It is based on new method to assess caries management

1. DR DITHYKUMARI
FIRST YEAR PG
Caries Management By Risk
Assessment (CAMBRA
The New Model for Managing Caries

2. ”

3. INTRODUCTION
• The results of the global burden of disease study released by
Lancet in 2017 showed that among 328 diseases, the
prevalence of permanent dental caries ranked first, and the
incidence ranked second.
• There are around 2.44 billion population worldwide suffering
from permanent tooth decay.

4. • In oral health, a dynamic balance is reached between the host,
the environment and the Microbiome (symbiosis)frequent intake
of sugar and/or reductions in saliva flow result in Extended
periods of low ph in the biofilm, which disrupts this symbiotic
relationship.
• Such conditions inhibit the growth of beneficial species and
drive the selection of bacteria with anacidproducing/acid-
tolerating phenotype, thereby increasing the risk of caries
(dysbiosis)

6. Shafer (1993) defined dental caries as an irreversible microbial
disease of the calcified tissues of the teeth, characterized by
demineralization of the inorganic portion and destruction of the
organic substance of the tooth, which often leads to cavitation.

8. TOOTH FACTORS
DEEP PITS ,GROOVES

9. DENTAL PLAQUE

10. SALIVA
COMPOSITION, PH, CONTENTS
CARIE PRONE INDUVIDUALS HAVE
LOWCALCIUM,PHOSPHOROUS LEVEL
XEROSTOMIA

11. MICROFLORA
STREPTOCOCCUS MUTANS
STREPTOCOCCUS SALIVARIUS

12. DIET

13. TYPE OF CARBOHYDRATE
FREQUENCY OF INTAKE
STAGNATED FOOD

14. Car(CAMBRA). Caries management by risk assessment is a
standard of care (Featherstone et al 2007) that involves identifying
potential causes of caries through individual risk assessment and
mitigating risk through behavioral changes and minimally invasive
dental care.
CAMBRA treatment intervention was proven to significantly
reduce caries risk levels and caries disease indicators in a two-
year randomized, controlled, parallel-arm, double-blind
clinical trial (Rechmann 2019).

16. CAMBRA was first proposed by the California Dental
Association in 2002, and was modified afterwards to form
the existing format. It consists of two tables: 0–6 years old
and over 6 years old. And its assessment criteria include
pathological indicators, risk factors, protective factors and
bioprotective factors

17. CARIES RISK ASSESSMENT:- Can
be defined as a procedure to
predict future caries
development before the clinical
onset of the diseases
Caries risk assessment is the determination of
the likelihood of the incidence of caries (ie,
the number of new cavitated or incipient
lesions) during a certain time period. It also
involves the probability that there will be a
change in the size or activity of the lesion in
the mouth.
Guideline on Caries-risk Assessment and Management for Infants, Children,
and Adolescents Reference manual 2011; 37( 6): 15 -16.

18. PRINCIPLES
ONCE CLINICIANS HAVE IDENTIFIED THE PATIENTS CARIES RISK (LOW,
MODERATE, HIGH OR EXTREME) A THERAPEUTIC AND/OR PREVENTIVE PLAN
SHOULD BE IMPLEMENTED.-
MOTIVATING PATIENTS TO ADHERE TO RECOMMENDATIONS IS
AN IMPORTANT ASPECT IN CARIES MANAGEMENT.-
ALONG WITH FLUORIDE, NEW PRODUCTS ARE AVAILABLE TO ASSIST
CLINICIANS WITH NON INVASIVE MANAGEMENT STRATEGIES

19. THE CARIES PROCESS
DEPENDS UPON THE INTERACTION OF PROTECTIVE AND PATHOLOGIC FACTORS IN
SALIVAAND PLAQUE BIOFILM.-
THE KEY OF CAMBRA IS TO MODIFY AND CORRECT THE COMPLEX DENTAL BIOFILM
THROUGH BEST-PRACTICES APPROACH THAT DECREASES CARIES RISK FACTORS,
INCREASES PROTECTIVE FACTORS ARE INCREASED.-
NON-CAVITATED CARIES LESIONS CAN BE ARRESTED IF THE CARIES CHALLENGE IS
REDUCED SUFFICIENTLY OR ELIMINATED, OR IF THE PROTECTIVE FACTORS ARE
INCREASE

20. CARIES BALANCE CONCEPT
THE MULTIFACTORIAL NATURE OF DENTAL CARIES-
THE BALANCE BETWEEN PATHOLOGICALAND PROTECTIVE
FACTORS-
THE DYNAMIC NATURE THAT OCCUR SEVERAL TIMES A DAY-
IF PATHOLOGICAL FACTORS OUTWEIGH PROTECTIVE FACTORS, THE
CARIES DISEASE PROCESS PROGRESSES

