Download Adopting caries risk assessment in all practice environments

Adopting caries risk assessment
in all practice environments
Claire Mills, BS ¢ Piyush Patel, DDS
Caries management by risk assessment (CAMBRA) is
an evidence-based model intended to provide dentists
with a protocol for diagnosis, treatment, and prevention
of caries by assessing and addressing a patient’s overall
oral health. The aim of this review was to examine the
literature on CAMBRA to determine its efficacy. Clinical
studies demonstrate that the CAMBRA approach is an
effective concept that is both predictive of dental caries
development and accurate in outlining appropriate
treatment options and preventive strategies that can
reduce the morbidity of this common disease process
across all patient demographics.
Received: March 26, 2015
Accepted: June 8, 2015
D
ental caries is a complex multifactorial disease that
cannot be controlled by reactive treatments such as
restorations or extractions alone. Evaluating each
individual’s risk for dental caries via caries risk assessment
(CRA) and developing an individualized, evidence-based
treatment plan allows identification of at-risk patients, thus
preventing future disease.1 Clinical studies have indicated that
caries management by risk assessment (CAMBRA) is both
predictive of dental caries development and accurate in outlining appropriate treatment options and preventive strategies
for patients of all demographics.2,3 The use of CAMBRA is
not limited to general dentists; dental specialists and healthcare providers can incorporate caries management into their
practices at minimal financial cost. Most patients who utilize
the treatment options offered by CAMBRA will see long-term
positive outcomes.3
One of the most expensive—yet preventable—healthcare
problems facing the United States today is dental caries.4
Dental caries is an infectious transmissible disease process
caused by a complex cariogenic biofilm, which, in the presence
of a susceptible oral environment, results in demineralization
and eventual cavitation of hard dental tissue.4 According to
the American Dental Association Health Policy Resources
Center, dental emergency department (ED) visits cost the US
healthcare system approximately $2 billion annually.5 This
is primarily because the number of dental patients presenting to the ED has risen greatly, from 1.1 million in 2000 to
2.1 million in 2010, which is proportionally greater than
the growth of the US population.5,6 Approximately 42% of
these dental ED visits were a direct result of dental caries.5
Emergency department treatment for dental caries is primarily limited to prescriptions for pain medicine and antibiotics.7
One of the main reasons cited as to why people with dental
caries present at the ED is that they are either unaware of
preventive measures to stop dental caries or have not implemented these practices into their lifestyle.5 Because ED treatment often does not address the actual source of caries, the
disease worsens, and patients may require extensive treatment
in the future. Infections requiring hospital stays and oral surgery as a consequence of untreated caries are still a common
problem in hospitals (Fig 1).5,6
Caries prevalence
Dental caries is a severe problem facing most people in the
world. Data from the World Health Organization in 2012
revealed that 60%-90% of schoolchildren and nearly 100% of
adults worldwide had dental caries.8 Additionally, 30% of adults
65-74 years of age had no teeth at all.8 This indicates a clear
trend that, as people age, caries rates and cavity severity will
increase, resulting in many cases that will necessitate either
extraction or extensive restoration of affected teeth.
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GENERAL DENTISTRY July/August 2016
A
B
Fig 1. Odontogenic infection in a 50-year-old woman who presented to a hospital in Atlanta,
Georgia, with a history of recurrent pain from her mandibular right first molar. A. Panoramic
radiograph at the time of presentation. B. The carious lesion associated with the first molar
had progressed to an infection requiring extensive treatment and hospitalization.
