CAMBRA: Leaving behind the Stone Age
According to Adam Burr, DDS, it's time to embrace the paradigm shift toward caries management by risk assessment (CAMBRA), the first sustained, albeit nascent, methodical treatment modality intended to identify risk, intercept inception, and reverse the seemingly inevitable removal of tooth structure.
According to Adam Burr, DDS, it's time to embrace the paradigm shift toward caries management by risk assessment (CAMBRA).
A beautiful ex situ specimen of a tooth demonstrating caries exacavation is shown above. The execution of decay removal isn't perfect by any means, but an honest attempt was made by the operator to excavate decay and conserve the natural tooth structure. Why isn't this preparation better? Was the operator poorly trained, rushed, or lacking the right equipment? As it turns out, this cavity preparation was done 14,000 years ago!1
It is disturbing to realize that, as a profession, we haven't moved our initial treatment modalities beyond apparently Paleolithic techniques. Caries management by risk assessment (CAMBRA) is the first sustained, albeit nascent, methodical treatment modality intended to identify risk, intercept inception, and reverse the seemingly inevitable removal of tooth structure.2 By better understanding its challenges and benefits, our profession can entirely embrace this paradigm shift.
What it is and what it isn't
CAMBRA is a treatment philosophy under which patients' risk for developing carious dental disease is diagnosed. This is usually done through the use of a simple questionnaire called a caries risk assessment (CRA).2 Based on the patient's risk category and individual risk factors, a customized risk reduction plan is put in place. The ultimate goal of this treatment plan is to modify patient behaviors and mitigate biological and physiological propensities that lead to carious dental disease.
CAMBRA is not a silver bullet. Successful implementation will not endanger our profession due to a lack of operative dentistry. We won't choose the perfect treatment plan for every patient, periodontal disease will persist, some patients will fail to comply, recurrent decay will still develop, existing dentistry will fail, and traumatic occlusion will continue to force restorative intervention. We will, however, prevent disease in our patients.
Personally, I think CAMBRA is the most beneficial treatment paradigm for our patients. The correct way to care for our patients is to push both the initiation and the intervals of the restorative cycle as far as possible. This will result in fewer surgical interventions and predictably lead to healthier patients. Communicating this to our patients will garner their respect and appreciation.
Financially, an intentional change in our approach to treating dental caries and implementing CAMBRA can be rewarding. Currently, there are nearly 20 rarely used codes that are directly related to the CAMBRA approach.3 The majority of these codes are uncovered benefits. In a fee-for-service practice, these codes should only expand the scope of practice. In a practice that relies on third-party payers, uncovered codes are a boon to overcoming the financial strain experienced by patients with some of the most common procedures we perform. Uncovered codes allow us to set reasonable and customary fees for these procedures.
Clinically, the move from demanding, technique-sensitive, and time-sensitive procedures can be transformational. Most of us wish our team members could be more involved in direct patient care. With careful training and intention, this can happen. In most states, much of the treatment under the CAMBRA umbrella can be delivered by someone other than the dentist. (Be sure to check your specific state's dental practice act.) We are always responsible for diagnosing, confirming, directing, customizing, and verifying the treatment plan, but our teams can do so much more.
The science behind CAMBRA and the proof of its success is indisputable.4-6 Implementation on a widespread scale, however, is generally lacking. There are several roadblocks in our way.
Clinically, CAMBRA requires a complete paradigm shift in the delivery of care. The benefits derived from increased team involvement in direct patient care require more training, clarity in communication, trust, and autonomy. This is not easy without complete buy-in from our teams.
Financially, current reimbursement practices strongly discourage doctor-patient verbal interactions. Our practices are built with both clinical and business operations systems to reflect that reality. Adding new procedural systems on both fronts can be cost-inefficient. In addition, the initial investment in the necessary equipment and supplies to use CAMBRA protocols effectively can be discouraging.
Additionally, most practitioners have not received any training on this subject. Implementing CAMBRA as a treatment philosophy requires knowledge of and confidence in its techniques. As a matter of integrity, we won't implement a new product or treatment modality until we've been trained and are confident it better serves our patients.
We can begin using CAMBRA in some form in our practices. To get started, we can pursue additional resources, such as continuing education courses, and use the following steps to create a plan:
• Choose a CRA form to use.
• Find suppliers and companies to provide any desired materials.
• Choose CDT codes to implement first (consider D0601-603, D1354, and D9630).
• Set fees to account for material and laboratory costs, the time to analyze the findings, and the time the team will spend administering treatment and educating patients.
• Decide how to present the CAMBRA treatment option to patients.
• Determine which team members will be responsible for treatments such as nutritional counseling, oral hygiene instructions, and collection of microorganisms.
• Create defined systems to ensure patients are adhering to their treatment plans, such as follow-up testing and verification procedures.
• Document the plan and present it to the team, along with intended changes, codes, and supplies.
After the logistics are covered, the real hurdle is discussing this with patients. The following questions may be extremely powerful in determining whether a patient is a good candidate for CAMBRA:
• Are you interested in preventing cavities for you and/or your children?
• The treatment recommendations are highly effective at preventing cavities but are generally not covered by dental insurance. Are you still interested in learning more about this approach to preventing cavities?
How patients respond to these questions will determine whether they are good candidates for a CAMBRA approach. Patients who are ready can begin by filling out a CRA form. From there, informed consent is obtained and fees can be discussed. We can then initiate the appropriate testing protocols and follow our systems.
Practices that implement modern, patient-oriented modalities have the upper hand in becoming the practices of choice in the markets they serve. Providers who show true concern for the well-being of their patients win trust, and trust leads to more dentistry.
1. Oxilia G. Earliest evidence of dental caries manipulation in the Late Upper Palaeolithic. Sci Rep. 2014;5:12150.
2. Caries Risk Assessment Form (Age>6). American Dental Association website. http://www.ada.org/~/media/ADA_Foundation/GKAS/Files/topics_caries_educational_over6.pdf?la=en. Accessed October 24, 2016.
3. Dental insurance and caries management by risk assessment (CAMBRA). CariFree website. http://carifree.com/dentist/learn/resource-guide/dental-insurance.html. Accessed October 24, 2016.
4. Featherstone JDB. The science and practice of caries prevention. J Am Dent Assoc. 2000;131(7):887-899.
5. Featherstone JDB. The caries balance: Contributing factors and early detection. J Calif Dent Assoc. 2003;31(2):129-133.
6. Domejean S, White J, Featherstone JDB. Validation of the CDA CAMBRA caries risk assessment--a six-year retrospective study. J Calif Dent Assoc. 2011;39(10):709-715.
Adam Burr, DDS, is a graduate of Loma Linda University School of Dentistry. He is an owner-dentist supported by Pacific Dental Services in Colorado Springs. Dr. Burr is married with four headstrong children.