Commentary

A 47-year-old obese male with type 2 diabetes has been on metformin for the last 2 years with good effect (hemoglobin A_1c of 6.8), and with exercise has been able to lose 5-10 pounds. His last two blood tests show creatinine levels of 1.5 and 1.6. What do you recommend?

A) Continue with metformin.

B) Stop metformin, start sulfonylurea.

C) Stop metformin, begin glargine.

D) Stop metformin, begin pioglitazone.

Myth: Metformin should not be used in patients with mild to moderate renal insufficiency because of an increased risk of lactic acidosis.

Metformin is the most commonly used oral agent for the treatment of type 2 diabetes in the United States, but the FDA-approved drug label states that it is contraindicated in patients with an abnormal creatinine clearance or serum creatinine of 1.4 in women and 1.5 in men.<sup/>The concern is for development of lactic acidosis in patients because the renally excreted metformin may build up as a result of decreased renal function.

Metformin was approved for use in the United States in 1995, many years after the drug was introduced in Europe. The first drug in its class, phenformin, was removed from the United States and most European markets in 1977 because of a high incidence of lactic acidosis occurring at therapeutic doses. One in 4,000 patients taking phenformin develops lactic acidosis (J. Emerg. Med. 1998;16:881-6). Phenformin has been shown to cause type B lactic acidosis, without evidence of hypoxia or hypoperfusion, and lactic acidosis because of phenformin carried a 50% mortality rate.

Deep concern for the possibility of a similar problem with metformin played an important role in its delay of availability in the United States. It isn’t clear, however, that diabetes patients on metformin have a higher risk of developing lactic acidosis than diabetes patients who are not on metformin.

A Cochrane review of 347 studies, including 70,490 person-years of metformin use, compared with 55,451 person-years in the nonmetformin group, showed no cases of fatal or nonfatal lactic acidosis in either group (Cochrane Database Syst. Rev. 2010 Apr 14:CD002967). More than half the studies included (53%) allowed for the inclusion of patients with creatinine levels greater than 1.5. There were no differences in lactate levels between metformin-treated patients and patients who did not receive metformin.

In a study using the Saskatchewan Health administrative database, which involved 11,797 patients with 22,296 years of metformin exposure, there were two cases of lactic acidosis (Diabetes Care 1999;22:925-7). This calculates to a rate of 9 cases per 100,000 person years, the same rate as in patients with diabetes who are not taking metformin (9.7 cases per 100,000) (Diabetes Care 1998;21:1659-63).

A recent study looked at the incidence of lactic acidosis in patients taking metformin with and without abnormalities in renal function (Diabetes Care 2014;37:2291-5). There was no statistically significant difference in the rates of lactic acidosis in patients who were on metformin with normal renal function, compared with those with varying degrees of renal insufficiency. The overall rate of lactic acidosis was 10.3 per 100,000 patient years, which is almost identical to the rates in the other studies mentioned, and there were no fatalities.

Several recommendations for using metformin in patients with renal insufficiency have been published (see table) (JAMA 2014;312:2668-75; Diabetes Care 2011;34:1431-7). Metformin has shown cardiovascular mortality benefits, compared with sulfonylureas, in the treatment of diabetes (Diabetes Care 2013;36:1304-11). Avoiding its use in patients with mild to moderate renal insufficiency in favor of other treatments that may not be as beneficial and may well lead to worse outcomes.

There is no evidence that metformin increases the lactic acidosis risk in patients with diabetes, but until there is a change in the FDA labeling, physicians will likely continue to be hesitant to use it in patients with renal insufficiency.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.

A 47-year-old obese male with type 2 diabetes has been on metformin for the last 2 years with good effect (hemoglobin A_1c of 6.8), and with exercise has been able to lose 5-10 pounds. His last two blood tests show creatinine levels of 1.5 and 1.6. What do you recommend?

A) Continue with metformin.

B) Stop metformin, start sulfonylurea.

C) Stop metformin, begin glargine.

D) Stop metformin, begin pioglitazone.

Myth: Metformin should not be used in patients with mild to moderate renal insufficiency because of an increased risk of lactic acidosis.

Metformin is the most commonly used oral agent for the treatment of type 2 diabetes in the United States, but the FDA-approved drug label states that it is contraindicated in patients with an abnormal creatinine clearance or serum creatinine of 1.4 in women and 1.5 in men.<sup/>The concern is for development of lactic acidosis in patients because the renally excreted metformin may build up as a result of decreased renal function.

Metformin was approved for use in the United States in 1995, many years after the drug was introduced in Europe. The first drug in its class, phenformin, was removed from the United States and most European markets in 1977 because of a high incidence of lactic acidosis occurring at therapeutic doses. One in 4,000 patients taking phenformin develops lactic acidosis (J. Emerg. Med. 1998;16:881-6). Phenformin has been shown to cause type B lactic acidosis, without evidence of hypoxia or hypoperfusion, and lactic acidosis because of phenformin carried a 50% mortality rate.

Deep concern for the possibility of a similar problem with metformin played an important role in its delay of availability in the United States. It isn’t clear, however, that diabetes patients on metformin have a higher risk of developing lactic acidosis than diabetes patients who are not on metformin.

A Cochrane review of 347 studies, including 70,490 person-years of metformin use, compared with 55,451 person-years in the nonmetformin group, showed no cases of fatal or nonfatal lactic acidosis in either group (Cochrane Database Syst. Rev. 2010 Apr 14:CD002967). More than half the studies included (53%) allowed for the inclusion of patients with creatinine levels greater than 1.5. There were no differences in lactate levels between metformin-treated patients and patients who did not receive metformin.

In a study using the Saskatchewan Health administrative database, which involved 11,797 patients with 22,296 years of metformin exposure, there were two cases of lactic acidosis (Diabetes Care 1999;22:925-7). This calculates to a rate of 9 cases per 100,000 person years, the same rate as in patients with diabetes who are not taking metformin (9.7 cases per 100,000) (Diabetes Care 1998;21:1659-63).

A recent study looked at the incidence of lactic acidosis in patients taking metformin with and without abnormalities in renal function (Diabetes Care 2014;37:2291-5). There was no statistically significant difference in the rates of lactic acidosis in patients who were on metformin with normal renal function, compared with those with varying degrees of renal insufficiency. The overall rate of lactic acidosis was 10.3 per 100,000 patient years, which is almost identical to the rates in the other studies mentioned, and there were no fatalities.

Several recommendations for using metformin in patients with renal insufficiency have been published (see table) (JAMA 2014;312:2668-75; Diabetes Care 2011;34:1431-7). Metformin has shown cardiovascular mortality benefits, compared with sulfonylureas, in the treatment of diabetes (Diabetes Care 2013;36:1304-11). Avoiding its use in patients with mild to moderate renal insufficiency in favor of other treatments that may not be as beneficial and may well lead to worse outcomes.

There is no evidence that metformin increases the lactic acidosis risk in patients with diabetes, but until there is a change in the FDA labeling, physicians will likely continue to be hesitant to use it in patients with renal insufficiency.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.

A 47-year-old obese male with type 2 diabetes has been on metformin for the last 2 years with good effect (hemoglobin A_1c of 6.8), and with exercise has been able to lose 5-10 pounds. His last two blood tests show creatinine levels of 1.5 and 1.6. What do you recommend?

A) Continue with metformin.

B) Stop metformin, start sulfonylurea.

C) Stop metformin, begin glargine.

D) Stop metformin, begin pioglitazone.

Myth: Metformin should not be used in patients with mild to moderate renal insufficiency because of an increased risk of lactic acidosis.

Metformin is the most commonly used oral agent for the treatment of type 2 diabetes in the United States, but the FDA-approved drug label states that it is contraindicated in patients with an abnormal creatinine clearance or serum creatinine of 1.4 in women and 1.5 in men.<sup/>The concern is for development of lactic acidosis in patients because the renally excreted metformin may build up as a result of decreased renal function.

Metformin was approved for use in the United States in 1995, many years after the drug was introduced in Europe. The first drug in its class, phenformin, was removed from the United States and most European markets in 1977 because of a high incidence of lactic acidosis occurring at therapeutic doses. One in 4,000 patients taking phenformin develops lactic acidosis (J. Emerg. Med. 1998;16:881-6). Phenformin has been shown to cause type B lactic acidosis, without evidence of hypoxia or hypoperfusion, and lactic acidosis because of phenformin carried a 50% mortality rate.

