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.

The objective of this study was to estimate the caries impact of providing training in infant feeding guidelines to workers at Brazilian public primary care clinics. In a cluster-randomized controlled trial (n = 20 clinics), health care workers either were trained in guidelines for infant nutrition, stressing healthful complementary feeding, or were assigned to a 'usual practices' control, which allowed for maternal counseling at practitioner discretion. Training occurred once; the amount of counseling provided to mothers was not assessed. Eligible pregnant women were enrolled to follow health outcomes in their children. Early childhood caries (ECC) was measured at age three years (n = 458 children). The overall reductions in ECC (relative risk, 0.92; 95%CI, 0.75, 1.12) and severe ECC (RR, 0.87; 95%CI, 0.64, 1.19) were not statistically significant. There was a protective effect among mothers who remained exclusively at the same health center (S-ECC RR, 0.68; 95%CI, 0.47, 0.99) and among those naming the health center as their principal source of feeding advice (S-ECC RR, 0.53; 95%CI, 0.29, 0.97). Health care worker training did not yield a statistically significant reduction in caries overall, although caries was reduced among children of mothers more connected to their health centers.

Objectives

Increasing dentists' visibility in the media to make the case for sugary beverage taxes can help advance public policy that improves oral health outcomes. We assessed California dentists' media engagement behaviors related to sugar restriction policies for dental caries prevention and correlates of engaging in such behavior.

Methods

Survey items related to sugar policies and media engagement were embedded in an electronically distributed statewide survey of dentists' tobacco cessation counseling behaviors. Descriptive statistics were calculated for respondent characteristics, perceived professional responsibility to discuss selected topics with patients, and attitudes and behaviors related to sugar restriction policy and media communication. Multivariable models identified independent correlates of media engagement.

Results

Of 624 respondents, most had never talked to traditional media (78%) or posted to social media (64%) about sugar or sugar policies for dental caries prevention. Respondents with the highest level of media engagement were more likely to agree that sugary beverage taxes are effective at reducing dental caries, that they had support from dental professional organizations to talk to the media, that it is realistic for patients to reduce their sugar consumption, and that sugar and sugary drinks are extremely harmful to health.

Conclusions

Efforts to increase dentists' media engagement related to sugar restriction policies for dental caries prevention should address dentists' negative attitudes toward the effectiveness of sugar restriction policies and may require increased support from dental professional societies.

Knowledge transfer statement

Study findings identify dentists' low engagement in media advocacy to support sugar restriction policy adoption. The results identify correlates of media engagement and of dentists' willingness and confidence to act, which could serve to inform interventions to support and enhance engagement.

Interdental cleaning is routinely recommended, despite limited evidence supporting efficacy to prevent advanced oral disease endpoints, such as caries and periodontal disease. We aimed to examine associations between interdental cleaning and oral health in a large, generalizable prospective cohort of adults in the United States. Data were drawn from wave 3 (2015 to 2016, n = 26,086 included in analysis) and wave 4 (2016 to 2018, n = 22,585) of the adult component (age ≥18 y) of the nationally representative Population Assessment of Tobacco and Health Study. Survey-weighted multivariable regression models estimated the associations between wave 3 weekly interdental cleaning frequency and 6 measures of self-reported oral health-overall rating, tooth extractions, gum bleeding, loose teeth, bone loss around teeth, and gum disease-cross-sectionally and prospectively, with adjustment for established periodontal disease risk factors. As compared with no interdental cleaning, interdental cleaning ≥7 times/wk was prospectively associated with greater odds of excellent self-rated oral health (adjusted odds ratio, 1.37; 95% CI, 1.17 to 1.62), lower odds of bleeding gums (adjusted odds ratio, 0.62; 95% CI, 0.54 to 0.70), but not statistically significantly lower odds of other oral health conditions in the following 12 mo. Older age, lower socioeconomic status, diabetes, and cigarette smoking were consistently associated with worse oral health across all outcome measures. Findings were largely robust to alternative model and variable specifications. Interdental cleaning is associated with better perceived oral health and less self-reported gingivitis. Prevention of more advanced disease states was not demonstrated. These findings should be interpreted cautiously given the self-reported nature of the measures and relatively short follow-up period.

