“I’ve been flossing every day — how do I still get cavities?”
“I just fixed that tooth last year — why is there decay again?”
If you’ve practiced dental hygiene for a while, you’ve heard this often. Patients commonly connect cavities to brushing and flossing alone, so when decay returns, they’re genuinely confused. These conversations remind us that caries is not just a hygiene issue — it’s a disease process.
Caries is biofilm-mediated and multifactorial. Bacteria, saliva, diet, medications, and daily habits all play a role. Fluoride at home and in-office matters, but when it’s recommended the same way for everyone regardless of risk, we often see the same pattern: the tooth gets restored, but the cause isn’t fully addressed.
The reality is hygienists already assess caries risk every day. We look at history, patterns, saliva, and clinical presentation — often without labeling it as CRA. The difference is that without structure, those observations don’t always translate into intentional treatment planning.
The integration of a CAMBRA-informed approach helps us organize our clinical findings and link categorical risk groups to phased and focused action.
Seeing risk as dynamic
Risk changes. A patient who was low risk two years ago may not be today. Medications, xerostomia, diet, and health changes can shift the oral environment quickly.
When CRA becomes part of recall, the conversation shifts from “Where is the cavity?” to “Why is this happening?”
Related article: Automating risk-factor tracking and screening in dental hygiene practice
A practical, phased approach
What worked for clinical team was keeping it simple. Patients are grouped into low, moderate, or high risk, and prevention is built in phases as a framework that guides our team’s clinical decision making if outcomes don’t improve.
Phase 1 – Foundational prevention
- Topical Fluoride varnish as indicated
- High-fluoride toothpaste (ex. Colgate Prevident)
- Antibacterial mouth rinses (ex. Listerine)
- Xylitol products
Often, this stabilizes risk.
Phase 2 – Behaviour & diet focus
(If outcomes don’t improve from Phase 1)
- Nutritional counselling
Phase 3 – Biological investigation
(If disease persists after Phase 2)
- Salivary testing
- Antimicrobial strategies
This phase is now shifting the focus on controlling the disease.
This system simply gives structure and keeps the team calibrated while allowing patient-specific care.
From scripted advice to intentional care
For our team, pairing CRA with CAMBRA has made recall visits feel more focused and purposeful. The shift toward prevention isn’t about doing more — it’s about being intentional with what we already do.
Prevention continues to evolve. Remineralization science and emerging therapies, including peptide-based approaches, remind us to keep reviewing and updating our CRA and CAMBRA protocols as evidence grows.
References
- Featherstone, J. D. B., Domejean, S., Jenson, L., & Rechmann, P. (2012). Caries management by risk assessment (CAMBRA). Journal of the California Dental Association, 40(5), 437–445.
- Young, D. A., Featherstone, J. D. B., Roth, J. R., Anderson, M., Autio-Gold, J., Christensen, G. J., Fontana, M., Meyer, D. M., Wolff, M. S., & Zeller, G. G. (2007). Caries management by risk assessment: Implementation guidelines. Journal of the California Dental Association, 35(11), 799–805.
- Canadian Dental Association. (2021). Position statement on the appropriate use of fluorides.
- https://www.cda-adc.ca/en/about/position_statements/fluoride/
- Public Health Agency of Canada. (2010). The state of oral health in Canada. https://www.canada.ca/en/public-health/services/publications/healthy-living/state-of-oral-health-in-canada.html
About the authors
Christie, a dental hygienist and clinical manager who has been with Clarence Street Dental Group for 25 years, brings extensive experience and leadership to the team, supporting clinical excellence and mentorship across the practice. She oversees IPAC implementation and evaluation, plays a key role in Health and Safety, and is actively involved in practice and facility maintenance to ensure a safe and high-performing clinical environment.
Rosy has been with CSDG for over a decade, practicing restorative dental hygiene and contributing in a clinical management role. Rosy and Christina Turcotte, they are committed to fostering team development and delivering patient-centred care.