Job Corps Health and Wellness WebinarJune 30, 2010

Introduction to CAMBRA

PresentersPamela Alston, DDS, MPPJob Corps Principal Dental Consultant,

Humanitas, Inc.

Keri Cassinelli, BS, RDHDental Hygienist, Sierra Nevada Job Corps

Center

Continuing Education Information

“This activity has been planned and implemented in accordance with the standards of the Academy of General Dentistry Program Approval for Continuing Education (PACE) through the joint program provider approval of the National Dental Association and Humanitas, Inc. The National Dental Association is approved for awarding FAGD/MAGD credit.”

CE PartnersNational Dental AssociationHumanitas, Inc.

CAMBRA Caries Management By Risk Assessment Scientifically proven Evidence based Patient specific

Prevalence of Caries 77.9% of 17 years olds have dental caries Low socioeconomic status increases risk

Source: U.S. Department of Health and Human Service. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

Introduction to CAMBRA—Caries Management by Risk Assessment

“What am I doing to help the students

prevent more

cavities from forming?”

Treating Carious Lesions vs. Treating the Cause of Carious Lesions

Failure to treat the cause of the caries lesions is like lathering dirty dishes and putting them in greasy rinse water. You’ll just have to lather them again.

Topics Caries balance and imbalance Caries risk assessments Therapeutic regimens Student self-responsibility JC oral health & wellness team-members’

responsibility

Agenda Pre-test CAMBRA Discussion Post-test Webinar evaluation

Learning ObjectivesAfter participating in this webinar, the participant should

be able to:

1. Understand the role of caries risk assessment in prevention

2. Understand how caries is an infectious disease in which the balance between cariogenic oral biofilm and the tooth becomes compromised

3. Describe the components of the CAMBRA approach

CAMBRA Principles Modification of the oral flora to favor health Patient education and informed

participation Remineralization Minimal operative intervention

Definitions Dental caries—an infectious disease

leading to loss of mineralized tissue in the tooth structure

Risk assessment—determining the risk for tooth decay in the future

Caries balance—balance among disease indicators, risk factors, and protective factors

Caries management—altering the balance between caries pathological and protective factors

Job Corps Priority Classification System of Lesions

A.Priority 4B.Priority 4C.Priority 4D.Priority 3E. Priority 3F. Priority 2G.Priority 1 or 2

Source: Andréa Ferreira Zandoná and Domenick T. Zero, “Diagnostic Tools for Early Caries Detection,” JADA, 2006, 137(12); 1675-1684, Copyright © 2006 American Dental Association. All rights reserved. Reprinted by permission.

Featherstone JDB, Gansky SA, et al.A randomized clinical trial of caries management by risk assessment.

Caries Res 39:295 (Abstract #25), 2005

CAMBRA Clinical Study

CAMBRA Clinical Study Conclusions The Caries Balance concept is confirmed Fluoride alone cannot overcome a high

bacterial challenge Restorations don’t reduce bacterial loading Chemical therapy markedly reduces level

of new caries

Biofilm

Dental Plaque

What are biofilms? “Biofilms are communities of micro-

organisms encased within an extra cellular polymeric slime (Eps) matrix living on surfaces.”(1)

Biofilms form when bacteria are exposed to a wet surface.

Where do we see biofilms? They are everywhere! We see them on

kitchen surfaces, bathrooms, fish tanks, coffee mugs, and in our mouth.

Dental plaque is a form of biofilm.

Film sequence by Dr. Wenyuan Shi @ UCLA, provided by Dr. V. Kim Kutsch

Bioflims and Carious Lesions

How do biofilms lead to cavitation?

Low pH This is the most important fact to

understand. Without an acidic environment (pH of 4.8 and lower) there would be no demineralization and cavitation.

What Creates a Lower pH? Initial changes in environment due to any

one factor: saliva flow decreases, poor diet, or poor homecare, can lead to an acidic pH in the mouth.

Demineralization

Bacteria

No one particular bacteria species causes carious lesions.

“Good biofilm bacteria” have been found to adapt and produce acid once the pH drops as well.

Protective Factors•Saliva flow and components• Fluoride - remineralization• Antibacterials - chlorhexidine, xylitol, new?

No CariesCaries

Pathological Factors•Acid-producing bacteria•Frequent eating/drinking of fermentable carbohydrates •Sub-normal saliva flow and function

Featherstone, Comm Dent Oral Epidemiol, 1999

The Caries Balance

Protective Factors• Saliva• Fluoride, Ca, P• Antibacterials

No CariesCaries Progression

Risk Factors•Acidogenic Bacteria•Frequent carbohydrates •Sub-normal saliva

Disease Indicators•Cavities/dentin•Enamel lesions•Restorations < 3 yr•White spots

Featherstone, Young, Wolff, 2007

The Caries Imbalance

CAMBRA Assessment Tool Caries disease factors (Exam) Caries risk factors (Interview) Caries protective factors (Interview) Caries risk level Bacteria and saliva testing Treatment plan for caries intervention and

prevention

Caries Risk Assessment Tool Caries risk factors (Interview) Caries protective factors (Interview) Caries disease factors (Exam) Caries risk level Bacteria and saliva testing Treatment plan for caries intervention and

prevention

Build Rapport Be sensitive Be culturally appropriate Show respect Remain non-judgmental and friendly Give positive reinforcement

Caries Risk Assessment Tool Caries risk factors (Interview) Caries protective factors (Interview) Caries disease factors (Exam) Caries risk level Bacteria and saliva testing Treatment plan for caries intervention and

prevention

Job Corps Priority Classification System of Lesions

A.Priority 4B.Priority 4C.Priority 4D.Priority 3E. Priority 3F. Priority 2G.Priority 1 or 2

Source: Zandona AF, Zero DT. Diagnostic tools for early caries detection. JADA 2006;137(12);1675-84. Copyright © 2006 American Dental Association. All rights reserved. Reproduced by permission.

