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CRA/CAMBRA and the dental hygiene process of care.

ADHA's Standards for Clinical Dental Hygiene Practice adopted last year require adherence to the dental hygiene process of care "to provide a structure for clinical practice that focuses on provision of patient-centered comprehensive care." Standard 1--assessment--includes the patient history, clinical evaluation and risk assessment, addressing each patient as an individual who exhibits unique characteristics and concerns and who will respond uniquely to professional oral health care interventions. Caries risk assessment (CRA) and caries management by risk assessment (CAMBRA) exemplify a rapidly changing facet of the dental hygiene process.


Rapidly Changing: But Is CRA New?

"If you think historically, risk assessment is not new," said Margherita Fontana, DDS, PhD, associate professor in the Department of Preventive and Community Dentistry at Indiana University School of Dentistry. "In dentistry, we collect data to help decide, like in the case of hygiene, how much prevention a patient might require or what kind of products you might recommend."

Fontana is director of the Microbial Caries Model Facility within the Oral Health Research Institute and director of the new Oral Biofilms in Caries Assessment and Management Research Program, as well as director of predoctoral education within her department. She said that whether on paper or simply in their minds, dentists try to base their treatment planning on patients' unique problems and circumstances.

"Not every patient with the same problem gets exactly the same treatment," Fontana said. "So we have always had elements of risk assessment in dentistry--for cariology, for periodontology and for everything that we do. It's just that traditionally, because our emphasis has always been on the surgical (restorative) treatment, the risk-based non-surgical aspect of caries management hasn't been very formal."

Fontana explained that oral health care researchers in Europe started talking about risk assessment in cariology decades ago. They recognized the need to watch individual factors carefully and document them to determine which ones were the best predictors of disease in patients of various ages. "It has been around dentistry for a long time," she said. "It just has been formalized in the last two or three decades or a bit more. In the United States, we're mostly talking about the last decade."

"Traditionally, CRA as we know it now was not done," said Douglas A. Young, DDS, MBA, MS, associate professor in the Department of Dental Practice at the University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, Calif. "The traditional method of assessing risk was to wait to see how many cavities a patient would have.

Terms were invented to describe 'high risk' such as 'rampant' decay, but classifying different risk levels and the idea of assessing risk using evidenced-based methodology was not yet being done," Young continued. "Traditional methods focused mainly on lesion detection using the mirror, explorer and radiographs, with some occasional help from the health history and nutritional record."

"Unfortunately, many of these provided only after-the-fact findings," said Cindy Lyon, RDH, DDS, chair of the Department of Dental Practice at the University of the Pacific Arthur A. Dugoni School of Dentistry.

Anne Gibbs, RDH, BS, a dental hygienist with the High Plains Community Health Center in Lamar, Colo., recalls, "We would witness a client at recare visits with a new lesion and take action. After the cavity event occurred, most dental professionals would really start talking about preventing cavities, prescribe a topical fluoride regimen and counsel on oral hygiene and dietary habits. But by then, we were too late!"

"Traditionally, dental hygienists and dentists have recommended that patients brushed, flossed and avoided sugary foods to prevent caries," agreed Deborah Johnson Horlak, RDH, MA, assistant professor and dental hygiene program director at the University of the Pacific's Arthur A. Dugoni School of Dentistry. "In addition, the dental profession touted the value of twice yearly dental check-ups and fluoride applications for children and adolescents. Plaque bacteria produced acids, so we needed to remove the plaque and strengthen the dentition. Evaluating an individual patient's susceptibility to caries--in other words, assessing the risk for caries--has evolved over the past 10 years or so. The dental profession has been focused on treating the symptoms of caries rather than the disease itself."


Horlak explained how, in 2002, the American Academy of Pediatric Dentistry (AAPD) adopted a Caries Risk Assessment Tool (CAT), which includes previously unconsidered data such as socioeconomic factors, use of dental services, special needs, salivary flow and the caries history of the patient's caregiver.

"The caries risk classification of high, moderate or low risk is made during a visualization of the teeth and oral cavity and interview of the patient, parent or guardian," added Michelle Gross-Panico, RDH, MA, who, along with a colleague, Lynnette Martin, RDH, AP, opened an elementary school-based preventive dental care clinic in partnership with Chandler Regional Hospital in Chandler, Ariz.

