the

service provided. Your ofce must ap-

preciate how important your counsel is to your patients. Patients can be comortable

with your CAMBRA-related ees once you

help them understand what value they are

receiving. So what i a patient’s insurancecontract will not reimburse or specic

important services? Many will not coverimplants, veneers and other cosmetic

procedures. Do we avoid presenting theseprocedures? Do patients decline having

them done? Perhaps another analogy

helps connect with your patients. Advise

that you don’t have tire insurance, butwhen your tires wear out, do you replace

them or the saety o your entire amily?

CAMBRA ees may result in signicant

monthly revenue as the process is integrat-ed completely into the practice. And much




n o v e m b e r 2 0 0 7 7 5

o CAMBRA does not require the presence

o the dentist or data collection. Patients

who nally manage to stabilize themselves

with CAMBRA interventions oten then de-cide to undertake more complex and nan-

cially productive restorative procedures, in-

cluding elective procedures once necessary

restorative treatment is reduced or elimi-

nated. What experienced CAMBRA prac-

tices are discovering is that the real reasonbehind why patients don’t have expensive

tooth replacement treatment done is be-

cause they don’t eel condent in it lasting.Tey have had a lietime o chronic misery

with dental caries, and the whole process

seems a mystery. Most o these CAMBRA

practices report an unanticipated increasein revenue rom previously declined

treatment knowing treatment will last.

Another consideration in the econom-

ics o practicing CAMBRA: direct reer-rals rom the practice’s existing patients.

For many patients, CAMBRA is a lie-changing experience. Tey change rom

continuous cavities and problems to beingdecay-ree or the rst time in their lives.

When patients appreciate and understand

the biolm component o dental caries

and experience rst hand how to nally control the disease, they want everybody

they know to experience the same ben-

ets. Word-o-mouth reerrals have led

to patients traveling hours just to locatea dental ofce that practices CAMBRA.

Te last economic consideration isoten the unspoken ear that dentists

are putting themselves out o business.What i your patients really didn’t develop

new cavities, what would you do? On the

other hand, what i every patient in your

practice stopped developing new singlesurace lesions and you could ocus on

complete restorative care? I your patients

decided to have ideal restorative dentistry

done, would you have enough time letin your career even to accomplish that?

CciMany private practices began practic-

ing CAMBRA a ew years ago, when there

was a wealth o scientic inormationand not much practical implementation

tips or advice. Tere were no validated

orms; there were no validated treatment

regimens or treating the bacterial biolm

disease. Tis was uncomortable terri-

tory or CAMBRA initiating dentists. Fora century we have had a one-size-ts-all

approach to disease: Surgically remove

the cavity, regardless o location, size, ornature, and replace it with an amalgam

restoration. Now, every patient must have

their risk assessment evaluated individu-

ally. Every patient is unique. reatmentwill need to be custom-designed or that

individual patient at the present time.

Ten, we must continue to monitor each

patient to prevent even a low-risk patientbecoming a high-risk patient tomorrow.

Rome wasn’t built in a day. Integrat-ing a signicant methodology change in

a dental practice requires some time andeort. Te key is to keep the changes

as simple as possible, break it down to

small logical sequential steps, and keep

the dental team involved in the process.Te CAMBRA approach, philosophy, and

treatment will continue to evolve and

change as more data is gathered over

time, but certainly this represents thebest standard o care today. Weighing the

risks versus the benets o CAMBRA or your patients, it is virtually all benet. It

all boils down to doing the right thing or your patient. How would you want to be

treated based on what you now know?

Between the direct economic benet

and the new patient reerrals, CAMBRA more than supports itsel rom a business

model. Te additional revenue rom the

increased restorative and elective treat-

ments gained by caries reduction addssignicantly to the average practice. From

a purely economic standpoint, CAMBRA is

dentistry’s best kept secret. But, nances

aside, the most important reason to

implement CAMBRA is or the patient’sbest interest. Tere is no greater reward

than making a signicant dierence in a

patient’s lie through improved dental

health that lasts a lietime. We owe this to

our patients and our proession.

ref erenes. F O, K E, D C: T -

. Bw M, O UK, .

2. F JD, A SM, , C y

: Ap . J Calif Dent

Assoc ():-69, M .

3. Y DA, Nw

: . Gen Dent

(4):- Jy-A .

4. M PD, H :

. J D R 68:6-, 989.

. F FM, K MI, , T q -

p y . J Clin Pediatr 8(4):-8,

S 4.

6. M PD, D pq f -

y – p . BMC Oral Health

6(Spp ):S4, 6.. F M, ZDT, A p’ . J Am

Dent Assoc (9):-9, Sp 6.

8. Bw DJ, MK AS, M PD, E y

p pH pp w -

. J Dent Res 68:98-, 989.

t request a prnted py f ts arte, p

V. K K, DMD, 4 S., SE, Ay, O., 9.



6 n o v e m b e r 2 0 0 7


Th l Dl

Hii, i, oc i CMbshirle gukoski, rdh, bsdh; debi gerger, rdh, mph; jean crease, rdh, dds;anna nelson, cda, rda, ma; and douglas a. oung, dds, mba, ms

corresponding treatment modalities.Several initial meetings will be neces-

sary and may include role-play exercisesor the sta to become comortable with

the inormation and protocols (see

Kutsch et al., this issue). Te entire team

must support the CAMBRA protocolor successul patient outcomes.1

Te role o the dental hygienist may

include medical history review, risk as-

sessment, necessary radiographs, intraoralphotos, saliva assessment and bacterial

testing, patient education about methodsto decrease the risk o dental disease, and

uoride varnish and sealant application.Te dental hygienist, as an example o

assessment, may use a laser uorescence

carious lesion detection device such as the

DIAGNOdent by KaVo. Tis device whenproperly used may assist in the evalua-

tion o occlusal suraces o the teeth and

has been reported to be more reliable

when these suraces are ree o biolm.2 One method or removing the organic

a st ra t T y

. P

, , ,

w y

y . T w

w

..

The role o the dental hygienistin implementation o caries

management by risk assess-ment will vary by the dental

practice philosophy and

will vary according to the state Dental

Practice Act. Hygienists are knowledge-able and prepared to contribute to risk

assessment through the development o

ofce protocols, the creation o patient

literature, and the expansion o treat-ment recommendations. Many o the

disease prevention and managementprocedures all within the purview o

the dental hygienist; however, only a synergistic relationship with other

members o the sta will establish a

comprehensive approach to CAMBRA.

Te role o the dental hygienist may be the initiation o CAMBRA protocols

in the ofce. One aspect o CAMBRA

incorporation will include sta meet-

ings about the philosophy and imple-mentation o risk assessment and the

auhors

hil gkki, rd,

sd,

, C L

P

Ex T,

S P, W.

Di g, rd, mp,

, ,

, R

Cy C

W L A C,

C, C.

J C, rd, dds, ,

C D Py

D C

, N Cy,

C.

Nl, da, rda,

ma, w

D A P,

Cy C S

F.

Dl . y, dds,

ms, ma,

, D

D P, Uy

Pf, A A.

D S

Dy.

t e d e n t a t e a m




n o v e m b e r 2 0 0 7

material is with the use o an air powder

polisher. Te removal o organic mate-

rial is important in gathering quality

inormation rom laser or beropticdetection instruments. Ater the hy-

gienist debrides the teeth, the suraces

are assessed and readings are recorded.

