Implementation of CAMBRA into Clinical Practice Karan Bershaw, MS, RDH Dental Hygiene Clinician,...
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Transcript of Implementation of CAMBRA into Clinical Practice Karan Bershaw, MS, RDH Dental Hygiene Clinician,...
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Implementation of
CAMBRA into Clinical
PracticeKaran Bershaw, MS, RDH
Dental Hygiene Clinician, Berkeley, CA
www.karanbershaw.com
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CAMBRACaries Risk Assessment
Implemented during:
Dental hygiene care (existing client)
Comprehensive exam (new client)
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Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
Dental Hygiene Process of Care
(Darby & Walsh, 2015)
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RISK LEVEL
BACTERIAL TEST
s. mutans & l. bacillus
10n/ml
ROOT EXPOSURE
DECAYSALIVA FLOW
PLAQUE INDEX
FERMENTABLE CARBOHYDRATE
SNACKSAPPLIANCES
LOW 3,3 No None>1.6ml/
min.<1 <1 No
MODERATE 4,4 Yes
Interprox. radiolucency/
decalcified spots
RootSurface
Discoloration1.6 ml/min. <2 <2 No
HIGH5,45,5
Yes1+ in dentin
<2pts>
1 soft or 1-2 Leather-like
leasions on root surface <2pts>
0.7-1.6 ml/min.
2-3 2-3/day Yes
VERY HIGH6.56,6
Yes2+ active<3pts>
2+ Lesions on root surface
<3pts>
<0.7 ml/min.<2pts>
3 3+/day Yes
North Berkeley Dental ArtsCaries Risk Assessment
*5 pts needed to determine caries risk
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Caries Risk Assessment
DATECULTURE
s. mutans/l. bacillus
PLAQUE INDEX
TREATMENT RECOMMENDATIONS TREATMENT COMPLETION MONITORING SITES
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Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
Dental Hygiene Process of Care
(Darby & Walsh, 2015)
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Chart Assessment
Incorporate existing data from client chart to fill in the caries risk assessment
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Review health history:
Oral side effects of medications
Reduced salivary flow
Health conditions that could hinder the clients ability to perform effective homecare
Chart Assessment
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Disease indicators
Restorations
White spot lesions
Incipient lesions (watch)
Reasons for treatment, e.g. dental caries, fractures
Frequency of dental caries
Chart Assessment
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Chart Assessment
Caries risk factors:
Review periodontal charting for recession
Review previous oral hygiene instructions and recommendations for improvement in plaque control
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Radiographs
Review for existing dentistry Frequency taken based on previous dental treatment:
Would I recommend increasing the interval?
Would I recommend decreasing the interval?
Would I recommend keeping it the same?
Chart Assessment
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Chairside Assessment
Client interview to review the health, dental and social histories and gather information related to food and snack choices.
Within this interview I introduce CAMBRA and the use of the caries risk assessment form as a preventive tool the office is using to better assess and improve oral health
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(Featherstone, et.al., 2007 p. 705)
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Chairside Assessment
If the client is a child, then I would interview the care giver about the child’s health and dental history
If the primary care giver has had active decay in the last 12 months, we assume the child is at high risk for dental caries
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Intraoral Assessment
Detect relevant data related to disease indicators and risk factors
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Intraoral Assessment
Saliva Assessments
Salivary flow rate
Culture s. mutans and l. bacillus (new client or baseline culture for existing client)
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Intraoral Assessment
Plaque index
Disclose for visual clarification
Client oral hygiene educational tool
Take a photo for baseline visual record and use to compare at future appointments
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Intraoral Assessment
Examination of teeth to determine the location and severity of decalcifications and possible carious lesions
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Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
Dental Hygiene Process of Care
(Darby & Walsh, 2015)
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Determine Caries Risk Level (“Diagnosis”)
Use evidence-based decision making to determine a client’s caries risk
Low Moderate High Extreme
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CAMBRACase Scenario
Scarlett is a 65 year old healthy female, but has reduced salivary flow. She has generalized moderate recession with 2 non-soft root lesions on posterior teeth. She has a very high culture reading (6, 5), moderate plaque index and snacks infrequently . In your opinion, what is Scarlett’s caries risk?
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RISK LEVEL
BACTERIAL TEST
s. mutans & l. bacillus
10n/ml
ROOT EXPOSURE
DECAYSALIVA FLOW
PLAQUE INDEX
FERMENTABLE CARBOHYDRATE
SNACKSAPPLIANCES
LOW 3,3 No None>1.6ml/
min.<1 <1 No
MODERATE 4,4 Yes
Interprox. radiolucency/
decalcified spots
RootSurface
Discoloration1.6 ml/min. <2 <2 No
HIGH5,45,5
Yes1+ in dentin
<2pts>
1 soft or 1-2 Leather-like
leasions on root surface <2pts>
0.7-1.6 ml/min.