As Debi Gerger, RDH, MPH, department chair of dental hygiene at West Coast University explained, the AAPD has a policy statement about caries risk management, including the tool which states that the intention of the CAT is to establish caries risk level without a diagnosis or clinical management approach, as this is to be determined by a qualified dentist." The intention of CAMBRA is to not only perform a caries risk assessment but to manage the infection based on risk level as part of an overall patient care plan.

New Protocols, Procedures and Products for CRA

"New and emerging methods of caries management require the dental team to consider the evidence as well as the technological tools that can aid the clinician in developing an appropriate care plan that is based on identifying and treating patients by risk," said Gerger.

"Dental professionals are starting to view caries as the chronic disease it is," added Gibbs. "Instead of labeling a person as 'cavity prone,' we recognize the disease as a multifactorial process that begins before the lesion appears. Truly understanding this paradigm shift is crucial. Many of the new methods for CRA include templates of interview and assessment questions. Bacterial load testing, which detects the number of cavity-causing bacteria in the client's oral flora, is also becoming very popular."

Gross-Panico listed two examples of emerging CRA methods. "The Caries Assessment and Risk Evaluation (CARE) test was developed by the USC School of Dentistry and professor Paul Denny. It measures proportions of different sugar chains, good and bad oligosaccharides, in saliva. Another is the CariScreen Caries Susceptibility Test by Oral Bio Tech. This is a one-minute chairside bacterial test on a swabbed sample of the patient's plaque."

"Knowledge regarding the number of Streptococcus mutans present in the oral flora provides the dental practitioner with an objective measurement of an important caries risk factor," said Horlak, who also cited the chairside test as a major development since culturing strep mutans can take several days. The test uses adenosine triphosphate (ATP) bioluminescence to detect the bacteria.

"Because of the interest that has been developed, especially in the last 10 years, there has been a big emphasis on trying to move caries diagnostic and non-surgical management options from the research world into practice," said Fontana, citing the example of long-available saliva tests to measure specific bacteria. "Regarding dental caries risk specifically, people have focused on the streptococci group and the lactobacilli group. I think those methods are getting and will get much more sophisticated with time, including a greater array of bacterial targets. We're moving into plaque-specific samples and certainly research-wide genetic sampling. I think these emergent technologies will keep evolving pretty fast, because technology always evolves faster than our knowledge."

Fontana continued that there are techniques to measure bacterial levels both in saliva and in plaque, and means to quantify pH in plaque, as well as a variety of new technologies that are trying to help dentists detect and monitor caries lesions in a quantitative manner. "We're going to see more and more of these technology aids being tested and developed because a lot of the science of caries risk assessment right now is subjective, and thus not very helpful to quantify a patients' progress over time."

Young explained that current and emerging CRA methods measure risk at the earliest possible stage, so it's no longer necessary to wait until a cavity appears. He said that one popular view of CRA is based on the 'Caries Balance' theory first described by noted cariology researcher Dr. John Featherstone, dean of the University of California San Francisco School of Dentistry, where caries risk is determined by assessing the dynamic balance between the individual's own pathogenic and protective factors. There are CRA forms (see the October 2007 California Dental Association Journal at that help the clinician weigh only those factors (and other disease indicators) that are validated by science to contribute to caries risk and because of this are thought to be 'evidence-based.' Current CRA forms gather information on pathogenic factors as well as the many protective factors such as topical fluoride, xylitol, antibacterial agents, sealants, etc. Modern CRA often includes bacterial cultures or CariScreen ATP screening meter (Oral BioTech), saliva flow, pH and buffering capacity test (GC America).

Young adds that lesion detection has not been eliminated from CRA; in fact, early detection is the focus of several emerging technologies, including the Qualitative Light Florescence (Inspecktor Pro) and optical detection devices such as the DiagnoDENT (Kavo) and Caries ID (Dentsply) among others.

Evidence into Action: from CRA to CAMBRA

"CAMBRA is an acronym that was developed initially on the west coast at the University of California San Francisco, University of the Pacific, and at several of the western dental schools," said Fontana. "It was a very smart way of packaging together the idea that you need to do risk assessment, but more importantly, you need to follow that up with a caries management plan based on the risk, which goes beyond just traditional restorative care, focusing on the management of the caries disease process and etiology."

