Kids who are designated as high risk for caries according to the caries management by risk assessment (CAMBRA) approach often end up developing the disease, according to a new study. The finding shows that CAMBRA appears to be an accurate prediction model for at least some populations.
Researchers at the University of California, San Francisco (UCSF) School of Dentistry looked at electronic CAMBRA risk assessments for more than 3,000 children younger than 6 years old. They found that nearly all caries risk assessment (CRA) factors were associated with providers' risk designation, and, in turn, several of the factors were significantly associated with future tooth decay.
"All CRA risk indicators and clinical indicators were positively and statistically significantly associated both with being classified as high caries risk and with the presence of evidence decay at baseline, except inadequate salivary flow," the study authors wrote in JDR Clinical & Translational Research (July 2016, Vol. 1:2, pp. 131-142).
Clinical risk factors are strong decay predictors
Caries Management by Risk Assessment was designed in the early to mid-2000s to assess individual caries risk for patients and help practitioners manage the disease, with an emphasis on preventive and minimally invasive care. However, few studies have evaluated how effective CAMBRA is for young children, especially in U.S. populations.
Lead author Benjamin Chaffee, DDS, MPH, PhD, and colleagues conducted this study to get a better idea for how risk factors influenced how practitioners designated caries risk for children between 6 months and 6 years old. They also looked at which factors were related to caries at the initial visit and which factors were associated with tooth decay at a follow-up visit.
Dr. Chaffee and colleagues looked at caries risk assessment and dental records for 3,810 children who visited the UCSF clinic between 2009 and 2015. They also analyzed the records for 1,315 kids who had a follow-up dental visit.
Specifically, the researchers examined CAMBRA's 17 caries risk factors, which include the following:
- Nine biological indicators, including having a caregiver or sibling with decay, or snacking three times per day or more
- Five protective indicators, including brushing daily with fluoride toothpaste or having a fluoride varnish in the past six months
- Three clinical indicators, including having visually obvious tooth decay or dental plaque
With the exception of salivary flow, all biological and clinical indicators were significantly associated with the presence of decay at the initial visit. The researchers also found that frequent snacking and dental plaque were the two most important predictors of baseline decay.
"In the current study, most individual items included in the CAMBRA CRA form for young children were independently associated with providers' caries risk determination," the authors wrote. "In turn, practitioners' assigned risk designations were strongly associated with future disease."
When the researchers looked at data for follow-up visits, all the clinical indicators and four of the biological indicators were significantly associated with evident decay. However, only baseline decay was both independently and significantly associated with decay at a follow-up visit.
"The fact that only existing disease consistently and independently predicted future disease in these statistical models does not imply that other measured CRA items are not fundamental to the caries process," the authors wrote. "On the contrary, existing evident decay implies an imbalance of pathological and protective factors that, without intervention, will continue to contribute to further tooth decay."
Individualized practitioner assessment is important
A 2015 study warned that risk assessment for early childhood caries is designed for large populations, and that it is impossible to apply population-level findings to an individual. Therefore, Dr. Chaffee and colleagues emphasized the importance for practitioners to look at patients individually and develop a customized caries management plan.
"Measurable factors associated with caries prevalence in epidemiological studies are not equivalent to the causal determinants for specific ECC [early childhood caries] cases," the authors wrote. "For practitioners, this necessitates consideration of each patient's disease-preventing and predisposing factors in context -- a process that a formal caries risk assessment can enhance, even if precise individual-level risk quantification is elusive."
While this study had the benefits of a long observation period and large sample size, it did have some drawbacks. Specifically, the population was heterogeneous, consisting of kids who were primarily from low socioeconomic status and lived in areas with community water fluoridation. While previous studies have reached similar conclusions, the results from this study cannot be translated to other, more general population samples.
The authors suggest future studies evaluate how CAMBRA is used by dentists outside of the educational environment, particularly when evaluating young children.
"The present study demonstrates that dental providers in this setting incorporate multiple patient variables in assigning risk status," the authors wrote. "Future investigation is necessary to show that thoughtful risk assessment leads to appropriate preventive care and improved patient outcomes."