Te dental assistant may be involved in

recording the data. Tis type o syn-

ergy between team members creates anenvironment o excellent patient care.

l h Dl iTe current dental practice model o

the dental hygienist as an income genera-

tor/producer and the dental assistant as

a support sta member can change withadditional CAMBRA direct patient care

duties or the dental assistant. Educa-

tion and licensure can support the dental

assistant with new responsibilities oran additional commitment to his or her

career. Te current workorce situationnds support sta available or practicing

disease prevention and management.3

Te dental assistant that is knowl-

edgeable and experienced in CAMBRA

can interview the patient, take diag-

nostic radiographs and photos, andperorm saliva and bacterial testing.4

Once a patient’s risk status has been

evaluated, the dental assistant can

explain the results and oer preven-tive counseling to the patient. Standing

orders can be relied on to provide ororal hygiene instruction, diet counseling,

and instructions in the use o chlorhexi-dine, uoride, and xylitol.5 Chemical

treatments such as chlorhexidine,

uoride, or xylitol must be communi-

cated to the patient with an emphasison the need to use the product exactly

as prescribed. Reminder phone calls are

recommended as a measure to encour-

age patient compliance. Additionally,the dental assistant can maintain the

necessary dental inventory or the dis-

ease prevention management protocols.

Tis new model creates a shit in the

responsibilities o the dental assistantsuch that he or she would contribute

to the overall of ce revenue, as well as

become a critical and valued member o

the CAMBRA team. With proper educa-

tion and training, and within the rules o

the state Dental Practice Act, the dental

l h iiiv Te administrative sta is pivotal in

supporting a CAMBRA prevention-o-

cused practice. Acting as practice ambas-sadors, the administrative sta is oten

the rst to be approached when patients

have questions about treatment, pro-

tocols, or of ce philosophy. Sta may

be involved with the development and

production o patient brochures andnewsletters. Drats can be discussed at

sta meetings or written communica-

tions can be distributed to the variousof ce departments or eedback. Te

administrative sta may also be respon-

sible or maintenance o the practice

Web site. Tis is an excellent method todisseminate knowledge about preven-

tion and to stimulate patient reerrals.

Te administrative sta is crucial in

the third-party payer process. Narrativeletters or benet coding are important

and necessary to ensure that patientsreceive optimal reimbursement or the

treatment received. Additionally, theadministrative sta is in a position to

process nancial transactions or respond

i insurance benets are denied. As dental

codes struggle to keep up with science,new diagnostic codes may need to be

developed. In some instances, medical

codes could be employed to bill medical

insurance or certain procedures. Educa-tion on billing codes is continuous.

Administrators may support the of ceprotocols with reminder phone calls or

post cards reinorcing CAMBRA inorma-tion and specic patient instructions. One

o the challenges patients ace is remem-

bering the steps they are to take each

day to decrease the risk or caries diseaseinection/transmission and carious lesion

progression and conversely increase the

chance o prevention and lesion repair.

A word on dispensing products rom thedental of ce is worthwhile. Te complex

assistant can administer portions o therisk assessment to include saliva and

bacterial testing and advising the patient

o the results with an explanation o diet,

nutrition, and oral hygiene modications.Use o a dental assistant in this

practice model helps to control the cost

o CAMBRA and will be reected in

reasonable patient ees while providingan increase in production or the of ce.

Te ADA Current Dental erminology book or 2007/2008 contains billing codes

or risk assessment, bacterial culturing,caries risk tests, saliva testing, nutritional

counseling, uoride varnish, and oral

hygiene instructions6 (tae 1). Strictly

traditional dental practices not practic-ing CAMBRA may nd themselves at an

economic disadvantage to their contem-

porary colleagues who grasp the CAM-

BRA model and see the benet or theirpatients (see Kutsch et al., this issue).

te admnstrate

CAMBRA

-

.



n o v e m b e r 2 0 0 7



Pc Dcii CDT C* Di-Cl C Pvi

O y D 4 D

C x w D D

Ex: P// x -/ -

D /D 4/ D 6/D

D

R: C /z w/ w D / D 4 / D

DA w CA X-yLICENSE, RDH

O/ D DA, RDH

C D 4 6 DA, RDH

C y D 4 6 DA, RDH

D D 4 DAL RDH

Pyx D RDH

Pyx D 49 RDH

T y ( ) D 6 RDA, RDH

Pyx w ( 6 ) D 6 RDH

F (y ) D RDA, RDH

F (y ) D 4 RDA, RDH

F D 6 6 6

RDH

N D DA, RDH

O y D DA, RDH

S D 4 RDA w , RDH

S D 46 RDA w , RDH

G D D

G D 646 D

G D 9 6 Py6 P

D

G D 9 6 Py6 P

D

S D 94 RDA, RDH

C , x D 94 D

O / : .., x, D 96 998 999 DA, RDH

Xy DA, RDH

F z (Rx) DA, RDH

A z D 99 8 w -y

DA, RDH

A z D 99 DA, RDH

E D 99 D

table 1

CMb-ci D Pc Dcii C wih Ci Pvi

*P ADA C D Ty -8




n o v e m b e r 2 0 0 7

fr ne patents,

y w

y

w .

pathogenic biolm responsible or cariesis not easy to modiy without proper

mechanical, chemical, and dietary aids.

Te importance o having products

available rom the of ce cannot be overstressed. Private practices and dental

school clinics experienced with CAMBRA

have reported that writing prescriptions

or telling patients to shop or products

does not work well. Patients leave with

good intentions then become discour-aged at the complexity o locating several

specialty items. Patients are best served

i support materials and supplies areoered immediately at the of ce.

Ticl iTe risk assessment appointment

can vary slightly depending on the

patient’s dental knowledge. Te rst

step in the clinical examination is the

completion o the caries risk assess-ment orm that has been adopted by the

dentist and sta (see Featherstone etal. in last month’s issue; Kutsch et al.,

this issue). For new patients, the dentistshould personally review the health

history and all risk assessment orms

with the patient. During this interview,

the dentist establishes a relationship o trust and orms a partnership o preven-

tion with the patient. Tis partnership

reects the philosophy where cavities

are treated as an inectious disease. Tedental hygienist or assistant will use

inormation obtained during the riskassessment to then ollow the CAMBRA

recommendations or disease preven-tion and management (tae 2). For

instance i the patient is determined

to be high risk, a bacterial test would

be administered ollowed by patienteducation and the recommendations or

and dispensing o antibacterial agents.

Te dental team and patient will work

together to treat the current condition.Patients appreciate a dental team that

takes time to tell them what they cando to prevent more disease rom occur-

ring. Ater this interview and a thorough

clinical evaluation, including inormation

gathered earlier by the team such as cariesrisk assessment data, radiographs, digital

photographs, ICDAS coding, and DIAG-

NOdent readings, along with periodontal,

oral cancer, and occlusal discrepancies, the

dentist will be able to assess the patient’s

risk status and make treatment plan

status o the patient, the dental hygien-ist will ollow the appropriate CAMBRA

protocol. Patients who are ound to be

moderate or high risk or caries will then

be reerred to the dental assistant or asubsequent appointment where ad-

ditional saliva assessment or bacterial

testing and prevention counseling can

occur. Te hygienist can continue the

process o CAMBRA through chairside

education and helping the patient toestablish a commitment to oral health.

Te dental hygienist or assistant can

provide oral hygiene instructions with aocus on brushing techniques and uoride

toothpastes or gels. Te of ce protocol or

uoride will be explained and dispensed,

as will the protocol or xylitol products(see Jenson et al., previous issue). Tis is

also a time or intraoral photographs that

document current conditions. Detailed

instructions on the use o each productshould be reviewed orally and supported

by written material (see Featherstoneet al., previous issue or sample letters

to patients). An involvement calendar,especially or chlorhexidine use, is a

very helpul tool to ensure that pa-

tients keep current with the regimen.

