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Profile in Oral Health: My Reluctance to Accept CAMBRA by Timothy Ives, RDH

More by this author (2)

When I graduated in 1990, a large proportion of my UK diploma in dental hygiene was related to aspects of dental caries, fluoride, fissure sealants, dietary advice and analysis and oral hygiene instruction. For the next 18 years, it was an exponential year-on-year decline in the amount of time I dedicated to the prevention of tooth-related problems and in 2008, almost all of my working day related to periodontal disease.

Why was this? My treatment of periodontal disease was continually being updated. My skills with various instruments were constantly being fine-tuned. I had a genuine interest in perio and it was an easy path to follow. My treatment and prevention of caries had not changed in 18 years. In 2008 I was giving, more or less, the same advice that I was giving in 1990. I’m not blaming anyone but myself for this approach, but in my defense, I had regularly attended clinical update meetings and scientific courses, but I do not recall reading many scientific articles or attending many lectures on the subject. Was it available then or was I not looking hard enough? I allowed myself to be steered down a path where I was in my comfort zone and the dentists and periodontists who were referring patients to me were obviously happy for me to continue along this path. Did dentists, the government, professional or governing bodies, or even the general public realize that hygienists have an important role to play in caries management? Why and how did I change?

My colleague, Mark, and I, were discussing caries management by risk assessment (CAMBRA) upon his return from practicing in New Zealand, where far from being a “backwater,” they appeared to be years ahead of the U.K. in caries management. I have the greatest respect for Mark, but I was skeptical about this new approach to caries. Mark confided that he too was skeptical at first, but one event changed his mind. While in New Zealand, he was invited to a dental peer group meeting where the Regional Dental Officer gathered the community dental therapists together to calibrate their reading of dental radiographs in children. They were all asked to bring examples to compare and discuss. Mark was shocked at the absence of any preventive approach to caries risk management. His fellow dental therapists perceived their responsibility to be addressing the vast flood of caries restoratively, especially in the indigenous Maori population and outer lying settlements of Northland. It appeared that to them, their only option was restorative dentistry! Mark realized how fortunate he was to be working in a clinic following the CAMBRA model and working to prevent caries, not just repair the damage. He was in a completely different environment than those hard-pressed therapists who focused only on restorative care.

After a year of listening to Mark I still wasn’t changing my approach. It was then he persuaded me to go to the Greater New York Dental Meeting to listen to an eminent speaker on the subject of CAMBRA. The room was crammed with hygienists, people were sitting on the floor and some stood up at the back. During this lecture, I had my “Eureka!” moment. With all the science laid out before me, CAMBRA did make sense and was something I felt obligated to offer my patients. My enthusiasm to completely change the practice overnight had to be tempered by reality. CAMBRA requires a significant change in mindset and CAMBRA conversion affects all systems within the practice, from scheduling and fees to diagnostics, treatment and patient education. Rome wasn’t built in a day. I’m happy that my working life is moving in the right direction.

Dental Caries

The prevalence of dental caries in the U.S. is described as a “silent epidemic” affecting “the most vulnerable citizens: poor children, the elderly and many members of racial and ethnic minority groups.” Statistics vary from 50 percent of children experiencing caries in deciduous teeth to 25 percent of adolescents experiencing caries in 80 percent of permanent teeth. In the U.K., statistics aren’t much different. Caries is a transmissible disease that requires primary prevention, strategies and agents to forestall the onset of disease and reverse or arrest the process of disease before secondary reparative treatment becomes necessary. Despite evidence that caries can be prevented, caries rates seem to be ever increasing.

The concept that dental caries is a process rather than a categorical disease with cavitated and non-cavitated states was reported more than 100 years ago, in 1886. Dr. Magitot divided the disease into three stages: caries of enamel, caries of dentine and deep caries. Two years later, Dr. Morsman stressed the importance of diagnosis as the first step in the management of dental caries. Dental caries is now defined as a transmissible bacterial infection that should be curable and preventable and whose etiological agents are specific bacteria that generate acids from fermentable carbohydrates.