"CRA assesses the patient's current caries balance and determines what factors are out of balance," said Young. "CAMBRA then uses evidence-based treatment interventions focused on returning the patient back into a healthy balance based on the CRA. This often requires the use of products to return the patient's oral chemistry to normal. The oral cavity is like a test tube, and an astute clinician is the chemist that determines the correct reagents to return the mouth to health."

Gerger cited the Featherstone, et al., study from 2007 explaining that the disease indicators are white spot lesions, restorations placed within the past three years, enamel lesions, and cavities in the dentin as evident in radiographs. The risk factors are medium of high levels of Streptococcus mutans and lactobacilli, reduced saliva flow, poor dietary habits, exposed roots, and orthodontic appliances. The protective factors are adequate saliva flow, sealants, regular antibacterial use, fluoride therapy and an effective diet.

"Putting it together under the acronym of CAMBRA was a really smart way to try to sell this away from research academia and into practice," said Fontana. "[It was a way] to get people in practice interested in the idea that you do have to manage dental caries a little bit differently to target the disease and not only the consequences of the disease--cavities."

"Medicine outside of dentistry has been managing diseases for years," said Gibbs. "In the community health center where I practice dental hygiene, we have panels of medical patients on whom we are managing chronic disease: diabetes, cardiovascular disease, asthma. Dentistry is finally catching up."

Gibbs stated that in the practice where she works, they use a series of questions to assess caries risk. Starting with young children ages 0-5 years, they ask:

* Number of times teeth are brushed

* Is fluoride toothpaste used?

* Is the child drinking fluoridated water?

* Is there obvious plaque present on the child's teeth?

* Does the gingiva bleed when the clinician brushes the child's teeth?

* Are there cavities present?

* Are there white spot lesions (decalcification) present?

* Has the child had recent history of cavities--in the past year?

* Is the child receiving frequent acidic or high carbohydrate snacks or drinks? More than three per day?

* Is the child sleeping with a bottle with anything other than water?

"Because most all of our clients at the community health center are of low socioeconomic status, we do not ask [about socioeconomic status]," she continued. "After answering those questions, we determine caries risk. If a client is determined to be high caries risk, we recommend a three-month recare visit that includes fluoride varnish application, and we encourage behavioral changes through self-management goal setting. Some of our really high-risk clients receive fluoride varnish applications at every dental visit--preventive and restorative."

CAMBRA requires parent or patient commitment along with anticipatory guidance and a treatment plan, Horlak added, or in other words, prevention and treatment. Treatment, she said, may take the form of antimicrobial use to reduce oral flora, acid neutralizing rinses or sprays, sealants, fluoride varnish, xylitol products and/or minimally invasive restorative measures. New remineralizing products, such as Recaldent, NovaMin and ACP have also been used with success to reverse demineralization. The recommendation for products depends on the determination of the patient's risk level.

"If you are doing risk assessment and following it up with a disease risk-based management plan, in a sense, you are doing CAMBRA," concluded Fontana. "If disease management is not part of the process, there's a disconnect. That's what dental schools are trying to teach future students, that there has to be that connection between level of risk and disease management intensity, type and frequency."

CAHBRA in Practice and Academia

"I think CRA in academic settings (at least at my institution) is far ahead of private practice," said Brian Novy, DDS, assistant professor of restorative dentistry at the School of Dentistry at Loma Linda University in Loma Linda, Calif. "This is one area where private practitioners are waiting to see what the dental schools are doing before doing it in private practice--and it's the reason Doug Young and I are so busy on the lecture circuit. Our dental school graduates ate better prepared than practicing dentists to treat caries medically."

Young said that both private practice and academic environments have their own sets of benefits and challenges when it comes to CAMBRA implementation.

"Our academic environment benefits by the fact that we have educators and researchers in our midst sharing the latest evidence-based information with each other," Lyon added. "Students have no preconceived ideas about how we used to do things and are open to sharing preventive ideas with patients."

Young continued, "In contrast, many practicing dentists and hygienists graduated from school before CAMBRA was being taught. Practitioners that do know about CAMBRA are struggling with a traditional system of reimbursement where dentists are paid mainly by restorative and surgical procedures and hygienists are paid to clean teeth."

Lyon added, "And as we all remember, dental hygiene and dental students have the luxury of longer appointments with multiple opportunities to counsel patients."

