Proactive dental care for overall wellness: Harnessing the power of P4 medicine in oral health


The nursing model process ADPIE (Assessment, Diagnosis, Planning, Implementation, and Evaluation) is the framework and foundation that guides practitioners in delivering effective and efficient patient care. However, this model can also lead to reactive care, focusing only on the symptoms of a disease rather than its causes. The same disease/condition can have multiple causes, and simply having a label or classification does not imply an understanding of why it occurs.

A reactive approach to treating periodontal patients may focus solely on meticulous plaque control. Although the cause of periodontal disease is undisputed, it is the host's inflammatory response that ultimately determines the extent of periodontal tissue destruction, not the amount of plaque.1 In 20% of cases, a one-size-fits-all reactive approach can render programs ineffective and reduce positive outcomes.1,2

The healthcare model has evolved from disease-based to evidence-based and now based on personalization.3 Will the current model still be enough in 2023, or are we at a turning point? If optimal aging for oral and overall health is the goal, more than just care based on individualization is needed. Like medicine, dentistry has the potential to revolutionize oral health care, shifting the focus from reacting to disease symptoms to proactively preventing disease symptoms and promoting healthy dentition and overall well-being in aging.

You might be right too. Is prevention without a comprehensive examination ethical, or even legal?

In 2011, biologist Leroy Hood envisioned a new approach to health care focused on four main pillars: predictive, preventive, personalized, and participatory care. This medical approach aims to provide patients with precise and personalized care by integrating advanced technology and data analytics to support all ADPIE elements, rather than just treating the disease and its symptoms. He coined the term “P4 Medicine” to summarize these concepts.4

Predictive

Oral health diseases and conditions are multifactorial and share risks with chronic diseases, including genetics, lifestyle and environment. Comprehensive dental clinical parameters are critical, but not populating data into risk-level assessments or predictive models can incorrectly identify patterns and focus treatment decisions on disease symptoms.4,5 Plans can only be comprehensive, personalized and predictive by capturing a patient's level of risk, disease and social determinants of health while integrating collaboration and coordination with other health and non-health professionals.1,2,6,7

Machine learning algorithms that manage large amounts of patient data (such as decision trees, neural networks, and support vector machines to determine risk levels) are powerful tools that can provide predictable and effective results that may not be seen through traditional practice.8 Even simply incorporating a three-tone display solution can identify areas of decay or risk levels of gum inflammation, initiating deeper conversations about biofilm acidity, saliva buffering capacity and nutritional counseling.

preventive

The goal is to proactively prevent disease, ultimately leading to better health outcomes and lower healthcare costs over time.9,10 The World Health Organization’s 2022 report states that “oral disease is largely preventable” and that the primary focus of oral health professionals “should be to provide evidence-based preventive care and minimally invasive interventions that support patients’ effective self-care practice.11

Gingivitis is a site-specific inflammatory condition as defined by Trombelli et al.12 Clinically reversible tissue changes can be induced, but the immune cells involved or trained immunity may be irreversible.13 Trained immunity refers to the enhanced response of innate immune cells to subsequent immune challenges after exposure to certain stimuli.

In gingivitis and periodontitis, chronic inflammation leads to a state of trained immunity in the affected tissues. Studies have shown that monocytes and macrophages in individual gingival tissues exhibit an altered phenotype characterized by increased expression of specific receptors and cytokines, which enhances their ability to recognize and respond to bacterial stimuli.13

Likewise, there is evidence that certain microbial products associated with periodontitis, such as lipopolysaccharide (LPS), can induce trained immunity in immune cells through epigenetic modifications.14,15 This suggests that exposure to oral bacteria may have long-term effects on the immune system even after the infection resolves clinically or returns to a probiotic state. Therefore, considering that gingivitis is a precursor to periodontitis and perpetuates chronic inflammation, it is critical to use effective, antibacterial, bioavailable therapeutic agents in self-care products to prevent gingivitis.13-15th

