CAMBRA meeting stresses need for common terminology

2009 08 13 15 01 03 189 Dictionary Education 70

caries n. A progressive destruction of bone or tooth.

cariology n. The study of dental caries and cariogenesis.

“There are thousands of practitioners out there who don't accept the principles of CAMBRA.”
— John Featherstone, M.Sc., Ph.D.,
     dean, UCSF School of Dentistry

SAN FRANCISCO - Is "caries" an infectious disease process or another name for tooth decay? Is "cariology" really a component of "operative dentistry," as some educators seem to think, or should it be its own department within every dental school? What are the roadblocks to clinician adoption of risk assessment tools, and how can they be overcome?

These were just some of the many issues debated during a closed-door session of the Western CAMBRA (caries management by risk assessment) coalition, held this week in conjunction with the World Congress of Minimally Invasive Dentistry in San Francisco.

A roomful of dental educators, clinicians, industry representatives, and third-party payors from across the U.S. and beyond spent much of August 12 discussing how to develop better ways to spread the CAMBRA message and get more of the dental community to understand the importance of adopting risk assessment and caries management tools into their practices.

Originated in 2002, CAMBRA is a method of assessing a patient's caries risk and making dental treatment and restoration recommendations based on that risk. While some U.S. dental schools -- including all five in California -- now include CAMBRA as part of their curriculum, getting the majority of dentists, hygienists, assistants, educators, and professional organizations to embrace the notion that true caries management entails much more than the traditional "drill and fill" approach remains a challenge.

"There are thousands of practitioners out there who don't accept the principles of CAMBRA," said John Featherstone, M.Sc., Ph.D., dean of the University of California, San Francisco School of Dentistry and co-chair of the coalition meeting.

One of the most critical factors in changing this mindset is terminology, according to many meeting attendees. A standardized dental terminology, especially for diagnostic procedures, would make risk assessment forms easier to use and pave the way for developing insurance codes for these procedures, which in turn should motivate more widespread adoption of CAMBRA.

"Clinicians will begin to understand that this is the correct and proper way to manage patients, and this will ultimately drive the development of diagnostic codes," said Peter Arsenault, D.M.D., assistant professor in the department of prosthodontics and operative dentistry at Tufts University School of Dental Medicine.

"The way we choose to communicate may reflect what we believe and how we eventually choose to act," stated Margherita Fontana, D.D.S., Ph.D., an associate professor at the Indiana University School of Dentistry, in her report on the efforts of the American Dental Education Association (ADEA) Cariology special interest group this past year. "As we come together to discuss ways to help bridge the gap in caries management between evidence-based research and clinical practice, it is important that we start our discussions with a critical review of nomenclature and its importance in driving diagnostic and management strategies."

Does 'caries' equal 'decay'?

CAMBRA clinical guidelines

  1. Caregiver/parent or patient answers the questions on the risk assessment form.

  2. Determine the overall caries risk as low, moderate, high, or extreme risk:

    • Low risk: No dental lesions, no visible plaque, optimal fluoride, regular dental care
    • Moderate risk: Dental lesion in previous 12 months, visible plaque, suboptimal fluoride, irregular dental care
    • High risk: One or more cavitated lesions, visible plaque, suboptimal fluoride, no dental care, high bacterial challenge, impaired saliva, medications, frequent snacking
    • Extreme risk: High-risk patient with special needs or severe hyposalivation

  3. Perform bacteria and saliva testing as indicated by risk level.

  4. Determine the plan for caries intervention and prevention:

    • 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 exams; oral hygiene instructions; xylitol and/or baking soda; sealants; and existing lesions.
    • Patients age 6 through adult: Consider the following based on patient risk level: frequency of radiographs; frequency of caries recall exams; 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.

  5. Discuss home care recommendations based on risk level.

  6. Provide follow-up care and reassess risk level.

Source: "CAMBRA: The New Model for Managing Caries"

For example, a fundamental shift is needed in the use of the word "caries," according to several speakers at the CAMBRA meeting. Too many practitioners consider the word interchangeable with "decay" or "cavity," rather than realizing that it is actually intended to describe an infectious disease process.

"There is a lack of understanding of caries as a bacterial disease," Featherstone said.

This thinking begins in the educational and testing environments, many speakers noted. In a breakout session focused on how to get CAMBRA principles better integrated into dental school curriculums, working group members discussed the various roadblocks -- including overcrowded curriculums and turf wars -- and ways to overcome them.

The key is to gain high-level administrative support and get cariology established as its own department within the dental school, the group concluded.

"You need someone to champion the process," said Edmond Hewlett, D.D.S., an associate professor in the division of restorative dentistry at the University of California, Los Angeles, in his report from the curriculum working group's findings. "The administration has to understand that managing this infectious disease requires giving it a higher profile in the curriculum. Cariology is often scattered around and across other departments, and too many people think of it as 'operative dentistry' because that's how we've always managed it."

"If you don't have the faculty buy-in at the schools, CAMBRA won't succeed," Featherstone agreed.

According to Dr. Fontana, the ADEA Cariology special interest group decided earlier this year to "take advantage of the best available evidence" and work with the ADA, the European Organization for Caries Research (ORCA), and the International Caries Detection and Assessment System Foundation (ICDAS) in their ongoing efforts to develop standardized terminology and codes for cariology and dental diagnostics. In addition, the ADA is moving forward with its Systematized Nomenclature of Dentistry (SNODENT) electronic health record initiative, which includes some 1,000 clinical diagnostic codes, according to John Luther, D.D.S., senior vice president of dental practice and professional affairs for the ADA.

SNODENT is expected to be finalized by the end of this year, Dr. Luther noted.

Copyright © 2009

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