"Dental and hygiene education often struggles with where CAMBRA belongs and how it is managed within the institution," Young said. "Collaboration and integration are often a challenge in bureaucratic settings."

Lyon considers herself at an advantage. "Having practiced for a number of years with an outstanding team, I know that we have greater control over how we deliver our message in private practice," she said. "With caries risk management, good patient understanding, motivation, and compliance are critical. If all team members in the practice are committed to a consistent message of education, motivation and encouragement of patients, we have a stronger chance for success, much in the same way we achieve a consistent periodontal care protocol.

"We also benefit in practice by the fact that we've created long-standing relationships and a level of trust with our patients that students may not have the time to truly do," said Lyon. "Finally, because we're gifted with treating many of our patients over a lifetime, we see the lasting results of downturns in their oral health or improvements in their habits. These are pretty powerful motivators for a reflective practitioner."

Fontana said that they started doing this formally as a competency-driven process in their school in 2000. "In academia, we don't only have the patient care component that private practice has, but we have the role of educating a future member of the dental team," she said. "So there are going to be some things that we do a bit more methodically that someone with more experience in general practice might do a bit faster."

As an example, she cites the risk forms developed or being developed by the American Dental Association, a variety of insurance companies and the American Academy of Pediatric Dentistry. "In general, these forms are very easy and meant for private practice where you don't want to spend a lot of time. Many practices may record many of those factors anyway--the forms are just a formalized way of recording on a chart that you actually gained that information and help drive the risk-based analysis. In an academic environment, it's a bit different because we want to make sure our students are doing it and that they're thinking about why they're doing it, and we need to assess how they're interpreting all those different pieces of information. So in general, in dental school settings, forms tend to be much more cumbersome than the forms we use in private practice because they are meant help drive and assess students to think in this manner (risk-based disease management) for every patient."

Gibbs agreed, saying that although the basic principles are the same, their process is more streamlined and less structured than what may be found in an academic setting. "When we first learned CRA, our community health center used a standardized form for each patient," Gibbs explained. "The paper form was nice for charts, but now that we are virtually paperless with Electronic Medical Records (EMR), we have integrated many of the caries risk factors into the clinical note template. EMR and an experienced and competent staff in gathering caries risk information have created a less formal CRA. When reading the clinical notes, one will find the answers to the risk factor questions, clinical findings (for example, areas of decalcification), the suggestions to the client or parent regarding ways to improve their oral health, and the phrase 'High Caries Risk' if so determined."

"No difference needs to exist between the academic and private practice settings," said Horlak. "The academic setting may allow more time to educate patients or parents than private practice, and the fees might be slightly less. However, when patients realize that a minimal investment in time and products can save them considerable expense over the long term by implementing CAMBRA principles, the clinical and private practice settings both can reap financial gains and happier patients as they control their disease."

Gerger said, "CAMBRA implementation is, most importantly, for the patient to achieve and maintain a healthy, balanced mouth. In the dental hygiene academic setting, students learn risk assessment as part of the dental hygiene process of care. In the general practice setting, the role of the dental hygienist will vary by the practice philosophy and by the state dental practice act."

CRA as Part of the Patient Appointment

For the office just starting to implement CRA/CAMBRA, Gerger points out that implementation must begin with the whole dental team understanding the evidence supporting the need for it, as well as the associated clinical guidelines. "The team should understand that caries is an infectious transmissible disease that is curable and preventable," she said. "Treatment decisions are based on risk level, which is determined by protective and pathological factors, and minimally invasive restorative procedures are a priority."

Once this understanding is established, Gerger said, an inventory is warranted to make sure the office has equipment and supplies necessary for the management phase of CAMBRA. She advocates role-playing conversations among team members to prepare for introducing risk assessment into the patient appointment, as well as learning how to obtain reimbursement for related services.

Fontana said that part-time faculty at Indiana University have told her that CRA is inherently part of the patient appointment because "we already do this in our minds when we are treatment planning. You know, we don't treatment plan Mrs. Smith and Johnnie the same way. But the fact is that if you don't document how to have done a risk-based caries disease assessment in the chart, legally, it didn't happen. The new standards of care are calling for not only a recording of this information but making sure that clinicians are indeed taking it into account and changing the paradigm that everyone with caries can be treated the same way. And unless you can base your treatment decisions in your chart data in some way, when insurance companies eventually begin to pay for this or question these data, you're going to have to defend why you placed someone on a certain regimen. To do that, you're going to have to collect risk data like we do for diagnosis nowadays."

