Caries Management by Risk Assessment: Results from a Practice-Based Research Network Study.

Thirty dentists with clinical practices outside of a university setting were trained and calibrated successfully in DMFS and ICDAS-scoring. This randomized, controlled, parallel-arm, double-blind 2-year clinical trial with individual-level caries risk assignment of 460 patients to standard of care as control versus active CAMBRA treatment as intervention demonstrated that caries risk level, as well as caries disease indicators, were significantly reduced in the CAMBRA intervention group compared to the controls at all recall time points.

MI Varnish and MI Paste Plus in a caries prevention and remineralization study: a randomized controlled trial.

OBJECTIVES: White spot lesions (WSLs) are a complication of orthodontic therapy. This study investigated the effect of MI (minimally invasive) Paste Plus (MIPP) and MI Varnish (MIV) on WSLs in orthodontic patients during a 12-month, randomized, single-blind, prospective, standard-of-care controlled clinical trial. MATERIALS AND METHODS: Forty subjects, recruited from the UCSF School of Dentistry Orthodontics Clinic, were randomly assigned to the experimental (twice-daily 1100 ppm fluoride toothpaste, daily MIPP, quarterly MIV application) or control group (twice-daily 1100 ppm fluoride toothpaste, fluoride rinse recommendation). Facial surfaces of incisors, canines, and first bicuspids were evaluated at baseline, 3, 6, and 12 months using the enamel decalcification index (EDI) and the international caries detection and assessment system (ICDAS). RESULTS: Findings from 37 subjects are reported. At 12 months, teeth receiving experimental treatment were at lower but not significantly different odds of increased EDI scores (odds ratio, OR 0.63; intra-patient cluster-adjusted 95% CI 0.43, 1.18) and not associated with increased ICDAS scores (OR 0.99; 95% CI 0.64, 1.54). There was no statistically significant difference in mean patient-level EDI sum (experimental group 40.2; control 41.3; t test p = 0.80), ICDAS score (experimental 22.3; control 22.6; Mann-Whitney U test p = 0.80), or percentage of scored surfaces with ICDAS > 0 (experimental 54.6%; control 55.2%; t test p = 0.88). Salivary fluoride levels were significantly higher at 12 months for the experimental than for the control group (0.20 ± 0.26 versus 0.04 ± 0.04 ppm, Mann-Whitney U test p < 0.01). CONCLUSIONS: Applying daily MIPP and quarterly MIV resulted in no statistically significant differences in EDI sum and ICDAS scores. Higher salivary fluoride levels in the experimental group suggest that MIPP and MIV effectively deliver fluoride when used clinically. CLINICAL RELEVANCE: Daily MIPP and quarterly MIV applications do not appear to reduce significantly WSLs incidence during fixed orthodontic treatment.

Calibration of dentists for Caries Management by Risk Assessment Research in a Practice Based Research Network - CAMBRA PBRN.

BACKGROUND: To prove that Caries Management by Risk Assessment (CAMBRA) can be successfully implemented in dental practices outside of the university setting, dentists in the San Francisco Bay Area (CA) were approached to participate in a Practice Based Research Network (PBRN) study. The overall goal of the CAMBRA-PBRN study was to recruit 30 dentists to perform a two-year study involving approximately 900 patients. Goal of the calibration study was to standardize and calibrate dentists potentially participating in the CAMBRA-PBRN study. METHODS: To minimize inter-examiner variability in data collection, including classification of carious lesions and recording of existing restorations, participating dentists were trained and calibrated in accurate DMFS (decayed, missing, filled surfaces) charting. Dentists were also trained and calibrated to diagnose and differentiate between sound surfaces and non-cavitated caries lesions (International Caries Detection and Assessment - ICDAS scores 1 and 2) for posterior occlusal surfaces. Thirty dentists were calibrated to a single gold standard examiner (BJ) during 6 calibration sessions, between 2011 and 2014. Kappa statistics were used to determine inter-examiner reliability on 13 or more patients, aged 12-63 (average age 38 ± 15 years), per examiner during each session, resulting in 94 patient encounters over the course of all 6 sessions. To participate in the main study, examiners needed to achieve a minimum required kappa of 0.75. During the calibration process, examiners scored between 1036 and 2220 tooth surfaces. RESULTS: The kappa values (unweighted kappa) of the participating dentists compared to the gold standard examiner ranged from 0.75 to 0.90, with an average kappa of 0.84 ± 0.03. 90% of the examiners achieved overall kappa values above 0.8. However, separate reliability for assessment of non-cavitated lesions, as in other studies, was lower (0.55 ± 0.15). Multiple subcategories were evaluated. All dentists reached sufficient reliability values to proceed into the study; nevertheless, one dentist discontinued with the study due to scheduling conflicts. CONCLUSIONS: The high inter-examiner reliability results have shown that dentists who work in primarily non-research based practices can be effectively standardized and calibrated in data collection, based on specific guidelines created to anticipate potential research study scenarios.