Deep concern for the possibility of a similar problem with metformin played an important role in its delay of availability in the United States. It isn’t clear, however, that diabetes patients on metformin have a higher risk of developing lactic acidosis than diabetes patients who are not on metformin.

A Cochrane review of 347 studies, including 70,490 person-years of metformin use, compared with 55,451 person-years in the nonmetformin group, showed no cases of fatal or nonfatal lactic acidosis in either group (Cochrane Database Syst. Rev. 2010 Apr 14:CD002967). More than half the studies included (53%) allowed for the inclusion of patients with creatinine levels greater than 1.5. There were no differences in lactate levels between metformin-treated patients and patients who did not receive metformin.

In a study using the Saskatchewan Health administrative database, which involved 11,797 patients with 22,296 years of metformin exposure, there were two cases of lactic acidosis (Diabetes Care 1999;22:925-7). This calculates to a rate of 9 cases per 100,000 person years, the same rate as in patients with diabetes who are not taking metformin (9.7 cases per 100,000) (Diabetes Care 1998;21:1659-63).

A recent study looked at the incidence of lactic acidosis in patients taking metformin with and without abnormalities in renal function (Diabetes Care 2014;37:2291-5). There was no statistically significant difference in the rates of lactic acidosis in patients who were on metformin with normal renal function, compared with those with varying degrees of renal insufficiency. The overall rate of lactic acidosis was 10.3 per 100,000 patient years, which is almost identical to the rates in the other studies mentioned, and there were no fatalities.

Several recommendations for using metformin in patients with renal insufficiency have been published (see table) (JAMA 2014;312:2668-75; Diabetes Care 2011;34:1431-7). Metformin has shown cardiovascular mortality benefits, compared with sulfonylureas, in the treatment of diabetes (Diabetes Care 2013;36:1304-11). Avoiding its use in patients with mild to moderate renal insufficiency in favor of other treatments that may not be as beneficial and may well lead to worse outcomes.

There is no evidence that metformin increases the lactic acidosis risk in patients with diabetes, but until there is a change in the FDA labeling, physicians will likely continue to be hesitant to use it in patients with renal insufficiency.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.

BOSTON – Four-thirty in the afternoon isn’t the time slot most conference presenters covet.

By that point, many attendees are done for the day – loaded up with new knowledge and weighed down with schwag-stuffed tote bags. By 4:30 p.m., the hotel bar is enjoying stronger attendance and better survey-sheet ratings than a closing-time clinical diagnosis session.

But, by 4:30 Thursday at the annual meeting of the American College of Physicians, cavernous room 107 in Boston’s convention center was filling up.

Was it hosting “Atrial Fibrillation 2015”? “Prescribing Chronic Opioids”? “Update in Endocrinology”?

In fact, the session’s topic wasn’t clinical, but its nature was definitely acute. Room 107’s attendees had arrived for a session with the potential for as much action as the weekend’s upcoming Mayweather-Pacquiao megafight: “ABIM: Understanding MOC Requirements.”

There behind the podium stood the subdued president and CEO of the American Board of Internal Medicine, Dr. Richard J. Baron, looking like a Yankees fan about to lecture the Fenway Park faithful on the many merits of Bucky “Bleepin’ ” Dent.

In fact, before him seethed bleachers of angry doctors eager to share their opinions about what they viewed as ABIM’s own Bucky Dent: the Maintenance of Certification program.

With the ABIM board’s chair-elect, Dr. Clarence Braddock III, sitting nearby on the dais, Dr. Baron dutifully outlined the MOC backtracking that came with February’s public apology by ABIM: updates to its internal medicine exam; suspension of the practice assessment, patient voice, and patient safety requirements for at least 2 years; and MOC enrollment fees set at or below the 2014 levels through at least 2017. And if those three requirements did return, ABIM would give physicians a year’s notice before they would have to start meeting them.

By the end of the year, ABIM also will unveil more flexible ways to earn MOC points, Dr. Baron noted. He also offered his listeners assurances that the fall 2015 MOC exam would better reflect doctors’ clinical experiences.

“The most important thing we learned from Feb. 3 is that ABIM needed to change to an organization much more rooted in the community,” Dr. Baron explained.

Then he opened the meeting to questions from the audience – triggering an Airing of Grievances worthy of a “Seinfeld” Festivus.

Terry Rudd/Frontline Medical Communications

Beginning with a New Jersey physician who vigorously aired her own grievances at a volume that made a microphone redundant – “Don’t scare us away – we WANT to keep up!” – room 107’s open mics amplified a steady stream of physicians eager to vent their MOC-fueled fury and despair.

What about changing the MOC exam to open-book? “ ‘Consult the gastroenterologist’ is the real-world approach to solving problems!” Why can’t multiple sources of CME credit count toward MOC? Why not dump the recertification exam and simply use the modules to keep physicians fresh?

One physician who spent most of his practice in urgent-care settings and occupational medicine – in which relationships with patients are, by nature, short-lived – worried that a return of the patient voice requirement would make failure certain for him.

“I may be 72, but I will retire before I do one of those Practice Improvement Modules again!” warned another physician.

Attendees also zeroed in on financial allegations made in two recent Newsweek articles about ABIM (“The Ugly Civil War in American Medicine” and “A Certified Medical Controversy”). “Is an independent group going to review reports about ABIM’s finances?” one attendee asked. Another stated that ABIM’s board shouldn’t be paid, a suggestion for which the doctor received a generous round of applause.

Dr. Baron categorically dismissed claims that ABIM was financially troubled and that it manipulated exams to drive down pass rates – and thus boost its revenues with retests. “We had the sixth-largest auditor review our finances, and they found no issue with our finances,” Dr. Baron countered. “Our audited finances are available on our website.”

Although the audience appeared unified in its deep displeasure with ABIM’s approach to the now-postponed MOC changes, the still-active issue of recertification exams revealed fissures between older and younger doctors.

One younger physician questioned the fairness of the dual system: “Why do older doctors not have to recertify? Abolish grandfathering!”

That drove “grandfathered” physicians to the room mics to defend their exclusion from recertification tests. Some stated that no data backed the belief that recertified physicians delivered better care. One grandfathered physician insisted she shouldn’t be “bullied into recertifying.”

Dr. Baron backed recertification by declaring that “we know that knowledge decays over time.” A study of grandfathered physicians vs. recertified physicians showed higher costs associated with grandfathers, he added.

After nearly an hour of open mics and talk therapy, the session came to a less-animated end. Attendees drifted off to evening events and, no doubt, nearby hotel bars for postgame MOC analysis. Dr. Baron left with the look of a New York fan relieved simply to escape Fenway Park physically unscathed after a Yankees win.

Will the communal catharsis from the Beantown Airing of Grievances – and similar sessions elsewhere – earn ABIM more time to morph MOC into something more acceptable and relevant to its test-takers and fee-payers before more physicians flee to upstart competing boards? Probably for many physicians, for whom ABIM’s MOC program remains at best a valued, necessary credential, and at worst a necessary evil.

But others say they’ve had enough.

As one physician emphatically declared to her colleagues in room 107 and beyond: “I would like the opportunity to put ‘Boycotting the MOC’ as my status on the ABIM website!”

trudd@frontlinemedcom.com

BOSTON – Four-thirty in the afternoon isn’t the time slot most conference presenters covet.

By that point, many attendees are done for the day – loaded up with new knowledge and weighed down with schwag-stuffed tote bags. By 4:30 p.m., the hotel bar is enjoying stronger attendance and better survey-sheet ratings than a closing-time clinical diagnosis session.

But, by 4:30 Thursday at the annual meeting of the American College of Physicians, cavernous room 107 in Boston’s convention center was filling up.

Was it hosting “Atrial Fibrillation 2015”? “Prescribing Chronic Opioids”? “Update in Endocrinology”?

In fact, the session’s topic wasn’t clinical, but its nature was definitely acute. Room 107’s attendees had arrived for a session with the potential for as much action as the weekend’s upcoming Mayweather-Pacquiao megafight: “ABIM: Understanding MOC Requirements.”

There behind the podium stood the subdued president and CEO of the American Board of Internal Medicine, Dr. Richard J. Baron, looking like a Yankees fan about to lecture the Fenway Park faithful on the many merits of Bucky “Bleepin’ ” Dent.