With the new patient, the dentist willhave already completed a comprehen-

sive hard and sot tissue examination

with a treatment plan or restorative

needs and sealant recommendations.Te dental team will have discussed the

results o the caries risk assessmentwith the patient. Te laser uores-

cence carious lesion examination andICDAS coding will be charted and the

requency o recall examinations will

be established. In Caliornia, registered

dental assistants who have completeda board-approved course are allowed to

place sealants. Te type o sealant to

be used, resin-based or glass ionomer,

will be discussed with the dentist and ntnues n 79 2

recommendations based on this assess-ment. I a patient is assessed as low risk,

the next step may be a prophylaxis ap-

pointment with another risk assessment

examination in a year’s time. I a patientis assessed as moderate or high risk, then

the next appointment should be with the

dental assistant or saliva assessment and

bacterial testing and CAMBRA counseling.Once the CAMBRA protocols are

established (see Ramos-Gomez et al.and Jenson et al., previous issue), the

dental hygienist can provide reinorce-ment and continue to assess the process

as well as report progress to the patient.

Introducing existing patients to

CAMBRA or the rst time can be done atthe recare appointment when the caries

risk assessment orm will be completed.

Te dental hygienist will then evaluate

the orms as part o the patient’s recareappointment. Depending on the risk



n o v e m b e r 2 0 0 7

table 2

CMb-l Th ci b Ci ik

patient. Sealants can be delivered at the

risk assessment appointment as outlinedpreviously. Te dental hygienist in some

states may take over at this point. I

radiographs are indicated, then the dental

assistant will take them as prescribedby standing orders or prescription.

Oten, the dental hygienist will nd

that the patient is taking a new medication

during the rst part o the recare appoint-ment. Tis red ag is oten overlooked

during the subsequent hard tissue examina-

tion unless numerous lesions are evident.Ofce protocol may include stopping at

the health history stage o the treatment

sequence to do a risk assessment or car-

ies. Te patient is oten engaged at thispoint and will ollow the discussion and

treatment recommendations. A saliva or

bacterial test, uoride varnish, dispensing

uoride, calcium-phosphate paste, apply-ing glass ionomer sealants to any remain-

ing pits and ssures will surely make up

or a loss in production or that time. Teplanned prophylaxis should be rescheduled.

Ti ccTe CAMBRA approach to patient

care can be readily incorporated into the

practice by collecting and evaluating data

as it relates to the patient’s risk or caries

development. Tere are several steps toconsider or successul implementation


t e denta team, ntnued fr m 78 9

NPi

ovhlibcilIci

P Di P liv Th

X X X X O y

X C x w

X X Ex: P// x -/-

X X X R: C /z w/ w

X X X X O/

X X C

X X X X C y X D

X X X X L

X X X Pyx

X X X Pyx

X T y ( )

X X X Pyx w ( 6 )

X X X F (y )

X X X X F (y )

X X X F

X X X N

X X O y

X X X S

X X S

X S

X X X X O / : .., x,

X X X X Xy

X X X F z (Rx)




n o v e m b e r 2 0 0 7

Hlh

o CAMBRA or the rst time. First, the

ofce must have meetings to discuss,

study, and role-play with CAMBRA so

that the dental team is comortable withthe inormation. Concurrently, the ofce

may need to order supplies such as risk

assessment orms, saliva or bacterial

tests, uoride varnish, advanced cari-

ostatic materials, and antibacterial rinses.

Te ofce will need time to develop abrochure and i applicable place CAMBRA

inormation on the ofce Web page.

Te ofce can begin by incorporatingCAMBRA into all new patient examina-

tions and all known high-risk patients.

Soon ater, the dental team can initi-

ate risk assessment and prevention ortreatment protocols with all patients. o

aid the patient in the implementation o

home regimes, the dental team may want

to consider the use o involvement calen-dars and diagnostic casts and disclosing

tablets to demonstrate the patient’s pat-tern o biolm. Additionally, rewards such

as a git certicate or children who returnwith a completed involvement calendar

and good oral hygiene are also useul.

One example o a population that

is in need o disease prevention andmanagement are pregnant women. Tey

are usually very open to behavior change

with the goal o a healthy pregnancy

and baby. Emphasis on the contagiousnature o caries can be stressed and

expectant moms can be inormed o how reducing levels o cariogenic patho-

gens in their own mouths can positively aect their child’s uture oral health.

Other examples o patient populations

in great need o disease prevention and

management are the patients with lowersocioeconomic status, the elderly, and spe-

cial needs patients. Oten these patients

do not have good access to care or do not

have the ability to obtain or apply currenttreatment interventions or products.

CcliTe team approach to CAMBRA is

integral to the decrease in the incidence

and prevalence o dental caries amongvarious populations. ogether, the dental

team can assist the patient in the preven-

tion or control o dental disease. Carious

lesions can and do aect the lives o people.Understanding and treating caries as a

curable and preventable inectious, biolmdisease is the single most important step a

dental practice can take to improve thelives o its patients and the quality o the

practice. Trough the process o assessment

and corresponding protocols, the dental

team can work with patients to motivate

and inspire behavior changes that will havea lasting impact.

ref erenes. Ax P, T -

y — y.

BMC Oral Health 6 S :S, J , 6.

. L A, Hw E, R -. Monogr Oral Sci :9-9, 6.

3. Bw TT, Fy TL, S RM, Hw w

y ? E-

C: 99-. J Am Dent Assoc 8():94-

, Jy .

4. H A, B K, D ’ y

- . Swed Dent J 8(6):4-9,

994.

5. B B, T xy-w w

J Am Dent Assoc ():9-6, Fy

6.

. Gw S, H M, T t

y. Oral Hyg (), Jy .

t request a prnted p f ts arte, pease n-

tat Sy Gw, RDH, BSDH, C L P

Ex T, Sw T, S P, W.,9.



79 n o v e m b e r 2 0 0 7


iky bi:Ilcig Polo Chgbruce pelier, phd, mba; philip einsein, phd; and richard redekind, dmd, ma

echnical advances in prevention have

evolved over the years to include im-provements in toothpastes and brushes,

enhancements in brushing techniques,radically dierent oss technology, ex-

panded techniques in uoride application

(both systemic and topical), instrumenta-

tion using rubber tips and toothpicks, ad-ditional mouthwash ormulations, dietary

recommendations that are supported

by empirical data, advances in adhesive

dental materials (e.g., resins and glassionomers), increased awareness o the

negative eect o tobacco and substanceabuse, and management o systemic

diseases likely to have a negative impacton oral health (e.g., diabetes and cancer).

Recent developments in caries risk assess-

ment, while helpul in managing dental

disease, have added a level o complex-ity or patients and practitioners alike.

Successul prevention requires an un-

derstanding o all o the options available

or maintaining oral health along with pa-tient “participation and cooperation, and

a st ra t T

gf . Mgg

y- y . N

CAMBRA . I w

w w y, w

.

revention o dental disease has

a long, but sketchy history, typi-ed by behavioral ambivalence

on the part o patients and prac-titioners alike. A case could be

made that o all the relevant stakehold-

ers, manuacturers o toothpaste have

taken the most consistent stance towardeective preventive dental care. In the

1940s and 1950s, practitioners searched

or “recipes” to induce appropriate patient

behavior. In the 1950s and 1960s, the U.S. Public Health Service studied uorida-

tion and promoted its implementation aspart o preventive services. Some dental

schools hired behavior scientists todevelop community prevention proto-

cols. Te 1980s saw increased attention to

health promotion and disease prevention

in both research and practical arenas. Inthe 1990s, goals and timelines were de-

veloped to reduce dental disease, and in

the 2000s, signicant research on caries

risk assessment and its implementationwithin dental education was completed.1,2

m t a t n p a t e n t s

auhors

bc Pli, pd, ma,

, Py-

gy E,

Uy Pf,

A A. Dg S

Dy, S F.

Phili wii, pd,

, D

P H S,

W G. Mg

H S C,

Uy Wg,

St.

ich Fki, dmd,

ma,

C S,

Uy Pf,

A A. Dg S

Dy, S F.

P




n o v e m b e r 2 0 0 7 79 5

a practitioner who can acilitate participa-

tion and cooperation.”3 In other words,

technology has advanced to a stage where

real prevention can take place, but it re-quires a signicant change in the behavior

o dentists, hygienists, and patients.

