CAMBRA treatment model expanding internationally

The Caries Management by Risk Assessment (CAMBRA) standard of care is expanding internationally. CAMBRA, which aims to diagnose and prevent caries through the process of assessing patients' risk for caries by examining various health and lifestyle factors as part of their regular dental checkup, is garnering interest from oral health professionals in Japan.

John Featherstone, PhD, is the dean of the University of California, San Francisco, School of Dentistry and has researched CAMBRA for decades, winning numerous national and international awards, including the International Association for Dental Research distinguished scientist award for research in dental caries. Featherstone was invited to give presentations on the CAMBRA approach in Japan in December. The Yoshida Dental Mfg. Co. sponsored the event in partnership with Osaka University and Meikai University.

The CDA Foundation and UCSF have had a partnership in the area of CAMBRA research for several years. Currently, the organizations are partnering to conduct a network study. Dental practices enrolled in the network contribute to research on the efficacy of aggressive nonsurgical interventions and home care, and how dentists, staff and patients perceive this practice. The network practices then assist in identifying barriers and challenges to full implementation of CAMBRA protocols with regard to patient adherence to the prescribed interventions, time commitment of dentists and staff and impact this practice philosophy has had on their practice. Findings will inform and support efforts of various groups nationally, including payers, who are attempting to establish risk-based models in practice. Currently, the work is partially funded by the DentaQuest Institute.

In 2004, the CDA Foundation started to support the annual meetings of a CAMBRA Workgroup, which is made up of academic representatives from dental schools throughout the U.S. In addition, several hundred people have attended CAMBRA forums and workshops offered by the CDA Foundation during CDA Presents from 2008 to 2010.

The CDA Foundation hosted a Caries Management by Risk Assessment Symposium in 2011 to facilitate dialogue about each group's responsibility in creating an oral health delivery system that favors caries prevention and early intervention. Dental researchers, practitioners, policy advocates and insurers from across the country attended the meeting.

CDA Update staff recently spoke to Featherstone about his trip to Japan and the current state of CAMBRA. Below are excerpts from the interview.

Tell us a little about this presentation you did in Japan.

This is a big dental supply company in Japan with a huge catalog of dental supplies. The company made a decision that they want to promote CAMBRA in Japan. They have been working with people at a few universities there and they have made a decision that this is a good thing to do for the good of people's health and they may get some more loyalty presumably. They are going to put together training courses and so I went over to train the trainers, basically.

Yoshida works with Osaka School of Dentistry and Osaka has a relationship with UCSF, so it is sort of a three-way connection of some sort. They found out about CAMBRA and what we have been doing in this country and felt this should be introduced into Japan for the good of everybody.

What did the training look like?

They have three people who are going to be doing continuing education courses there just like I would do here as a speaker. So they'll be mounting C.E. courses that people can take and Yoshida will support them. Sort of the way it works in Japan to some extent is that people get loyal to particular companies if they do something good for them. I see it as a big plus because CAMBRA is going to be taught by professors and those who are in dental practices.

I have done three levels of training. I had already worked with their key person who came over and sat down with me in San Francisco to develop his material. He's doing the translating and making sure it is right. Another aspect I am doing here is I am doing an all-day continuing education course just the same way as I have done in other parts of the world. I did a six-hour course at CDA Presents that was similar. It will be open to any practitioner in Japan who wants to come. I had people writing to me to ask about the lecture way before it happened. The presenters sat in on the course in Japan. And then the day after that I sat down with the three of them and we went step-by-step through everything to make sure they are on the same wavelength with what I am presenting.

Is there any type of treatment strategy in Japan right now that is similar to CAMBRA?

Yes, but it is a few practitioners who for some reason or another caught on to this. So the person who is going to be one of the key presenters in Japan is already working with CAMBRA in his practice. I did an online course the last two years and we had people from 32 different countries sign up to do that, including some from Japan, so these folks have already participated in my courses.

You have been involved in CAMBRA research for a long time. It must be pretty exciting for you to see it catching on internationally. What was going through your head when you heard Yoshida was interested in this?

I must admit their first approach came to me and I was a little suspicious as to what it was all about and then my colleague at UCSF, who is fluent in Japanese and works with people at Osaka, said these guys are genuine they really want to launch this as a program in Japan and make it part of the standard of care. And I thought, 'wow, OK; let's help them out.'

Where is the state of CAMBRA right now? I know there have been trials taking place and we're getting to a point where there is beginning to be some statistical evidence of its effectiveness.

We've got probably two-thirds of the dental schools in the country that are teaching the philosophy to some extent or another. We've got hundreds, if not thousands, of dentists across the country who are embracing CAMBRA in some way, shape or form in their practice, but it's hard to tell just how many of them are successfully using the CAMBRA approach. We have been publishing data on CAMBRA since 1999. We have very successful outcomes data from our predoctoral clinics at UCSF, but we needed to know what happened in the real world of dentistry in the community. The UCSF trials on CAMBRA will be finished June 2016 and it may have to run a little bit longer than that to finish up the last subjects, but we have preliminary results and they look promising.

What's next for CAMBRA?

The goal is to implement it as a standard of practice as part of the standard of care for dentistry. We've had some outcome results, which we just published about two weeks ago, and since 2003 at UCSF, we've had CAMBRA as the norm for all patients of our predoctoral patients. Now, that's theoretically -- in actual practice, it's taken us more than 10 years to get to the point where almost every patient is having a risk assessment. That's step one. To actually put the chemical therapy into practice is another huge hurdle. Traditional dentists, including some of our faculty, are cautious about embracing something that is different from what they were taught so it's a long process. What we just published recently in the BMC Oral Health journal was some outcome data. It compared one group of patients who got the care for free, including the chemical therapy, and a group of patients who did not accept the free care. There's a 42 percent reduction in dental decay, which is pretty staggering. Overall, in our clinics over a period of several years we've got approximately a 20 percent reduction in dental decay for those who have used the products versus those who wouldn't accept it.

What do you think this interest in CAMBRA from Japan is going to do for dentistry in general?

I'm not sure the two are related, but the Japanese culture, they'll tend to implement something and make it happen, where our culture is a little different. We roll something out and people accept it or they don't.

So we'll see.

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The October and November 2011 issues of the CDA Journal published evidence-based CAMBRA research that demonstrated caries could be prevented and managed through risk assessment. For more information, visit cda.org/journal.

Related Items

Dentists interested in learning about and implementing Caries Management By Risk Assessments (CAMBRA) into their practices can take advantage of the new app developed by the UCSF School of Dentistry and Firsthand Technology Inc. The MyCAMBRA mobile app, available in the iTunes store, lets dentists perform a CAMBRA risk assessment right on their iPhone or iPad.

The CDA Foundation and the UCSF School of Dentistry are attempting to alter the way dentists prevent caries through a practice-based clinical trial, and volunteers are needed. The Caries Management By Risk Assessment (CAMBRA) Practice-Based Research Network formalizes the process to assess a patient’s risk for caries by examining various health and lifestyle factors as part of their regular dental checkup. The Foundation and UCSF are looking to expand an already established research network, which focuses on the implementation of CAMBRA.