Data from the National Institutes of Health revealed that
the percentage of people with dental caries increases from
21% of children (6-11 years) to 59% of adolescents (12-19 years)
to 92% of adults (20-64 years) to 93% of seniors (65 years and
older).9 The severity of dental caries also worsens as people
grow older.5 The number of decayed, missing, and filled teeth
(DMFT) measures, on average, how many teeth are affected
by dental caries. In the United States, the DMFT per person
in permanent teeth starts at 0.19 in children aged 6-11 years.9
The number then rises to 2.55 in adolescents. Young adults
(20-34 years) have a DMFT of 6.16, which increases to 10.91
in older adults (35-49 years). People 50-64 years of age have
a DMFT of 15.05, and those aged 65 years and older have an
average DMFT of 17.96.9 Across all age groups, approximately
21.75% of people have untreated dental caries.9 Untreated
dental caries never improves; it only worsens over time, causing patients severe pain and discomfort. These data illustrate
not only that more people experience dental caries as they age
but also that (on average) significantly more teeth are affected.9
Dental caries is also a severe problem in other developed
countries. In the United Kingdom, the Child Dental Health
Survey is commissioned every 10 years to determine the caries
rates in children. Results from the 2013 survey indicated that
46% of 8 year olds had experienced dental caries.10 Similarly, in
Norway, results from a study conducted in 2004 indicated that
12-year-old children experienced a dental caries rate of 59.8%,
compared to 52.2% in the same age group in 2002.11
Data from emerging and developing countries also illustrate
that dental caries is a severe health problem. Data from China
in 2008 indicated that individuals aged 5-74 years had a 100%
caries rate.11 In India, the caries rates were 53.8% for 12-year-old
children, 80.2% for adults (35-44 years), and 85.0% for seniors
(65-74 years).11 A 2006 study of Russian military personnel
showed that 100% had dental caries.11 While more research is
needed in these nations to accurately establish a trend between
age and dental caries rate, the high percentages of those with
dental caries in isolated age groups illustrates the severity of the
problem in older people. The startlingly high numbers from these
emerging and developing countries may illustrate a positive trend
between a country’s industrialization and caries rates. As nations
become developed, many people leave rural farming life for urban
labor, resulting in negative changes in diet, lifestyle, and health.11
Fig 2. White-spot lesions located at the
cervical aspects of the posterior teeth.
Caries development
A common misunderstanding in the general public regarding
cavities is the assumption that dental caries and cavities are
synonymous. Cavities are the end result of dental caries. Many
species of bacteria contribute to dental caries, including streptococci (Streptococcus salivarius, Streptococcus sanguis, and
Streptococcus sobrinus), lactobacilli (Lactobacillus acidophilus
and Lactobacillus casei), and actinomycetes (Actinomyces viscosus and Actinomyces naeslundii). The dominant organisms
of dental caries, however, are Streptococcus mutans (MS) and
Lactobacillus acidophilus (LB), which are both acidogenic (acid
producing) and aciduric (able to live in low pH environments).4
Streptococcus mutans is considered to be the most harmful
bacteria in cases of dental caries, due to its ability to metabolize
sucrose more effectively than other bacteria, a regulatory system
that stimulates the conversion of dietary carbohydrates to acid,
and its ability to survive long periods of sugar starvation.12
Streptococcus mutans metabolizes fermentable carbohydrates
and creates organic acids—such as lactic, acetic, formic, and
propionic acids—as by-products.4 These acids diffuse into the
tooth, and, when they reach a susceptible site on a crystal surface, calcium and phosphate are dissolved into the surrounding
aqueous phase. If caries is left untreated, the end result will be a
cavity.4 The earliest clinical sign that dental caries is in progress
is known as the white-spot lesion, a subsurface noncavitated
carious lesion (Fig 2). In the initial stages, demineralization
can only be seen at the electron microscopic level. As demineralization progresses, the mineral loss advances deeper into
the enamel or exposed dentin until it can be detected visually,
radiographically, or by other optical methods, such as laserinduced fluorescence.4
A carious lesion that is noncavitated, especially if it is
in the enamel, can be reversed or arrested chemically.
Remineralization is a natural repair process for white-spot
lesions. Calcium and phosphate, primarily found in saliva (or
other topical sources), diffuses into the tooth, and, with the
help of fluoride, builds on existing crystal remnants rather
than forming new crystals entirely.4 The new crystal surface,
fluorapatite, is composed of a veneer of calcium, phosphate, and
fluoride (dependent on the amount of fluoride present). The
new layer is much more acid resistant due to a lower solubility
than the original mineral.4
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Adopting caries risk assessment in all practice environments
This process of mineralization is cyclic; for tooth decay to occur,
a combination of factors must be present: salivation levels must be
insufficient, a high concentration of bacteria must be present, and
the patient must be consuming a sufficient amount of carbohydrates.4,13 While cavitated lesions form over long periods of time,
several disease indicators exist in order to identify whether caries
disease is present. These include visible cavities, radiographic
proof of dentin penetration or proximal enamel lesions, white
spots on smooth enamel surfaces, and a history of placement of
dental restorations in the last 3 years.13 These indicators illustrate
that tooth decay either has happened or is rapidly occurring. They
can also be indicative of whether future cavities will form.
