Caries Management by Risk
Assessment in Children
Niki Fallah D.D.S
3/26/13
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Research Committee:
Ling Zhan D.D.S., Ph.D
John D. B. Featherstone M.Sc., Ph.D.
Pamela Den Besten D.D.S., M.S.
Jing Cheng, MD, MS, PhD
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Background:
•Dental caries is the single most common chronic infectious
disease amongst children in United States.
•Main bacteria: mutans streptococci (MS)
• Studies have demonstrated the progression of caries from
the primary dentition to the permanent dentition as a major
problem, with 6-9 year old age groups being at the highest
risk.
•More than 51 million school hours are lost each year to
dental-related illness.
•The annual cost of dental caries treatment in children
accounts for as least $4.5 billion in the US
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Caries Risk:
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CAMBRA
• New strategies of Caries Management by Risk
Assessment (CAMBRA) were implemented 8 years ago
for adults in the pre-doctoral dental clinics at the
University of California San Francisco (UCSF).
• These CAMBRA guidelines for adults are currently also
recommended for children over 6 years. However, no
study has been conducted to validate the efficacy of
CAMBRA in children.
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CAMBRA Protocol – Adult
Risk Level
Antimicrobials
Home Fluoride
Professional
CRA and F-
Xylitol and/or
Baking soda
Low
Not Indicated
Regular OTC
Fluoride
containing
toothpaste twice
daily
CRA every 12
months
Not Indicated
Moderate
Not Indicated
Rx 5000ppm
fluoride
toothpaste twice
daily
CRA every 6
months
Fluoride varnish
every 6 months
Xylitol gum or
mints. 8g daily
High
Chlorhexidine
0.12%rinse for 1
min daily for 1
week each month
Rx 5000ppm
fluoride
toothpaste twice
daily
CRA every 6
months
Fluoride varnish
every 6 months
Xylitol gum or
mints. 8g daily
Extreme
Chlorhexidine
0.12%rinse for 1
min daily for 1
week each month
Trays for home
application
5000ppm F- gel q
d x 5min
CRA every 3-6
monthsFluoride
varnish every 3-6
months
Xylitol gum or
mints. 8g daily.
Baking soda rinse
4-6 x daily
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Modified CAMBRA for children:
•
•
•
•
Eliminate chlorhexidine mouth-rinse and
high concentration home use fluoride
regimens for children aged 5-9 years.
Adopt a regimen including more frequent
professional fluoride application, xylitol
products, and baking soda rinse for high
and extreme risk patients.
The regimen will focus on building good
diet and oral hygiene habits and controlled
office fluoride varnish delivery.
Xylitol mints will be incorporated to modify
the caries-causing oral microbial flora.
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Xylitol:
•
•
•
•
sugar sweetener, in the sugar
alcohol or polyol family
commonly used as a sugar
substitute, maintaining the same
level of sweetness as table sugar
with half the amount of calories.
In the same category as other
universally known sweeteners
such as sorbitol, mannitol, and
maltitol.
xylitol has been well accepted to
be non-cariogenic along with its
cariostatic effect in chewing gum
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Mechanism of Xylitol:
• Cannot be metabolized by MS.
• It competes with sucrose in the intra-cellular
metabolism process, reducing the energy source for
MS.
• Short-term consumption of xylitol is associated with
decreased S mutans levels in both saliva and plaque.
• Long-term habitual consumption of xylitol appears to
have selective effects on S mutans strains
• This results in populations that are less virulent and
less capable of adhering to tooth surfaces and, thus,
are shed more easily from plaque into saliva
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Aim:
The aim of the study is to evaluate the efficacy of
a modified Caries Management by Risk
Assessment (CAMBRA) model in a clinical trial in
children aged 6-9 years treated in a schoolbased community pediatric dental clinic setting.
Specifically:
– Reducing MS & LB levels
– Improving the oral hygiene and dietary habits.
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Hypothesis:
In 5-9 year old children, a modified
CAMBRA protocol will significantly reduce
the cariogenic bacterial load, improve oral
hygiene care and dietary habits as
compared to the conventional prevention
regimen.