Caries inhibition with a CO2 9.3 µm laser: An in vitro study.

BACKGROUND AND OBJECTIVES: The caries preventive effects of different laser wavelengths have been studied in the laboratory as well as in pilot clinical trials. The objective of this in vitro study was to evaluate whether irradiation with a new 9.3 µm microsecond short-pulsed CO2 -laser could enhance enamel caries resistance with and without additional fluoride applications. STUDY DESIGN/MATERIALS AND METHODS: One hundred and one human tooth enamel samples were divided into seven groups. Each group was treated with different laser parameters (CO2 -laser, wavelength 9.3 µm, 43 Hz pulse-repetition rate, pulse duration between 3 µs at 1.5 mJ/pulse to 7 µs at 2.9 mJ/pulse). A laboratory pH-cycling model followed by cross-sectional microhardness testing determined the mean relative mineral loss delta Z (ΔZ) for each group to assess caries inhibition in tooth enamel by the CO2 9.3 µm short-pulsed laser irradiation. The pH-cycling was performed with or without additional fluoride. RESULTS: The non-laser control groups with additional fluoride had a relative mineral loss (ΔZ, vol% × µm) that ranged between 646 ± 215 and 773 ± 223 (mean ± SD). The laser irradiated and fluoride treated samples had a mean ΔZ ranging between 209 ± 133 and 403 ± 245 for an average 55% ± 9% reduction in mineral loss (ANOVA test, P < 0.0001). Increased mean mineral loss (ΔZ between 1166 ± 571 and 1339 ± 347) was found for the non-laser treated controls without additional fluoride. In contrast, the laser treated groups without additional fluoride showed a ΔZ between 470 ± 240 and 669 ± 209 (ANOVA test, P < 0.0001) representing an average 53% ± 11% reduction in mineral loss. Scanning electron microscopical assessment revealed that 3 µs pulses did not markedly change the enamel surface, while 7 µs pulses caused some enamel ablation. CONCLUSION: The CO2 9.3 µm short-pulsed laser energy renders enamel caries resistant with and without additional fluoride use. The observed enhanced acid resistance occurred with the laser irradiation parameters used without obvious melting of the enamel surface as well as after irradiation with energies causing cutting of the enamel. Lasers Surg. Med. 48:546-554, 2016. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Sustained effects of blue light on Streptococcus mutans in regrown biofilm.

In prior studies, exposure of Streptococcus mutans in biofilm to blue light using high fluences of up to 680 J/cm(2) did not interfere with bacterial capability to reform an initial biofilm; however, a delayed antibacterial effect was observed. Our aim was to determine the sustained effecttts of blue light-emitting diode (LED) curing light on the pathogenicity of the newly formed biofilm. S. mutans were grown to form biofilm that was exposed to blue light (wavelengths, 460-480 nm) for 1, 3, and 7 min (equivalent to 37, 112, and 262 J/cm(2), respectively). Then, bacteria were suspended and allowed to regrow into new biofilms. The regrown biofilms were assessed for bacterial quantification by optical density (OD) measurement and quantitative polymerase chain reaction (qPCR), bacterial viability and extracellular polysaccharide production by fluorescent staining using confocal scanning laser microscopy, acid production by bacteria (acidogenicity), and bacterial survival at low pH (aciduricity) using qPCR. Bacterial growth in the regrown biofilms was increased when samples were previously exposed to light; however, under the confocal microscopy, a higher proportion of dead bacteria and a reduction in polysaccharide production were observed. The acidogenicity from the regrown biofilm was lowered as fluences of light increased. The aciduricity of the regrown biofilm was decreased, meaning less growth of bacteria into biofilm in low pH with increasing fluences. Blue light has sustained effects on S. mutans bacteria grown into new biofilm. Although bacterial growth in biofilm increased, bacterial viability and virulence characteristics were impaired. The cariogenic potential over time of S. mutans previously exposed to blue light when grown on tooth surfaces is yet to be determined.