2-3 2-3/day Yes
VERY HIGH6.56,6
Yes2+ active<3pts>
2+ Lesions on root surface
<3pts>
<0.7 ml/min.<2pts>
3 3+/day Yes
North Berkeley Dental ArtsCaries Risk Assessment
*5 pts needed to determine caries risk
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Caries Risk Assessment
DATECULTURE
s. mutans/l. bacillus
PLAQUE INDEX
TREATMENT RECOMMENDATIONS TREATMENT COMPLETIONMONITORING
SITES
6, 5 < 2 TAKE BWX 1/YEAR3-4 MONTH RECALL
SILVER FLUORIDE (AgF) ON MONITORED SITES AT DH APPT (arrest)
#3 B#19 B
CHLORHEXIDINE DAILY FOR 1 WEEK/MONTH
USE AgF ON POSTERIOR ROOT SURFACES FOR PREVENTION
BRUSH 2X DAY WITH PREVIDENT
FM FLUORIDE VARNISH AT DH APPT
XYLITOL GUM AT LEAST 6 G/DAY
MI PASTE
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Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
Dental Hygiene Process of Care
(Darby & Walsh, 2015)
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Planning & Implementation
Design an evidence-based therapy appropriate for the client’s caries risk
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Planning & Implementation
My proposed treatment for Scarlett
Oral hygiene instruction for better plaque control – mechanically displace the biofilm
Recommend gum or candies sweetened with 100% xylitol (6-10 g/day)
5000 ppm toothpaste 2x day
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Planning & Implementation
My proposed treatment for Scarlett
Chlorhexidine rinse for 1 week/month, client may receive monthly reminder via text or email
MI Paste – low salivary flow
3-4 month recall interval for dental hygiene care appointment
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Planning & Implementation
My proposed treatment for Scarlett
Professionally applied AgF (silver fluoride) on the incipient lesions for arrest and all posterior root surfaces for prevention, in conjunction with full mouth fluoride varnish at the 3-4 month dental hygiene care appointment
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Products We Dispense from North Berkeley Dental Arts
Prevident 5000
Prevident 5000 for dry mouth
MI Paste (ACP & CCP) e.g. Recaldent
Chlorhexidine rinse
Chlorhexidine rinse without alcohol
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Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
Dental Hygiene Process of Care
(Darby & Walsh, 2015)
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Evaluation
Subsequent dental hygiene care appointments
Review caries risk assessment with Scarlett
Oral hygiene instructions
Health changes
Rescore plaque index
AgF on incipient lesions and posterior root surfaces, followed with full mouth varnish
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Evaluation
Subsequent dental hygiene care appointments
Review the use of dispensed products
5000ppm toothpaste
Chlorhexidine rinse 1 week/month
Note any changes in monitored sites
Consider need for modification of treatment
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Assessment
Diagnosis
Planning
Implementation
Evaluation
Documentation
Dental Hygiene Process of Care
(Darby & Walsh, 2015)
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Documentation
Document client’s caries risk
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Documentation
Paper chart
Caries risk assessment form in chart (blue card stock)
Add client’s caries risk to route slip
Future electronic chart
We will add pop-up alert
Add caries risk to the schedule
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Motivation of Our Dental Team
Started with the Dentist
Standard of care
CAMBRA prepares the practice for the coming changes in dentistry
Clients appreciate prevention focused oral care, treat the infection, not just the signs & symptoms
Value added service (benefit to client & practice)
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Motivation of Dental Assistants and Administrative Staff
Knowledge is key
Lunch & learn to start the CAMBRA education process
Basics of Biofilm Role of pH Demineralization & Remineralization Products dispensed from office
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Motivation of HygienistsKnowledge is key
Reviewed CAMBRA guidelines to ensure comprehension and achieve buy-in
Requested recommendations for modifications of guidelines and caries risk assessment form
Reviewed products used during the dental hygiene care appointment & products dispensed
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Current State of CAMBRA at North Berkeley Dental Arts
Knowledge is key
Review and update knowledge
A form to improve communication of client’s disease risk status to insure continuity of care
Dental team recommendations or improvements to be made to CAMBRA protocols
What’s working well & address what’s not
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Conclusion
CAMBRA is a dental practice philosophy. By initiating broad implementation of CAMBRA, our dental team has a renewed enthusiasm for helping our clients achieve optimum oral health. As you can see from my presentation today there are many ways to implement CAMBRA and it’s ever-evolving.
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References1. Darby, M.L. & Walsh, M. Dental Hygiene Diagnosis. In Dental Hygiene Theory and
Practice (4th ed.). Editors Darby, M.L. & Walsh, M. (2015). St-Louis, Missouri: Saunders Elsevier.
2. Featherstone JD, Domejean-Orliaguet S, Jensen L, et al: Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 35:703, 2007.
3. Hurlbutt, M (2011). CAMBRA Best practices in dental caries management. RDH 31:95-108.
4. CRT ® Bacteria: www.ivoclarvivadent.com/en/products/.../crt-bacteria
5. Colgate ®: www.colgateprofessional.com/products/colgate-prevident-5000
6. GC America: MI Paste™: www.gcamerica.com/products/preventive/MI_paste
7. Scott S, Fierce Conversations. (2004) New York, New York: Berkeley.
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