Such a situation is not unique to

dentistry or novel in the human experi-

ence. Most people know rench ries

are not good or them. We know weshould exercise regularly. We should

start working on our taxes late in Janu-

ary. We should moderate alcohol intake,eat more broccoli, and oss our teeth.

Yet, we oten do not do those things that

are clearly in our own best interest.

For example, prevention in dentistry includes educational techniques or e-

ective plaque removal. Unortunately,

studies have shown that while patient

education may increase knowledge, itoten provides only temporary improve-

ments in plaque control.4,5 Te 2003 American Dental Association Public

Opinion Survey determined that whilemore than 86 percent o women met

the ADA recommendation o brush-

ing at least twice daily, less than 70

percent o men met this standard.6 As the complexity o prevention

increases the disparity between what we

know and what we do is likely to widen.

I prevention in dental care is to really take hold, an understanding o short and

long-term behavior change process seemsessential. It is clear we cannot simply tell

patients (and dentists) to do what weknow is good or them. Tat is not likely

to result in actual behavior change.

ChllgIt helps to know the enemy i you

are to engage in a serious ght. What

ollows is a listing o some o the real

and perceived challenges that CAMBRA and disease prevention currently ace.7

nCAMBRA is a new and dierent orm

o dental health care. It requires that sig-

nicant resources be spent on nonsurgical

methods, many o which are not currently apart o the culture o the proession.

n CAMBRA is a complex process

involving numerous treatments that must

rst be learned by the dental health care

worker then eectively passed on to the

patient and accommodated into theirdaily schedule.

capacity to conduct reliable ollow

through with patients over extended

periods o time.n Ef cacy is not yet well established in

the literature. Tere are many studies with

promising results; however, numerous

aculty members and practitioners believe

there is not yet a rich, comprehensive

literature on the ef cacy o CAMBRA.9

Tkig bhvio iolyI CAMBRA is to have any realistic

chance o succeeding as a paradigm shitin dental care, the behavioral side o the

equation must be taken seriously. Lip ser-

vice will simply not suf ce. First, it must

be said, dentists themselves have to truly “get on board.” I dentists do not believe

in the ef cacy and value o prevention

methods, patients are unlikely to succeed.

Dentists must be willing to take the timeand make the eort to demonstrate that

they are serious about CAMBRA and itsimplementation. o do this, change is

required and change is a complex process.

g o Chg Thoy According to transtheoretical models

o change, that is, models that involvestages, people pass through a predict-

able process as they move rom accep-

tance to maintenance.10 Te “Stages o

Change” perspective has been useul toexplain how individuals change a wide

range o problem behaviors, rom smok-ing cessation to exercise acquisition to

condom use.11,12 Tere are ve stages o change: precontemplation (uninterested

in change); contemplation (consider-

ing change); preparation (committed to

change); action (implementing change);and maintenance (preserving change).

Te importance o this model lies in

the act that strategies and activities to

promote change dier signicantly acrossstages. Individuals in dierent stages

n Patient training is perceived as more

time consuming than traditional preven-

tive techniques.n Signicant recordkeeping is an

essential component o the CAMBRA

approach.n Tere are costs to both patient and

practitioner. Tird-party payers typically do not provide compensation or reim-

bursement or these procedures andmaterials. A air and comprehensive ee

structure or these procedures has not yetbeen determined by practitioners, nor are

CD codes ully established.8

n Te vast majority o dental practices,

even those enthusiastic about prevention,have not established an ef cient, work-

able method to manage the process in a

real-lie private practice.n Dental health care workers have not

generally demonstrated the ability or

f dentsts

y

,

y

.



79 6 n o v e m b e r 2 0 0 7


utilize dierent processes o change.13

Stage status is also useul in predicting

how close a person is to behavior change

and how much eort is required o themand the intervention to move them to

action. Such a perspective is useul in

structuring tailored interventions to

target at-risk populations.14 Measures

o readiness to change dental behaviors

have been developed and validated.15,16

Patients at the initial “precontempla-

tive” stage do not see their behavior as a

problem and have no intention o chang-ing their behavior. Tey are unknowing,

unable, or unwilling to acknowledge that

a problem exists. Tere is no reason to act.

Tis same observation can be made aboutdentists who do not take prevention

seriously in their practice. Tose at the

“contemplative” stage are aware a problem

exists but are ambivalent. Tey value thechange but perceive obstacles to action.

When properly motivated, patients willprepare to change by deciding how to

make it happen. Once this is determined,the patient moves into action by actually

implementing the change. Ater action,

there is concern over maintaining the

new behaviors and avoiding relapse.3

Strategies to move rom the precontem-

plative to the contemplative stage involve

helping the patient, parent, or guardian eel

the need or healthy dentition or avoid theconsequences o dental pathology — pain,

embarrassment, tooth loss, etc. Strategiesto move rom contemplation to action in-

volve identiying and overcoming obstacles.For example, Mrs. Lee has a 6-year-old son

with a history o rampant caries and an

18-month-old baby. She said she elt terrible

when she brought her child in or emer-gency care and learned that her son, then

3 years old, had serious dental problems

requiring oral rehabilitation under general

anesthesia. In the dental of ce, her baby has a bottle with milk in it. Mrs. Lee, when

questioned, admitted to putting the child to

bed with the bottle. At what stage is she?

I Mrs. Lee tells you it is inevitable

her kids will have dental problems, sheis likely to be in the precontemplative

stage. On the other hand, she may tell

you that while she does not want her

baby to have the dental problems her

older child has, she nonetheless eels she

cannot ollow the recommendation to

leagues who know what they are do-

ing is not working. Such colleagues

requently report that insurance does

not pay or eective prevention orthat eect prevention takes too much

time to be practical. Tese colleagues

are at the contemplative stage.

Dental school aculty and administra-

tors may also be at dierent stages. Most

dental schools are ocused on trainingtheir students to develop surgical skills.

Te vast majority o clinical instruction

is dedicated to basic surgical prociency.Many aculty and administrators see

time away rom the development o

these skills to be counterproductive.

Tey are at the precontemplative stage.On the other hand, there are those who

are aware that students who graduate

rom their dental schools do not have the

basic behavioral competencies neededto control caries in high-risk popula-

tions. While students may have taken ashort course in communications skills

and cultural competency as a reshman,there is awareness o the inadequacies o

dental education. Given the obstacles in

altering the curriculum, such individu-

als are at the contemplative stage.

Moiviol IviigWhile the “Stages o Change” theory

provides understanding o the process o change and overall strategies, “motiva-

tional interviewing,” a brie counselingapproach that ocuses on skills needed to

motivate others, provides tactics to movepatients rom inaction to action.17 Tis

approach has been successul in elimi-

nating addictive behaviors and has been

used to establish positive health-relatedbehaviors.18 Weinstein, Harrison, and

Benton reported a study o 240 high-risk

inants aged 6- to 18-months-old and

their parents.19,20 Tey were randomly assigned to motivational interviewing or

wean that child at 1 year, nor does she

think she can put the baby to bed without

a bottle. Inability to tolerate child upset

and inconvenience are alluded to. She islikely to be at the contemplative stage.

Te “Stages o Change” theory applies

to practitioners and educators as well as

patients. Te theory is useul in under-standing how individuals respond to or

ignore innovations and change. Many dentists in practice behave as i traditional

restorative treatment stops the caries pro-cess. Moreover, preventive activities are

limited, brie, and carried out in a robotic

ashion, resembling the reading o rights

to a suspect beore arresting him. Somedentists are overcome with skepticism,

reporting that prevention just does not

work. “Been there; done that.” Tese col-

leagues are at the precontemplative stage.Contrast those dentists to our col-

te mp rtane

g

g

gy

g.

m t a t n p a t e n t s




n o v e m b e r 2 0 0 7 79 7

traditional health education groups. Lay

women were trained to conduct the inter-

vention, which consisted o a counseling

session and ollow-up telephone calls. Ater two years there was a 50 percent

reduction in the incidence o caries in

the motivational interviewing group.