Performance of a light fluorescence device for the detection of microbial plaque and gingival inflammation.

OBJECTIVES: The hypothesis to be tested was that using the SOPROCARE system in fluorescence perio-mode allows scoring of microbial plaque that is comparable to the Turesky modification of the Quigley Hein plaque index (T-QH) and scoring of gingival inflammation comparable to the Silness and Löe gingival inflammation index (GI). MATERIALS AND METHODS: Fifty-five subjects with various amounts of microbial plaque were recruited. The T-QH and GI index were recorded. SOPROCARE pictures were recorded in fluorescence perio-mode and in daylight mode. Finally, conventional digital photographs were taken. All pictures were assessed using the same criteria as described for the clinical indices. RESULTS: The average T-QH was 1.1 ± 1.2 (mean ± SD). Scoring with SOPROCARE perio-mode led to a slightly higher average than the T-QH scores. SOPROCARE daylight mode and digital photography showed the highest plaque scores. The average GI index was 0.7 ± 0.9. SOPROCARE in perio-mode scored slightly lower. Linear regression fits between the different clinical indices and SOPROCARE scores were significantly different from zero demonstrating high goodness of fit. CONCLUSIONS: The study demonstrated that the SOPROCARE fluorescence assessment tool in perio-mode allows reliable judgment of microbial plaque and gingival inflammation levels similar to the established Turesky-modified Quigley Hein index and the Silness and Löe gingival inflammation index. Training on plaque-free teeth will actually reduce scoring errors. CLINICAL RELEVANCE: The SOPROCARE fluorescence tool in perio-mode provides reliable evaluation of microbial plaque and gingival inflammation for the dental clinician.

Non-operative anti-caries agents and dental caries increment among adults at high caries risk: a retrospective cohort study.

BACKGROUND: Consensus guidelines support non-operative preventives for dental caries management; yet, their use in practice is far from universal. The purpose of this study was to evaluate the effectiveness of non-operative anti-caries agents in caries prevention among high caries risk adults at a university clinic where risk-based caries management is emphasized. METHODS: This retrospective observational study drew data from the electronic patient records of non-edentulous adult patients deemed to be at high risk for dental caries during baseline oral evaluations that were completed between July 1, 2007 and December 31, 2012 at a dental university in the United States. We calculated and compared adjusted mean estimates for the number of new decayed or restored teeth (DFT increment) from baseline to the next completed oral evaluation (N = 2,724 patients with follow-up) across three categories of delivery of non-operative anti-caries agents (e.g., high-concentration fluoride toothpaste, chlorhexidine rinse, xylitol products): never, at a single appointment, or at ≥2 appointments ≥4 weeks apart. Estimates were adjusted for patient and provider characteristics, baseline dental status, losses-to-follow-up, and follow-up time. RESULTS: Approximately half the patients did not receive any form of non-operative anti-caries agent. Most that received anti-caries agents were given more than one type of product in combination. One-time delivery of anti-caries agents was associated with a similar DFT increment as receiving no such therapy (difference in increment: -0.04; 95% CI: -0.28, 0.21). However, repeated, spaced delivery of anti-caries agents was associated with approximately one decayed or restored tooth prevented over 18 months for every three patients treated (difference in increment: -0.35; 95% CI: -0.65, -0.08). CONCLUSIONS: These results lend evidence that repeatedly receiving anti-caries agents can reduce tooth decay among high-risk patients engaged in regular dental care.

Effects of CO2 laser irradiation on tooth enamel coated with biofilm.

