Caries Prevention in the 21st Century
How P4 Medicine is changing the face of dentistry
V. Kim Kutsch, DMD
Dental caries is the most common disease tracked by the World Health Organization (WHO). It is number one in nearly every country and demographic worldwide. Tooth decay seems ubiquitous in our modern condition. Historically, dental caries was a less common disease, and current disease rates are thought to be tied to the increased dietary consumption of refined sugars. However, there are other risk factors that contribute to the progression of this disease, including hyposalivation, genetic susceptibility, and the characteristics of the biofilm itself. Early models attempted to identify a single pathogen that was responsible for the disease, and at one time, the dental profession focused on Streptococcus mutans as the pathologic agent. However, we now know that dental caries is much more complex; it truly is a multifactorial disease that results from biofilm dysfunction.
Traditionally, the primary treatment for dental caries has been the surgical removal of the diseased portion of the tooth followed by repair with an assortment of restorative materials to reestablish function and esthetics. The dental professional may have also offered patients suggestions to limit dietary sugar and improve brushing and flossing habits and provided a fluoride treatment for good measure. Community water fluoridation was introduced to optimize access to the benefits of fluoride exposure. By some measures, fluoride treatment has been effective in repairing damage from the disease, but despite its benefits, it fails to address and mitigate the cause of the disease, and patients continue to develop new decay after treatment. Consequently, decay rates have remained constant or even increased.
Enter the 21st century and "P4 Medicine." This new approach employs a model that is predictive, preventive, personalized, and participatory-points that the traditional surgical dental model fails to fully incorporate. Today, the best practice for the care of dental caries is to adopt a risk management-based philosophy. Caries risk assessment has been demonstrated to be predictive in clinical trials. It also focuses on preventive strategies, including the identification of risk factors and the development of a regimen to prevent future disease. Approaches to prevention have a long history in dentistry, but the application of the P4 medical model to modern dentistry not only includes primary, secondary, and tertiary prevention but also quaternary prevention. Primary prevention includes health promotion strategies that are designed to help people avoid the onset of disease and reduce its incidence. Secondary prevention involves the prevention of the recurrence or exacerbation of a disease that has been diagnosed, and tertiary prevention focuses on reducing the progression of disease and associated suffering. Quaternary prevention is a new concept that strives to mitigate the unnecessary or excessive intervention of the healthcare system. It is important to note that new technological developments in diagnostic instruments also carry the risk of increasing the incidence of surgical intervention, which may not be appropriate because guidelines for nonsurgical approaches are improving.
A risk management approach to the care of dental caries is also personalized because it identifies the specific risk factors that are contributing to an individual's disease. This elevates the conversation to a new level. Damaged teeth still need to be restored, but now professionals can more accurately discuss what is causing a patient's disease. The process then becomes participatory because the professional can use wellness coaching techniques to help the patient create personalized strategies for behavioral change to reduce specific risk factors.
One challenge for today's clinician is taking the results from cross-sectional population studies and applying that data to clinical practice on an individual patient for whom they have the longitudinal responsibility for care. Another challenge exists regarding the design of research studies, which is to isolate and identify risk factors and then test them in clinical trials with targeted strategies.
The concepts behind P4 Medicine and quaternary prevention may create new challenges for the dental profession, but they also offer new opportunities. As we continue to grow and change, new systems such as caries risk management will allow us to create predictable and better outcomes for our patients in the future, which has always been the goal.
About the Author
V. Kim Kutsch, DMD, is a mentor at the Kois Center in Seattle, Washington, and maintains a private practice in Albany, Oregon.