21. CARIES IMBALANCE
Disease indicators:
•White spots
•Restorations
>3 years
•Enamel lesions
•Cavities/ dentin
Risk Factors
•Bad bacteria
•Absence of saliva
•Dietary
habits(poor)
Protective factors:
•Saliva & sealants
•Antibacterial
•Fluorides
•Effective diet
No caries
Caries progression

22. CARIES RISK FACTORS
PLAQUE
IMPORTANT TO ESTIMATE
• THE NUMBER OF SURFACES AFFECTED
• THE AMOUNT OF PLAQUE ACCUMULATED
• AGE OF THE PLAQUE
• WHETHER ITS PRESENCE IS ASSOCIATED WITH CARIOUS LESIONS IN THOSE
SAME SITES

23. CARIES DISEASE INDICATORS
–low (socioeconomic status);
development problems
presence of cavities
white spots
restorations placed in the previous 3 years

24. CARIES RISK FACTORS
TYPE AND QUANTITY OF MUTANS
STREPTOCOCCI (MS) AND LACTOBACILLI(LB)
VISIBLE PLAQUE
EXPOSED ROOTS
SALIVA REDUCING FACTORS
INADEQUATE SALIVA FLOW
FREQUENT SNACKS
DEEP PITS AND FISSURES
ORTHODONTIC APPLIANCES

25. CARIES
PROTECTIVE
FACTORS
– SYSTEMIC AND TOPICAL FLUORIDE SOURCES;
ADEQUATE SALIVA FLOW; AND REGULAR USE OF
CHLORHEXIDINE, XYLITOL, AND CALCIUM AND
PHOSPHATE PASTE

26. CLINICAL
EXAMINATION
– presence of white spots, decalcification, restorations,
and plaque; and bacterial culture and saliva flow tests

27. CAMBRA CLINICAL
GUIDELINES

28. 1.CAREGIVER/PARENT OR PATIENT ANSWERS THE
QUESTIONS ON THE RISK ASSESSMENT FORM

29. 2 DETERMINE THE OVERALL CARIES RISK AS
LOW, MODERATE, HIGH OR EXTREME
1. LOW RISK – NO DENTAL LESIONS, NO VISIBLE
PLAQUE, OPTIMAL FLUORIDE, REGULAR
DENTAL CARE
2. MODERATE RISK – DENTAL LESION IN
PREVIOUS 12 MONTHS, VISIBLE PLAQUE,
SUBOPTIMAL FLUORIDE, IRREGULAR DENTAL
CARE
3. HIGH RISK – ONE OR MORE CAVITATED
LESIONS, VISIBLE PLAQUE, SUBOPTIMAL
FLUORIDE, NO DENTAL CARE, HIGH
BACTERIAL CHALLENGE, IMPAIRED SALIVA,
MEDICATIONS, FREQUENT SNACKING
4. EXTREME RISK – HIGH-RISK PATIENT WITH
SPECIAL NEEDS OR SEVERE HYPOSALIVATION

30. 3 PERFORM BACTERIA AND SALIVA TESTING AS INDICATED BY RISK LEVEL
4 DETERMINE THE PLAN FOR CARIES INTERVENTION AND PREVENTION
1. PATIENTS AGE 0 TO 5 – CONSIDER THE FOLLOWING FOR THE
CAREGIVER AND PATIENT BASED ON RISK LEVEL: SALIVA AND
BACTERIAL TESTING; ANTIBACTERIALS; FLUORIDE CONSUMPTION, USE,
AND PROFESSIONAL APPLICATION OF FLUORIDE VARNISH; FREQUENCY
OF RADIOGRAPHS; FREQUENCY OF PERIODIC EXAMINATIONS; ORAL
HYGIENE INSTRUCTIONS; XYLITOL AND/OR BAKING SODA; SEALANTS;
AND EXISTING LESIONS.3
2. PATIENTS AGE 6 THROUGH ADULT – CONSIDER THE FOLLOWING BASED
ON PATIENT RISK LEVEL: FREQUENCY OF RADIOGRAPHS; FREQUENCY
OF CARIES RECALL EXAMINATIONS; ORAL HYGIENE INSTRUCTIONS;
SALIVA AND BACTERIAL TESTING; ANTIBACTERIALS SUCH AS
CHLORHEXIDINE AND XYLITOL; FLUORIDE USE AND PROFESSIONAL
APPLICATION OF FLUORIDE VARNISH; PH CONTROL; CALCIUM AND
PHOSPHATE; AND SEALANTS.4

