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, 29 (1), 9-14

The Evidence for Caries Management by Risk Assessment (CAMBRA®)


The Evidence for Caries Management by Risk Assessment (CAMBRA®)

J D B Featherstone et al. Adv Dent Res.


A system for Caries Management by Risk Assessment (CAMBRA®) has been developed in California. The purpose of this article is to summarize the science behind the methodology, the history of the development of CAMBRA, and the outcomes of clinical application. The CAMBRA caries risk assessment (CRA) tool for ages 6 y through adult has been used at the University of California, San Francisco (UCSF), for 14 y, and outcome studies involving thousands of patients have been conducted. Three outcomes assessments, each on different patient cohorts, demonstrated a clear relationship between CAMBRA-CRA risk levels of low, moderate, high, and extreme with cavitation or lesions into dentin (by radiograph) at follow-up. This validated risk prediction tool has been updated with time and is now routinely used at UCSF and in other settings worldwide as part of normal clinical practice. The CAMBRA-CRA tool for 0- to 5-y-olds has demonstrated similar predictive validity and is in routine use. The addition of chemical therapy (antibacterial plus fluoride) to the traditional restorative treatment plan, based on caries risk status, has been shown to reduce the caries increment by about 20% to 38% in high-caries-risk adult patients. The chemical therapy used for high-risk patients is a combination of daily antibacterial therapy (0.12% w/v chlorhexidine gluconate mouth rinse) and twice-daily high-concentration fluoride toothpaste (5,000 ppm F), both for home use. These outcomes assessments provide the evidence to use these CRA tools with confidence. Caries can be managed by adding chemical therapy, based on the assessed caries risk level, coupled with necessary restorative procedures. For high- and extreme-risk patients, a combination of antibacterial and fluoride therapy is necessary. The fluoride therapy must be supplemented by antibacterial therapy to reduce the bacterial challenge, modify the biofilm, and provide prevention rather than continued caries progression.

Keywords: caries risk assessment; chlorhexidine; dental caries; dental plaque; disease indicators; fluoride.

Conflict of interest statement

The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.


Figure 1.
Figure 1.
Mean (SE) log of mutans streptococci counts in saliva (colony-forming units per milliliter) at baseline and at follow-up visits every 6 mo in a randomized controlled clinical trial that examined caries management by risk assessment using chemical intervention therapy (Featherstone et al. 2012). Between sampling visits 1 and 3, all restorative work was completed. Visits 3 to 7 represent the 2-y period between “restorations complete” and the final examination. The upper line is the control group (conventional dental and restorative treatment). The lower line is the intervention group that received chlorhexidine rinse and fluoride toothpaste.
Figure 2.
Figure 2.
Percentage of adult patients with evident cavitation or caries into dentin (by radiograph) at follow-up, stratified by risk level assessed at baseline: n = 12,954 at baseline and n = 2,571 at the follow-up examination.
Figure 3.
Figure 3.
Percentage of children, aged 0 to 5 y, with evident dental decay at follow-up, stratified by caries risk status at baseline (Chaffee et al. 2016): n = 3,810 at baseline and n = 1,315 at the follow-up examination.

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