In fact, before him seethed bleachers of angry doctors eager to share their opinions about what they viewed as ABIM’s own Bucky Dent: the Maintenance of Certification program.

With the ABIM board’s chair-elect, Dr. Clarence Braddock III, sitting nearby on the dais, Dr. Baron dutifully outlined the MOC backtracking that came with February’s public apology by ABIM: updates to its internal medicine exam; suspension of the practice assessment, patient voice, and patient safety requirements for at least 2 years; and MOC enrollment fees set at or below the 2014 levels through at least 2017. And if those three requirements did return, ABIM would give physicians a year’s notice before they would have to start meeting them.

By the end of the year, ABIM also will unveil more flexible ways to earn MOC points, Dr. Baron noted. He also offered his listeners assurances that the fall 2015 MOC exam would better reflect doctors’ clinical experiences.

“The most important thing we learned from Feb. 3 is that ABIM needed to change to an organization much more rooted in the community,” Dr. Baron explained.

Then he opened the meeting to questions from the audience – triggering an Airing of Grievances worthy of a “Seinfeld” Festivus.

Terry Rudd/Frontline Medical Communications

Beginning with a New Jersey physician who vigorously aired her own grievances at a volume that made a microphone redundant – “Don’t scare us away – we WANT to keep up!” – room 107’s open mics amplified a steady stream of physicians eager to vent their MOC-fueled fury and despair.

What about changing the MOC exam to open-book? “ ‘Consult the gastroenterologist’ is the real-world approach to solving problems!” Why can’t multiple sources of CME credit count toward MOC? Why not dump the recertification exam and simply use the modules to keep physicians fresh?

One physician who spent most of his practice in urgent-care settings and occupational medicine – in which relationships with patients are, by nature, short-lived – worried that a return of the patient voice requirement would make failure certain for him.

“I may be 72, but I will retire before I do one of those Practice Improvement Modules again!” warned another physician.

Attendees also zeroed in on financial allegations made in two recent Newsweek articles about ABIM (“The Ugly Civil War in American Medicine” and “A Certified Medical Controversy”). “Is an independent group going to review reports about ABIM’s finances?” one attendee asked. Another stated that ABIM’s board shouldn’t be paid, a suggestion for which the doctor received a generous round of applause.

Dr. Baron categorically dismissed claims that ABIM was financially troubled and that it manipulated exams to drive down pass rates – and thus boost its revenues with retests. “We had the sixth-largest auditor review our finances, and they found no issue with our finances,” Dr. Baron countered. “Our audited finances are available on our website.”

Although the audience appeared unified in its deep displeasure with ABIM’s approach to the now-postponed MOC changes, the still-active issue of recertification exams revealed fissures between older and younger doctors.

One younger physician questioned the fairness of the dual system: “Why do older doctors not have to recertify? Abolish grandfathering!”

That drove “grandfathered” physicians to the room mics to defend their exclusion from recertification tests. Some stated that no data backed the belief that recertified physicians delivered better care. One grandfathered physician insisted she shouldn’t be “bullied into recertifying.”

Dr. Baron backed recertification by declaring that “we know that knowledge decays over time.” A study of grandfathered physicians vs. recertified physicians showed higher costs associated with grandfathers, he added.

After nearly an hour of open mics and talk therapy, the session came to a less-animated end. Attendees drifted off to evening events and, no doubt, nearby hotel bars for postgame MOC analysis. Dr. Baron left with the look of a New York fan relieved simply to escape Fenway Park physically unscathed after a Yankees win.

Will the communal catharsis from the Beantown Airing of Grievances – and similar sessions elsewhere – earn ABIM more time to morph MOC into something more acceptable and relevant to its test-takers and fee-payers before more physicians flee to upstart competing boards? Probably for many physicians, for whom ABIM’s MOC program remains at best a valued, necessary credential, and at worst a necessary evil.

But others say they’ve had enough.

As one physician emphatically declared to her colleagues in room 107 and beyond: “I would like the opportunity to put ‘Boycotting the MOC’ as my status on the ABIM website!”

trudd@frontlinemedcom.com

BOSTON – Four-thirty in the afternoon isn’t the time slot most conference presenters covet.

By that point, many attendees are done for the day – loaded up with new knowledge and weighed down with schwag-stuffed tote bags. By 4:30 p.m., the hotel bar is enjoying stronger attendance and better survey-sheet ratings than a closing-time clinical diagnosis session.

But, by 4:30 Thursday at the annual meeting of the American College of Physicians, cavernous room 107 in Boston’s convention center was filling up.

Was it hosting “Atrial Fibrillation 2015”? “Prescribing Chronic Opioids”? “Update in Endocrinology”?

In fact, the session’s topic wasn’t clinical, but its nature was definitely acute. Room 107’s attendees had arrived for a session with the potential for as much action as the weekend’s upcoming Mayweather-Pacquiao megafight: “ABIM: Understanding MOC Requirements.”

There behind the podium stood the subdued president and CEO of the American Board of Internal Medicine, Dr. Richard J. Baron, looking like a Yankees fan about to lecture the Fenway Park faithful on the many merits of Bucky “Bleepin’ ” Dent.

In fact, before him seethed bleachers of angry doctors eager to share their opinions about what they viewed as ABIM’s own Bucky Dent: the Maintenance of Certification program.

With the ABIM board’s chair-elect, Dr. Clarence Braddock III, sitting nearby on the dais, Dr. Baron dutifully outlined the MOC backtracking that came with February’s public apology by ABIM: updates to its internal medicine exam; suspension of the practice assessment, patient voice, and patient safety requirements for at least 2 years; and MOC enrollment fees set at or below the 2014 levels through at least 2017. And if those three requirements did return, ABIM would give physicians a year’s notice before they would have to start meeting them.

By the end of the year, ABIM also will unveil more flexible ways to earn MOC points, Dr. Baron noted. He also offered his listeners assurances that the fall 2015 MOC exam would better reflect doctors’ clinical experiences.

“The most important thing we learned from Feb. 3 is that ABIM needed to change to an organization much more rooted in the community,” Dr. Baron explained.

Then he opened the meeting to questions from the audience – triggering an Airing of Grievances worthy of a “Seinfeld” Festivus.

Terry Rudd/Frontline Medical Communications

Beginning with a New Jersey physician who vigorously aired her own grievances at a volume that made a microphone redundant – “Don’t scare us away – we WANT to keep up!” – room 107’s open mics amplified a steady stream of physicians eager to vent their MOC-fueled fury and despair.

What about changing the MOC exam to open-book? “ ‘Consult the gastroenterologist’ is the real-world approach to solving problems!” Why can’t multiple sources of CME credit count toward MOC? Why not dump the recertification exam and simply use the modules to keep physicians fresh?

One physician who spent most of his practice in urgent-care settings and occupational medicine – in which relationships with patients are, by nature, short-lived – worried that a return of the patient voice requirement would make failure certain for him.

“I may be 72, but I will retire before I do one of those Practice Improvement Modules again!” warned another physician.

Attendees also zeroed in on financial allegations made in two recent Newsweek articles about ABIM (“The Ugly Civil War in American Medicine” and “A Certified Medical Controversy”). “Is an independent group going to review reports about ABIM’s finances?” one attendee asked. Another stated that ABIM’s board shouldn’t be paid, a suggestion for which the doctor received a generous round of applause.

Dr. Baron categorically dismissed claims that ABIM was financially troubled and that it manipulated exams to drive down pass rates – and thus boost its revenues with retests. “We had the sixth-largest auditor review our finances, and they found no issue with our finances,” Dr. Baron countered. “Our audited finances are available on our website.”

Although the audience appeared unified in its deep displeasure with ABIM’s approach to the now-postponed MOC changes, the still-active issue of recertification exams revealed fissures between older and younger doctors.

One younger physician questioned the fairness of the dual system: “Why do older doctors not have to recertify? Abolish grandfathering!”

That drove “grandfathered” physicians to the room mics to defend their exclusion from recertification tests. Some stated that no data backed the belief that recertified physicians delivered better care. One grandfathered physician insisted she shouldn’t be “bullied into recertifying.”

Dr. Baron backed recertification by declaring that “we know that knowledge decays over time.” A study of grandfathered physicians vs. recertified physicians showed higher costs associated with grandfathers, he added.

