By Dr. Peter Rechmann, Professor, Division of Prosthodontics and Director, Clinical Sciences Research Group, Department of Preventive and Restorative Dental Sciences, UCSF School of Dentistry
MyCAMBRA takes the guesswork out of caries risk assessment, and delivers a customized Action Plan to reduce caries. Following is the story of the development of the MyCAMBRA App by Drs Peter Rechmann, Richard Kinsel, and Dean John D.B. Featherstone of the UCSF School of Dentistry.
CAMBRA (Caries Management By Risk Assessment)
CAMBRA (CAries Management By Risk Assessment) is leading a paradigm shift to move beyond the outdated focus on "remove decay and restore" - the proverbial “drill and fill” mindset. CAMBRA provides a scientific, reliable procedure to identify caries risk and prevent further caries.
Currently, the majority of dental practices operate under a surgical model for the treatment of caries (“drill and fill”), but evidence shows that by adopting a medical model of disease management including a regimen of aggressive prevention protocols that prevent and treat the disease, caries can be successfully managed through non-surgical interventions (1).
Dr. Kinsel, private dental practitioner and part-time faculty at UCSF Dentistry, says "Caries has a diverse etiology—host, environment, and bacteria. Cariogenic bacteria do not care about the dentist’s restorative skills, the precision of the impression and restorations, the restorative material used, and the luting agent. Recurrence of dental caries after our best efforts is frustrating for both the dentist and patient."
Dean Featherstone conducted two studies that confirmed that restorative treatment of caries alone is not effective in preventing future carious lesions (cavities). In contrast to this disappointing reality, one study concluded that combining Chlorhexidine a disinfectant to reduce the bacterial challenge, and fluoride to enhance remineralization, successfully and significantly reduced caries risk by a factor of three, and suggested a reduced caries increment (1).
The other study showed that restorative treatment alone without management of risk factors did not solve the problem of future caries and resulted in about 70 percent of patients returning with new cavities in one to two years (2).
CAMBRA is a medical approach to caries management that relies on evidence-based treatment decisions based on the caries risk status of the individual, as determined by the balance or imbalance of disease indicators, pathological (risk) factors, and protective factors, in each patient. The so-called "Caries Balance."
Disease indicators include caries on radiograph to dentin, approximal lesions on radiographs, active white spots, or recent restorations due to decay. Risk factors may include visible heavy plaque, deep pits and fissures, inadequate saliva flow and orthodontic appliances. Among the protective factors are the use of fluoridated toothpaste and/or mouthrinses, use of Xylitol gum or lozenges, topical fluoride varnish, and adequate saliva flow. Once a patient’s caries risk is assessed, appropriate interventions that are consistent with CAMBRA clinical protocols can be implemented in order to influence caries progression. An imbalance toward either pathological or protective factors will determine whether caries progresses, halts, or reverses.
The MyCambra App
Dr. Rechmann is currently conducting a two-year prospective, randomized, double-blind, controlled clinical CAMBRA trial in a newly established Practice Based Research Network (PBRN) in the Bay Area, in cooperation with the California Dental Association Foundation. He had the idea of creating a "computerized Caries Risk assessment tool" when faced with the task that in this new network of 30 dentist-researchers should be calibrated on the administration of a caries risk assessment, and on the recommended treatment modalities.
Rechmann asks "How can I guarantee that each individual practitioner in the PBRN correctly identifies the caries risk of a given patient? An easy to use, computerized Caries Risk Assessment tool based on CAMBRA Caries Balance had to be created."
The MyCambra app was designed to educate, promote, and simplify CAMBRA for dentists and their patients. The app quickly identifies caries risk, and suggests appropriate treatment protocols.
The CAMBRA assessment of disease indicators, risk, and protective factors, standardizes and simplifies caries risk assessment. Based on research and treatment of thousands of patients at the UCSF School of Dentistry, MyCAMBRA assesses and determines the patient’s caries risk level, and suggests preventive treatment measures:
- Low Risk: Cariogenic bacteria are in check, and the patient is healthy. Promote daily maintenance to keep caries risk low.
- Moderate Risk: Elevated caries risk is present and requires preventive treatment to avoid a frustrating cycle of drill and fill.
- High Risk: Intense, focused, preventive treatment is required to reduce cariogenic bacteria and lower the caries risk. Chance of new cavities is high.
- Extremely High Risk: Caries is a serious health problem. Aggressive preventive treatment is required to halt the disease and preserve existing teeth.
MyCAMBRA presents the assessment results graphically, with easy-to-understand treatment instructions. The interactive Risk Meter connects the benefit of each component in the Action Plan to reducing caries risk.
MyCAMBRA is a tool to promote dialogue with the patient that will move them toward better health. Patients are informed of their assessment at their dentist’s office and receive an email detailing their individual risks, with specific recommendations. Ongoing caries evaluations documenting improvement encourage each patient’s continued involvement. HIPAA compliance is assured, using patient-specific encryption.
Promoting Compliance
Every dentist knows that even the best self-care plan is ineffective if the patient doesn’t follow it. MyCAMBRA gives tools to present the message of caries and bacteria in a memorable and motivating way. MyCAMBRA includes characters, images, video from "Attack of the S. Mutans!," and a cognitive science-based program, developed with funding from the National Institute for Dental and Craniofacial Research (NIDCR).
Howard Rose, President of Firsthand Technology says: "MyCAMBRA allows you to take the pieces you want to share with your patient to help emphasize the bacterial causes of caries, or promote better self-care strategies, Integrate Caries Risk Assessment and Caries Management into your practice easily and efficiently, deliver a custom Action Plan targeted to your patient’s caries risk level, use the interactive Risk Meter and health literacy tools to help your patients appreciate oral health in a new way."
Dean Featherstone describes MyCAMBRA as a step into the new world of precision medicine – with CAMBRA as an approach to preventive dentistry, taking off around the world, invented at the UCSF School of Dentistry. "I was the keynote speaker on this topic at the International Academy of Pediatric Dentistry a couple of weeks ago in Korea, with 64 countries represented. The App is one definitive way of strongly linking CAMBRA with UCSF."
The app was created in joint partnership between the UCSF School of Dentistry and Firsthand Technology. While CAMBRA is the first medical approach to manage caries by risk assessment, this kind of cooperation was also a first. "I understand the relationship between the UCSF School of Dentistry and Firsthand to be a joint partnership, where each party — UCSF and Firsthand — has 50/50 ownership in the app. This actually is the first instance of such an arrangement that we have seen" observes Barbara J. French, UCSF Vice Chancellor for Strategic Communications and University Relations, in support of this new and evolving business arrangement between UCSF School of Dentistry and private industry.
The MyCambra™ app is available from the iTunes store and at www.mycambra.com, for iPhones 4 and 5, and for all iPads.
Drs. Rechmann, Kinsel and Featherstone are already thinking ahead: "In future versions, location services will direct patients to MyCambra™-certified dentists. This comprehensive approach will be well received by the public seeking a dentist who wants to reduce their risk of tooth decay. As the legal standard of care evolves, general dentists, specialists, and physicians will come to appreciate the health impacts of destructive oral bacterial flora. The CAMBRA concept can be easily included in every dental practice."
- Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, Zhan L, Gansky SA. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Research 2012:46(2):118-29.
- Domejean S, White JM, Featherstone JD. Validation of the CDA CAMBRA caries risk assessment--a six-year retrospective study. Journal of the California Dental Association 2011:39(10):709-15.
Pictured
MyCAMBRA website
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