Cephalometric study of Class II Division 1 patients treated with an extended-duration, reinforced, banded Herbst appliance followed by fixed appliances.

INTRODUCTION: The Herbst appliance has been used in the treatment of Class II malocclusions with deficient mandibles. Various protocols, including different durations of the orthopedic treatment phase and stepwise advancement of the mandible, have been advocated for increasing the orthopedic effects. The objective of this study was to investigate the skeletal and dental changes in patients treated with a reinforced banded Herbst appliance for an extended duration and fixed appliance therapy. METHODS: The study group consisted of 30 patients (16 boys, 14 girls; mean age, 12.3 ± 2.5 years) with Class II Division 1 malocclusions who were successfully treated with the new Herbst protocol followed by fixed appliances. Lateral cephalometric radiographs were taken before treatment, at the completion of Herbst treatment, and after removal of fixed appliances. The average treatment times were 1.5 ± 0.7 years for the Herbst treatment and 1.8 ± 0.5 years for the fixed appliances. A control Class II sample from the Bolton-Brush study was used to subtract growth from treatment changes to determine the appliance effect. Data were analyzed using analysis of variance and the Tukey-Kramer test. RESULTS: After the Herbst treatment, the incisal relationships of all subjects had been overcorrected to end-to-end relationships. Overjet was reduced by 7.2 mm after subtracting changes from growth. The skeletal contribution was 2.5 mm (35%), and the dental contribution was 4.7 mm (65%). The molar relationship was overcorrected to a more Class I relationship by 7.5 mm. The Wits appraisal was improved by 4.2 mm. Vertically, overbite was decreased by 3.3 mm. The maxillary and mandibular molars were extruded by 1 mm. The occlusal plane rotated clockwise by 5° with little change in the mandibular plane angle. After the treatment with fixed appliances, the overjet correction was maintained at 7.6 mm. The skeletal contribution was 2.9 mm (38%), and the dental contribution was 4.7 mm (62%). The molar relationship was corrected to a Class I relationship by 5.9 mm. The Wits appraisal was improved by 3.2 mm. Vertically, overbite was decreased by 4.2 mm. The maxillary and mandibular molars were extruded by 0.3 and 0.8 mm, respectively. The occlusal plane rotated clockwise by 1.2° with little change in the mandibular plane angle. CONCLUSIONS: Doubling the usual orthopedic treatment time with the reinforced Herbst appliance followed by fixed appliance therapy was effective in correcting Class II Division 1 malocclusions with excess overjet and overbite. In this sample of successfully treated patients, most changes after Herbst and fixed appliance therapy were dentoalveolar (62%). However, the skeletal changes attained in the orthopedic phase of treatment were maintained after fixed appliance therapy.

Comparison of two maxillary protraction protocols: tooth-borne versus bone-anchored protraction facemask treatment.

BACKGROUND: Protraction facemask has been advocated for treatment of class III malocclusion with maxillary deficiency. Studies using tooth-borne rapid palatal expansion (RPE) appliance as anchorage have experienced side effects such as forward movement of the maxillary molars, excessive proclination of the maxillary incisors, and an increase in lower face height. A new Hybrid Hyrax bone-anchored RPE appliance claimed to minimize the side effects of maxillary expansion and protraction. A retrospective study was conducted to compare the skeletal and dentoalveolar changes in patients treated with these two protocols. METHODS: Twenty class III patients (8 males, 12 females, mean age 9.8 ± 1.6 years) who were treated consecutively with the tooth-borne maxillary RPE and protraction device were compared with 20 class III patients (8 males, 12 females, mean age 9.6 ± 1.2 years) who were treated consecutively with the bone-anchored maxillary RPE and protraction appliances. Lateral cephalograms were taken at the start of treatment and at the end of maxillary protraction. A control group of class III patients with no treatment was included to subtract changes due to growth to obtain the true appliance effect. A custom cephalometric analysis based on measurements described by Bjork and Pancherz, McNamara, Tweed, and Steiner analyses was used to determine skeletal and dental changes. Data were analyzed using a one-way analysis of variance. RESULTS: Significant differences between the two groups were found in 8 out of 29 cephalometric variables (p < .05). Subjects in the tooth-borne facemask group had more proclination of maxillary incisors (OLp-Is, Is-SNL), increase in overjet correction, and correction in molar relationship. Subjects in the bone-anchored facemask group had less downward movement of the "A" point, less opening of the mandibular plane (SNL-ML and FH-ML), and more vertical eruption of the maxillary incisors. CONCLUSIONS: The Hybrid Hyrax bone-anchored RPE appliance minimized the side effect encounter by tooth-borne RPE appliance for maxillary expansion and protraction and may serve as an alternative treatment appliance for correcting class III patients with a hyperdivergent growth pattern.