Objective

Although several studies have found an association between excessive gestational weight gain (GWG) and obesity later in life, to the best of our knowledge, no studies have explored the role of GWG events across the life course.

Design and methods

We describe how the prevalence of midlife obesity (BMI⩾30 at age 40 or 41) among women varies by life course patterns of GWG (using 2009 IOM guidelines) in the USA's National Longitudinal Survey of Youth 1979 cohort.

Results

Among women who reported 1-3 births before age 40, the prevalence of midlife obesity increased with a rising number of excessive GWG events: from none (23.4%, n=875) to one (37.6%, n=707), from none (23.4%, n=875) to two (46.8%, n=427) and from none (23.4%, n=875) to three (54.6%, n=108), P<0.00005 for trend. Obesity prevalence was similar for the same number of excessive GWG events, regardless of parity. No clear pattern emerged for the sequencing of excessive GWG event(s) and later obesity.

Conclusions

In our descriptive exploratory study, excessive GWG events appear to be associated with increased prevalence of obesity for parous women, suggesting the importance of preventive interventions regardless of timing of pregnancy-related weight changes over the life course.

To demonstrate that Caries Management by Risk Assessment (CAMBRA) can be successfully implemented in dental practice, 30 dentists were recruited to perform a 2-y CAMBRA trial. Twenty-one dentists (18 private practices, 3 community clinics) participated in a randomized, controlled, parallel-arm, double-blind clinical trial with individual-level assignment of 460 participants to standard of care (control) versus active CAMBRA treatment (intervention). Control or active antimicrobial and remineralizing agents were dispensed at baseline and 6-, 12-, 18-, and 24-mo recall visits according to risk level and assigned treatment arm. Primary outcome measure was dentist-determined caries risk level at recall. Among initially high-risk participants, secondary outcomes were recorded disease indicators. Generalized estimating equations were used to fit log-linear models for each outcome while accounting for repeated measurements. At 24 mo, follow-up rates were 34.3% for high-risk participants (32.1% intervention, 37.1% control) and 44.2% for low-risk participants (38.7% intervention, 49.5% control). Among 242 participants classified as high caries risk at baseline (137 intervention, 105 control), a lower percentage of participants remained at high risk in the intervention group (statistically significant at all time points). At 24 mo, 25% in the intervention group and 54% in the control group remained at high risk ( P = 0.003). Among 192 participants initially classified as low risk (93 intervention, 99 control), most participants remained at low risk. At 24 mo, 89% in the intervention group and 71% in the control group were low caries risk ( P = 0.18). The percentage of initially high-risk participants with recorded disease indicators decreased over time in both intervention and control groups, being always lower for the intervention group (statistically significant at the 12- and 18-mo time point). In this practice-based clinical trial, a significantly greater percentage of high-caries-risk participants were classified at a lower risk level after CAMBRA preventive therapies were provided. Most participants initially assessed at low caries risk stayed at low risk (ClinicalTrials.gov NCT01176396).

Objectives

California features low smoking prevalence, cautionary electronic cigarette (e-cigarette) public messaging, and legal recreational cannabis: a unique landscape for dental professionals to navigate tobacco cessation promotion. This cross-sectional study assessed California dental professionals' self-reported tobacco patient counseling behaviors and the correlates of providing such assistance.

Methods

Statewide surveys of dental hygienists (n = 701) and dentists (n = 725) were distributed electronically. The dentist survey was weighted for sampling and nonresponse. Prevalence of asking patients about use was compared for cigarette and noncigarette products (e.g., e-cigarettes, cannabis). Multivariable models identified independent correlates of providing cessation assistance to tobacco-using patients.

