Prevention-oriented approach to dentistry helps patients avoid the drill

October 21, 2016 by Nina Bai, University of California, San Francisco
Credit: University of California, San Francisco

Several years ago, Peter Rechmann, DMD, PhD, professor of Preventive & Restorative Dental Science at UC San Francisco's School of Dentistry, saw a patient who was convinced that she needed a new set of dental crowns.

"That sounded good for my practice, but I didn't do any crowns for her," Rechmann said.

He was using what was then a new approach to dentistry known as Caries Management by Risk Assessment (CAMBRA), which emphasizes prevention and risk assessment rather than surgical procedures.

Rechmann forewent an easily billable procedure and instead, advised his patient to use a high-concentration fluoride toothpaste, anti-bacterial rinse, and xylitol chewing gum. When she returned a few months later, her teeth enamel had remineralized so much that she was no longer a candidate for crowns.

"I could show her in the mirror how hard the enamel was, and she was amazed," Rechmann said.

Years after CAMBRA was developed at UCSF, it is starting to make inroads among dental professionals nationwide, and Rechmann is leading the first large study of the protocol in community dental practices. Researchers are hoping the study will validate the protocol's effectiveness of catching early signs of caries, or cavities, and reversing them by addressing the underlying disease factors.

A Preventable Disease

CAMBRA is a departure from the "drill and fill" approach to that is still dominant, said John Featherstone, PhD, dean of the School of Dentistry and one of the researchers at UCSF who helped to develop the CAMBRA approach in the early 2000s. Since then, Featherstone has been invited around the world to assist with CAMBRA implementation, including Japan, Argentina, Mexico, New Zealand, China, and Israel.

"Traditionally, most dental schools around the world taught their students to deal with a pre-cavitated lesion by drilling it out and filling it with some so-called restorative material – and that's gotten very sophisticated over the years," he said. "But this was really not solving the problem because it was not dealing with the bacteria."

Dental caries is an infectious disease caused by acid-producing bacteria that feed on fermentable carbohydrates in the mouth. The acids can dissolve minerals in the tooth surface, creating lesions that eventually become cavities. Simply filling the lesion does little to stem the underlying bacterial infection, and more than 70 percent of restorative dental treatments are performed on previously restored teeth.

Every first-year dental student learns the science behind caries, but the relevance to clinical practice has not always been made clear. "In the early 1990s it became pretty obvious that we should take everything we knew and put it into a different way of managing the disease," said Featherstone, who has been studying dental caries for 40 years.

Prevention-oriented approach to dentistry helps patients avoid the drill
John Featherstone (center), PhD, dean of the School of Dentistry, helped to develop the CAMBRA approach in the early 2000s. Credit: Noah Berger

Assessing Caries Risk

CAMBRA weighs, in a standardized way, the many biological and lifestyle factors that determine caries risk. The most negative factors are disease indicators, such as visible cavities, enamel lesions, white spots and fillings within the last three years. Other contributors include the presence of harmful bacteria, inadequate saliva flow and frequent snacking. These risk factors are weighed against protective factors, such as living in a community with a fluoridated water supply, using fluoride toothpaste and antibacterial mouth rinses, and adequate saliva flow.

Based on these factors, CAMBRA guides a dentist in categorizing a patient as having low, medium, high or extreme risk, and in determining an appropriate caries management strategy. A patient at higher risk might be prescribed a potent fluoride toothpaste and antibacterial mouth rinse, and asked to reduce snacking between meals.

CAMBRA is already widely taught and applied at academic dental clinics, but has made only minor inroads into private dental practices. One barrier is that most insurance companies do not yet reimburse preventive therapies for adults, meaning patients face higher costs and dentists make less profit. But this is changing, said Rechmann. As insurance companies see proof of the long-term cost savings of prevention, they are likely to expand coverage to these measures.

Every year at the meeting of the National CAMBRA Coalition, more and more insurance companies show up, Rechmann said.

Another barrier is convincing practitioners to switch playbooks. "Changing habits is an enormous thing," Rechmann said. Everyone in a dental office – dentists, assistants and the front desk – has to be on board for the CAMBRA approach to be successful, he said.