Gross-Panico and Gibbs both perform CRA at the beginning of every patient appointment. "Our dental hygiene team gathers information regarding home care habits, other anticipatory guidance, and clinical findings such as decalcification and amount of plaque present," Gibbs explained. "The dentist notes if there are any cavities. The dental hygiene team makes suggestions to the client/parent about ways they could decrease caries risk. If the CRA is found to be high, the patient/parent is notified and more frequent recare visits are suggested."

Novy stressed that CRA should De performed at every recall visit. "In my opinion, more information is gleaned from the clinical observation of 'warning signs' (for example, low resting pH, low buffering capacity, high biofilm ATP, etc.) than by filling out a form. Plus, the patient becomes more involved in the diagnosis, and they are apt to ask their dentist or hygienist questions. Until the patient asks a question, they can't take any ownership of the disease."

The Dental Hygienist's Role

Gerger explained that the dental hygienist can be the key dental team member responsible for the creation, implementation and evaluation of patient and practice success. She said he or she may take the leadership role and review the literature for office protocol development, design of patient literature, and expand the preventive and clinical care supplies for caries management. Dependent on the state dental practice act, each team member will have differing responsibilities associated with CAMBRA protocols. Gerger listed services the dental hygienist is typically able to perform legally (see box on this page). "Along with the dentist, dental assistant and administrative staff, the dental hygienist can establish protocols for CRA and the corresponding clinical care modalities," Gerger said.

"The really neat thing about modern CRAs is that hygienists can (and should) do the whole CRA," agreed Novy. "They can even interpret the results for the patient and start offering broad treatment rationales."

"I believe emerging CRA protocols belong very logically in the hands of the dental hygienist--the prevention expert," said Lyon. "Presumably hygienists are already having important conversations with patients about oral cancer risk reduction, periodontal preventive care and nutritional habits. We can easily share current caries risk reduction strategies as well during these same discussions about improving oral health."

Lyon emphasized that because caries risk management may require minimally invasive restorative care, a team approach is important.

Fontana agreed that since the dental hygienist is already talking to patients about caries risk factors, she or he should also be the person collecting the risk data. "Depending on the state, the dental hygienist might be able to chip in regarding some of the diagnosis, but certainly can participate in the decision of the risk status of that patient, and then work together with the dentist on the appropriate caries disease management plan. [CAMBRA] cannot work in today's practice structure in the U.S. without the dental hygienist."

Which Patients Benefit Most from CAMBRA?

"Every patient benefits from a CRA ... in fact, the people who benefit the most are the ones who don't yet have any cavities," said Novy. "We can predict really well if a patient will have a cavity two years in the future using our modern tests. That's of tremendous benefit to our college-age patients who've never had a cavity and are leaving their 'dental home.'" "CRA is a win-win for all patients, but it is those individuals who are caught early in the disease process and managed well enough to prevent cavitated lesions that are the success stories," said Gibbs. "I will be most proud of the children who, as infants, started preventive dental visits with our clinic and as adults, never experience cavities."

Young said that all patients benefit from CAMBRA "because treatment is based on risk. The people that are at high risk get treatment, and those low-risk patients that do not need treatment get more of a preventive strategy. Resources are better managed compared to the 'one treatment fits all' strategy."

"A person's oral environment and caries risk can, and will, change over time depending on alterations in diet, physical ability to accomplish ideal home care, exposure to fluoride, medications causing xerostomia as a side effect, etc.," added Lyon. "So, any patient may go through periods of higher risk during which caries risk management is important.

"Patients with special needs, in particular, can benefit hugely from a customized caries risk reduction regime," Lyon continued. "Patients with disabilities that necessitate the help of a caregiver to provide daily oral home care can also benefit tremendously. If a hospital visit is the only way to accomplish restorative care for a patient with special needs, prevention takes on a whole new level of importance."

Horlak and Fontana both said they thought that while every patient benefits to some degree, CAMBRA is most effective for the patients at high risk. "If you're low risk, you're probably not going to benefit from it healthwise too much, other than maybe, monetarily, since you don't have to come into the office that frequently," said Fontana. "If you try to take a low-risk person and tell them, 'You don't need to come every six months,' they are the ones who want to come: maybe the reason they're low risk is because they want to come and are more health conscious. It is the high-risk people who don't even come twice a year who really require more energy and would probably benefit the most from more frequent recalls and attention in disease management."