In addition to the aforementioned indications that the disease
of caries is present, a concise list of risk factors has been identified to accurately predict whether cavities will form. These
include a medium to high concentration of bacteria, visibly
heavy plaque build-up on teeth, frequent snacking between daily
meals, deep pits and fissures, recreational drug and/or tobacco
use, hyposalivation, saliva-reducing factors (such as certain
medications), exposed roots, and orthodontic appliances.14 The
more risk factors a patient has, the more likely irreversible tooth
decay will develop.
Disease
indicators
•White spots
•Restorations
<3y
•Enamel lesions
•Cavities/dentin
Caries progression
Risk factors
•Bad bacteria
•Absence of saliva
•Dietary habits
(poor)
Protective
factors
•Saliva and
sealants
•Antibacterials
•Fluoride
•Effective diet
No caries
Fig 3. The caries imbalance. (Adapted from Featherstone JD,
Domejean-Orliaquet S, Jenson L, Wolff M, Young DA. Caries risk
assessment in practice for age 6 through adult. J Calif Dent Assoc.
2007;35(10):703-707, 710-713.13 Reprinted with permission from the
California Dental Association. Copyright © October 2007.)
Caries management by risk assessment is an evidence-based
model that addresses a patient’s overall oral health as opposed
to a restorative/surgical model that only addresses an individual
tooth. CAMBRA evaluates the presence of disease indicators
and assesses the patient’s risk based on biological, behavioral,
and medical history factors. Its purpose is to provide clinicians
with a protocol for diagnosis, treatment, and prevention of
caries, including nonsurgical means to repair tooth structure.14
After assigning patients to a risk category of low, moderate,
high, or extreme risk, a clinician can provide the patient with a
personalized plan to halt dental caries.
category is based on criteria regarding their own biology and
behavior. Ideal salivary flow should be greater than 1 mL/min.
Salivary flow can be easily measured by having the patient chew
gum and then collecting all saliva produced over 5 minutes in a
cup. Measuring this quantity will reveal whether the patient is
hyposalivating (0.07-0.99 mL/min, mild hyposalivation; less than
0.05 mL/min, severe hyposalivation).13
After the patient is assigned a risk category based on responses
to the questionnaire and the clinician’s judgment, the patient can
be given a personalized recommendation letter detailing treatment options. A follow-up letter can also be generated and individualized for each patient. Stock letters that detail treatment
recommendations in lay language for each risk category can be
made available for distribution within any practice.
Assessment factors and indicators
Treatment
CAMBRA
Figure 3 presents the CAMBRA model as a metaphorical seesaw
illustrating that, for caries to progress to cavities beyond reversible repair, a clear imbalance must be struck.13 In the cases where
there is a progression in caries, protective factors are insufficient, risk factors are present, and disease indicators confirm
damage has been done.