Te motivational interviewing ap-

proach allows exploration o a problem in

a supportive environment that expressesacceptance and provides af rmations o

the person’s strengths. It involves asking

questions beore providing inormationand advice. Individuals are encouraged to

talk and there is an attempt to understand

their rame o reerence. Tese techniques

are borrowed rom nondirective patient-centered therapy. However, the approach

is directive, advice is given, with the

person’s permission, and is accompanied

with encouragement to make choices.Tere are two phases to motivational

interviewing; the patient is active in both.First, there is an attempt to establish

rapport and trust and to help identiy theproblem o concern. During this phase the

patient moves rom the precontemplative

to the contemplative stage. Te goals are

achieved primarily by asking open-endedquestions and demonstrating the listener

has heard the person by paraphrasing

or summarizing (active listening). For

example, in the protocol with the parentso 6- to 18-month-old high-risk children,

parents were asked to report “What isit like to be immy’s mom?” Te next

question ocused on oral health. “ell meabout your dental health and the health

o your amily?” Tis was ollowed by

“What do you want or immy’s den-

tal health,” or “I I could grant you onewish or immy’s teeth, what would it

be?” Te last question “sets the hook”;

the parent is now telling us what she

desires or the oral health o her child.Te second phase involves moving

recommendations or dentists and their

auxiliaries interested in CAMBRA success:

1. ake time to listen to patients. Let

them tell their story and explain whatthey think o their teeth and their role

in the maintenance o their oral health.

Make sure you understand their point o

view beore you try to inuence them.

2. Find out whether patients have

distorted, incorrect, or irrational viewso dentistry and oral health. Gently

correct those views, beginning with

the normalizing comment that “many people eel the way that you do.”

3. Provide reasons or the prevention

activities that you recommend. Patients

are more likely to ollow through withhome care i they understand “why” they

are doing what they are asked to do.

4. each and demonstrate what

you want patients to do. Actively teachhygiene methods and get patients to

demonstrate how to brush and osswhile they are in the dentist’s of ce. Show

pictures and videos o the techniques you recommend. Many patients preer

to have good hygiene habits and skills,

but they simply do not know correct

techniques — or worse, the techniquesthey apply are inadequate or harmul.

5. Conduct a “unctional analysis”

to determine what actors in a patient’s

lie are likely to increase likelihood o enhanced prevention activities and

which actors might get in the way.6. Explore your patient’s reinorce-

ment structure. Behavior is a unctiono its consequences. A desired behavior

ollowed by something pleasant is likely

to be repeated. Analyze the contingen-

cies o reinorcement to ensure thatdesired prevention behaviors are ap-

propriately rewarded. Tis, o course,

means that dentists must note positive

changes, even small ones, and commenton them (“you are doing a good job in

rom the contemplative to the prepara-

tion/action stage. Te person is asked

to weigh the pros and cons o chang-

ing. “What are the costs, the benetso changing? What happens i you do

nothing?” Choice is emphasized and

there is brie discussion o the potential

obstacles to action or each action option.

Working with the person ocuses mainly

on identiying a plan to act. “Menus” o

potential changes are used in even brieer

versions o motivational interviewing.

Such menus are appropriate with multi-

actorial diseases like caries. A motiva-tional interviewing training manual or

dental health care workers is available.21

iiol ochTere are additional theories that ex-

plain behavior change and interpersonalinuence in psychology including behav-

ioral models o reinorcement, social psy-chology’s experimental ndings, emphasis

on acceptance and listening skills, amily

system views on group homeostasis, cog-

nitive methods to change thinking, andhypnotic inuence. Tese may be used in

conjunction with or independent o moti-

vational interviewing. A distillation o the

best and most appropriate lessons romthose theories would include the ollowing

te appra s

, g,

w ’

,

w

g

.



79 n o v e m b e r 2 0 0 7


the ront on the let side”). Dentists

can help patients set up explicit reward

structures to reinorce the behavior

they want to increase at home.7. Explore the involvement o the

patient’s entire amily in the CAM-

BRA process. It is more likely that a

patient will make a behavior change

i the whole amily participates.

8. Use hypnotic language andindirect suggestion to inuence pa-

tients. ell stories about successul

cases and patients. Employ vivid im-ages o healthy and unhealthy situa-

tions to make your points (“pus” versus

“nice resh teeth and breath”).22

9. Help patients set small, reason-able goals. Meet those goals, reinorce

the progress, and set new ones. Engage

patients oten. wice-a-year appoint-

ments are unlikely to be very inuential.10. Consider making appropriate

treatment “deals” with patients. Agree toprovide services they desire in alignment

with a set schedule o oral health improve-ment. “We can put those veneers on as

soon as you bring your decay-causing bac-

teria level down to a 2.” or “Reduce those

pockets to 4 millimeters and I’ll start thepreparation or the crown you need.”

11. Above all, dentists and their aux-

iliaries must truly care about prevention

and the hygiene behaviors o patients.Teir interest in prevention o disease

must be obvious to sta and patients i they hope to positively inuence them.

Tis is a wonderul role or hygienistsand assistants as well as the dentist.

CoclioDierent people have dierent

motivations that determine their behavior.

Tis paper described numerous theories

and approaches that can be used to

positively inuence the behavior o patients and dental health care workers so

1. W P, H R, B T, Mg

yg . J Am Dent Assoc

(6):-8, J 4.

20. W P, H R, B T, Mg

: fg f g.J

Am Dent Assoc (6):89-9, J 6.

21. W P, M y : w.

Uy Wg P. St, W., .

22. P B, Hy Dy. (I) My D, B-

Dy. A, Iw, Bw-Mg Pg

Cy, 6.

t request a prnted p f ts arte, pease n-

tat B P, PD, MBA, Uy Pf, A

A. Dg S Dy, W S., S F,

C., 94.

they actively engage the CAMBRA process.

It is important or dentists to establish

which option works best with each o the

employees in his/her ofce, and or thedental care team to do the same with each

patient in the practice.

ref erenes1. Pygy y:

. WA Ay (). T Hw P, N.Y., .

2. C LK, Hy y. P g, Dy

g, M FRG, Jy 98.

3. K A, H g g. (I)

B y. My DI, Fg AG, G DB,

(). Bw Pg, A, Iw, 49-6, 6.

4. Bw LF, R

: w . Health Educ Q ():8-

, Sg 994, w.

. Ky E, L D, A y w

g . Community

Dent Health ():-44, S 998.

. A D A P O Sy,

O H U.S. P, .

. Pg W Cg My I

Dy g, St W., Ag 6.

8. CDT: gy, -8. C D

Bf Pg. A D A, .. B WF, C . J Calif Dent

Assoc ():-6, M .

10. P JO, DC CC, T

: g g. Dy

P, Hw I., 984.

11. P JO, DC CC, Sg g

f . I Pg

f. H, E, M (). Sg, Nwy P

C., 84-8, 99.

12. P JO, V WF, , Sg g

. Health Psychol

():9-46, Jy 994.

13. DC CC, M wg g

g. I M wg: g

g . M R (). G,

N.Y. 9-, 99.

14. Lw T, Ay P, , A z - g w g

(g g)

. Tobacco Contr :68-, .

1. W P, Ry CA, T y y

RAPIDD S: g

. ASDC J Dent Child 68 ():9-, M-

A .

1. B T, H R, W P, M’

g : y

RAPIDD S . J Dent Res 8:A-84, .

1. M WR, R S, M wg (f .),

G P, N.Y., 99.