Patient Understanding and Acceptance of CRA

"From my experience, most patients understand and accept CRA," said Gross-Panico. "Most patients appreciate it when I explain their caries risk classification."

"I think they understand it when they see something taking place," added Novy. "If you are just placing checkmarks on a piece of paper, they don't understand what you're doing. But when you ask them to spit in a cup and analyze their saliva, or wipe their teeth with a special swab and put that swab in a testing meter which gives a read-out, they want to understand, and they always accept."

"As with most if not all clinical care, the scientific knowledge and skills of the clinician must be presented to the patient in a manner that is appropriate for understanding and acceptance," said Gerger. "From the moment a patient calls the dental office to when care is complete, the message of CRA must be continuous and constant." She added that patients accept assessment and care best when they understand that caries is infectious and transmissible, and that this message is reinforced when it is consistent throughout the practice.

"I like to personalize caries and relate it to another health care crisis that many people can relate to," said Gibbs. "In my own family, most of us struggle with weight. Sure, maybe obesity is common in my family, but it is mostly because of habits we established at a young age. There are some families where everyone is thin, and they seem to eat anything they want. Not my family! I have to work hard to stay fit--exercise and eat a healthy diet.

"Caries, like weight, is controllable. There are some people who may have to work harder to keep the balance tipped toward the cavity-free side, but cavities are 100 percent preventable. After assessing a client's daily habits and clinical oral health, our dental team is equipped to discuss a client's caries risk. We discuss what affects cavities risk--diet, plaque removal, tobacco use, medications, existing restorations, systemic diseases like Sjogren's Syndrome, orthodontic treatment, communicable nature of caries, etc. People do understand and accept CRA, although some people may not be ready to make a change--for example, not drinking a six-pack of soda every day--to decrease their caries risk."

Fontana said that it is a little different in the academic setting, but when the student methodically presents the risk factors during conversation with the patient, the patient is often surprised. "People will say, 'You know, no one has ever explained to me the role that my saliva has on my propensity to cavities,'" she said.


Fontana pointed out that for dental hygienists who need more information, a wealth of resources exist, and that health organizations both inside and outside dentistry have policy addressing risk assessment as a standard of care. "Pediatricians might help screen children to help refer for care earlier than children who need care the most (high risk).

"So this is going beyond dentistry. Now you have CAMBRA coalitions all over the country. Now we have a cariology special interest group in ADEA that will help unify coalitions' efforts, saying, 'How do we need to modify dental curricula in the U.S. to make sure that hygienists are part of that group as well, so that we're all talking about the same things? What should we all be teaching at the minimum?' Not everyone is going to agree on the same details, but at least the principles should be such that everyone is doing it. As long as what you are doing is based on the best evidence, I think that's the standard of care nowadays."

* A Community Health Approach

"Colorado is very progressive in CRA," said Anne Gibbs, RDH, BS, a dental hygienist with the High Plains Community Health Center in Lamar, Colo. "Through a state initiative, 'Cavity Free at Three,' an easy-to-use CRA form (available at has been developed to help dental and medical professionals join forces in combating caries in young children. Partnering with other medical disciplines in fighting the most common disease in children may be key to combating caries. At the community health center where I work, the medical team discusses oral health at well-child visits to our patients, who are all high-risk. We host a Kids' Day at the medical office, targeting children at high risk, and provide medical and dental preventive services during one visit. When an individual is identified as high risk, it is important to talk teeth as much as possible!"

* CRA/CAMBRA Services the Dental Hygienist May Typically Provide Legally

* Review the medical history

* Risk assessment patient interview

* Clinical evaluation including the use of caries detection devices

* Necessary radiographs and intraoral photos

* Saliva assessment

* Bacterial testing

* Fluoride therapy

* Sealant application

* Patient education

* Recommendations for home regimens

Jean Majeski is Access' managing editor.
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Title Annotation:lead story; Caries risk assessment/caries management by risk assessment
Author:Majeski, Jean
Article Type:Report
Geographic Code:1USA
Date:Feb 1, 2009
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