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Dental Caries

Caries Management by Risk Assessment (CAMBRA): an update for use in clinical practice for patients aged 6 through adult

Featherstone.et.al- 2019

Relevance :

24 in 2024

Conclusion :

This paper provides a practical, straightforward, evidence-based update for the clinician to use in practice for patients aged 6 through adult.

Use of this updated CAMBRA tool allows For the practicing dentist, implementing up-to-date evidence-based approaches is key to providing patients with the best possible care ,preparation of an individualized, risk-based treatment plan that combines chemical therapy

Chemical therapy, such as fl uoride toothpaste, must be included in the treatment plan for all patients (even low risk). Fluoride-containing agents are likely to be sufficient to maintain a healthy caries balance in low-risk or moderate-risk patients.

Low-Caries-Risk Chemical Therapy : The guideline is to “keep it simple.” Whatever the patient is doing appears to be working. If the plaque levels are low, oral hygiene looks good and the patient uses a fluoride toothpaste daily, then the recommendation is simple: “Keep doing what you are doing and use an over-the-counter fl uoride toothpaste (1,000–1,450 ppm F) at least twice daily.” Recall for a follow-up visit at 12-month intervals

Moderate-Caries-Risk Chemical Therapy:The moderate-caries-risk patient needs additional therapy to keep them where they are, or better, to move them to low caries risk.
Two alternatives are given, depending on the level of compliance.
■Alternative 1: Over-the-counter fluoride toothpaste twice daily + 0.05% sodium fluoride mouthrinse daily at night. The patient should also be counseled to reduce between-meal snacking and to conscientiously follow this regimen.
■Alternative 2: Prescription high-fluoride (5,000 ppm F) toothpaste at least twice daily plus counseling on reducing between-meal snacking of fermentable carbohydrates (substituting with xylitol-containing lozenges or candies). .Recall at six-month intervals for follow-up visit

High-Caries-Risk Chemical Therapy :The high-caries-risk patient must have antibacterial therapy to lower the bacterial challenge. Fluoride alone, at whatever concentration and frequency, will not be enough and the caries will continue to develop. Recall at four- to six-month intervals for follow-up visits.

The best proven antibacterial therapy currently available is chlorhexidine mouthrinse (or gel). It is not ideal, as it is only partially effective

SDF (Silver diamine fluoride) has recently gained popularity and guidelines for use in young children have been published but it has severe staining as a side effect and can only be used in limited settings.
Hypochlorite (bleach)-based antibacterial caries rinse is also marketed, but at the time of writing there is no published clinical trial demonstrating its effi cacy and there may be safety concerns for use in children.

New antibacterial agents are in development, specifically for caries control, but none are currently available.As of the time of writing, the following is the proven chemical therapy for high-caries-risk patients.

There are three components:
a. Fluoride varnish applied in the clinic at the time of the clinical visit and reapplied every four to six months (for children and adults).
b. Brushing with a prescription, high-fl uoride (5,000 ppm F) toothpaste, at least twice daily, plus counseling on reducing between-meal snacking of fermentable carbohydrates.
c. Rinse for one minute once daily for one week each month with a chlorhexidine gluconate mouthrinse (0.12%).1 This should be done at least one hour apart from the fluoride toothbrushing, preferably last thing at night before bed.
Extreme-Caries-Risk Chemical Therapy: The extreme-caries-risk patient must have antibacterial therapy to lower the bacterial challenge. Fluoride alone, at whatever concentration and frequency, will not be enough and the caries will continue to develop. The therapy is the same as for high risk (including antibacterial therapy) plus additional buffering.
a. Fluoride varnish applied in the clinic at the time of the clinical visit and reapplied every four to six months (for children and adults).
b. Brushing with a prescription, high-fl uoride (5,000 ppm F) toothpaste, at least twice daily, plus counseling on reducing between-meal snacking of fermentable carbohydrates.
c. Rinse for one minute once daily for one week each month with 10 ml of a chlorhexidine gluconate mouthrinse (0.12%). This should be done at least one hour apart from the fl uoride toothbrushing, preferably last thing at night before bed.
The regimen is to be continued for at least a year, until the disease is controlled and the risk level is lowered to moderate or low.
d. Rinse ad libitum throughout the day every day with a baking soda solution made fresh daily (2 teaspoons in 8 ounces (250 ml) of water).
e. Home use of fluoride trays with 5,000 ppm F gel for five minutes daily.

Recall at three- to four-month intervals for follow-up visit


Keywords:

CAMBRA Update,
Risk Assessment,
Clinical Practice

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