After nearly an hour of open mics and talk therapy, the session came to a less-animated end. Attendees drifted off to evening events and, no doubt, nearby hotel bars for postgame MOC analysis. Dr. Baron left with the look of a New York fan relieved simply to escape Fenway Park physically unscathed after a Yankees win.

Will the communal catharsis from the Beantown Airing of Grievances – and similar sessions elsewhere – earn ABIM more time to morph MOC into something more acceptable and relevant to its test-takers and fee-payers before more physicians flee to upstart competing boards? Probably for many physicians, for whom ABIM’s MOC program remains at best a valued, necessary credential, and at worst a necessary evil.

But others say they’ve had enough.

As one physician emphatically declared to her colleagues in room 107 and beyond: “I would like the opportunity to put ‘Boycotting the MOC’ as my status on the ABIM website!”

trudd@frontlinemedcom.com

We are writing in response to the Clinical Inquiry, “Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties?” by Cawse-Lucas et al (J Fam Pract. 2015;64:126-127).

We respectfully disagree with the authors’ conclusion that frenotomy probably isn’t helpful in overcoming breastfeeding difficulties and that “the evidence concerning improvements in maternal comfort is conflicting.” In addition, the authors cited only randomized controlled trials (RCTs). We believe they were remiss for not referencing systematic reviews that have found an association between frenotomy and improved breastfeeding.

In a systematic review of 5 RCTs and 9 case studies, Finigan and Long¹ found that frenotomy offered long-term improvement in more than half of cases. Edmunds et al² reviewed 25 papers and concluded that for most infants, frenotomy offers the best chance of improved and continued breastfeeding. In a review that included 4 RCTs and 12 observational studies, Ito³ found “moderate quality” evidence for the effectiveness of frenotomy in treating breastfeeding difficulties.

We also believe that qualitative data from breastfeeding mothers should be used to inform quantitative research. We need to explore—and offer—any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Sarah Oakley, BA (Hons), RN, RHV, IBCLC
Annabelle MacKenzie
Association of Tongue-tie Practitioners and Tongue-tie UK
Clapham, Beddford, England

Authors’ response:
Clinical Inquiries prioritizes the RCT as the best method to evaluate whether a treatment is valid and helpful because these trials can tell us whether treatment produces a significantly better outcome than expectant management.

We need to offer any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Other types of studies included in systematic reviews (eg, cohort, case series, observational) can only demonstrate an association between an intervention (frenotomy) and an outcome (subsequent improvement in breastfeeding). They cannot demonstrate whether the treatment produced the improvement or if the babies would have improved anyway without frenotomy.

Based on the highest quality evidence—the 4 RCTs we described in our article—it appears frenotomy produces a small and temporary reduction in maternal nipple pain in infants younger than 2 weeks, but no overall improvements in validated breastfeeding scores.

Frenotomy for tongue-tie in breastfeeding infants is understandably controversial, and will remain so as long as there is a paucity of high-quality research on this topic. We look forward to future RCTs, perhaps informed by the experiences of nursing mothers and using validated tools, that may further elucidate the question.

Jeanne Cawse-Lucas, MD
Shannon Waterman, MD
Leilani St. Anna, MLIS, AHIP
E. Chris Vincent, MD
Seattle, Wash

We are writing in response to the Clinical Inquiry, “Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties?” by Cawse-Lucas et al (J Fam Pract. 2015;64:126-127).

We respectfully disagree with the authors’ conclusion that frenotomy probably isn’t helpful in overcoming breastfeeding difficulties and that “the evidence concerning improvements in maternal comfort is conflicting.” In addition, the authors cited only randomized controlled trials (RCTs). We believe they were remiss for not referencing systematic reviews that have found an association between frenotomy and improved breastfeeding.

In a systematic review of 5 RCTs and 9 case studies, Finigan and Long¹ found that frenotomy offered long-term improvement in more than half of cases. Edmunds et al² reviewed 25 papers and concluded that for most infants, frenotomy offers the best chance of improved and continued breastfeeding. In a review that included 4 RCTs and 12 observational studies, Ito³ found “moderate quality” evidence for the effectiveness of frenotomy in treating breastfeeding difficulties.

We also believe that qualitative data from breastfeeding mothers should be used to inform quantitative research. We need to explore—and offer—any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Sarah Oakley, BA (Hons), RN, RHV, IBCLC
Annabelle MacKenzie
Association of Tongue-tie Practitioners and Tongue-tie UK
Clapham, Beddford, England

Authors’ response:
Clinical Inquiries prioritizes the RCT as the best method to evaluate whether a treatment is valid and helpful because these trials can tell us whether treatment produces a significantly better outcome than expectant management.

We need to offer any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Other types of studies included in systematic reviews (eg, cohort, case series, observational) can only demonstrate an association between an intervention (frenotomy) and an outcome (subsequent improvement in breastfeeding). They cannot demonstrate whether the treatment produced the improvement or if the babies would have improved anyway without frenotomy.

Based on the highest quality evidence—the 4 RCTs we described in our article—it appears frenotomy produces a small and temporary reduction in maternal nipple pain in infants younger than 2 weeks, but no overall improvements in validated breastfeeding scores.

Frenotomy for tongue-tie in breastfeeding infants is understandably controversial, and will remain so as long as there is a paucity of high-quality research on this topic. We look forward to future RCTs, perhaps informed by the experiences of nursing mothers and using validated tools, that may further elucidate the question.

Jeanne Cawse-Lucas, MD
Shannon Waterman, MD
Leilani St. Anna, MLIS, AHIP
E. Chris Vincent, MD
Seattle, Wash

We are writing in response to the Clinical Inquiry, “Does frenotomy help infants with tongue-tie overcome breastfeeding difficulties?” by Cawse-Lucas et al (J Fam Pract. 2015;64:126-127).

We respectfully disagree with the authors’ conclusion that frenotomy probably isn’t helpful in overcoming breastfeeding difficulties and that “the evidence concerning improvements in maternal comfort is conflicting.” In addition, the authors cited only randomized controlled trials (RCTs). We believe they were remiss for not referencing systematic reviews that have found an association between frenotomy and improved breastfeeding.

In a systematic review of 5 RCTs and 9 case studies, Finigan and Long¹ found that frenotomy offered long-term improvement in more than half of cases. Edmunds et al² reviewed 25 papers and concluded that for most infants, frenotomy offers the best chance of improved and continued breastfeeding. In a review that included 4 RCTs and 12 observational studies, Ito³ found “moderate quality” evidence for the effectiveness of frenotomy in treating breastfeeding difficulties.

We also believe that qualitative data from breastfeeding mothers should be used to inform quantitative research. We need to explore—and offer—any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Sarah Oakley, BA (Hons), RN, RHV, IBCLC
Annabelle MacKenzie
Association of Tongue-tie Practitioners and Tongue-tie UK
Clapham, Beddford, England

Authors’ response:
Clinical Inquiries prioritizes the RCT as the best method to evaluate whether a treatment is valid and helpful because these trials can tell us whether treatment produces a significantly better outcome than expectant management.

We need to offer any interventions that are deemed safe and have the potential to improve breastfeeding duration.

Other types of studies included in systematic reviews (eg, cohort, case series, observational) can only demonstrate an association between an intervention (frenotomy) and an outcome (subsequent improvement in breastfeeding). They cannot demonstrate whether the treatment produced the improvement or if the babies would have improved anyway without frenotomy.

Based on the highest quality evidence—the 4 RCTs we described in our article—it appears frenotomy produces a small and temporary reduction in maternal nipple pain in infants younger than 2 weeks, but no overall improvements in validated breastfeeding scores.

Frenotomy for tongue-tie in breastfeeding infants is understandably controversial, and will remain so as long as there is a paucity of high-quality research on this topic. We look forward to future RCTs, perhaps informed by the experiences of nursing mothers and using validated tools, that may further elucidate the question.

Jeanne Cawse-Lucas, MD
Shannon Waterman, MD
Leilani St. Anna, MLIS, AHIP
E. Chris Vincent, MD
Seattle, Wash

The prevalence of Lyme disease in the United States has steadily increased over the past several years. In 2013, the disease was reported in all but 8 states.¹ Prevention, as we know, is key.