Validating the System

Several large-scale studies have validated CAMBRA's accuracy in identifying who will likely develop caries. In one study, 69 percent of patients rated as high risk and 88 percent of those rated as extreme risk developed caries by the next visit, an average of 16 months later. In children up to six years old, a study published earlier this year found that only 20 percent of low-risk patients had tooth decay at follow-up visits, compared to nearly 70 percent of those at high-risk.

Now, researchers are looking at CAMBRA's ability to keep caries at bay. The UCSF Dental Center clinic has followed CAMBRA protocols for 13 years, and studies have shown reductions in new decay in patients who use the prescribed products. A 2015 study of adults at high risk found that, when anti-cavity agents were dispensed multiple times over a period of 18 months, CAMBRA prevented one decayed or restored tooth for every three patients.

Rechmann is leading the first trial of CAMBRA in community dental offices, a collaboration between the School of Dentistry and the California Dental Association Foundation. The two-year study, which will be published in 2017, recruited 30 dental offices in the Bay Area, trained the practitioners in CAMBRA, and assessed the patients every six months, half receiving CAMBRA care, the other half standard care. Rechmann said the preliminary results are promising.

"We can for sure show that caries risk for patients at high risk drops to low risk, if they follow the CAMBRA protocol," he said.

Switching over to CAMBRA may initially require extra work for a dental office, but it's ultimately good business, said Rechmann. When patients see a dentist who gives them options and does not turn to the drill first – they tell their friends. "CAMBRA finally gives the patient a chance to prevent caries," he said.

Explore further: Assessing risk helps dentists tailor preventive treatments for young children

Related Stories

Assessing risk helps dentists tailor preventive treatments for young children

July 7, 2016
Taking patients' risk of developing dental caries ("cavities") into account can help dentists effectively tailor individual prevention and treatment efforts, according to a recent study led by researchers from the UC San ...

Predicting caries risk at 30-months of age in medical settings

March 19, 2016
Today at the 45th Annual Meeting & Exhibition of the American Association for Dental Research, researcher Margherita Fontana, University of Michigan School of Dentistry, Ann Arbor, USA, will present a study titled "Predicting ...

Dental caries prevention breakthrough

September 9, 2015
A new way to preserve caries-infected teeth and prolong the life of dental fillings has been developed at the University of Otago.

Evidence-practice gap for sealant application: Results from a dental PBRN

March 18, 2016
Today at the 45th Annual Meeting & Exhibition of the American Association for Dental Research, researcher Naoki Kakudate, Kyushu Dental University, Kyushu Dental University, Japan, will present a study titled "Evidence-Practice ...

Study finds 'no-drill' dentistry stops tooth decay

December 6, 2015
A University of Sydney study has revealed that tooth decay (dental caries) can be stopped, reversed, and prevented without the need for the traditional 'fill and drill' approach that has dominated dental care for decades.

Recommended for you

Painless dental lasers can render teeth cavity-resistant

November 21, 2017
Almost as soon as lasers were invented in the 1960s, curious dentists wondered if these powerful forms of light could be used on teeth, though those early lasers were much too crude for any useful dental work.

Nanodiamonds show promise for aiding recovery from root canal

October 23, 2017
People who undergo root canals may soon have a tiny but powerful ally that could prevent infection after treatment.

Research shows aspirin could repair tooth decay

September 8, 2017
Researchers at Queen's University Belfast have discovered that aspirin could reverse the effects of tooth decay resulting in a reduction in the need for fillings. Currently about 7 million fillings are provided by the NHS ...

New dental imaging method uses squid ink to fish for gum disease

September 7, 2017
Squid ink might be a great ingredient to make black pasta, but it could also one day make getting checked for gum disease at the dentist less tedious and even painless. By combining squid ink with light and ultrasound, a ...

A new dental restoration composite proves more durable than the conventional material

August 21, 2017
Fewer trips to the dentist may be in your future, and you have mussels to thank.

Small molecule inhibitor prevents or impedes tooth cavities in a preclinical model

August 10, 2017
University of Alabama at Birmingham researchers have created a small molecule that prevents or impedes tooth cavities in a preclinical model. The inhibitor blocks the function of a key virulence enzyme in an oral bacterium, ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.