In order to assign patients to a risk level, a group of experts
from the California Dental Association (CDA) developed CRA
forms, which are subdivided into categories based on risk factors, protective factors, and disease indicators.2,14-16 These forms
are commonly known as CDA CRA forms. Disease indicators
automatically put the patient into a high or extreme risk category because visible dental damage can be seen. Additionally,
if the patient says yes to any of the disease indicators, a bacterial
culture should be taken to better evaluate risk factors.13 Simpleto-use products that can be used in-office to determine bacterial
counts (MS and LB) are readily available to any practitioner. Risk
evaluation forms are available from multiple sources. Figure 4
presents a CDA CRA form for patients aged 6 years and older.13
Children aged 0-5 years are assigned a risk category based on
criteria related to the biology and behavior of both the mother
and child.16 For patients 6 years and older, the assigned risk
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GENERAL DENTISTRY July/August 2016
Recommended treatments for patients aged 6 years and older
in each risk category are detailed in the Table.15 One strategy is
the use of xylitol, a naturally occurring, diabetic-safe, low-calorie
sugar that MS are unable to metabolize.17 The bacteria are unable
to process xylitol, resulting in starvation similar to that which
occurs when sucrose is removed from the diet. Xylitol also prevents MS from colonizing the mouth, as it inhibits attachment
to teeth. Because xylitol gums and mints stimulate salivary flow,
the buffering capacity and remineralization ability of saliva are
drawn in as well. The consequential neutral pH environment
favors nonacidogenic bacteria.17 Xylitol-containing gums, mints,
candy, and cookies have been clinically shown to decrease
caries, reverse carious lesions, and stop vertical transmission
of bacteria from mother to child.17 To achieve positive effects,
approximately 6-10 g of xylitol per day is recommended.17
Two other antibacterial solutions exist as well. Chlorhexidine
(CHX) and 1% iodine treatment have been shown to reduce
MS.17 Chlorhexidine attaches to bacteria over a period of
4-12 hours and works by attacking the cell walls, making
it effective against a broad spectrum of microorganisms.17
However, LB counts are not affected as significantly by CHX
as are MS counts.17 Alternatively, 1% iodine treatment has been
Patient name:____________________________________ Chart No.:_____________________ Date:_____________________________
Assessment date:__________________________________ Is this (please check)  Baseline or  Recall
Disease indicators (Any one Yes signifies likely “high risk” and to do a bacteria test**)
Yes = Circle Yes = Circle Yes = Circle
Visible cavities or radiographic penetration of the dentin
Yes
Radiographic approximal enamel lesions (not in dentin)
Yes
White spots on smooth surfaces
Yes
Restorations in last 3 years
Yes
Risk factors (biological predisposing factors)
MS and LB both medium or high (by culture**)
Yes
Visible heavy plaque on teeth
Yes
Frequent snack (> 3× daily between meals)
Yes
Deep pits and fissures
Yes
Recreational drug use
Yes
Inadequate saliva flow by observation or measurement (**if measured, note the flow rate below)
Yes
Saliva-reducing factors (medications/radiation/systemic)
Yes
Exposed roots
Yes
Orthodontic appliances
Yes
Protective factors
Lives/work/school fluoridated community
Yes
Fluoride toothpaste at least once daily
Yes
Fluoride toothpaste at least 2× daily
Yes
Fluoride mouthrinse (0.05% NaF) daily
Yes
5000-ppm fluoride toothpaste daily
Yes
Fluoride varnish in last 6 months
Yes
Office fluoride, topical, in last 6 months
Yes
Chlorhexidine prescribed/used 1 week each of last 6 months
Yes
Xylitol gum/lozenges 4× daily last 6 months
Yes
Calcium and phosphate paste during last 6 months
Yes
Adequate saliva flow (> 1 mL/min stimulated)
Yes
** Bacteria/saliva test results: MS:________ LB:_______ Flow rate:________ mL/min Date:________
Visualize caries balance (use circled indicators/factors above)
Extreme risk = high risk + severe salivary gland hypofunction
Caries risk assessment (please check)
 Extreme  High  Moderate  Low
Dentist signature:_______________________________________________________________ Date:_____________________________
Fig 4. California Dental Association Caries Risk Assessment (CDA CRA) form for ages 6 years through adulthood. LB, lactobacilli; MS,
mutans streptococci; NaF, sodium fluoride. (Adapted from Featherstone JD, Domejean-Orliaquet S, Jenson L, Wolff M, Young DA. Caries
risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703-707, 710-713.13 Reprinted with permission from the
California Dental Association. Copyright © October 2007.)
used to combat gram-positive and gram-negative bacteria,
fungi, mycobacteria, viruses, and protozoans. This treatment
can be used effectively against MS and LB in the mouth.17
Clinical studies illustrate that a 1% iodine treatment applied
topically is very effective in children, but there is limited evidence that it is effective for adults.17
Healthy patients are able to produce sufficient saliva such
that remineralization of carious lesions can occur with the help
of calcium and phosphate. Saliva acts protectively in that it
lubricates the mouth, buffers the pH of the mouth, and acts as
an antimicrobial.17 However, many adults suffer from hyposalivation and thus are unable to stop the demineralization process.