Common preventive steps include using DEET insect repellent, wearing long pants and sleeves outdoors, tucking pants into socks, wearing light-colored clothing to make ticks more visible, and checking one’s body daily for ticks.^2,3 The next best way to prevent Lyme disease is timely tick removal, as it is believed that in most cases the Lyme disease bacterium can be transmitted after 36 to 48 hours of tick attachment.^2,3

The safest and most effective method of removal remains controversial. The Centers for Disease Control and Prevention (CDC) recommends using forceps or tweezers to grab the tick as close to the skin as possible, and without twisting, pulling it straight up with steady, even pressure.⁴

We have used an alternate method of removing ticks that can be done at home or in a clinic without the use of special tools. It has been 100% effective in the 9 patients who presented to our clinic with attached deer ticks. With a cotton swab, apply liquid soap in circles over the tick for about 30 to 60 seconds. Then, use a dry cotton swab to wipe away the soap. The tick will be found on the swab with its head intact. We found this “home remedy” to be fast, easy, and painless; it also doesn’t appear to rely on suffocation.

Because there is no squeezing or twisting, the risk of regurgitation is minimized, and thus, the process is much less frightening for children—and maybe even for some adults.

Dionna Rookey, PA-C
Lebanon, NH
Louis A. Kazal, Jr, MD, FAAFP
Hanover, NH

The prevalence of Lyme disease in the United States has steadily increased over the past several years. In 2013, the disease was reported in all but 8 states.¹ Prevention, as we know, is key.

Common preventive steps include using DEET insect repellent, wearing long pants and sleeves outdoors, tucking pants into socks, wearing light-colored clothing to make ticks more visible, and checking one’s body daily for ticks.^2,3 The next best way to prevent Lyme disease is timely tick removal, as it is believed that in most cases the Lyme disease bacterium can be transmitted after 36 to 48 hours of tick attachment.^2,3

The safest and most effective method of removal remains controversial. The Centers for Disease Control and Prevention (CDC) recommends using forceps or tweezers to grab the tick as close to the skin as possible, and without twisting, pulling it straight up with steady, even pressure.⁴

We have used an alternate method of removing ticks that can be done at home or in a clinic without the use of special tools. It has been 100% effective in the 9 patients who presented to our clinic with attached deer ticks. With a cotton swab, apply liquid soap in circles over the tick for about 30 to 60 seconds. Then, use a dry cotton swab to wipe away the soap. The tick will be found on the swab with its head intact. We found this “home remedy” to be fast, easy, and painless; it also doesn’t appear to rely on suffocation.

Because there is no squeezing or twisting, the risk of regurgitation is minimized, and thus, the process is much less frightening for children—and maybe even for some adults.

Dionna Rookey, PA-C
Lebanon, NH
Louis A. Kazal, Jr, MD, FAAFP
Hanover, NH

The prevalence of Lyme disease in the United States has steadily increased over the past several years. In 2013, the disease was reported in all but 8 states.¹ Prevention, as we know, is key.

Common preventive steps include using DEET insect repellent, wearing long pants and sleeves outdoors, tucking pants into socks, wearing light-colored clothing to make ticks more visible, and checking one’s body daily for ticks.^2,3 The next best way to prevent Lyme disease is timely tick removal, as it is believed that in most cases the Lyme disease bacterium can be transmitted after 36 to 48 hours of tick attachment.^2,3

The safest and most effective method of removal remains controversial. The Centers for Disease Control and Prevention (CDC) recommends using forceps or tweezers to grab the tick as close to the skin as possible, and without twisting, pulling it straight up with steady, even pressure.⁴

We have used an alternate method of removing ticks that can be done at home or in a clinic without the use of special tools. It has been 100% effective in the 9 patients who presented to our clinic with attached deer ticks. With a cotton swab, apply liquid soap in circles over the tick for about 30 to 60 seconds. Then, use a dry cotton swab to wipe away the soap. The tick will be found on the swab with its head intact. We found this “home remedy” to be fast, easy, and painless; it also doesn’t appear to rely on suffocation.

Because there is no squeezing or twisting, the risk of regurgitation is minimized, and thus, the process is much less frightening for children—and maybe even for some adults.

Dionna Rookey, PA-C
Lebanon, NH
Louis A. Kazal, Jr, MD, FAAFP
Hanover, NH

Dear readers, I assure you it is pure coincidence that your editors-in-chief would choose to write on similar topics in consecutive months. Although Randy Danielsen and I are simpatico in many ways, we do not actually sit down and coordinate our subject matter. It is simply a matter of similar tastes (ha) that leads me to present you with some musings on the same part of the anatomy that my counterpart focused on last month. Isn’t it about time the mouth got some attention?

So let me ask you: What is the first thing you notice about a person? I recently conducted a survey (albeit limited in scope and scientific rigor) to determine the answer to this question. What I found was that five out of six people notice someone’s face. Going one step further, I queried which specific component of the face they noticed; the majority said a person’s mouth and/or smile.

Smiling is a simple motion that requires only a fraction of the 36 facial muscles to produce. The pertinent percentage is source dependent—and controversial—so I will not include a specific percent or number here. What I will say is that having a smile to be proud of is not controversial at all. Moreover, what people evaluate (or, let’s be honest, pass judgment on) is the teeth as a component of that smile. Yet many children—who grow into adults, naturally—do not have healthy-looking teeth. And that, my friends, is a preventable indignity.

While conducting my research, I was intrigued to learn that Pierre Fauchard (1678-1761) was one of the first practitioners to promote scaling of the teeth and debridement of the root surfaces to prevent periodontal disease.¹ Another interesting finding was that the first oral hygiene school opened in Bridgeport, Connecticut, in 1913; the Bridgeport School Board employed the first graduating class to clean the schoolchildren’s teeth, which resulted in a decreased incidence of dental caries.² In 1945, Newburgh, New York, and Grand Rapids, Michigan, added fluoride to the public water supply, another step toward decreasing the incidence of dental caries.

Many of us recall the toothpaste commercial in which the young child comes home proudly announcing, “Look, Mom—no cavities.”³ That was more than 50 years ago, when having a cavity-free mouth was quite an accomplishment, given the limited access to dental care. And yet, sadly, access to oral health services—and the dental caries that result from lack of care—remain a serious public health problem.

But while we pride ourselves on (and admire) a beautiful smile, those pearly whites aren’t necessarily healthy. In fact, they can mask underlying oral health problems.⁴ It cannot be emphasized enough: Good dental health is essential to overall health.

In his editorial last month, Dr Danielsen reminded us that the mouth “is the gateway and window into health in our body.”⁵ We know that properly functioning teeth allow for good nutrition, which can contribute to overall health, while poor dentition can impede eating. (It can also cause speech impediments.) Unhealthy teeth and gums can contribute to pain syndromes and systemic conditions and can lead to bacterial infections in the gums, pharynx, and major organs.⁶ Moreover, chronic dental infections can compromise the treatment of patients with comprehensive medical conditions, including diabetes, hypertension, renal disease, or cancer.

Dental caries (or cavities) persist as the most common chronic condition among American children: 26% of preschoolers, 44% of kindergarteners, and more than half of adolescents experience preventable tooth decay.^7,8 Cavities occur when certain bacteria in oral plaque utilize dietary sugars to produce acid; this gradually erodes the tooth enamel, resulting in a cavity.⁹ When these same bacteria spread, they cause serious facial infections that result in swelling, toxicity, and sometimes death.

The impact of oral disease is a major public health problem that must not be ignored. The disparities in oral health care cannot be mitigated simply by performing more dental procedures.⁹ We, as primary care providers, must emphasize the importance of prevention. We already do this with other aspects of health care; to neglect the mouth as part of the body is a regretful oversight.

As health care providers, we need to understand, and communicate to our patients, the basics of common problems such as periodontal disease—including risk factors that compromise overall health and wellness.⁹ We can also share with them prevention practices that will help them to manage their disease. These elements merge well with routine health maintenance.

Nurse practitioners, nurse-midwives, and physician assistants, as frontline health care providers, are in a prime position to intercede and improve the dental health of all our patients. But while we are the most likely health professionals to take the lead in advancing patient-centered care that includes a dental evaluation, our formal curricula do not include the necessary skills.