Results

Respondents reported frequently (often/always) documenting patient tobacco use (hygienists: 80%; dentists: 73%) but less commonly provided forms of assistance (hygienists: 27%-49%; dentists: 10%-31%). Most respondents asked patients about cigarette smoking, but noncigarette product use (cigar, hookah, pipe, e-cigarette, or cannabis) was not commonly assessed. Greater confidence and willingness to assist were positively associated with providing assistance in multivariable models, but perceived barriers (e.g., lack of time and remuneration) were not. Results were robust to model specifications.

Conclusions

California dental professionals often ask about smoking but lag in providing cessation assistance and inquiring about noncigarette products. Successful efforts to encourage dental professionals' engagement in tobacco prevention and cessation must enhance providers' self-efficacy and motivation and likely will require system and organizational change.

Knowledge transfer statement

Study findings identify substantial gaps in dental professionals' engagement in patient tobacco cessation. The results identify correlates of providing assistance and of dental professionals' willingness and confidence to do so, which could serve to inform interventions to support and enhance engagement.

The Caries Management By Risk Assessment (CAMBRA) randomized controlled trial showed that an intervention featuring combined antibacterial and fluoride therapy significantly reduced bacterial load and suggested reduced caries increment in adults with 1 to 7 baseline cavitated teeth. While trial results speak to the overall effectiveness of an intervention, insight can be gained from understanding the mechanism by which an intervention acts on putative intermediate variables (mediators) to affect outcomes. This study conducted mediation analyses on 109 participants who completed the trial to understand whether the intervention reduced caries increment through its action on potential mediators (oral bacterial load, fluoride levels, and overall caries risk based on the composite of bacterial challenge and salivary fluoride) between the intervention and dental outcomes. The primary outcome was the increment from baseline in decayed, missing, and filled permanent surfaces (ΔDMFS) 24 mo after completing restorations for baseline cavitated lesions. Analyses adjusted for baseline overall risk, bacterial challenge, and fluoride values under a potential outcome framework using generalized linear models. Overall, the CAMBRA intervention was suggestive in reducing the 24-mo DMFS increment (reduction in ΔDMFS: -0.96; 95% confidence interval [CI]: -2.01 to 0.08; P = 0.07); the intervention significantly reduced the 12-mo overall risk (reduction in overall risk: -19%; 95% CI, -7 to -41%;], P = 0.005). Individual mediators, salivary log10 mutans streptococci, log10 lactobacilli, and fluoride level, did not represent statistically significant pathways alone through which the intervention effect was transmitted. However, 36% of the intervention effect on 24-mo DMFS increment was through a mediation effect on 12-mo overall risk (P = 0.03). These findings suggest a greater intervention effect carried through the combined action on multiple aspects of the caries process rather than through any single factor. In addition, a substantial portion of the total effect of the CAMBRA intervention may have operated through unanticipated or unmeasured pathways not included among the potential mediators studied.

Objective

To calculate the association of maternal salivary bacterial challenge (mutans streptococci [MS] and lactobacilli [LB]) from pregnancy through 24 months' postpartum with child caries incidence (≥1 cavitated or restored teeth) at 36 months.

Materials & methods

Dental, salivary bacterial, sociodemographic, and behavioral measures were collected at three- to six-month intervals from a birth cohort of low-income Hispanic mother-child dyads (N = 243). We calculated the relative child caries incidence, adjusted for confounding, following higher maternal challenge of MS (>4500 colony-forming units per milliliter of saliva [CFU/mL]) and LB (>50 CFU/mL) based on multivariable models.

Results

Salivary MS and LB levels were greater among mothers of caries-affected children versus caries-free children. Mothers with higher salivary MS challenge were more likely to have MS-positive children (>0 CFU/mL), but maternal LB challenge was not a statistically significant predictor of child LB-positive status. Adjusting for sociodemographics, feeding and care practices, and maternal dental status, higher maternal salivary challenge of both MS and LB over the study period predicted nearly double the child caries incidence versus lower MS and LB (cumulative incidence ratio: 1.9; 95% confidence interval: 1.1, 3.8).

Conclusion

Maternal salivary bacterial challenge not only is associated with oral infection among children but also predicts increased early childhood caries occurrence.