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69
Adopting caries risk assessment in all practice environments
Table. Caries management by risk assessment: clinical guidelines for patients 6 years of age and older. a
Risk
level
Frequency
of radiographs
Frequency
of caries recall
examinations
Antimicrobials
Saliva test (saliva flow (chlorhexidine and
and bacterial culture) xylitol)
Low risk
Bitewing
radiographs every
24-36 mo
Every 6-12 mo to
reevaluate caries
risk
May be done as a
baseline reference for
new patients
Per saliva test if done
OTC fluoridecontaining toothpaste
twice daily, after
breakfast and at
bedtime. Optional: NaF
varnish if excessive root
exposure or sensitivity
Moderate risk
Bitewing
radiographs every
18-24 mo
Every 4-6 mo to
reevaluate caries
risk
May be done as a
baseline reference
for new patients or
if there is suspicion
of high bacterial
challenge and to
assess efficacy and
patient cooperation
Per saliva test if done
Xylitol (6-10 g/d) gum or
candies: 2 tabs of gum or
2 candies 4 times daily
OTC fluoridecontaining toothpaste
twice daily plus 0.05%
NaF rinse daily
Initially, 1-2 applications
of NaF varnish; 1
application at 4- to
6-mo recall
High risk
Bitewing
radiographs every
6-18 mo or until
no cavitated
lesions are
evident
Every 3-4 mo to
reevaluate caries
risk and apply
fluoride varnish
Saliva flow test and
bacterial culture
initially and at
every caries recall
appointment to
assess efficacy and
patient cooperation
Chlorhexidine gluconate,
0.12%: 10-mL rinse for
1 min daily for 1 wk
each month
Xylitol (6-10 g/d) gum or
candies: 2 tabs of gum or
2 candies 4 times daily
1.1% NaF toothpaste
twice daily
Initially, 1-3 applications
of NaF varnish; 1
application at 3- to
4-mo recall
Extreme risk
Bitewing
radiographs every
6 mo or until no
cavitated lesions
are evident
Every 3 mo to
reevaluate caries
risk and apply
fluoride varnish
Saliva flow test and
bacterial culture
initially and at
every caries recall
appointment to assess
efficacy and patient
cooperation
Chlorhexidine gluconate,
0.12%: 10-mL rinse for
1 min daily for 1 wk
each month
Xylitol (6-10 g/day) gum
or candies: 2 tabs of gum
or 2 candies 4 times daily
1.1% NaF toothpaste
twice daily
Initially, 1-3 applications
of NaF varnish; 1
application at 3- to
4-mo recall
Fluoride
a
Adapted from Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk
assessment. J Calif Dent Assoc. 2007;35(30):714-723.15 Reprinted with permission from the California Dental Association. Copyright © October 2007.
Abbreviations: ICDAS, International Caries Detection and Assessment System; NaF, sodium fluoride; OTC, over-the-counter.
Irradiation, many medications, and systemic diseases can reduce
the flow of saliva.17 It has been reported that 80% of the most
commonly prescribed medications cause xerostomia.17
To combat the body’s inability to buffer the pH in the mouth as
a result of hyposalivation, toothpastes with sodium bicarbonate
are recommended.17 Additionally, a solution of water and sodium
bicarbonate (2 tsp per 12-16 oz of water) can be used as a neutralizing rinse throughout the day. These treatments have been shown
to reduce demineralization and inhibit colonization by MS.17
After bacteria and the pH of the mouth are stabilized, remineralization is necessary to prevent cavitation and reverse
any demineralization. To maximize remineralization, fluoride
treatment should be used for all patients, regardless of age or
risk. Fluoride inhibits plaque, halts demineralization, speeds
remineralization, and, when combined with calcium and phosphate, forms a hard fluorapatite coating on top of demineralized tooth crystals.17
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GENERAL DENTISTRY July/August 2016
Fluoride can be employed as a topical agent such as in toothpaste or a varnish. Fluoride toothpaste in concentrations of
1000-1100 ppm should be used twice per day in a pea-sized
amount.17 Patients in high and extreme caries risk categories
(especially those with root sensitivity or who are hyposalivating)
should use 1.1% sodium fluoride (NaF) toothpaste (5000 ppm).17
Additionally, all at-risk patients should use over-the-counter
0.05% NaF mouthrinses twice per day for 30-60 seconds to stop
demineralization and stimulate remineralization.