18. M WR, R S, M wg (

.), G P, N.Y., .




n o v e m b e r 2 0 0 7

Ci M

i :Ii giidouglas a. oung, dds, ms, mba; john d.b. eahersone, msc, phd;jon r. roh, ms, cae; max anderson, dds, ms, med; jaana auio-gold, dds, phd;gordon j. chrisensen, dds, msd, phd; margheria onana, dds, phd;v. kim kusch, dmd; mahilde (ill) c. peers, dmd, phd ;richard j. simonsen, dds, ms; and mark s. ol, dds, phd

a st ra t T y y

w : f , ,

z, . T

.

auhors

D . y, dds,

ms, ma, , D

D P, Uy

Pf, A A.

D S Dy

S F.

Jh D.b. Fh,

M, PD, ,

Uy C,

S F, S

Dy, -

D

P R-

D S

UCSF.

J . h, ms, ae,

C D A-

F.

Mx , dds, ms,

med, w AD C

Sq, W.

J i-g, dds,

pd,

y, D

O Dy,

y Uy

F C D-

y G, F.

g J. Chi,

dds, msd, pd, St C

Dy,

P C C,

,

CRA F, P,

U.

dopted by the authors o

this issue o the Journal of the California Dental Associa-

tion and the general assem-bly o the World Congress

o Minimally Invasive Dentistry.

Members o the Western, Central, and

Eastern CAMBRA Coalitions, ADEA Cari-ology Special Interest Group, WCMID, and

others listed in tae recognize the 2002

FDI Policy Statement, Minimal Interven-

tion in the Management o Dental Cariesas the current clinical standard or caries

management and urther support imple-mentation o the ollowing principles:

Main principles or CAMBRA imple-mentation

nModication o the oral ora to

avor health.nPatient education and inormed

participation.nRemineralization o non-cavitated

lesions o enamel and dentin/cementum,

and

Mhi F, dds,

pd, ,

M C Fy,

O H R I-

, ,

P E

D P-

Cy

Dy I

Uy S

Dy I.

v. ki kch, dmd,

Ay,

O.

Mhi (Ti) C. P,

dmd, pd, ,

D Cy,

R S

E,

Uy M

S Dy

A A.

n s e n s u s s t at e m e n t

ich J. i, dds,

ms, C D M,

Mw Uy,

G, Az.

M . w, dds, pd,

,

D Cy

C C

Nw Y Uy

C Dy,

Nw Y.

ntnues n 8 2



00 n o v e m b e r 2 0 0 7


table 1

Th i izi/iii h i ici hi c . Th hi i iiizi ci c i i i i ci . Tici i iii ic, c i i cc h h hi c .

estern amraatn

iz ch Di o HhR J. S(currently at MidwesternUniversity; see below)

Ci C FcicA N

l li iiC J. G ()B BB NWy OD RD T

Mi iiC D MiciR J. S ()

o Hh ciciiM CJ B. CJ FP GR J

ii Ci CD GM H

c C DiG J. C ()

ii Cii oic h PiWy R. H

ii Cii,l N-H P ()J J. CE R. HwV W. SyR SLy WyWy S

ii Cii, FcicJ D.B. F (D)W F. BS BP K. DBS DW. S ES GyR P. HS T. H

Ly JB LHw P

F R-GzM M. WJ M. W

ii N,l vS HyRy TzzWy W

ii h Pciic, FcicP F ()A A. D ( )P BA Bz

F FEy FR FP GD HR LW LCy LyC MN A. NW NB PP SP WC S. Y

D A. Yii h CiiH S ()L AS JM MR U

ii whi M S ()S DW GG IR L. SyP W

w l CD G

H ii J,IO FB SE I. W

ii i, iJ MIyG MH N

ii ,C-F, FcS D-O

Cii D ciiCDA B T* CDA F

Cii ci Piic DiM RwR UA. Jy W

Pi PcicJ CyW DN KV. K K

G MEw J. ZF R. R

g/ PD NR SwA T

ch IiR C, CR A

entra amraatn

Cih ii Mic

C ch DiS F ()F AyJ HwN KM LL MR. S SyJ S

Ii ii ch DiH EM FC Gzz-CzJy A. P

lii iiHh cic C ch DiE H ()A H. RR S. S

N h iiC D MiciD AS A

N FPy FAy G

F G-GyE KJ KLw LM P

ohi ii C DiJ J. MD. Sy SR G. R

h Iii ii ch D MiciP J

T ii kch DiJ E. AJ Hw

ii biih ch DiHw F. T ()

ii Ccicch D MiciJ C. M

ii Di Mcch DiSz M. GJ B. L

ii Fi C DiT D ()K AJ A-GP K. BM E. DV V. GI MöE MM E. OCy SK-J SöK. D Sw

S L. TBy W

ii Iii Chicch DiA B-RG. W KF PyA S-CS S




n o v e m b e r 2 0 0 7 01

ii I C DiD J ()S AMy BJ CD CG Dy

S Gz-AM HzM KS KJ L. KE LyS LyM MQT SJ WJ W

ii lii ch DiJ B. MC

ii Michi ch DiP P ()J A. BS ByJ R. ByM FzJ MGwA I. IP P. KWy KMy E MLWy MMG F. NM C. PS PzD G. SwG W. TyJ V

ii Mi ch DiI LJ PC PJ SO Z

ii Mii-kCi ch DiP OJ PJ T

ii N MicC C DiJ R ()N. B CLy D. HM P. MHy A. S. G

ii Nh Cich Di, Ch HiLz A PA ST L. Z

ii oh C Di

S S. KTy J. F

ii P ic ch DiY R ()J A. A CA EA J. GzJ R. ML A. Rz

ii Tx Dbch HC M. Fz ()Py O’N

W H. T

ii Tx Hhcic C iB T. AK M. GC W. HBy W. HB A. MNJ. D. OR PH. R RwJ B. SEw F. W

F-i FcK Fz, A, G.

eastern amraatn

ii b, ch D MiciD GF A. SO Sy

Ci ii C D MiciR M. L

Mic C gi

ch DiS M. A

H ii C DiT E. CCy E. S. FyA D. JJ M

H iiCy FyJ M

ii Mici Di N JK J Mwz

N y ii ch Di, N y, N.y.C B ()J R. C

D GzB GJ KJ LPK MM S. PAw SV TR VM W

b iiD FA N

T ii ch

D MiciG BH GM J. Hw

viii Chii ch DiP M

w viii ii ch DiK. B Bw

ter unerstes

cic C Di

— h NhJM C

l ii Fc D Mici — QcCSy M

ii chC Di — CGy Uw ()A K

ii M— M, iM Bw

M J Ty

ci oizi

D Ci ci Ig

D Cci

i Ci hCi oiDi c (CoD)

ndustr

D CiM A

bIol Tch, Ic.Jy W. JW E. Bw, J.

C li PiSy Gw

Dic DJ FM GM M

gC icM HT KW My

Jh & JhC & PPc wi

Ez RK SB W

kv DJ T

oMNI Pi C, MP CS PA P

o biTch, llCR J. BwB C

M P D PcS MR R

Pc & gS B ()R FK GM SzP W

DV DD F

*D , y

CDA H D, N.-4, .



0 n o v e m b e r 2 0 0 7



nsensus statement, ntnued fr m 79 9

ares, te mst

,

y

,

nMinimal operative intervention o

cavitated lesions and deective restorations.

Ii gii Ciic Pcic

Te ollowing statements are sug-

gested ways to implement caries manage-

ment by risk assessment principles into

clinical practice:

. treatn te dsease f aresSuccessul clinical use o CAMBRA

requires the dental team to understand:nCaries is dened as an inectious,

transmissible disease process where a

complex cariogenic biolm, in the pres-

ence o an oral environmental status thatis more pathological than protective,

leads to the demineralization and even-

tual cavitation o dental hard tissues.nCaries, the most common chronic

disease o our children, and virtually

universal among adults, is both curableand preventable, and thereore should be

given top priority and the ull resources o our proession.

nTe conventional restorative ap-

proach alone will not eliminate the

disease o caries. Preventing caries andremineralizing early lesions are cost-eec-

tive treatment options and will enhance

success o all aspects o dentistry.nCAMBRA uses evidence-based

treatment decisions based on the car-

ies risk status o the individual asdetermined by the balance or imbal-

ance between the pathological actorsand protective actors o each patient.