The Affordable Care Act (ACA) provided an opportunity to expand dental coverage to millions of children nationwide. The provision to designate oral health services as “essential health benefits” establishes oral health as a critical piece of overall health.^10,11 Educational programs for NPs and PAs must follow suit and capitalize on the evidence-based knowledge and tools of our dental colleagues, so we can add oral health as an element of the health and wellness examination. The time has come to integrate the concepts of interprofessional oral health into the curriculum for NPs, PAs, and all health care providers.¹²

Remember, a “conscientiously applied program of oral hygiene and regular professional care” is an effective means of achieving a healthy smile!¹³ Let’s become providers of at least some of that professional care. Please share your thoughts with me at NPEditor@frontlinemedcom.com.

REFERENCES
1. Feinberg EM. A short history of modern dentistry. www.edwardfeinbergdmd.com/history-of-dentistry. Accessed April 8, 2015.
2. American Dental Association. History of dentistry timeline. www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline. Accessed April 8, 2015.
3. 1958 Crest toothpaste commercial. www.youtube.com/watch?v=v72NHYp8KD4. Accessed April 8, 2015.
4. Proctor & Gamble. Crest heritage. www.crest.com/about-crest/crestheritage.aspx. Ac­cessed April 8, 2015.
5. Danielsen RDD. It’s all about the spit! Clin Rev. 2015;25(4):4,6.
6. Feinberg EM. The importance of dentistry. www.edwardfeinbergdmd.com/adult-den tistry/importance-of-dentistry. Accessed April 8, 2015.
7. American Dental Association and the CDC. Water fluoridation: nature’s way to prevent tooth decay. www.cdc.gov/Fluoridation/pdf/natures_way.pdf. Accessed April 8, 2015.
8. Dye BA, Tan S, Smith V, et al; National Center for Health Statistics. (2007), Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248).
9. American  Dental Association. Four dental conditions—prevention summit primer (2013). www.ada.org/~/media/ADA/Public%20Programs/File/2013_Prevention_Summit_Primer_on_Four_Dental_Conditions.ashx. Accessed April 8, 2015.
10. Stahl EM, Reusch C. Ensuring access to pediatric dental benefits in the Affordable Care Act (ACA). http://neach.communitycatalyst.org/publications/asset/Pedi_dental_final_5-29-13.pdf. Accessed April 8, 2015.
11. Patient Protection and Affordable Care Act. Section 1302(b)(4)(F).
12. Haber J, Altman S, Moursi A, et al. Oral health challenges in pregnancy and childhood [webinar]. National Organization of Nurse Practi­tion­er Faculties. 2015.  www.nonpf.org/events/event_details.asp?id=508645. Accessed April 8, 2015.
13. American Dental Association, Council on Dental Therapeutics. Evaluation of Crest toothpaste. J Am Dent Assoc. 1960;61:272-274.

Dear readers, I assure you it is pure coincidence that your editors-in-chief would choose to write on similar topics in consecutive months. Although Randy Danielsen and I are simpatico in many ways, we do not actually sit down and coordinate our subject matter. It is simply a matter of similar tastes (ha) that leads me to present you with some musings on the same part of the anatomy that my counterpart focused on last month. Isn’t it about time the mouth got some attention?

So let me ask you: What is the first thing you notice about a person? I recently conducted a survey (albeit limited in scope and scientific rigor) to determine the answer to this question. What I found was that five out of six people notice someone’s face. Going one step further, I queried which specific component of the face they noticed; the majority said a person’s mouth and/or smile.

Smiling is a simple motion that requires only a fraction of the 36 facial muscles to produce. The pertinent percentage is source dependent—and controversial—so I will not include a specific percent or number here. What I will say is that having a smile to be proud of is not controversial at all. Moreover, what people evaluate (or, let’s be honest, pass judgment on) is the teeth as a component of that smile. Yet many children—who grow into adults, naturally—do not have healthy-looking teeth. And that, my friends, is a preventable indignity.

While conducting my research, I was intrigued to learn that Pierre Fauchard (1678-1761) was one of the first practitioners to promote scaling of the teeth and debridement of the root surfaces to prevent periodontal disease.¹ Another interesting finding was that the first oral hygiene school opened in Bridgeport, Connecticut, in 1913; the Bridgeport School Board employed the first graduating class to clean the schoolchildren’s teeth, which resulted in a decreased incidence of dental caries.² In 1945, Newburgh, New York, and Grand Rapids, Michigan, added fluoride to the public water supply, another step toward decreasing the incidence of dental caries.

Many of us recall the toothpaste commercial in which the young child comes home proudly announcing, “Look, Mom—no cavities.”³ That was more than 50 years ago, when having a cavity-free mouth was quite an accomplishment, given the limited access to dental care. And yet, sadly, access to oral health services—and the dental caries that result from lack of care—remain a serious public health problem.

But while we pride ourselves on (and admire) a beautiful smile, those pearly whites aren’t necessarily healthy. In fact, they can mask underlying oral health problems.⁴ It cannot be emphasized enough: Good dental health is essential to overall health.

In his editorial last month, Dr Danielsen reminded us that the mouth “is the gateway and window into health in our body.”⁵ We know that properly functioning teeth allow for good nutrition, which can contribute to overall health, while poor dentition can impede eating. (It can also cause speech impediments.) Unhealthy teeth and gums can contribute to pain syndromes and systemic conditions and can lead to bacterial infections in the gums, pharynx, and major organs.⁶ Moreover, chronic dental infections can compromise the treatment of patients with comprehensive medical conditions, including diabetes, hypertension, renal disease, or cancer.

Dental caries (or cavities) persist as the most common chronic condition among American children: 26% of preschoolers, 44% of kindergarteners, and more than half of adolescents experience preventable tooth decay.^7,8 Cavities occur when certain bacteria in oral plaque utilize dietary sugars to produce acid; this gradually erodes the tooth enamel, resulting in a cavity.⁹ When these same bacteria spread, they cause serious facial infections that result in swelling, toxicity, and sometimes death.

The impact of oral disease is a major public health problem that must not be ignored. The disparities in oral health care cannot be mitigated simply by performing more dental procedures.⁹ We, as primary care providers, must emphasize the importance of prevention. We already do this with other aspects of health care; to neglect the mouth as part of the body is a regretful oversight.

As health care providers, we need to understand, and communicate to our patients, the basics of common problems such as periodontal disease—including risk factors that compromise overall health and wellness.⁹ We can also share with them prevention practices that will help them to manage their disease. These elements merge well with routine health maintenance.

Nurse practitioners, nurse-midwives, and physician assistants, as frontline health care providers, are in a prime position to intercede and improve the dental health of all our patients. But while we are the most likely health professionals to take the lead in advancing patient-centered care that includes a dental evaluation, our formal curricula do not include the necessary skills.

The Affordable Care Act (ACA) provided an opportunity to expand dental coverage to millions of children nationwide. The provision to designate oral health services as “essential health benefits” establishes oral health as a critical piece of overall health.^10,11 Educational programs for NPs and PAs must follow suit and capitalize on the evidence-based knowledge and tools of our dental colleagues, so we can add oral health as an element of the health and wellness examination. The time has come to integrate the concepts of interprofessional oral health into the curriculum for NPs, PAs, and all health care providers.¹²

Remember, a “conscientiously applied program of oral hygiene and regular professional care” is an effective means of achieving a healthy smile!¹³ Let’s become providers of at least some of that professional care. Please share your thoughts with me at NPEditor@frontlinemedcom.com.