BACKGROUND AND OBJECTIVES: CO2 laser irradiation of tooth enamel can inhibit demineralization of tooth enamel, by changing enamel composition and resistance to acid attack. The aim of this work was to examine these effects of CO2 laser irradiation on enamel covered by biofilm. MATERIALS AND METHODS: Streptococcus mutans was grown on bovine enamel surfaces for 48 hours to form a mature biofilm. Samples were irradiated by CO2 laser (wavelength of 10.6 µm) at a power of 0.08 W in a super-pulse mode for 1 second and 24 pulses/second, with an energy density of 0.77 J/cm(2) per pulse. Untreated controls and laser treated samples with and without biofilm were examined for the morphology of the biofilm and the enamel surface by scanning electron microscopy (SEM). Structural biofilm viability was assessed using confocal laser scanning microscopy with live/dead staining. The biofilm was removed in a sonication water bath and the non-treated and irradiated enamel samples were chemically analyzed using energy dispersive X-ray spectrometry (EDS) and Fourier transform infrared spectroscopy (FTIR). RESULTS: Irradiated samples showed a melt zone with micro-cracks in the center of the irradiating beam position, which was smaller when irradiated enamel was covered by biofilm. Confocal microscopy images demonstrated higher proportion of dead bacteria at the margins of the irradiated spot area, while at the spot center the bacteria were evaporated exposing the enamel surface to direct laser irradiation. EDS analysis showed an increase in Ca/P ratio after irradiation of enamel covered with biofilm. FTIR analysis showed an approximately 40% carbonate loss in the irradiated enamel samples, including those with biofilms. CONCLUSION: Biofilms protect enamel surfaces from possible morphological irradiation damage without interfering with the resultant chemical changes that may increase the enamel resistance to acid attack. Therefore, under certain exposure regimens that are thermally and mechanically safe for enamel, CO2 laser irradiation of biofilms on dental hard tissues is suggested as a potential novel preventive treatment for controlling dental caries.

Laser all-ceramic crown removal-a laboratory proof-of-principle study-phase 1 material characteristics.

BACKGROUND AND OBJECTIVES: The removal of all-ceramic crowns is a time consuming and destructive procedure in the dental office. The removal of all-ceramic crowns using Er:YAG lasers has not been previously described in the scientific literature. The objective of this laboratory proof-of-principle study was to evaluate whether with regards to absorption and transmission characteristics of bonding cements and ceramics all-ceramic crowns can be removed from natural teeth using an Erbium laser. STUDY DESIGN/MATERIALS AND METHODS: The Fourier Transform Infrared Spectroscopy (FTIR) was used on flat ceramic samples (IPS Empress Esthetic (EE), E.max CAD, and E.max ZirCAD) to assess which infrared laser wavelengths transmit through the ceramics. Additionally, FTIR spectra for four bonding cements (Variolink Veneer, Variolink II, Multilink Automix, and SpeedCEM) were obtained. The Er:YAG laser energy transmission (wavelength 2,940 nm, 10 Hz repetition rate, pulse duration 100 µs at 126 mJ/pulse to 300 µs at 508 mJ/pulse) through different ceramic thicknesses was measured. Ablation thresholds for bonding cements were determined. Cement samples were directly irradiated or laser light was transmitted through ceramic samples. RESULTS: While the ceramics did not show any characteristic water absorption bands in the FTIR, all bonding cements showed a broad H2 O/OH absorption band. Some cements exhibited a distinct absorption peak at the Er:YAG laser emission wavelength. Depending on the ceramic thickness, EE and E.max CAD ceramics transmitted between 21 and 60% of the incident Er:YAG energy, with E.max CAD transmitting more energy than EE at comparable thicknesses. In contrast, E.max ZirCAD transmitted only 5-10% of the incident energy. Initial signs of cement deterioration occurred at 1.3-2.6 J/cm(2) . Multilink Automix, SpeedCEM, and Variolink II started ablation at 4.4-4.7 J/cm(2) . Variolink Veneer needed 44% less energy for ablation. CONCLUSION: Er:YAG laser energy can be transmitted through all-ceramic materials and those transmitted energies are sufficient for ablation of bonding cements.

In-vivo occlusal caries prevention by pulsed CO2 -laser and fluoride varnish treatment--a clinical pilot study.