Fluoride varnishes can be applied at intervals that depend on
the patient’s risk.18 Varnishes are effective because they adhere
well to tooth surfaces even in the presence of saliva and provide
a high concentration of fluoride (5% NaF), improving the rate
and degree of remineralization.17 The use of fluoride varnish,
especially at 4-month intervals, has been shown to be efficacious for those individuals with a moderate or greater risk.18
Fluoride varnish can be applied easily outside a dental office
pH
Control
Calcium
phosphate topical
supplements
between 2 categories, the patient was assigned to the higher
category. The presence of any disease indicator automatically
placed the patient in the high-risk category. Additionally,
if any disease indicator was combined with dry mouth, the
patient was automatically deemed to be at extreme risk for
dental caries.2
Results of the 6-year study confirmed that the CDA CRA
form is a valid tool for assigning patients to appropriate risk
categories.2 All of the disease indicators and pathological risk
factors on the CDA CRA form showed a statistically significant
(odds ratio greater than 1) positive relationship to the presence of cavitation or penetration into dentin. Those patients
deemed at high or extreme risk of dental caries had developed
caries at follow-up. Conversely, 76% of those deemed to be at
low risk returned with no new cavities.2 All of the results illustrated that the CDA CRA form was predictive of dental caries.
According to another clinical study conducted at the
University of California, San Francisco, from 2010 to 2012,
caries risk assessment—including aggressive preventive treatment and minimal restorations—resulted in a reduced caries
increment compared to that found in adults who did not use this
approach.3 CAMBRA intervention led to a statistically significant reduction in caries risk and MS bacteria. Additionally, placing restorations in the control group did not significantly reduce
MS bacteria counts or change the risk of caries.3
Sealants (resin-based
or glass ionomer)
Not required
Not required
Optional: for
excessive root
exposure or
sensitivity
Optional
Not required
Not required
Optional: for
excessive root
exposure or
sensitivity
As per ICDAS sealant
protocol
Not required
Optional
Apply calcium
phosphate paste
several times daily
As per ICDAS sealant
protocol
Conclusion
setting, as no special equipment is needed; however, this task
must be carried out in accordance with the rules and regulations of local practice acts.
Dental caries is a burden on patients, clinicians, and hospitals.
Severe odontogenic infections requiring inpatient and even
intensive care unit stays are familiar challenges to every oral
and maxillofacial surgeon and are often the result of untreated
carious lesions. Many patients admitted to hospitals for severe
odontogenic infections had previously been treated by an outside dentist or physician who employed either a targeted restorative treatment or an antibiotic prescription.19 These types of
treatment are not sufficient. Dental caries is a complex disease
that requires aggressive preventive treatment. CAMBRA is an
evidence-based preventive method that provides an effective
measure of which risk factors are out of balance and which
protective factors can restore balance. Protective factors are
needed to both arrest carious lesions and inhibit further formation.13 Any healthcare provider can easily adopt a caries risk
assessment such as CAMBRA for every patient encounter. Early
implementation of preventive strategies can reduce the morbidity of this common disease process.
Success of the CAMBRA model
Author information
Acid-neutralizing
rinse as needed if
mouth feels dry,
after snacking,
at bedtime, and
after breakfast
Required
Apply calcium
phosphate paste
twice daily
As per ICDAS sealant
protocol
Clinical studies have shown that CAMBRA accurately assigns
patients to risk categories, predicts how likely a patient in a
certain risk category is to develop dental caries, and, if recommended treatments are followed, reverses and inhibits progression of damage from dental caries.2,3 One study reviewing the
success of the CDA CRA form and CAMBRA protocols for
patients older than 6 years was conducted from 2003 to 2009.2
Dental students and faculty at the University of California,
San Francisco, were trained to perform an overall caries risk
assessment by evaluating the patient’s yes or no answers to the
CDA CRA form and making a clinical judgment as to which
category best fit the patient. If it was found that the patient fell
Ms Mills is a research assistant, Lombaert Lab, University of
Michigan, School of Dentistry, Ann Arbor. Dr Patel is in private
practice, Dunwoody, Georgia.
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71
Adopting caries risk assessment in all practice environments
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GENERAL DENTISTRY July/August 2016