Pathological actors include cariogenic

bacteria, requent ingestion o erment-

able carbohydrates, and salivary dysunc-tion. Protective actors include, but are

not limited to, adequate saliva and its

caries preventive components, uoride

therapy, and antibacterial therapy.nEvidence-based dentistry, as

ling caries as a multiactorial disease.nDiagnosing the disease o dental

caries is much more involved than simply

detecting the signs o the disease pro-cess (the physical changes on teeth).

nTe contemporary denition o

prevention is the art and science o man-

aging the risk actors o each individual

patient to promote optimum oral health.n

Elevating the standard or cariesmanagement requires global collabora-

tion among the entire dental proes-

sion, industry, and government.

2. pedatr rsK assessment fr ted frm rt t ae 5

n Assessment o the caries risk statuso the young child is essential beore a

treatment plan can be designed.nChildren should be under the care o

a dental proessional by age 1.nCaries risk assessment or the young

child starts with a parent or caregiverinterview and education.

n A clinical examination o the childcompletes the assessment.

nTe risk assessment drives the

decisions about preventive, therapeutic,

behavioral, and restorative approachesand determines which o the risk actors

involved needs modication to correct the

imbalance.nTe overall aim is to determine

whether the child has active dental caries,

or is likely to have dental caries in theuture, and to intervene with patient/

caregiver education and a combination o approaches designed to arrest or reverse

the disease and markedly improve the

uture oral health status o the child.

3. rsK assessment fr ae 6tru adut

n Assessment o the caries risk status

o children and adults is essential beorea treatment plan can be designed.

dened by the American Dental Asso-

ciation Council on Scientic Aairs in

2006, is an approach to oral health care

that requires the judicious integrationo systematic assessments o clinically

relevant scientic evidence relating to the

patient’s oral and medical condition and

history, with the dentist’s clinical exper-

tise and the patient’s treatment needs

and preerences (www.ada.org/pro/re-

sources/pubs/jada/reports/index.asp).nCAMBRA, which includes mini-

mally invasive restorative procedures,

is a way to clinically implement theprinciples outlined in the 2002 FDI

Policy Statement, Minimal Intervention

in the Management o Dental Caries.

CAMBRA, Minimal Intervention, andMinimally Invasive Dentistry are all

terms that support these principles.nMinimally invasive dentistry is

a concept involving early to advancedcarious lesions and their treatment by

minimal intervention. It includes the

principles o remineralization techniques

or early and advanced lesions, treatmento cariogenic plaque to reduce and pre-

vent uture carious lesions, use o mini-

mal intervention or cavitated lesions,

repair rather than replacing deectiverestorations when possible and control-




n o v e m b e r 2 0 0 7 0

nCaries risk assessment or the child

and adult combines an assessment o

disease indicators and risk actors.n A small number o key disease indi-

cators and risk actors determine whether

the individual is at low, moderate, high, or

an additional category called extreme risk.

Extreme risk is designated when a patient

at high risk rom other actors also has se-

vere hyposalivation or other special needs.nRisk actors are biological, behav-

ioral, or socioeconomic contributors to

the caries disease process that can bemodied as part o the treatment plan.

nI the disease is currently active, or

i there is the uture risk o progression o

dental caries, intervention appropriate tothe risk status is required to correct the

caries imbalance beore cavitation occurs.

4. na prts

Te clinical management of dental caries isbased upon the caries risk assessment.

nFollowing a caries risk assessment,an evidence-based treatment plan is

developed based upon the level o risk,

namely low, moderate, high, or extreme.nTe objective clinical judgment o the

dentist, i.e., the ability to combine and use

the identied risk actors based on the

patient’s clinical situation, has been shown

to be one o the most powerul ways todetermine an individual’s caries risk.

n

High- and extreme-risk individualsrequire antibacterial therapy, reduction

o identied risk actors, remineraliza-tion therapy. Extreme risk individu-

als with severe salivary dysunction

require additional therapy, such as the

use o buering agents and calciumand phosphate supplementation.

nModerate-risk individuals require

improved remineralization therapy and

reduction o other risk actors, whichmay include antibacterial therapy.

nopical antibacterial therapy should

be used whenever a high cariogenic bacte-

rial challenge is identied and patients

should be inormed it could require re-peated treatments. In addition to bringing

down the bacterial challenge, intensive

remineralizing actions must be taken.nElements o a successul remineral-

ization therapy include thorough caries

disease diagnosis, early lesion detection,

mulation. Unortunately, restorative work

alone does not deal with the bacterial

inection in the remainder o the mouth.nCaries recall appointments at

appropriate intervals are essential to

monitor, renew, and reinorce the pro-

posed caries management and preven-

tion plan or the individual patient.nReassessment o the caries risk sta-

tus is necessary at each caries recall visit.nTe overall aim o the clinical

protocol is to reduce the acidogenic

bacterial challenge, to reduce or eliminateother risk actors, to enhance salivary

unction where needed, to enhance the

repair process by remineralization, and

to employ a minimally invasive approachwhen restorative treatment is needed.

n All patients should be inormed

o preventive choices and appropriate

minimally invasive restorative options, i needed, based on the location (site), depth

(severity), and activity o the problem aswell as their current caries risk status.

n Adhesive dental materials suchas composite resin and glass ionomer

products should be considered or

conservative treatment o caries. Glass

ionomer because o its chemical, ratherthan micromechanical, interaction (seal)

to tooth mineral may have additional

caries protective eects, especially on

dentin or cementum (root suraces).

5. prdutsnTe evidence base or current

products used to treat and preventdental caries should be evaluated and

considered prior to use in practice.n Antibacterials (e.g., chlorhexidine,

iodine, xylitol, combinations o essen-tials oils, chlorine-based products) can

be used to reduce levels o pathogenic

organisms. Bacterial assessment may

help in monitoring the process andmotivating patient involvement.

and determination o proper treatment

interventions based on location, activ-

ity, and severity o the carious lesions,

including the development o a treat-ment plan to minimize surgical treat-

ment based on the individual risk level.nChemical therapy is employed to ad-

just the imbalance between the pathologicalactors and the protective actors in order to

reverse or halt the progression o early cari-ous lesion progression toward cavitation.nMinimally invasive restorative

work is included in the treatment plan

as needed to restore the unction and

esthetics o the tooth. Proper mate-

rial selection should be based on theindividual risk assessment to reduce

uture ailures in restored teeth.nRestoration may be needed to

restore the unction o the tooth andeliminate retentive sites or plaque accu-

etreme rsK s

w

y

.



0 n o v e m b e r 2 0 0 7


nBuering products are needed

to neutralize acid attacks when

there is a lack o healthy saliva.nopical uoride rom numerous

sources (ofce and home) should be used

to enhance remineralization. (e.g., 5 per-

cent sodium uoride varnish, 1,000-5,000

ppm uoride toothpastes, .05 percent

sodium uoride rinses). Patients not ad-

hering to home-care uoride recommen-dations should receive more individual

ofce-based proessional topical applica-

tions o uoride, such as uoride varnish.nTe evidence-based clinical recommen-

dations or proessionally applied topical

uoride, as endorsed by the ADA Council on

Scientic Aairs in 2006, can serve as achairside reerence or patient care and can

be ound at www.ada.org/pro/resources/

pubs/jada/reports/index.asp.no increase patient cooperation,

products can be dispensed directly by

the clinician, rather than prescribed.nCalcium and phosphate products

can be used to replace those mineralsmissing in patients with reduced salivary

unction. Other patients with observed

surace demineralization (e.g., white

spots) may benet rom this therapy in addition to uoride treatments.

nNew products and treatment strate-

gies are emerging that are expected to be

even more useul to eectively modiy theoral environment and should be evalu-

ated and considered when appropriate.

