The P4 Approach: What is it and How is it Being Used in Dental Sleep Medicine?

P4 medicine is an evolving approach to personalized medicine that involves four key elements of care: 1) predicting who will develop disease and comorbidities, 2) preventing rather than reacting to disease, 3) personalizing diagnosis and treatment, 4) having patients participate in their own care.¹ This approach is gaining traction in both medicine and dentistry as technology and research evolve, and we gain a greater appreciation for the importance of personalized medicine. Even though P4 terminology isn’t often used in dental sleep medicine, it is an approach that American Academy of Dental Sleep Medicine (AADSM) Qualified Dentists apply in their practices every day. The model below is used to identify and treat obstructive sleep apnea (OSA) but also ensures patients are active participants in their journey to better overall health.²

Predict

Most dental organizations recommend that all dentists screen for OSA during biannual hygiene visits. Through physical assessment, validated screening questionnaires and tools, and medical history and clinical findings, dentists can identify patients suspected of having OSA. Dentists see their patients regularly and build relationships, sometimes across generations, so they can identify changes in lifestyle or health that may signal that the patient is at a higher risk for OSA.²

Prevent

Treatment of OSA is not only key to managing symptoms like snoring, but it is also essential for preventing conditions that may develop when left untreated. For example, untreated OSA has been associated with many cardiovascular diseases. Currently, there aren’t any evidence-based therapies to prevent OSA, but dentists do frequently discuss obesity and sugar intake with patients throughout their everyday interactions, hoping not only to prevent OSA but also cavities and other dental diseases. Using oral appliances also can help prevent dangerous side effects of lack of sleep, including sleepiness, brain fog, and drowsiness while driving.

Personalize

By definition, oral appliances (OA) are custom-fit and personalized for each patient. A qualified dentist selects the appropriate type of appliance for a patient based on individual craniofacial structures and oral, dental, and periodontal tissues; cognitive ability, manual dexterity, visual acuity, range of motion, and nasal patency; and number, location, and health of remaining teeth.

The clinical tooth height, angulation, undercuts, current dental restorative conditions, and anticipated dental restorative needs, along with allergies and/or sensitivities, are also considered because they may limit the type and material to be used in the fabrication of an oral appliance. Appliance selection considers patient preferences, including comfort, ease of use, and patient financial considerations.

The calibration of the appliance to the appropriate therapeutic position is also personalized to each patient. Calibration is based on multiple factors, including the patient’s range of motion, level of disease severity, patient comfort, and resolution or improvement of signs and symptoms. The appropriate endpoint to the oral appliance advancement process achieves improvement of signs, symptoms, or objective indices while allowing the patient to use the appliance comfortably every time they sleep.

The patient education qualified dentists provide covers individualized risk factors based on demographics, ethnicity, and sex, as well as individualized risk modifiers that can shape disease severity. Education includes reviewing information with the patient about their OSA severity and the metrics that will be critical for determining whether oral appliance therapy (OAT) treatment is successful, as determined by the patient, qualified dentist, and the patient’s treating medical provider. Open communication with the patient is important in achieving success with OAT, and qualified dentists are sensitive to each patient’s unique concerns and desired outcomes, including additional therapies that might be considered in the face of an inadequate response to OAT.

Participate

Oral appliance therapy requires patients to actively participate in their therapy, as they are responsible for wearing their appliance while they sleep. To ensure patients understand the importance of wearing their appliance consistently, qualified dentists explain the impact of OSA on a patient’s overall health and educate them about the importance of sleep hygiene and sleep deprivation. During discussions about adherence, qualified dentists stress that the patient should sleep a minimum of seven hours per night and wear their appliance for the duration of their sleep period. The AADSM defines compliance as “the appliance being worn for a minimum of ≥80% per night, starting when the OA is placed in the mouth and ending when the OA is removed from the mouth, ≥5 nights per week.”³ The AADSM encourages qualified dentists to categorize patients as fully compliant, improving over time, or non-compliant based on the collected compliance data and to encourage patients to improve their compliance.

Qualified dentists also follow up with patients every six months during the first year and at least annually thereafter. This follow-up schedule is important for evaluating patient compliance and any factors that may reduce compliance. During these appointments, the dentist evaluates the function and structural integrity of the appliance, reviews any side effects that may be occurring, and takes steps to reduce or minimize them to ensure the patient can continue to adhere to therapy. The follow-up visits also monitor symptoms and changes in sleep, lifestyle, and medical factors that may impact the severity of OSA.

The AADSM’s standards for practice guides qualified dentists in how to provide personalized care to their patients. To ensure that patients are receiving the personalized care they deserve, it is important to refer patients to qualified dentists for oral appliance therapy. ⁴

Source: Kevin Postol, DDS

Kevin Postol, DDS, serves as president of the American Academy of Dental Sleep Medicine

References

1. Lim DC, Sutherland K, Cistulli PA, Pack AI. P4 medicine approach to obstructive sleep apnoea. Respirology. 2017;22(5):849-860. doi:10.1111/resp.13063
2. American Dental Association. Policy Statement on the Role of Dentistry in the Treatment of Sleep Related Breathing Disorders
3. Radmand R, Chiang H, Di Giosia M, et al. Defining and measuring compliance with oral appliance therapy. J Dent Sleep Med. 2021;8(3)
4. Levine M, Cantwell M, Postol K, Schwartz D. Dental sleep medicine standards for screening, treating, and management of sleep-related breathing disorders in adults using oral appliance therapy. J Dent Sleep Med. 2022;9(4)