New paradigms are being sought to address deep concerns among health-care professionals to meet these challenges. CAMBRA was developed in the United States and is presently being embraced throughout the world. CAMBRA is an evidence- based caries management system that is founded on a team approach and an understanding of the nature, prevention and treatment of dental caries. It incorporates the ethos that risk assessment and interventions are based on the concept of altering the caries balance in favor of health by identifying and treating pathological (risk) factors such as pathogenic bacteria, unhealthy saliva and poor dietary habits (i.e. frequent ingestion of fermentable carbohydrates) and promoting protective factors including saliva, sealants, antimicrobials, fluoride, oral probiotics and a healthy diet.

It is also clear that the current concept of caries is constantly being redefined as new evidence and information is presented. It should now be looked upon as an infectious transmissible disease process where a cariogenic biofilm, in the presence of an oral status that is more pathological than protective leads to the demineralization of the dental hard tissues.

Caries Risk Assessment

Caries risk assessment (CRA) is defined as the procedure to predict future caries development before the clinical onset of the disease. The CRA can be carried out as part of the dentist’s clinical examination in conjunction with the medical history or by the hygienist/therapist when referred by a dentist. CRA forms consist of a questionnaire that collects information on the existing pathogenic and protective factors present. These factors would include various stages of carious lesions, diet, fluoride, health, medication, socio-economic, age, oral hygiene, saliva, plaque and bacterial balance. Gathering as much information as accurately as possible is essential for the success of the treatment, engagement and education of the patient. After completing these forms, the clinician can determine the level of risk that these factors indicate to the individual. Forms can be completed for child and adult groups.

The Californian Dental Association (CDA) suggests placing patients in either a high-, medium- or low-risk category. Determining the risk is not an exact science but a clinical determination based upon visible (intra-oral and screening) and radiographic evidence, the individuals health and dental histories and lifestyle factors. The imperative is to understand the individual’s balance of risk against the protective factors and identify his or her status accordingly. Then a process of management can begin to alter or modify risk and protective factors accordingly. These are managed by the clinician and patient and reviewed at appropriate intervals depending upon risk.

The completed assessment will help structure the data collected and shed light upon the management of the individual where treatment options are challenging. For example, think about two caries-free children with different mutans Streptococci levels in their saliva. Assuming each has the same diet, it is very likely that the child with higher counts will develop more caries than the other with low levels. However, if the child with low levels eats sugary foods frequently and the higher one doesn’t, who has the greatest chance of developing caries? Imagine that the low bacterial count child supplements sugary foods with fluoride and the other does not, again, who will develop more caries, and so forth? In this way, by adding several aggravating and counteracting risk factors the permutations are potentially vast. The risk assessments intention is to help unlock this puzzle.

The development of CRA and caries risk management (CRM) have proved to be a continually evolving experience. Surprisingly the challenge was not that of critically appraising research and creating a strategy but of discovering the agents and materials to complement and implement the assessment and guidelines scattered amongst the dental profession and dental suppliers and not unified under one umbrella. If such a strategy is to evolve, then not only should the profession embrace developing acceptable guidelines but also the corporate industry coming together unified as part of this collaboration. Professionally, I feel like I’ve been given a new lease of life. I’m now looking at all of my patients through different eyes. I have a much greater understanding of the importance of balancing oral health, looking at each individual patient holistically and I spend as much time listening and gathering information now as I do talking.

My appointment book looks much more interesting and the whole team is really enjoying getting involved in something new. My own resistance to change makes me realize that making changes in the practice and with patients is going to be a rocky, yet exciting and rewarding road ahead.

Next Month: Part 2 – Technologies Used in Caries Risk Assessment and Prevention
Author’s Bio
Timothy Ives, RDH, spent 22 years in the Royal Air Force, much of that time providing dental hygiene services. His tours of duty included Hong Kong, Cyprus, Germany, New Zealand, Holland and the U.K. Besides clinical practice, he also has a certificate in appraisal of dental practices. He has a passion for minimally invasive dentistry (MID) and co-runs an MID-based Web site with his friend, Dave Bridges, RDH: www.dentalvillage.co.uk. Tim is an active Townie, member of the Hygientown.com Advisory Board and available for in-office CAMBRA training
Dentaltown Magazine
September 2025
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