Stannous fluoride (SnF2) as a therapeutic agent must have stable composition and bioavailability to effectively inhibit plaque growth, metabolism and suppress pathogen virulence.16 SnF2 can inhibit the growth and reproduction of bacteria, inhibit the metabolic production of short-chain fatty acids (SCFA) and other toxins, increase the permeability of host cell membranes, enable LPS and lipoteichoic acid (LTA) to participate in Gram-negative bacterial membranes, and increase Toll Reactivity of TLR-like receptors, which are involved in detecting pathogens and triggering signaling cascades.number 17 Crest's proprietary SnF2 formula directly inhibits LPS/LTA through TLRs, reducing pathogen virulence and supporting the host to restore biocompatibility.16-19th Bisbrock et al. Results showed that the proprietary SnF2 formulation demonstrated an odds ratio of 3.7 for a shift in gingival health compared to sodium fluoride toothpaste containing SnF2, achieving a subgingival penetration depth of 4 mm.16

Krukoska et al. Research shows that subjects who brushed with bioavailable Gluconate Chelated SnF2 toothpaste (another Crest proprietary formula) experienced a 51% reduction in the average number of bleeding sites compared to a negative control toothpaste, even when inflammation was not yet present. Plaque toxicity was also reduced at symptomatic sites.19

personalize

This approach takes into account an individual’s unique genetic, environmental and lifestyle risks to tailor a plan to their needs. It differs from the traditional “one size fits all” approach, in which treatment is often based on average and reactive care for the general population.1,4

Personalized medicine is advancing with advances in genomics and bioinformatics, an interdisciplinary field that combines biology, computer science, mathematics and statistics to analyze and interpret biological data.1,20 Technological advances can identify specific genetic variants associated with an increased risk of certain diseases or conditions by analyzing an individual's genetic data, such as periodontal disease, oral cancer, and developmental disorders that affect the teeth and jaw.twenty one This area of ​​research could enable earlier intervention and more personalized care plans.

As technology advances, the role of epigenetics, biomarkers, and point-of-care devices in dentistry is likely to increase.

participatory

This pillar of health care emphasizes active participation and involvement of patients in their own care. It recognizes that patients are experts on their own disease and treatment experiences and aims to help them make decisions about their own health.1,4

Standard patient and dental history forms, although comprehensive, often contain closed-ended questions, which may limit the quality, detail, and importance of the information. This may result in health professionals asking several follow-up questions during clinical appointments, which are often met with resistance from patients.twenty two The self-report form is filled out before and after the appointment and is framed to allow patients more time to reflect on their health and dental history, aiming to obtain accurate, detailed information.22,23

The most common engaging oral self-care (OSC) practices and products are critical to achieving and maintaining oral and overall health.2,12,18 However, the traditional method of providing OSC education is near the end or after debridement during clinical/patient care appointments. A simple shift in delivering OSC education at the beginning of the appointment emphasizes the importance of patients being actively engaged in oral health care, supporting life-changing positive behavior changes.

Advances in oral care product technology such as electric toothbrushes (EBs) can support patients in achieving oral health. EB is well documented for its ability to disrupt plaque/biofilm and reduce gum bleeding, with a 2020 general review demonstrating its preventative benefits for periodontal disease.twenty four

Oral-B Oscillating Rotation (OR) technology has been supporting patients' oral health since 1991. It follows the next generation of OR, Oral-B iO, with a complete interior and exterior redesign.26 The smart display on the handlebar provides instant bimodal feedback on the pressure sensor – 0.8-2.5N, with green indicating optimal pressure and effectiveness, and red indicating pressure greater than 2.5N. Artificial intelligence technology uses 3D tooth tracking through the Oral-B iO app (Figure 1) to provide real-time personal guidance to promote thorough brushing of all areas and surfaces, supporting patient participation in care.24-27th



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