BACKGROUND AND OBJECTIVES: High caries prevalence in occlusal pits and fissures warrants novel prevention methods. An 86% reduction in dental enamel smooth surface demineralization in-vivo following short-pulsed 9.6 µm-CO(2) -laser irradiation was recently reported. The objective of this study was to conduct a blinded 12-month-pilot clinical trial of occlusal pit and fissure caries inhibition using the same CO(2) -laser irradiation conditions. STUDY DESIGN/MATERIALS AND METHODS: Twenty subjects, average age 14 years, were recruited. At baseline, second molars were randomized into test and control groups, assessed by International Caries Detection & Assessment System (ICDAS-II), SOPROLIFE light-induced fluorescence evaluator in daylight and blue-fluorescence mode and DIAGNOdent. An independent investigator irradiated test molars with a CO(2) -laser, wavelength 9.6 µm, pulse-duration 20 µs, pulse-repetition-rate 20 Hz, beam diameter 800 µm, average fluence 4.5 ± 0.5 J/cm(2), 20 laser pulses per spot. At 3-, 6- and 12-month recall teeth were assessed by ICDAS, SOPROLIFE and DIAGNOdent. All subjects received fluoride varnish applications at baseline and 6-month recall. RESULTS: All subjects completed the 3-month, 19 the 6-month and 16 the 12-month recall. At all recalls average ICDAS scores had decreased for the test and increased for the control fissures (laser vs. control, 3-month: -0.10 ± 0.14, 0.30 ± 0.18, P > 0.05; 6-month: -0.26 ± 0.13, 0.47 ± 0.16, P = 0.001; 12-month: -0.31 ± 0.15, 0.75 ± 0.17, P < 0.0001; mean ± SE, unpaired t-test) being statistically significantly different at 6- and 12-month recalls. SOPROLIFE daylight evaluation revealed at 6- and 12-months statistically significant differences in changes between baseline and recall for test and control molars, respectively (laser vs. control, 6-month: 0.22 ± 0.13, 0.17 ± 0.09, P = 0.02; 12-month: 0.28 ± 0.19, 0.25 ± 0.17, P = 0.03). For SOPROLIFE blue-fluorescence evaluation mean changes in comparison to baseline for the control and the laser treated teeth were also statistically significant for the 6- and 12-month recall. CONCLUSION: Specific microsecond short-pulsed 9.6 µm CO(2) -laser irradiation markedly inhibits caries progression in pits and fissures in comparison to fluoride varnish alone over 12 months.

Mother and youth access (MAYA) maternal chlorhexidine, counselling and paediatric fluoride varnish randomized clinical trial to prevent early childhood caries.

BACKGROUND: Mexican-American children have a higher caries prevalence than the U.S. average. The Mothers and Youth Access (MAYA) study was a randomized clinical trial initiated to address this problem. AIM: Comparison of the efficacy of two prevention interventions in reducing early childhood caries (ECC). DESIGN: All 361 randomized mother-child dyads received oral health counselling. Beginning at 4 months postpartum, intervention mothers received chlorhexidine (CHX) mouthrinse for 3 months beginning 4 months postpartum and children received fluoride varnish (FV) every 6 months from age 12-36 months. Control group children received FV if precavitated lesions developed. Salivary mutans streptococci (MS) and lactobacilli were assessed. RESULTS: No significant difference in children's 36-month caries incidence between groups; 34% in each group developed caries [(d(2+) fs) > 0]. About half of control group developed precavitated lesions and received therapeutic FV. Maternal MS levels declined during CHX use, but increased when discontinued. CONCLUSIONS: Maternal postpartum CHX regimen, oral health counselling and preventive child FV applications were not more efficacious than maternal counselling with child therapeutic FV for precavitated lesions for ECC prevention. FV for young children with brief maternal CHX use and oral health counselling may need to be combined with additional or longer-term therapies to significantly reduce ECC in high-risk populations.

Caries detection using light-based diagnostic tools.

