This document discusses CAMBRA (Caries Management By Risk Assessment), a clinical review for managing dental caries risk in children. CAMBRA integrates caries risk assessment into comprehensive oral health visits for children from birth to age 5. It involves assessing risk factors, customizing preventive care plans, and determining recall schedules based on risk. The review describes the CAMBRA process, which includes examining protective and risk factors, clinical exams, fluoride varnish application, setting self-management goals, and developing individualized care paths. Barriers to caries risk assessment and recommendations to address them are also discussed.

1. CAMBRA
A Clinical Review
AlWaleed Abushanan, BDS
UCLA – Section of Pediatric Dentistry

2. • According to the 2007 Report by the Centers
For Disease Control and Prevention ( the most
current report to date), cavities have increased
for toddlers and preschoolers. Cavities in
children ages 2 to 5 increased from 24 percent
to 28 percent between 1988-1994 and 1999-
2004.

3. For children
aged 2 to 5, 70%
of the caries is
found in 8% of
the population

4. • ECC is disproportionately
concentrated among
socially disadvantaged
children, especially those
who qualify for Medicaid.

5. White Spot Lesions, and Enamel
Hypoplasia
(What is The difference between them)

6. White Spot Lesions
• They initiate below the surface of the enamel and appear
as a pale stain.
• The term “white spot lesion” is defined by Fejerskov et al.
As the first sign of carious lesion on enamel that can be
detected with the naked eye and used along side with
terms “initial” or “incipient” lesions.

7. Prevention and Management
• Enhancing enamel resistance using
topical fluorides.
• Fluoride ion has a preventive
effect against caries by:
• Modifying bacterial Metabolism in dental plaque.
• Inhibiting the production of acids.
• Reducing demineralization and favors the
remineralization of early carious lesions.

8. Enamel Hypoplasia
• Enamel Hypoplasia is defined as an
incomplete or defective formation of
the organic enamel matrix of the
teeth in the embryonic stage of the
tooth.

9. • Hereditary:
• Ectodermal disturbance that occurred during the embryonic development of
the enamel. The mesodermal components are normal. Both the primary and
permanent teeth are involved, and only the enamel is affected.
Enamel Hypoplasia

10. • Environmental:
• Caused by the factors that causes damage to the enamel cells. Either primary
or permanent teeth are involved and sometimes a single tooth is involved.
Here both the enamel and dentin are involved in varying degrees.
• Nutritional deficiencies (Vit A, C , D).
• Exanthematous diseases (Measles, Chickenpox, Scarlet Fever).
• Congenital Syphilis.
• Hypocalcemia.
• During birth (Birth Injuries, Prematurity, Rh hemolytic disease)
• Local infection or Trauma
• Ingestion of Chemicals.
Enamel Hypoplasia

11. • There are many distinct features that are seen in
cases of enamel hypoplasia :
• Enamel that has not formed to a full thickness
• The crowns of teeth may show discoloration, such as white spots, or cloudy
opacities.
• Hypoplasia due to local infection or trauma exhibits mild brownish
discoloration of the enamel to severe pitting of the crown.
• When ingesting excessive fluoride during the time of the tooth formation, it
results in mottled enamel.
Features of Enamel Hypoplasia

12. • The enamel can become stained with a brown color
and so for cosmetic reasons, the affected tooth is
bleached with an agent (Hydrogen peroxide).
• When an area is affected by caries, the enamel might
crumble as the enamel is weaker in those areas. The
decayed portion of the tooth may be filled with a tooth
colored restoration.
• If the cavity is extensive, it may need a bigger
permanent restoration.
Treatment of Enamel Hypoplasia

13. Diagnosing White Spot Lesions

14. • “We are starting to see law suits in
the United States against dentists
who did not warn and explain to
their patients about the prognosis of
their oral condition, and the
probability of the progression of
their carious diseases” Dr. Francisco
Ramos-Gomez.

15. • Women from underserved communities fail to recognize
the value of good oral health and relevant importance
of regular dental visits and care during pregnancy.

16. • Increased Awareness of the caries
and consequences of ECC could
help families.
• “Interventions that reduce risks
and increase protective factors
can change the health trajectory
of individuals and populations” US
Dept. of Health and Human Services, Maternal and
Child Health Bureau

17. CAMBRA

18. CAMBRA
CAries
Management
By
Risk
Assessment

19. • Is designed to be used with newborns until the age of
5 years old. It integrate the risk assessment of the
childhood caries as an integral component of a
comprehensive oral health visit.
CAMBRA

20. • Assists the provider to systematically:
1. Assess each child’s and his caregiver’s caries risk
in an individualized manner.
2. Customize a restorative plan on conjunction with
preventive care.
3. Plan a timely, specific and appropriate periodicity
schedule based on caries risk.
CAMBRA

21. • Asking question regarding
protective and risk factors.
1. CAMBRA

22. • Child is supine, head in care
provider's lap.
• The child can see the
parent.
• The parent can see what
care provider sees.
2. Knee To Knee

23. 3. Tooth Brush Prophylaxis
• Aids in plaque removal.
• Demonstration of proper
brushing technique.

