Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation: A Proposal for Standardization in Fellowship and Training Programs.

The need to be competent in neuromodulation is and should be a prerequisite prior to completing a fellowship in interventional pain medicine. Unfortunately, many programs lack acceptable candidates for these advanced therapies, and fellows may not receive adequate exposure to neuromodulation procedures. The American Society of Pain and Neuroscience (ASPN) desires to create a consensus of experts to set a minimum standard of competence for neurostimulation procedures, including spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), and peripheral nerve stimulation (PNS). The executive board of ASPN accepted nominations for colleagues with excellence in the subject matter of neuromodulation and physician education. This diverse group used peer-reviewed literature and, based on grading of evidence and expert opinion, developed critical consensus guides for training that all accredited fellowship programs should adopt. For each consensus point, transparency and recusal were used to eliminate bias, and an author was nominated for evidence grading oversight and bias control. Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation sets a standard for neuromodulation training in pain fellowship training programs. The consensus panel has determined several recommendations to improve care in the United States for patients undergoing neuromodulation. As neuromodulation training in the United States has evolved dramatically, these therapies have become ubiquitous in pain medicine. Unfortunately, fellowship programs and the Accreditation Council for Graduate Medical Education (ACGME) pain program requirements have not progressed training to match the demands of modern advancements. PEAK sets a new standard for fellowship training and presents thirteen practice areas vital for physician competence in neuromodulation.

Dental clearance prior to elective arthroplasty may not be needed for everyone.

We investigated the prevalence and risk factors for preoperative dental clearance failure in joint arthroplasty patients. Over a 5-month period, all patients scheduling total joint arthroplasty completed a dental questionnaire. Data collected included demographics, medical and dental history, dental hygiene practices, frequency of dental care, and results of dental clearance. Of the 300 patients, 35 (12%) failed dental clearance. Risk factors included tobacco use, poor flossing habits, history of tooth extraction, age, narcotic use, and lack of a dentist visit within 12 months. Of 189 patients who lacked the 3 least prevalent risk factors (tobacco use, narcotic use, no dental visit within 12 months), 11 (6%) failed dental clearance. Selective dental clearance based on patient risk stratification may be a reasonable approach.