Modern caries treatment concepts like caries management by risk assessment--CAMBRA--entail diagnosing early caries lesions in a precavitated stage to make it possible to reverse the caries process with remineralization and bacteria reduction efforts. Newer, sensitive caries diagnostic tools can serve not only for early detection but also for monitoring of caries lesions to confirm the success of prevention and remineralization efforts. This article describes light-based caries diagnostic tools, with emphasis on fluorescence-based techniques, and compares the most common available fluorescence-based tools with a standardized visual caries inspection system-the International Caries Detection and Assessment System (ICDAS II). Fluorescence tools that provide high-resolution fluorescence pictures are likely to provide more reliable scores than fluorescence devices that assess via a single spot. The better visibility of the high-resolution fluorescence imaging could prevent unnecessary operative interventions.

Dental restorative materials containing quaternary ammonium compounds have sustained antibacterial action.

BACKGROUND: This narrative review addresses dental restorative materials with sustained antibacterial action, especially those containing quaternary ammonium compounds. Secondary caries occurs around restorations, causing further loss of mineral and breakdown of the restoration. Lesions adjacent to restorations account for more than 40% of needed restorations. Restorative materials with antibacterial properties will potentially solve this problem. TYPES OF STUDIES REVIEWED: Several groups are researching composite restorative materials that incorporate antibacterial agents. These agents are mostly exhausted over time. Newer studies involve materials that incorporate antibacterial microparticles that remain active and do not leach out. RESULTS: One such antibacterial agent, quaternary ammonium coupled with inorganic silica into minute particles (QASi), has been studied in the laboratory and in humans. QASi particles incorporated into dental materials retain their antibacterial action over time without leaching or loss of activity. A clinical in situ study in humans using dental composite containing QASi resulted in highly significantly less demineralization in the adjacent enamel than the control composite material. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Dental restorative materials that contain QASi have sustained antibacterial properties, have mechanical properties comparable to those of presently marketed materials, and have been cleared by the US Food and Drug Administration. Clinical studies have shown that composites incorporating QASi have the potential to markedly reduce the occurrence of caries around restorations. Because caries around restorations is a major problem, restorative materials with sustained antibacterial properties will have an important effect in reducing secondary caries around restorations.

Recommendation for a non-animal alternative to rat caries testing.

PURPOSE: As a requirement of the Food & Drug Administration's final monograph on "Anticaries drug products for over-the-counter human use", the toothpaste industry has been conducting animal caries tests on every fluoride-containing toothpaste introduced into the U.S. market since 1996. The practice of testing in animals, although required by law, is in stark conflict with the corporate policy of many U.S. and global toothpaste manufacturers, in which, if possible, alternatives to animal testing are utilized. A provision does exist within the regulation which allows the use of an alternative method to demonstrate efficacy. However, to take advantage of this provision, a petition must be submitted to the FDA and in this petition data demonstrating the alternative provides results of "equivalent accuracy" must be included. After many years of research, model development and model comparisons, we have identified one particular laboratory model that demonstrated excellent correlation with the currently accepted animal caries models. This model, known as the Featherstone pH cycling model, is discussed in this paper. METHODS: The Featherstone pH cycling model has been shown to produce results of equivalent accuracy to the animal caries model by: (1) demonstrating a clinically relevant fluoride dose response similar to that shown in the animal caries model (including 1100 ppm F, 250 ppm F and placebo); (2) demonstrating similar results to the animal caries model for clinically proven dentifrice formulations relative to positive and negative controls; (3) demonstrating discriminating ability in strong agreement with the animal caries model for differentiating between a dentifrice formulation with attenuated fluoride activity and a USP standard; and (4) providing a clinically relevant representation of the caries process, as demonstrated by orthodontic banding studies. In addition, the model sufficiently addresses both salivary and abrasive/anticalculus agent interference concerns. RESULTS: For more than 50 years, fluoride has been the first defense in the fight against dental caries. The clinical effectiveness of fluoride is well accepted and documented extensively in the literature. The mechanism through which fluoride provides its benefit is very straightforward and well understood. The proposed laboratory model effectively simulates the effect of the caries process and has been shown to demonstrate equivalent accuracy to animal caries. This indicates that there are strong scientific grounds for the use of this model as an alternative to the animal caries test. Based on the strength of the data and the correlations noted between the two models, we recommend that the scientific community and the toothpaste industry broadly accept the Featherstone laboratory pH cycling model as an appropriate alternative to animal testing, particularly for ionic fluoride based dentifrices.

The Featherstone laboratory pH cycling model: a prospective, multi-site validation exercise.