31. 5DISCUSS HOME CARE RECOMMENDATIONS
BASED ON RISK LEVEL
1.PROVIDE FOLLOW-UP CARE AND REASSESS RISK
LEVEL

33. AMERICAN DENTAL ASSOCIATION (ADA) CARIES RISK ASSESSMENT
This risk assessment system was proposed by the ada in 2004 and is divided into two
forms.
One form is for patients ages 0–6 years of age and the other is for patients over 6 years
of age.
It mainly includes three aspects: contributing conditions, general health conditions, and
clinical conditions.
Contributing factors refer to external factors that could influence the occurrence and
development of dental caries;
General health conditions refer to the physical conditions of patients;
Clinical conditions refer to intraoral conditions that directly related to dental caries.
The system divides caries risk into high, moderate, and low grades, and is mainly used
to assist dentists in assessing patient’s caries risk in clinical practice.

34. CARIES-RISK ASSESSMENT TOOL (CAT)
CAT IS DEVELOPED BY THE AMERICAN ACADEMY OF PEDIATRIC DENTISTRY AND
IS DIVIDED INTO 2 FORMS:
(1) FOR CHILDREN AGED 0–5 (DENTAL PRACTITIONERS, PHYSICIANS, AND
OTHER NON-DENTAL HEALTH CARE PROVIDERS)
(2) (2) FOR CHILDREN ≥ 6 YEARS OLD, ADOLESCENTS AND ADULTS (USED BY
DENTAL PROVIDERS).
CAT’S EVALUATION INDICATORS COVER RISK FACTORS (SOCIAL/BIOLOGICAL),
PROTECTIVE FACTORS AND CLINICAL FINDINGS, AND IT IS MOSTLY USED FOR
CRA IN INFANTS, CHILDREN AND ADOLESCENTS.

35. CARIOGRAM
Cariogram is a new way in which to illustrate the interaction
Between caries related factors.
• This educational interactive program has been developed for
Better understanding of the multifactorial aspects of dental caries
And to act as a guide in the attempts to estimate the caries risk.

38. PETERSSON GH. ASSESSING CARIES RISK-USING THE
CARIOGRAM MODEL. SWED DENT J SUPPL.
2003;(158):1-65
Peterson G et al in 2003 gave the opinion that the
cariogram predicted caries increment more accurately
than any includedsingle-factor model.

39. Traffic Light Matrix (TLM):
This is a commonly used CRAtool.
TLM is based on 19 criteria in 5 different categories including saliva (6
criteria), plaque (3 criteria), diet (2 criteria), fluoride exposure (3
criteria) and modifying factors (5 criteria
• Traffic light colours convey varying caries
levels(red=high,yellow=moderate and green=low).

41. Icdas-caries lesion activity assessment (also called in
the literature ICDAS-CAA for icdas-clinical
characteristic assessment) was proposed in 2009,
which is based on combinations of visual (appearance
and plaque stagnation) and tactile criteria

43. The ideal prerequisite of a CRA, as described by stammet
al is that “to be useful, a working [caries prediction1model
should produce a sensitivity level of 0.75or higher and
specificity level of at least 0.85 or higher

48. FIRST CAMBRA CLINICAL TRIAL
The first CAMBRA study was performed at the university of california,
San francisco (UCSF) between 1999 and 2004.
The study was a randomized,prospective, controlled clinical trial over two years.
The results indicated that an over-the-counter (otc) fluoride toothpaste and rinse combined with an
antibacterial agent (chlorhexidine) were able to significantly reduce the cariogenic bacterial load over
the study period.
In the control group, placing restorations alone did not reduce the mutans
Streptococci (MS) bacterial challenge.
The cambra intervention group was significantly lower at each recall visit.

49. CONCLUSION
Risk-based noninvasive caries management, as embraced in CAMBRA,
Effectively and significantly lowers the occurrence of new caries lesions in
continuing dental patients.
However, CAMBRA falls short of eliminating caries risk entirely.
cambra risk assessment and management guidelines Offer a
straightforward protocol, grounded in evidence, but are not intended to be
prescriptive.
Adding clinical reasoning and judgment allows the clinician to work
collaboratively with the patient to develop a caries management plan that
accounts for individual patient

50. Featherstone JD, Crystal YO, Alston P, Chaffee BW, Doméjean S, Rechmann P, Zhan L,
Ramos-Gomez F. A comparison of four caries risk assessment methods. Frontiers in Oral
Health. 2021 Apr 28;2:656558.
• Axelsson P
. Diagnosis and risk prediction of dental caries. Slovakia
Quintessence International 2004; p. 29.
• Bratthall D et al. Cariogram a multifunctional risk assessment model for a
multifactorial disease. Community Dent Oral Epidemiol 2005; 33: 256–64.
References