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CAMBRA

A clinical review
by

Karim El Mofty

on 12 June 2014

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Transcript of CAMBRA

A clinical review
CAMBRA
"We are starting to see law suits in the united states against dentists who did not warn and explain to their patients about the prognosis of their oral condition, and the probability of the progression of their caries disease." Dr. F. Ramos-Gomez
Who is a dentist?

A dentist is someone we go to to fix our teeth when they hurt.

Many parents and caretakers are unaware of the role they play in the oral bacterial transmission to their children.
Women from under-served communities fail to recognize the value of good oral health and relevant importance of regular dental visits and care during pregnancy.
www.growingyourbaby.com
Increased awareness of the caries and consequences of ECC (Early Childhood Caries) could help families.




“Interventions that reduce risks and increase protective factors can change the health trajectory of individuals and populations”, The US dept. of health and human services, Maternal and child health bureau.
CAMBRA is designed to be used with newborns until the age of 5 years old. It integrates the risk assessment of the childhood caries as an integral component of a comprehensive oral health visit.
CAMBRA
CAries Management By Risk Assessment
CAMBRA assists providers to systematically:

1-Assess each child’s and his caregiver’s caries risk in an individualized manner.

2-Customize a restorative plan on conjunction with preventive care.

3-Plan a timely, specific and appropriate periodicity schedule based on caries risk.
1. CAMBRA:
Asking questions regarding protective factors and risk factors.
2.Knee to Knee exam:
Child is supine, head in care provider’s lap. So the child can see the parent, the parent can see what care-provider sees.
3.Tooth brush prophylaxis:


-Aids in plaque removal
-Demonstration of the proper brushing technique.
4.Clinical Exam;
To complete the third domain of the CAMBRA information gathering from the patient.
Following 6 steps of Infant Oral Care:
5.Fluoride Varnish Application:
To prevent tooth decay. Every 3-6 months depending on caries risk.
Risk Factors
Protective Factors
OK
5.Mutual agreement on self management goals:
Care-provider explains what he saw and evaluated, and how caries happen.
Then agrees with the parent on 2 goals to work upon, to increase the protective factors and lower the risk factors for the following visit.
-Tables were developed for easily and rapidly placing the patient in his proper care need and frequency.

-Taking his age, his caries risk level into consideration as well as the modality of prevention needed.

-Tables that are very simple to use, and the idea of turning them into an “app” was suggested, a CAMBRA app.
The major 3 barriers in the way of caries risk assessment and carious disease management are:
1.Service provider’s lack of knowledge, comfort and skills.

2.Parent’s knowledge, preference and expectations.

3.Reimbursement favoring surgical management of caries and not encouraging protective management.
Quality improvement, the combined and un-easing effort of everyone - health care professionals, patients and their families, researchers, payers, planners and educators - to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional learning.
QI is not familiar to dentistry yet but offers the potential to transform oral health care delivery in order to provide better oral health care, improve oral health outcomes and to reduce costs of treatment of caries.
CAMBRA’s easy to use organized format of disease
indicators, risk and protective factors, clinical findings and self management goals
helps to facilitate oral health education, deepens the appreciation of oral health information and increases the understanding of how individual behaviors can affect caries development and progression.

- By embracing the concepts of caries assessment, early intervention and establishment of a dental home.
KIKO
-2 years old
-Uses the bottle, 3 times a day
-Still breast feeding
-Doesn't brush
-Has White lesions on DEFG
-
Mother Wants to know if he needs Fluoride
CAMBRA
A multifaceted care-path appropriate for the family, based on the child’s age and individualized needs is designed.

A care-path, decision tree can aid the provider in determining a specific combination of
diagnostic, preventive and restorative procedures
and the
periodicity
of these recommended measures to
improve or stabilize
the caries high risk profile.
These care-paths are expected to be dynamic and change with the emergence of new evidence based modalities with the aim of prevention. A careful consideration regarding every patient’s specific needs must be made.
Thank you

Supervised by: Prof. F.Ramos-Gomez
Prepared by:
Dr. Karim El Mofty, BDS
Dr. Eline Abreu, DDS