PURPOSE: To demonstrate the robustness of the Featherstone pH cycling model when tested in three independent laboratories and to evaluate the use of "non-inferiority" testing at those laboratories. METHODS: The fundamental principles for the Featherstone laboratory pH cycling model to be an appropriate alternative to animal testing is that it must demonstrate equivalent accuracy to the "Gold Standard" (rat caries model) by: (1) providing a meaningful representation of the caries process; (2) demonstrating a proportionate response to fluoride dose (or concentration); (3) being able to show that clinically proven formulations perform similarly relative to the controls; and (4) differentiating products that have attenuated fluoride activity. RESULTS: This cross-validation study confirmed the ability of the three independent laboratories to discriminate between various concentrations of fluoride-containing dentifrice formulations, demonstrated that clinically proven formulas perform as expected and identified an attenuated fluoride formulation (NaF/CaCO3 dentifrice - 1100 ppm NaF) as inferior compared to the 1100 ppm F (NaF/silica) positive control.

Caries risk assessment and management for the prosthodontic patient.

Prosthodontic patients are often at a high risk for caries, and assessing that risk prior to treatment is important. Historically, the nature of dental education and clinical practice has oriented clinicians toward recognizing and correcting the damaging effects of caries, rather than actively assessing and managing caries risk potential. New developments have led to better diagnostics and protocols for caries management, although one adapted to the specific needs of the prosthodontic patient has not been proposed. Our purpose is to outline caries risk assessment and management for the prosthodontic patient.

A view from both sides.

This letter to the editor is from one of the key figures in caries management by risk assessment. Dr. Featherstone brings a unique perspective to the access issue. He grew up in New Zealand and experienced care under the dental therapist provider model. His letter is included here because it complements the other articles by providing his views on CAMBRA in the context of addressing barriers to care.

Validation of the CDA CAMBRA caries risk assessment--a six-year retrospective study.

The present manuscript presents the results of a six-year retrospective study validating caries risk assessment in a caries management by risk assessment program in a large predominantly adult patient population seeking dental care. CRA was successful in accurately identifying patients at high caries risk. Caries risk assessment in a CAMBRA program is a good clinical tool for everyday dental practice.

Changing the face and practice of dentistry: a 10-year plan.

Jan. 7 through 9, 2011, the California Dental Association Foundation hosted a symposium on caries management by risk assessment in which a diverse range of stakeholders from across the nation gathered to discuss current and future status of CAMBRA. The consensus of the group was to develop a national strategic plan for CAMBRA implementation which will chart the course to improve the standard in caries disease management within the next decade. This paper represents the initial start of this living document.

A Comparison of Four Caries Risk Assessment Methods.

Introduction: Caries risk assessment (CRA) is essential as the basis for successful management of dental caries. Of the many published CRA tools, four well-known ones are CAMBRA, Cariogram, American Dental Association (ADA), and American Academy of Pediatric Dentistry (AAPD) CRAs. The predictive accuracy of CAMBRA and Cariogram CRA tools have been examined in clinical outcomes studies in thousands of patients and the tools are widely used all over the world. The purpose of the present paper is three-fold, namely (1) to briefly review, compare and contrast these four CRA methods, (2) to provide a concise method for CRA introducing a quantitative component to the CAMBRA forms (CAMBRA 123), and (3) to guide the choice of CRA methods that will support caries management decisions. Comparison of Caries Risk Assessment Methods: In the present evaluation, the above-mentioned four CRA methods for ages 0-6 years and 6 years-adult were compared using 26 hypothetical patients (13 per age group). Comparison results show that Cariogram and CAMBRA categorized patients into identical risk categories. Each of the ADA and AAPD tools gave different results than CAMBRA and Cariogram in several comparison examples. CAMBRA 123 gave the same caries risk level results as the Cariogram and the CAMBRA methods for all hypothetical patients for both age groups. Conclusions: Both the Cariogram and the CAMBRA CRA methods are equally useful for identifying the future risk of dental caries. CAMBRA 123 shows promise as an easy-to-use quantitative method for CRA in clinical practice. The health care providers will be the ones to decide which CRA method will allow them to establish individualized, successful caries management therapies and how to combine these for the best care of their patients.