24. 4. Clinical Exam
• To complete the third
domain of the CAMBRA
information gathering
from the patient.

25. ICDAS

26. ICDAS

27. 5. Fluoride Varnish Application
• To prevent tooth decay.
• Every 3-6 months depending on caries risk.

28. 6. Self Management Goals
• Care-provider explains what he saw and evaluated,
and how caries happen.
• Then agrees with the patient on two goals to work
upon, to increase the protective factors and lower the
risk factors for the following visits.

29. Self Management Goals

30. • Open-ended Questions
• Affirmations
• Reflective listening
• Summaries
Motivational Interviewing

31. • An open-ended question allows the patient to create
the impetus for forward movement.
• the open-ended question creates a forward
momentum that we wish to use in helping the patient
explore change.
Open- Ended Questions

32. • Statements of recognition about patients strengths.
• Wonderful rapport builders.
• However, they must be congruent and genuine. If the
patients thinks you are insincere, then rapport can be
damaged rather than built.
Affirmations

33. • listen carefully to your patients. They will tell you
what has worked and what hasn't.
• You will actively guide the client towards certain
materials.
Reflective Listening

34. • Specialized form of reflective listening where you
reflect back to the patient, what he or she has been
telling you.
• An effective way to communicate your interest in a
patient, build rapport, call attention to salient
elements of the discussion and to shift attention or
direction.
Summaries

35. • A multifaceted care-path appropriate for the family,
based on the child’s age, and individualized needs is
designed.
• A care-path, decision tree can aid the provider in
determining a specific combination of diagnositc,
preventive, and restorative procedures and the
periodicity of these recommended measures to
improve or stabilize the caries high risk profile.
Care-Path

36. • Tables were developed for easily and rapidly placing
the patient in his proper care need and frequency.
• Taking his age, his caries risk level into consideration
as well as the modality of prevention needed.
• Tables that are very simple to use, and the idea of
turning them into an app was suggested.
Care-Path

37. • 2 Years old
• Uses the bottle (3 times a day)
• Still breastfed
• Doesn’t brush
• Has white lesion on DEFG
• Mother wants to know if he needs fluoride.
Care-Path

38. Care-Path

39. • 4 Years old
• Has Asthma (uses Albuterol)
• Brushes once a day
• Her favorite drink is sugared apple juice twice a day
• Has white lesion on DEFG
• Father is concerned about the necessity of
radiographs.
Care-Path

40. Care-Path

41. • These care-paths are expected to be dynamic and
change with the emergence of new evidence based
modalities with the aim of prevention.
• A careful consideration regarding every patient’s
specific needs must be made.
Care-Path

42. • The world thought that toothpaste containing Fluoride
should never be used by young children.
Once upon a time …
• We refer to this concept as a myth, because more
evidence based work proved otherwise.

43. Evidence Based Dentistry

44. Recommendations

45. Recommendations
<3 years >3 years

46. Use of Fluoridated toothpaste *2014 ADA Consensus
• Fluoridated toothpaste is recommended for all children.
• A smear (the size of a grain of rice) of toothpaste should be used up to
age 3.
• After the 3rd birthday, a pea-sized amount may be used.
• Parents should dispense toothpaste for young children and
supervise and assist with brushing.
• Fluoride varnish is recommended in the primary care setting
every 3–6 months starting at tooth emergence.
• Over-the counter fluoride rinse is not recommended for children
younger than 6 years.

47. • The major barriers in the way of caries risk
assessment and carious disease management are:
1. Service provider’s lack of knowledge, comfort
and skills.
2. Parent’s knowledge, preference and
expectations.
3. Reimbursement favoring surgical management
of caries and not encouraging protective
management.
Barriers

48. • The combined and un-easing effort of everyone –
health care professionals, patients, and their families,
researchers, payers, planners, and educators- to
make changes that will lead to better patient
outcomes (health), better system performance (care)
and better professional learning.
Quality Improvement

49. • Is not familiar to dentistry yet but offers the potential
to transform oral health care delivery in order to
provide better oral health care, improve oral health
outcomes and to reduce costs of treatment of caries
Quality Improvement

50. • CAMBRA’s easy to use organized format of disease
indicators, risk and protective factors, clinical
findings, and self management goals helps to
facilitate oral health education, deepens the
appreciation of oral health information and increases
the understanding of how individual behaviors can
affect caries development and progression.