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http://asktheortho.blogspot.com/
INFANT ORAL HEALTH AND ORAL HABITS
Arthur J. Nowak, DMDa, c, John J. Warren, DDS, MS
http://www.dimensionsofdentalhygiene.com
Tooth Decay - Surely More Than Drill and Fill or Teeth Extraction
by Malcolm Levinkind(more info)
listed in dentistry, originally published in issue 159 - June 2009
http://www.medicalvoyce.com
Baby Teeth | Aren’t they just baby teeth?
Joshua B. Erickson DDS MSD, Kirk A. Skidmore DDS
KIKA
- 4 years old
- Has Asthma and uses albuterol
- Brushes her teeth once a day
- Her favorite drink is sugared apple juice, 2 times a day
- Father is concerned about necessity of radiographs
Once upon a time...
The world thought that toothpaste containing Fluoride should never be used by young children!
Now...
We refer to this concept as a myth, because more evidence based work proved otherwise..
According to the 2007 Report by the Centers for Disease Control and
Prevention (the most current report to date), cavities have increased for
toddlers and preschoolers. Cavities in children ages 2 to 5 increased from
24 percent to 28 percent between 1988-1994 and 1999-2004.
For children ages 2 to 5, 70% of the caries is found in 8% of the population
ECC is disproportionately concentrated among socially disadvantaged children, especially those who qualify for Medicaid coverage.
trialx.com
Diagnosing white spot lesions
Features Of Enamel Hypoplasia
There are many distinct features that are seen in cases of enamel hypoplasia:

1. Enamel that has not formed to a full thickness The enamel is soft and thin that are chipped away more easily from the underlying dentin.

2. The crowns of the tooth may show discoloration such as white spots or cloudy opacities that varies depending upon the type of the disorder ranging from white, yellowish white, to brown.

4. The hypoplasia seen due to local infection or trauma during the tooth formation exhibits mild brownish discoloration of the enamel to severe pitting and irregularity of the tooth crown.

5. When ingesting excessive fluoride during the time of tooth formation results in mottled enamel characterized by occasional white flecks or spotting of the enamel.


There are 2 basic types of enamel hypoplasia:



1-
Hereditary:
Ectodermal disturbance that occurred during the embryonic development of the enamel. The mesodermal components are normal. Both the deciduous and permanent teeth are involved and only the enamel is affected.




2-
Environmental
:Caused by the environmental factors that causes damage to the enamel cells. Either deciduous or permanent teeth are involved and sometimes a single tooth is involved.
Here both the enamel and the dentin are involved in varying degrees.


References

http://www2.aap.org/commpeds/dochs/oralhealth/index.html
http://www.guideline.gov/search/search.aspx?term=white+spot+lesions
http://www.dentistrytoday.com/restorative/minimally-invasive-dentistry/1492
http://www.kidsoralhealth.org/?page=pcp-screening-assessment

Treatment for Enamel Hypoplasia
It will depend on the condition of the affected enamel.

The enamel can becomes stained with a brown color and so for cosmetic reasons, the affected tooth is bleached with an agent such as the hydrogen peroxide, the procedure is done periodically since it can recur.

When an area is affected by caries, the enamel might crumble as the enamel is weaker in those areas. The decayed portion of the tooth may be filled with a tooth colored cement.

If the cavity is advanced or extensive, it may need a bigger permanent restoration such as crowns, onlays, etc.



White spot lesions and enamel hypoplasia


Nutritional deficiency, includes vitamins A, C, and D.

Exanthematous diseases (skin diseases) such as measles, chickenpox, scarlet fever etc.

Congenital syphilis.

Hypocalcemia.

During birth, such as birth injury, prematurity, Rh hemolytic disease etc.

Local infection or trauma.

Ingestion of chemicals such as fluoride etc.

Unknown causes.
American Academy of Pediatrics. 2008. Oral Health Risk

Prevention and Management
Enhancing Enamel Resistance Using Topical Fluorides

The fluoride ion has a preventive effect against caries by:

Modifying bacterial metabolism in dental plaque by inhibiting some enzyme processes;

Inhibiting the production of acids by acting on the composition of the bacterial flora and (or) on the metabolic activity of microorganisms;

Reducing demineralization and favors the remineralization of early carious lesions by exerting a remineralization effect, especially at low concentrations.


The favorable action of fluorides is now well established, being used as:
-Fluoride Mouth Rinse,
-Fluoride Gel,
-Fluoride Toothpaste,
-Fluoride Varnish.

white spot lesions
They initiate below the surface of the enamel and appear as a pale stain.

The term “
white spot lesion” is defined by Fejerskov et al
. as “the first sign of caries lesion on enamel that can be detected with the naked eye” and used along side with terms “initial” or “incipient” lesions.

http://intranet.tdmu.edu.ua/data/kafedra/internal/stomat_ter_dit/classes_stud/en/stomat/ptn/child%20therapeutic%20dentistry/4/08.%20X-ray%20diagnosis%20of%20dental%20caries.htm

http://www.kidsoralhealth.org/?page=pcp-screening-assessment

What is the difference between them?
http://www.mchoralhealth.org/flvarnish/mod3_2_3.html

http://www.mchoralhealth.org/flvarnish/mod3_2_3.html

Enamel hypoplasia
Enamel hypoplasia is defined as an incomplete or defective formation of the organic enamel matrix of the teeth in the embryonic stage of the tooth.

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