Nine Questions on Using Caries Management by Risk Assessment

Caries Management by Risk Assessment (CAMBRA) has existed for more than 20 years. But many oral health providers may be unfamiliar with why or how to use it. 

To help, Care Quest Institute and the American Dental Therapy Association recently partnered in an expert-led webinar about applying this valuable tool. Erinne Kennedy, DMD, MPH, MMSc, assistant dean for curriculum and integrated learning at College of Dental Medicine, Kansas City University, and Kari Ann Kuntzelman (Chickasaw Nation), dental health aide specialist and dental therapist at Northwest Portland Area Indian Health Board and president of the American Dental Therapy Association, provided education on the tool and personal stories on why CAMBRA is such a valuable and patient-centered tool. 

Nearly 500 oral health professionals joined the call and asked a variety of thoughtful questions about integrating CAMBRA into practice. Here are the top nine questions (and abbreviated answers from the experts) that arose during the webinar. 

1. What is CAMBRA? 

CAMBRA is an evidence-based disease management strategy to assess a patient’s risks and protective factors for developing caries, the disease that causes tooth decay. Patient supports and barriers can be identified at the individual level, such as diet or tobacco use, and the community level, such as water fluoridation or other social determinants of health. Providers use risk assessments to design an individually tailored treatment plan focused on minimally invasive care and supporting a patient’s behavior change. 

2. What does research say about using CAMBRA in clinical care? 

Studies show that CAMBRA improves patients’ oral health: 

• Patients at high risk for caries lowered their likelihood of disease by 24% after two years of CAMBRA. 
• CAMBRA helps identify low, moderate, and high risk of dental decay with validity. 
• Combination therapy (using both antimicrobial and fluoride treatments), which CAMBRA may suggest, is very effective in lowering patients’ risk of decay. 

Other notable research can help clinicians adopt CAMBRA. They include a systematic review of risk assessments and their measurement properties, and a comparison of four types of risk assessments. 

3. How does CAMBRA support patient-centered care? 

With CAMBRA, providers have an evidence-based process to determine the right care for each patient based on their individual dental needs and oral health barriers in their daily life. It promotes treatment plans that fit each patient — rather than using a “one-size-fits- all” approach. CAMBRA also emphasizes patient education and setting goals to improve their oral health over time. 

4. Does CAMBRA play a role in advancing oral health equity? 

This strategy invites providers to have curious, rather than judgmental, conversations with patients about dental disease. This is especially important for people who have faced racism and other inequities in health care. 

For example, due to how providers delivered treatment, American Indian and Alaska Native communities have generational trauma with dental care. Historically, they have the highest rates of dental disease compared to other US populations. 

Taking time to listen to patients’ experiences and needs builds trust. Over time, trust can make a difference in preventing cavities and promoting oral health equity. 

5. Do I need certain tools to integrate CAMBRA in my practice? 

Whether you are one clinic or have multiple offices, providers will need to adopt routine processes and forms: 

• Develop standardized processes for patient intake, especially for taking medical history and using a notes template for continued information gathering. A standard process helps ascertain details that are key to guiding individualized care. 
• Choose a standard caries risk assessment form (digital or paper), including codes and documentation procedures. You can adapt existing forms to fit your practice or program. 
• Use caries risk assessment calibration exercises to align your team. They have been shown to improve assessment accuracy. 

6. What does motivational interviewing have to do with CAMBRA? 

Motivational interviewing is a form of coaching for behavior change. It doesn’t work for providers to tell patients what to do or what they’re doing wrong. It is more effective to ask patients open-ended questions to reflect on their oral health and then help them choose their own specific, obtainable action step for improvement. For example, one goal could be brushing one more day per week between this and the next dental visit. Another example may be swapping the practice of sipping on coffee all day to drinking coffee only with meals. Providers can support adults and children with education on dental disease and impactful behaviors. Offering affirmation and encouragement for patients’ commitment to their oral health is another critical part of the process. 

7. How can I ensure CAMBRA works for my patients? 

Providers can use a variety of resources to support patient success: 

• Oral health education materials, such as visuals explaining the disease process, help patients better understand their oral health. 
• Resources for nutrition and habit coaching can empower patients toward change. Motivational interview aides might include an illustrated menu of possible risk-reducing behaviors. 
• Microbiome management tools can both treat and teach patients about dental disease. Discuss oral bacteria and antimicrobials. Show patients their mouth pH level and how to modify it with accessible items such as baking soda rinses. 
• Take-home reminders, such as post-its or window clings, can help patients achieve their self-management goal by writing it down and putting it up at home. 

8. If CAMBRA is new to my practice, what strategies can help us be successful? 

Practice and share feedback with colleagues. For example, motivational interviewing is effective for driving patient behavioral change, but it can be difficult to do well. Conducting role-plays with colleagues is a good way to get comfortable asking open-ended questions and taking good chart notes. 

You can also place yourself in your patients’ shoes. Ask your own provider to use CAMBRA with you and apply lessons learned in your care delivery. 

9. Where can I learn more about CAMBRA and stay up to date on similar techniques? 

CareQuest Institute is launching a Kit for Dental Education on Caries, which will include a CAMBRA protocol curriculum. It will have a range of resources for providers to use in dental team trainings, study clubs, and other continuing education efforts. 

Additional opportunities for collaborative learning and support include: 

• CAMBRA Coalition
• The ADEA Section on Cariology 
• American Dental Therapy Association Annual Conference 

Watch the full webinar and access presenter slides online here.