REFERENCES
1. Feinberg EM. A short history of modern dentistry. www.edwardfeinbergdmd.com/history-of-dentistry. Accessed April 8, 2015.
2. American Dental Association. History of dentistry timeline. www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline. Accessed April 8, 2015.
3. 1958 Crest toothpaste commercial. www.youtube.com/watch?v=v72NHYp8KD4. Accessed April 8, 2015.
4. Proctor & Gamble. Crest heritage. www.crest.com/about-crest/crestheritage.aspx. Ac­cessed April 8, 2015.
5. Danielsen RDD. It’s all about the spit! Clin Rev. 2015;25(4):4,6.
6. Feinberg EM. The importance of dentistry. www.edwardfeinbergdmd.com/adult-den tistry/importance-of-dentistry. Accessed April 8, 2015.
7. American Dental Association and the CDC. Water fluoridation: nature’s way to prevent tooth decay. www.cdc.gov/Fluoridation/pdf/natures_way.pdf. Accessed April 8, 2015.
8. Dye BA, Tan S, Smith V, et al; National Center for Health Statistics. (2007), Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248).
9. American  Dental Association. Four dental conditions—prevention summit primer (2013). www.ada.org/~/media/ADA/Public%20Programs/File/2013_Prevention_Summit_Primer_on_Four_Dental_Conditions.ashx. Accessed April 8, 2015.
10. Stahl EM, Reusch C. Ensuring access to pediatric dental benefits in the Affordable Care Act (ACA). http://neach.communitycatalyst.org/publications/asset/Pedi_dental_final_5-29-13.pdf. Accessed April 8, 2015.
11. Patient Protection and Affordable Care Act. Section 1302(b)(4)(F).
12. Haber J, Altman S, Moursi A, et al. Oral health challenges in pregnancy and childhood [webinar]. National Organization of Nurse Practi­tion­er Faculties. 2015.  www.nonpf.org/events/event_details.asp?id=508645. Accessed April 8, 2015.
13. American Dental Association, Council on Dental Therapeutics. Evaluation of Crest toothpaste. J Am Dent Assoc. 1960;61:272-274.

Dear readers, I assure you it is pure coincidence that your editors-in-chief would choose to write on similar topics in consecutive months. Although Randy Danielsen and I are simpatico in many ways, we do not actually sit down and coordinate our subject matter. It is simply a matter of similar tastes (ha) that leads me to present you with some musings on the same part of the anatomy that my counterpart focused on last month. Isn’t it about time the mouth got some attention?

So let me ask you: What is the first thing you notice about a person? I recently conducted a survey (albeit limited in scope and scientific rigor) to determine the answer to this question. What I found was that five out of six people notice someone’s face. Going one step further, I queried which specific component of the face they noticed; the majority said a person’s mouth and/or smile.

Smiling is a simple motion that requires only a fraction of the 36 facial muscles to produce. The pertinent percentage is source dependent—and controversial—so I will not include a specific percent or number here. What I will say is that having a smile to be proud of is not controversial at all. Moreover, what people evaluate (or, let’s be honest, pass judgment on) is the teeth as a component of that smile. Yet many children—who grow into adults, naturally—do not have healthy-looking teeth. And that, my friends, is a preventable indignity.

While conducting my research, I was intrigued to learn that Pierre Fauchard (1678-1761) was one of the first practitioners to promote scaling of the teeth and debridement of the root surfaces to prevent periodontal disease.¹ Another interesting finding was that the first oral hygiene school opened in Bridgeport, Connecticut, in 1913; the Bridgeport School Board employed the first graduating class to clean the schoolchildren’s teeth, which resulted in a decreased incidence of dental caries.² In 1945, Newburgh, New York, and Grand Rapids, Michigan, added fluoride to the public water supply, another step toward decreasing the incidence of dental caries.

Many of us recall the toothpaste commercial in which the young child comes home proudly announcing, “Look, Mom—no cavities.”³ That was more than 50 years ago, when having a cavity-free mouth was quite an accomplishment, given the limited access to dental care. And yet, sadly, access to oral health services—and the dental caries that result from lack of care—remain a serious public health problem.

But while we pride ourselves on (and admire) a beautiful smile, those pearly whites aren’t necessarily healthy. In fact, they can mask underlying oral health problems.⁴ It cannot be emphasized enough: Good dental health is essential to overall health.

In his editorial last month, Dr Danielsen reminded us that the mouth “is the gateway and window into health in our body.”⁵ We know that properly functioning teeth allow for good nutrition, which can contribute to overall health, while poor dentition can impede eating. (It can also cause speech impediments.) Unhealthy teeth and gums can contribute to pain syndromes and systemic conditions and can lead to bacterial infections in the gums, pharynx, and major organs.⁶ Moreover, chronic dental infections can compromise the treatment of patients with comprehensive medical conditions, including diabetes, hypertension, renal disease, or cancer.

Dental caries (or cavities) persist as the most common chronic condition among American children: 26% of preschoolers, 44% of kindergarteners, and more than half of adolescents experience preventable tooth decay.^7,8 Cavities occur when certain bacteria in oral plaque utilize dietary sugars to produce acid; this gradually erodes the tooth enamel, resulting in a cavity.⁹ When these same bacteria spread, they cause serious facial infections that result in swelling, toxicity, and sometimes death.

The impact of oral disease is a major public health problem that must not be ignored. The disparities in oral health care cannot be mitigated simply by performing more dental procedures.⁹ We, as primary care providers, must emphasize the importance of prevention. We already do this with other aspects of health care; to neglect the mouth as part of the body is a regretful oversight.

As health care providers, we need to understand, and communicate to our patients, the basics of common problems such as periodontal disease—including risk factors that compromise overall health and wellness.⁹ We can also share with them prevention practices that will help them to manage their disease. These elements merge well with routine health maintenance.

Nurse practitioners, nurse-midwives, and physician assistants, as frontline health care providers, are in a prime position to intercede and improve the dental health of all our patients. But while we are the most likely health professionals to take the lead in advancing patient-centered care that includes a dental evaluation, our formal curricula do not include the necessary skills.

The Affordable Care Act (ACA) provided an opportunity to expand dental coverage to millions of children nationwide. The provision to designate oral health services as “essential health benefits” establishes oral health as a critical piece of overall health.^10,11 Educational programs for NPs and PAs must follow suit and capitalize on the evidence-based knowledge and tools of our dental colleagues, so we can add oral health as an element of the health and wellness examination. The time has come to integrate the concepts of interprofessional oral health into the curriculum for NPs, PAs, and all health care providers.¹²

Remember, a “conscientiously applied program of oral hygiene and regular professional care” is an effective means of achieving a healthy smile!¹³ Let’s become providers of at least some of that professional care. Please share your thoughts with me at NPEditor@frontlinemedcom.com.

REFERENCES
1. Feinberg EM. A short history of modern dentistry. www.edwardfeinbergdmd.com/history-of-dentistry. Accessed April 8, 2015.
2. American Dental Association. History of dentistry timeline. www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline. Accessed April 8, 2015.
3. 1958 Crest toothpaste commercial. www.youtube.com/watch?v=v72NHYp8KD4. Accessed April 8, 2015.
4. Proctor & Gamble. Crest heritage. www.crest.com/about-crest/crestheritage.aspx. Ac­cessed April 8, 2015.
5. Danielsen RDD. It’s all about the spit! Clin Rev. 2015;25(4):4,6.
6. Feinberg EM. The importance of dentistry. www.edwardfeinbergdmd.com/adult-den tistry/importance-of-dentistry. Accessed April 8, 2015.
7. American Dental Association and the CDC. Water fluoridation: nature’s way to prevent tooth decay. www.cdc.gov/Fluoridation/pdf/natures_way.pdf. Accessed April 8, 2015.
8. Dye BA, Tan S, Smith V, et al; National Center for Health Statistics. (2007), Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248).
9. American  Dental Association. Four dental conditions—prevention summit primer (2013). www.ada.org/~/media/ADA/Public%20Programs/File/2013_Prevention_Summit_Primer_on_Four_Dental_Conditions.ashx. Accessed April 8, 2015.
10. Stahl EM, Reusch C. Ensuring access to pediatric dental benefits in the Affordable Care Act (ACA). http://neach.communitycatalyst.org/publications/asset/Pedi_dental_final_5-29-13.pdf. Accessed April 8, 2015.
11. Patient Protection and Affordable Care Act. Section 1302(b)(4)(F).
12. Haber J, Altman S, Moursi A, et al. Oral health challenges in pregnancy and childhood [webinar]. National Organization of Nurse Practi­tion­er Faculties. 2015.  www.nonpf.org/events/event_details.asp?id=508645. Accessed April 8, 2015.
13. American Dental Association, Council on Dental Therapeutics. Evaluation of Crest toothpaste. J Am Dent Assoc. 1960;61:272-274.

A chair of orthopedic surgery at Rochester General Hospital and a lifelong automobile enthusiast, Dr States was also the track physician at Watkins Glen International Speedway, where he soon realized that even though the speeds of car crashes on the track were far greater than those on the highways, race-car drivers, protected by seatbelts, helmets, and safety cages or rollbars, typically walked away from their crashes, while drivers and passengers in highway accidents often did not.