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Study Design
66 subjects between the ages of 5-9 years old and currently enrolled
at the Tenderloin Elementary School
Baseline Visit
(dmfs/DMFS, caries risk assessment, and saliva sample)
Randomization
Control Group
(Conventional Treatment)
Caries risk assessment at 6 months
Saliva sample
Final visit at 12 months
(saliva sample, dmfs/DMFS, caries risk
assessment)
Intervention Group
(Conventional treatment + CAMBRA intervention)
Caries risk assessment at 6 months
Saliva sample
Final visit at 12 months
(saliva sample, dmfs/DMFS, caries risk
assessment)
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Site selection and recruitment:
• The UCSF school-based Pediatric
Dental Clinic in the Tenderloin
Community is located in Tenderloin
Elementary School sponsored by a
non-profit
organization,
Bay-Area
Women.
• The clinic is operated one day a
week by UCSF Pediatric Dentistry
faculties, pediatric dental residents and
staff.
• Over 200 children aged 5-9 years are
currently enrolled in the school
• The clinic sees large numbers of lowincome patients likely to be at high risk
for caries.
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Inclusion Criteria:
Participants will be patients of record at the UCSF Pediatric
Dental Clinic in the Tenderloin Community and must be:
1) 5-9 years old
2) able to give informed assent, consent and answer
questionnaires in English, Spanish, Chinese or Vietnamese by
parents or guardian
3) unlikely to move from the school during the study period
4) willing to participate regardless of group assignment and
comply with all study procedures.
Exclusion Criteria:
Persons with:
1) Long-term antibiotic use in the past month
2) Dental needs outside the realm of the community pediatric
clinics, such as care provided in specialty clinics
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Materials/Method
Modified CAMBRA regimen:
• Building good diet and oral hygiene
• More frequent professional visits and office fluoride
varnish
• Use of a daily xylitol mints
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Sample size: n= 130
Randomization: Computer generated randomization sheets
were used for subject assignment into intervention or control
groups. Treatment team assignments were kept in
consecutively numbered, sealed, opaque envelopes.
Saliva analysis: MS and LB levels in saliva were measured by
selective culture according to routine procedures.
*All participants received a $10 Target gift card at each
saliva collection, totaling $30 by the end of their
participation in the study.
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Caries Status Assessment:
• Dr. Ling Zhan assessed caries status at the initial
exam and at the final visit in a standard dental
operatory in the clinic.
• Traditional DMFS/dmfs scores were obtained on all
teeth.
• Non-cavitated lesions were recorded if any were
noted. Supplementary radiographic evidence was
used for proximal surfaces as part of patient care at
the beginning and end of the study for all subjects.
• Caries risk categories were identified by using the
CRA form that is being used at UCSF Pediatric
Dentistry Clinic.
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Statistical Analysis:
• All data was entered into a computerized database.
• Demographics, compliance, and questionnaire items for the two
groups were compared using Fisher exact tests, chi-square
tests, t-tests, and Wilcoxon rank sum tests, depending on the
scale of the item.
• Salivary components (MS, LB, and F) for the two groups were
assessed with rank analysis of covariance (RANCOVA)
adjusting for baseline values.
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Results:
Results
Table 1: Baseline values of total, smooth surface decay and DMFS of subjects
• 60 subjects completed the study.
• The baseline parameters were comparable in the two groups
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Results
• No statistic
significant
differences
were found
in logMS,
• No
statistic
significant
difference
logLB andlogLB
logTVC and
levels between
thelevels
two groups
at
logTVC
between
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baseline, 6 month and 1 year.
• No statistic significant differences were found in logMS,
logLB and logTVC levels between the two groups at
baseline, 6 month and 1 year.
• There was minimal increase in cavitated lesions in both
groups at 1 year.
• There was an overall suggestive difference in enamel
lesions between the CAMBRA and the conventionaltreatment group, especially in buccal-lingual smooth
surface enamel lesions (T-test; P< 0.06).
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smooth surface enamel
lesions.
Conclusion:
Conclusions
The CAMBRA protocol used in the study
• did not modify the cariogenic bacteria levels
• showed promises in prevention of new caries formation
and reversion of enamel lesions in 5-9 year old children.
Acknowledgement: The project is funded by Pilot Research
Awards for Junior Investigators of Resource Allocation Program
from University of California, San Francisco.
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Limitations of study:
•
•
•
•
Actual number of subjects: 66
Patient compliance with xylitol
Student transfer rate out of school
School schedule (daily schedules,
summer/winter vacation)
• Communication with parents
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THANK YOU!
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