Commentary on “Thoughts on the Current and Future Practice of Dental Sleep Medicine”

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Can we seize the moment and join the precision medicine movement?

by John E. Remmers, MD
Ignore the “M.D.” behind my name; in spirit I am a dental scientist devoted to dental sleep medicine. My heart and soul are focused on the massive public health problem we face in the epidemic of sleep disordered breathing (SDB). My advice: Read This Article By Gilles Lavigne. It’s the best analysis of our current status and challenges, and it is clad in beautiful prose with touches of pure poetry. Don’t miss a word of it.
The article grapples with all of sleep medicine, traditional medical and dental.  The thesis is deceptively simple, namely: practice “precision medicine”. To this end, we should “classify individuals to subpopulations that differ in their response to a specific treatment… so that therapeutic interventions can then be concentrated on those who will benefit, sparing expense and side for those who will not.” This is the gospel according to Gilles, and what a message it is, provocative and compelling.
The author spares no one and trucks no sacred cows. He asserts, for instance, that: AHI is a flawed parameter that pretends that oxyhemoglobin saturation is unimportant; that guidelines are guides, not laws, established by committee members with vested interests; and we have not established a causal link between bruxism or TMD and SDB. Heavy stuff and so right!
The article ends with sage advice for the practitioner: “move on from the traditional silo dentistry model and build a collaborative network”. Let’s get on with precision medicine.

by Robert R. Rogers, DMD, DABDSM
After more than a quarter century, the field of dental sleep medicine is expanding and evolving at lightning speed. We dental sleep medicine practitioners are now granted the luxury of improved technology, recognition by physicians and third-party insurance carriers, and acceptance by patients.
So now what?
The article by Dr. Gilles Lavigne leverages the unique intellect and experience of one of our finest researchers,
educators and thinkers. By choosing to publish this paper in a non-academic style journal, he steps slightly out of character but offers us a wonderful glimpse into our fast-changing field. He urges us focus on what he considers some major challenges such as the complexities of sleep disordered breathing, understanding the principles of a patient-centered approach (Precision Medicine), improved access to address critical public health issues, balancing guidelines with evidence-based medicine and updating strategies for a fast-moving sleep medicine world.
He notes that sleep medicine has become a shining example of an integrated, interdisciplinary health domain but progress is needed before optimal oral appliance therapy can be provided to the greatest number of sleep-disordered breathing patients. As a jumping-off point, effective management of sleep-disordered breathing requires a shift from fixing what’s in front of us to a longer-term objective of focusing on patient well-being.
Regarding treatment, Dr. Lavigne speaks of the importance of identifying cases early in life and preventative actions needing to be taken to avoid more extensive care in adults. But when adults do need to be treated, the need to identify certain phenotypes to predict best outcomes in a given population. Becoming known as precision medicine or personalized medicine (PM), he urges us to move from a one-size-fits-all paradigm to an advanced decision-making process.
The article goes on to underscore the reality that an apnea-hypopnea index (AHI) alone is insufficiently reliable or predictive of health risks when selecting a treatment and assessing outcomes. Absent a keen understanding of hypoxia and autonomic activity along with other risk factors we are likely to land in a place he describes as “the gray area of patient assessment”.
The contemporary need for more and better sleep-disordered breathing diagnosis and management seems to be giving rise to a move from the expert physician-only paradigm to a more open approach including minimally sleep-trained family physicians and non-physicians (dentists, for instance). Dr. Lavigne points out that this does not mean a free-for-all and suggests that integrity and responsibility must prevail through the development of professional collaborations.
Are we up for the challenge?

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