A decade ago, Leroy Hood proposed that medicine should move from reactive disease management to proactive care that is predictive, preventive, personalized and participatory.1 The tenets of this philosophy are now referred to as P4 Medicine. Combining technology, biology and a wellness approach, medicine is capable of providing care on a molecular, cellular and organ level to personalize each individual’s unique health experience. This information will make medical care radically more cost effective by personalizing care to each person’s unique biology and by treating the causes rather than the symptoms of disease. It will also create the environment for consumers to improve their heath as they make behavior and lifestyle changes. Working together, the health care system and patients should be able to reduce the incidence of complex chronic diseases. But this movement also comes at the risk of overutilization of technology and tests without a prior consideration of the patient’s individualized risk for a given disease. In addition to primary prevention, which involves measures to prevent a disease from occurring, and secondary prevention which attempts slow or reverse progression of a disease, and tertiary prevention which involves active treatment of the disease, P4 medicine now includes quarternary prevention, which considers patient risk and possible overtreatment.2
In this changing model of medicine, how does this affect dentistry? The dental profession has traditionally been built on the surgical model of disease management.3 However, that model rapidly changing too. With the overdue recognition that the mouth is connected to the rest of the body, healthcare is starting to recognize that oral diseases have an impact on systemic health.4 Long gone are the days of scraping roots to treat periodontal disease, drilling holes in teeth to treat dental caries.
Just looking at dental caries risk management in light of the P4 medical model, this new approach includes care that is predictive, preventive, personalized and participatory. The surgical dental model fails on each point. The best practice of care for dental caries today is a risk management based philosophy. Caries risk assessment had been demonstrated to be predictive in clinical trials.5 It also focuses on preventive strategies, identifying risk factors and developing a regimen to prevent future disease.6 The prevention approach has a long history in dentistry. Today’s preventive dentistry should include not only primary, secondary and tertiary prevention, but also quarternary prevention. Quarternary prevention strives to mitigate unnecessary or excessive intervention of the health care system while guidelines for non-surgical approaches are improving.
Caries risk management is also personalized as it identifies the specific risk factors contributing to an individual’s disease.7 This leads to a new conversation. Damaged teeth still need to be restored, but now professionals can discuss what’s causing the patient’s disease. The process then becomes participatory as the professional utilizes wellness coaching techniques to help the patient create personalized strategies for behavioral change to decrease specific caries risk factors.8
The new models of P4 Medicine and the Quarternary Prevention create new challenges but also new opportunities for the dental profession. As we continue to grow and change, new systems like Caries Risk Management allow us to create predictable and better outcomes for our patients in the 21st century, which has always been our goal.9
- Flores M, Glusman G, Brogaard K, Price ND, Hood L. P4 medicine: how systems medicine will transform the healthcare sector and society. Per Med. 2013; 10(6): 565–576. doi: 10.2217/PME.13.57
- Kalra S, Gupta Y, Kalra B. Quaternary prevention and gestational diabetes mellitus. Indian J Endocrinol Metab. 2017 Jan-Feb; 21(1): 1–3. doi: 10.4103/2230-8210.196021
- Innes NPT, Chu CH, Fontana M, Lo ECM, Thomson WM, et al. A Century of Change towards Prevention and Minimal Intervention in Cariology. J Dent Res. 2019 Jun;98(6):611-617. doi: 10.1177/0022034519837252
- Kim K, Choi S, Chang J, Kim SM, Kim SJ, et al. Severity of dental caries and risk of coronary heart disease in middle-aged men and women: a population-based cohort study of Korean adults, 2002-2013. Sci Rep. 2019 Jul 19;9(1):10491.
- Chaffee BW, Cheng J, Featherstone JD. Baseline caries risk assessment as a predictor of caries incidence. J Dent. 2015 May;43(5):518-24.
- Kutsch VK. Dental caries: An updated medical model of risk assessment. J Prosthet Dent 2014 April. 111(4):280-5.
- Young D, Kutsch VK, Whitehouse J. A clinician's guide to CAMBRA: a simple approach. Compend Contin Educ Dent. 2009 Mar;30(2):92-4, 96, 98, passim.
- Malterud MI, Kutsch VK. The evolution of dental caries treatment. Gen Dent. 2012 Sep-Oct;60(5):386-9.
- Kutsch VK. Caries prevention in the 21st century: how p4 medicine is changing the face of dentistry. Inside Dentistry October 2019. (10)76.
V. Kim Kutsch, DMD
Dr. V. Kim Kutsch received his undergraduate degree from Westminster College in Utah and then completed his DMD at University of Oregon School of Dentistry in 1979. He is an inventor holding seventeen patents in dentistry, product consultant, internationally recognized speaker, is past president of the Academy of Laser Dentistry, and the World Congress of Minimally Invasive Dentistry. He also has served on the board of directors for the World Clinical Laser Institute and the American Academy of Cosmetic Dentistry. As an author, Dr. Kutsch has published over 100 articles and abstracts on minimally invasive dentistry, caries risk assessment, digital radiography and other technologies in both dental and medical journals and contributed chapters to numerous textbooks. He coauthored Balance, a textbook on dental decay with 100,000 copies in print, and wrote the Rough World series, a young adult science fiction trilogy. He acts as a reviewer for several journals including the Journal of the American Dental Association and Compendium. Dr. Kutsch also serves as CEO of Dental Alliance Holdings LLC, manufacturer of the Carifree system, and Remin Media. As a clinician he is a Graduate, Mentor and Scientific Advisor of Dental Caries at the prestigious Kois Center. Dr. Kutsch maintains a private practice in Albany Oregon.