Dr States began to research and to document the causes and consequences of severe crashes on his own—even before he began to receive federal funding to establish accident investigation teams. He often interrupted family drives when he came upon a crash site in order to take measurements and obtain information and went on to develop the Abbreviated Injury Scale (AIS) used throughout the world to standardize the measurements of automobile-related trauma injuries. According to the Association for the Advancement of Automotive Medicine, an organization he helped to found and lead, Dr States became an expert in the biomechanics of knee, hip, and spinal injuries, enabling him to develop seatbelt, dashboard, and airbag designs to reduce injuries.

Although Dr States was consulted frequently by auto manufacturers on ways to make cars safer, they did not heed his advice to voluntarily install seatbelts and other safety devices before it became the law. Acting on Dr States’ recommendations, New York State required manufacturers to equip all new cars with seatbelts beginning in 1964 and in 1984 became the first state to mandate their use. Similar laws followed in all but one other state, and John D. States has since been known as “Dr Seatbelt.”

Although mandatory seatbelt usage has been estimated to save 12,000 lives a year, Dr States never suggested that seatbelts alone could prevent all deaths and injuries from automobile crashes. In one of the 83 papers he authored or coauthored, a 1994 Journal of Trauma study (1994;37[3]:404-447) found that the patterns of injury resulting in the deaths of 91 unrestrained and 27 restrained vehicle crash victims were largely the same, with the exception of a 19.8% decrease in injuries resulting from ejection and a lower incidence of cerebral contusions (37% vs 71%) in the restrained group. Head, thoracic, and abdominal injuries followed similar patterns, with cranial injuries being the most likely cause of death in almost two thirds of the victims of both groups. Dr States and his colleagues concluded that accidents involving crushing, intrusion, and significant deceleration exceed the ability of restraints alone to prevent many fatal injuries.

Some of the implications of this data have already resulted in more protective automobile passenger compartments and additional safety features such as side airbags, collapsible steering wheels, and recessed instrumentation. 

Along with increasing the numbers of crash victims reaching EDs alive, safety features now incorporated into automobiles based on Dr States’ work have resulted in significant economic benefits to society and to the auto manufacturers who would not voluntarily adopt the safety measures he had advocated. Of the 12,000 lives a year saved, many undoubtedly go on to purchase replacement vehicles and probably continue to purchase new vehicles for many years to come. And, should the next generation of vehicles incorporate sensors and systems to prevent impacts independently of driver-controlled measures, the ideas and principles that John D. States, MD, championed throughout his life may someday reduce ED overcrowding as well.

A chair of orthopedic surgery at Rochester General Hospital and a lifelong automobile enthusiast, Dr States was also the track physician at Watkins Glen International Speedway, where he soon realized that even though the speeds of car crashes on the track were far greater than those on the highways, race-car drivers, protected by seatbelts, helmets, and safety cages or rollbars, typically walked away from their crashes, while drivers and passengers in highway accidents often did not.

Dr States began to research and to document the causes and consequences of severe crashes on his own—even before he began to receive federal funding to establish accident investigation teams. He often interrupted family drives when he came upon a crash site in order to take measurements and obtain information and went on to develop the Abbreviated Injury Scale (AIS) used throughout the world to standardize the measurements of automobile-related trauma injuries. According to the Association for the Advancement of Automotive Medicine, an organization he helped to found and lead, Dr States became an expert in the biomechanics of knee, hip, and spinal injuries, enabling him to develop seatbelt, dashboard, and airbag designs to reduce injuries.

Although Dr States was consulted frequently by auto manufacturers on ways to make cars safer, they did not heed his advice to voluntarily install seatbelts and other safety devices before it became the law. Acting on Dr States’ recommendations, New York State required manufacturers to equip all new cars with seatbelts beginning in 1964 and in 1984 became the first state to mandate their use. Similar laws followed in all but one other state, and John D. States has since been known as “Dr Seatbelt.”

Although mandatory seatbelt usage has been estimated to save 12,000 lives a year, Dr States never suggested that seatbelts alone could prevent all deaths and injuries from automobile crashes. In one of the 83 papers he authored or coauthored, a 1994 Journal of Trauma study (1994;37[3]:404-447) found that the patterns of injury resulting in the deaths of 91 unrestrained and 27 restrained vehicle crash victims were largely the same, with the exception of a 19.8% decrease in injuries resulting from ejection and a lower incidence of cerebral contusions (37% vs 71%) in the restrained group. Head, thoracic, and abdominal injuries followed similar patterns, with cranial injuries being the most likely cause of death in almost two thirds of the victims of both groups. Dr States and his colleagues concluded that accidents involving crushing, intrusion, and significant deceleration exceed the ability of restraints alone to prevent many fatal injuries.

Some of the implications of this data have already resulted in more protective automobile passenger compartments and additional safety features such as side airbags, collapsible steering wheels, and recessed instrumentation. 

Along with increasing the numbers of crash victims reaching EDs alive, safety features now incorporated into automobiles based on Dr States’ work have resulted in significant economic benefits to society and to the auto manufacturers who would not voluntarily adopt the safety measures he had advocated. Of the 12,000 lives a year saved, many undoubtedly go on to purchase replacement vehicles and probably continue to purchase new vehicles for many years to come. And, should the next generation of vehicles incorporate sensors and systems to prevent impacts independently of driver-controlled measures, the ideas and principles that John D. States, MD, championed throughout his life may someday reduce ED overcrowding as well.

A chair of orthopedic surgery at Rochester General Hospital and a lifelong automobile enthusiast, Dr States was also the track physician at Watkins Glen International Speedway, where he soon realized that even though the speeds of car crashes on the track were far greater than those on the highways, race-car drivers, protected by seatbelts, helmets, and safety cages or rollbars, typically walked away from their crashes, while drivers and passengers in highway accidents often did not.

Dr States began to research and to document the causes and consequences of severe crashes on his own—even before he began to receive federal funding to establish accident investigation teams. He often interrupted family drives when he came upon a crash site in order to take measurements and obtain information and went on to develop the Abbreviated Injury Scale (AIS) used throughout the world to standardize the measurements of automobile-related trauma injuries. According to the Association for the Advancement of Automotive Medicine, an organization he helped to found and lead, Dr States became an expert in the biomechanics of knee, hip, and spinal injuries, enabling him to develop seatbelt, dashboard, and airbag designs to reduce injuries.

Although Dr States was consulted frequently by auto manufacturers on ways to make cars safer, they did not heed his advice to voluntarily install seatbelts and other safety devices before it became the law. Acting on Dr States’ recommendations, New York State required manufacturers to equip all new cars with seatbelts beginning in 1964 and in 1984 became the first state to mandate their use. Similar laws followed in all but one other state, and John D. States has since been known as “Dr Seatbelt.”

Although mandatory seatbelt usage has been estimated to save 12,000 lives a year, Dr States never suggested that seatbelts alone could prevent all deaths and injuries from automobile crashes. In one of the 83 papers he authored or coauthored, a 1994 Journal of Trauma study (1994;37[3]:404-447) found that the patterns of injury resulting in the deaths of 91 unrestrained and 27 restrained vehicle crash victims were largely the same, with the exception of a 19.8% decrease in injuries resulting from ejection and a lower incidence of cerebral contusions (37% vs 71%) in the restrained group. Head, thoracic, and abdominal injuries followed similar patterns, with cranial injuries being the most likely cause of death in almost two thirds of the victims of both groups. Dr States and his colleagues concluded that accidents involving crushing, intrusion, and significant deceleration exceed the ability of restraints alone to prevent many fatal injuries.

Some of the implications of this data have already resulted in more protective automobile passenger compartments and additional safety features such as side airbags, collapsible steering wheels, and recessed instrumentation. 

Along with increasing the numbers of crash victims reaching EDs alive, safety features now incorporated into automobiles based on Dr States’ work have resulted in significant economic benefits to society and to the auto manufacturers who would not voluntarily adopt the safety measures he had advocated. Of the 12,000 lives a year saved, many undoubtedly go on to purchase replacement vehicles and probably continue to purchase new vehicles for many years to come. And, should the next generation of vehicles incorporate sensors and systems to prevent impacts independently of driver-controlled measures, the ideas and principles that John D. States, MD, championed throughout his life may someday reduce ED overcrowding as well.