6. mpementatn nt pratenTere are many reasons to imple-

ment CAMBRA into practice, including

ethical, legal, and standard o care issues,

but the most important reason is thebenet to the patient. CAMBRA provides

strategies to attain and maintain a healthy

environment in a patient’s mouth.nTe dentist must communicate pas-

sionately to the dental team the goals and

visions in a concise, concrete, and easy-

to-understand manner, as well as provide

the resources required or the acquisition

o new skills, knowledge, or materials.nSuccessully integrating CAM-

BRA into a practice requires that the

entire dental team understands and

supports the philosophical change.

Once an implementation strategy is

set, deciding which team members areresponsible or each step is crucial.nUse established networks

and evidence-based resources tond inormation and colleagues

or support and advice such as:lwww.cdaoundation.org/journallwww.rst5oralhealth.orglwww.adea.org/DMS/sections/

sigcariology/sigcariology.htmllwww.aapd.orglwww.icdas.orglwww.midentistry.orglwww.wcmid.com

nSupplement patient education

sessions using mu ltiple approaches(e.g., newsletters, Web sites, pamphlets,

handouts, and literature search engines

such as PubMed or DVDs). Fully inorm

patients o all options available to them,including recommended, as well as elec-

tive procedures, and let them choose.nIt is important to ollow the prin-

ciples and rules o high-quality practice.lUse proper documentation and

record clinical and radiographicndings.lInclude location, activity, and

severity o lesions (e.g., use o ICDAS

codes, laser uorescence readings,

photographs beore, during, and ater

treatment, etc.)lRecord accurately the agreed-

upon treatment plan and include

detailed progress note entries.nEstablish a sound business model

or CAMBRA procedures that generates

sufcient revenue to justiy its economic

existence. Te entire dental team must

be comortable with charging patients

a ee commensurate with the serviceprovided. Patients may be comortable

with CAMBRA-related ees once the

dental proessional helps them under-

stand what value they are receiving.

7. te team appranTe team approach is essential

or the successul caries management

program in the dental ofce, and the roleo the dental auxiliary is critical in the

overall management o the program. Te

dental auxiliary will prepare and maintain

the CAMBRA dental practice by provid-ing the caries risk assessment, thorough

patient education and necessary supplies.n A CAMBRA-trained dental auxiliary

(dental hygienist or dental assistant) canbe the designated prevention special-

ist overseeing all CAMBRA activitiesin the practice (where permissible by

the Dental Practice Act). Tis preven-tion specialist will ensure the CAMBRA

protocol is being implemented with

each patient encounter to develop and

implement preventive patient carebased on the patient’s risk assessment.

nTe practice administrative sta

plays an important role as practice

ambassadors. Te administrative sta will take the lead role in CAMBRA

patient communication and third-party payer reimbursement opportunities.nTe dental team, led by the den-

tist, is a practical way to make CAM-

BRA work. Te dentist will support

the CAMBRA process nancially and

philosophically to provide a success-ul environment or implementation.

nNew and existing patients ben-

et rom the CAMBRA protocol by

having the disease addressed beoreexpensive restorative procedures are




n o v e m b e r 2 0 0 7

c d a j o u r n a l , v o l 3 5 , n º 1 1Dr. Bob

I’m getting along in years now and,

with more time on my hands, I’m startingto think more about Te End than Te

Beginning.

When I used to go to Sunday school

with a dime tied in the corner o my handkerchie or the ofering, I recall

being told that, assuming we got there,

heaven would be a place where all our

questions would be answered, where per-ect understanding would at last be ours,

and presumably there would be no popquizzes to spoil the lessons. Tat pleases

me no end, because I have some questionsthat need answering.

Tese people who regularly report to

the National Enquirer about their out-o-

body experiences all seem to agree onone point — they are all drawn, as i by a

celestial magnet, toward a beautiul white

light. So one o the rst things I do when I

get there is ask some questions about lightand its properties. Tis has been bother-

ing me or a long time, ever since the th

grade when I rst learned that light travelsat a speed o 186,282 miles a second.

Te concept o light traveling is un-

clear to me. I think light just is. Or it isn’t.

Tat’s what switches are or. Click! Lighton. Click! Light of. I remember mysel

clearly at 10 years o age as a sort o

prepubescent detective Columbo bracing

my teacher.“Ma’am, could I ask you just one ques-

tion here? I’m a little conused, I’m sorry,that’s the way I am, I get mixed up easily. I

won’t take a minute o your time, I know you’re busy. I apologize or bothering you,

but maybe you could just help me out

here. Just or a minute, I won’t keep you.”

Ten I would try to nd out how weknow that it takes light 32 light years to

travel rom a certain star to the Earth.

Who threw that switch? Is this written

down someplace? What makes light go?

Robert E.Horseman,

DDS

illustration

b charlie o.

haard

,

cntinues n 82

S y ,I w

y f g. T

f g

“p.” I g

w Jp .

Hy Pg Lg




Why doesn’t it just stay where it is? Does

it go in a straight line just to our planetlike a ashlight beam, or does it go to all

the other planets as well and at the same

time? My teacher aged visibly during the

th grade, developed a tic and seemedgenuinely relieved when we got of astron-

omy and into the American Revolution.

But now, some 70 years later, I still

wonder about the mysteries o light. Te

smallest unit o light is called a “photon.” I

thought that was a Japanese bed. Did youknow that? I don’t mean to bother you,

but there’s just one more thing. Like, i I

point a ashlight with a couple o C cellsinto the dark, the beam will penetrate,

say, a hundred eet or so, and then what?

Does the light go, “Well, that’s it! I’m

pooped, I can’t go any arther, I’m notgonna make it!” and just stops in midair

or describes a gentle trajectory towards

the ground? At 186,282 miles a second,

it doesn’t have much time to decide on acourse o action.

It must be the same with these distantstars. Suppose some olks on Alpha

Centauri want to dazzle us with a littlelight show, some colored strobes and

dancing ountains; anybody in charge

there would veto this idea as impractical

because it would take 157 gazillion yearsor the display to reach us and by that

time most o us would have tired o wait-

ing and gone home. “Tese Earth people

have no patience,” the Alpha Centaurianswould complain. “Tey won’t even wait or

Christmas; start decorating in October,or crying out loud!”

And since the Earth turns on its axis(another leap o aith), suppose the light

did nally reach us and we were on the

opposite side? By the time we ound a

parking space and located a good view-ing angle — WHOOM! — at 11,176,920

even with resh alkaline cells.

From a practical viewpoint, our lightwould take as long to get to them as theirs

to us, so what they are looking at even as

we speak is probably primordial ooze and

not even worth sending down a saucer tocheck out.

With dentistry edging into lasers at

slightly less than the speed o light, could

I bother to ask one little question here?

Tere’s something I don’t understand. I’m

sorry, it’s not your ault, it’s mine. I know you told me all this beore, but could we

just go over it once more? Just take a min-

ute. I remember the acronym stands or“light amplication by stimulated emis-

sion o radiation,” or LABSEOR, which

n v e m b e r 0 7 d r . b b

dr. bb, cntinued frm 822

Ho

was shortened to LASER because “by and

“o” are prepositions and thus orbiddento appear in the middle o acronyms by

the Joint Emergency Reserve Kibitzer

Service (JERKS).

Laser’s big eature is that it’s coherentlight. What might render you incoherent

is the price. My question: What do I get

or my $40,000 dental laser besides some

very ancy light that can cut, coagulate,

and vaporize?

Could I achieve the same degree o one-upmanship on the cutting edge o

my ever-shortening lie with a $40,000

BMW? I’m just asking. I know it will only go about 120 mph, but at least it’s the

kind o traveling I understand.

journal of the california dental association nov 2007

Documents