Caries Risk Assessment Tool Caries risk factors (Interview) Caries protective factors (Interview) Caries disease factors (Exam) Caries risk level Bacteria and saliva testing Treatment plan for caries intervention and

prevention

Caries Risk Assessment Tool Caries risk factors (Interview) Caries protective factors (Interview) Caries disease factors (Exam) Caries risk level Bacteria and saliva testing Treatment plan for caries intervention and

prevention

Caries Risk Assessment Tool Caries risk factors (Interview) Caries protective factors (Interview) Caries disease factors (Exam) Caries risk level Bacteria and saliva testing Treatment plan for caries intervention

and prevention

Self-Management Vital Behaviors What are two vital behaviors that you feel will

help you avoid signs of caries disease? Why did you pick these two vital behaviors? What can you see getting in the way of making

these vital behaviors habits? What are some ideas you have to overcome

those obstacles? How will you feel when your vital behaviors

become habits?

Effectiveness of Therapeutics

Source: Andréa Ferreira Zandoná and Domenick T. Zero, “Diagnostic Tools for Early Caries Detection,” JADA, 2006, 137(12); 1675-1684, Copyright © 2006 American Dental Association. All rights reserved. Reprinted by permission.

Role of Therapeutics

Balancing the pH issue pH positive products of 6.8 or greater Xylitol Combat xeristomia Keeping biofilm bacterial levels in check

Role of Health Education

“Not everything faced can be changed,

but nothing can be changed until it is faced.”

-James Baldwin, writer and novelist

Role of Health Education Understanding their sense of “self” What is their dental I.Q.? How do they view the dental profession? Be an active participant on campus

Understanding Their Sense of “Self” These students are acutely aware of what

they don’t have. Loss of teeth and replacement with bridge work, flippers, dentures, or even implants is seen not only as physically diminishing, but as placing them at the very bottom of the socio-economic totem pole.

What is Their Dental I.Q.? Do they understand basic oral

hygiene? Have them demonstrate their homecare skills.

Understanding the environment from which they came. If they moved a lot, lived on the streets, or had a history of substance abuse, oral hygiene was most likely not a taught skill or priority.

Be careful of dental jargon. Words like plaque, tarter, calculus, periodontal

disease, or root canal, are all foreign to the majority of Job Corps population.

How Do They View the Dental Profession? Many of our students have never been to a

dental practice, are from foreign countries, or sought cheap quick fixes that yielded poor results. In other words, they are terrified of us.

This will result in broken appointments, miscommunication, and lack of compliance. All efforts should be made to promote a safe and compassionate environment.

Be an Active Participant on Campus Classrooms

Keep information simple, understandable, and impactful. Walk the campus grounds

This allows students to see you outside the clinic, and ask questions in a non-clinical setting.

Participate in other campus programsAt my center I lecture in weight management class, diabetes clinics, tobacco cessation programs, etc. Always relating dentistry to the field I am participating in.

Host motivational speakersGruen Von Behrens with the help of local sponsors recently visited our campus and spoke about the effects of tobacco use.

References1. Center for Genomic Sciences, West Penn Allagheny Health Systems.

http://www.centerforgenomicsciences.org/research/biofilm.html.2. Marsh, P.D. “Dental Plaque as a Biofilm and a Microbial Community-

Implications for Health and Disease.” BMC Oral Health. 2006. 6(Suppl 1) : 514.

3. Marquis, M.E. “Oxygen Metabolism, Oxidative Stress and Acid-Base Physiology of Dental Plaque Biofilms.” Journal of Industrial Microbiology. Vol 15. p. 198-207.

4. Young, Douglas A., et al. “Curing the Silent Epidemic: Caries Management in the 21st Century and Beyond.” CDA. Vol 35, 10. p. 681-85.

5. Nield-Gehrig, Jill S. “Dental Plaque Biofilms.” http://www.dentalcarestamford.com

6. Frutiger, Anna. “Dental Plaque Biofilms.” http://www.microbewiki.Kenyon.edu/index.php/Dental_Plaque_Biofilms.com

7. Garcia-Godoy, Franklin and Hicks, John M. “Maintaining the Integrity of the Enamel Surface: The Role of Dental Biofilm, Saliva and Preventive Agents in Enamel Demineralization and Remineralization.” JADA. 2008; 139;2S-34S

8. Kutsch, V. Kim, and Milicich, Graeme. “Understanding the Biofilm Battle.” http://carifree.com/dentists/online downloads. html. Recorded June 2, 2009.

References9. Young, Douglas A. DDS, MS, MBA; Featherstone, MSc, PhD,

John DB; Roth, Jon R. MS, CAE; et al, “Consensus Statement Caries Management by Risk Assessment: Implementation Guidelines.” Journal of the California Dental Association, Vol 35, Number 11, p 799

10. Peltier, Bruce, PhD, MBA; Weinstein, Phillip, PhD; and Fredekind, Richard, DMD, MA, “Risky Business: Influencing People to Change,” CDA Journal, Vol 35, No 11, p 794-798

11. Patel, Seena, BS, MPH; Bay, Curtis R. PhD; Glick, Michael DMD, “A systematic review of dental recall intervals and incidence of dental caries,” JADA, Vol 141, May 2010

How does the CAMBRA approach

fit into Job Corps?