Treatment effects of a fixed intermaxillary device to correct class II malocclusions in growing patients.

BACKGROUND: The objective of this study was to evaluate the treatment effects of Forsus™ Fatigue Resistant Device (FRD; 3M Unitek, Monrovia, CA, USA) in growing patients with Class II non-extraction malocclusions. METHODS: A retrospective sample of 24 class II patients treated consecutively with the FRD followed by comprehensive orthodontic treatment was compared to a sample of untreated control subjects from the Bolton Brush Study who was matched in age, sex, and craniofacial morphology. Lateral cephalometric radiographs were taken before treatment (T1) and after removal of fixed appliances (T2). Growth changes were subtracted from the treatment changes to obtain the treatment effects of the appliance. Data were analyzed using ANOVA and a match paired t test. RESULTS: Significant differences were found between the treated and control groups for 12 of the 29 measured variables (Co-Gn minus Co-Apt, Wits, Is-OLp, Ii-OLp, overjet, Mi-OLp, molar relationship, overbite, Mic-ML, SNA, ANB, and Ii-ML). With 27.8 months of treatment, all patients were corrected to a class I dental arch relationship. Overjet and molar relationships were improved by an average of 4.7 and 3.1 mm, respectively. This was contributed by a 1.2 mm of restraint in forward maxillary growth, 0.7 mm of forward movement of the mandible, 1.5 mm of backward movement of the maxillary incisors, 1.3 mm forward movement of the mandibular incisors, 0.5 mm backward movement of the maxillary molars, and 1.3 mm of forward movement of the mandibular molars. The overbite was decreased by 2 mm with no significant change in the occlusal, palatal, or mandibular plane. Individual variations in response to the FRD treatment were large for most of the parameters tested. Significant differences in treatment changes between male and female subjects were found only in a few parameters measured. CONCLUSIONS: These results demonstrate that significant overjet and overbite corrections can be obtained with the Forsus FRD in conjunction with comprehensive orthodontic treatment.

Class III correction using an inter-arch spring-loaded module.

BACKGROUND: A retrospective study was conducted to determine the cephalometric changes in a group of Class III patients treated with the inter-arch spring-loaded module (CS2000®, Dynaflex, St. Ann, MO, USA). METHODS: Thirty Caucasian patients (15 males, 15 females) with an average pre-treatment age of 9.6 years were treated consecutively with this appliance and compared with a control group of subjects from the Bolton-Brush Study who were matched in age, gender, and craniofacial morphology to the treatment group. Lateral cephalograms were taken before treatment and after removal of the CS2000® appliance. The treatment effects of the CS2000® appliance were calculated by subtracting the changes due to growth (control group) from the treatment changes. RESULTS: All patients were improved to a Class I dental arch relationship with a positive overjet. Significant sagittal, vertical, and angular changes were found between the pre- and post-treatment radiographs. With an average treatment time of 1.3 years, the maxillary base moved forward by 0.8 mm, while the mandibular base moved backward by 2.8 mm together with improvements in the ANB and Wits measurements. The maxillary incisor moved forward by 1.3 mm and the mandibular incisor moved forward by 1.0 mm. The maxillary molar moved forward by 1.0 mm while the mandibular molar moved backward by 0.6 mm. The average overjet correction was 3.9 mm and 92% of the correction was due to skeletal contribution and 8% was due to dental contribution. The average molar correction was 5.2 mm and 69% of the correction was due to skeletal contribution and 31% was due to dental contribution. CONCLUSIONS: Mild to moderate Class III malocclusion can be corrected using the inter-arch spring-loaded appliance with minimal patient compliance. The overjet correction was contributed by forward movement of the maxilla, backward and downward movement of the mandible, and proclination of the maxillary incisors. The molar relationship was corrected by mesialization of the maxillary molars, distalization of the mandibular molars together with a rotation of the occlusal plane.

Evaluation of masseter muscle morphology in different types of malocclusions using cone beam computed tomography.

OBJECTIVES: To evaluate the length and orientation of masseter in different types of malocclusions using Cone Beam Computed Tomography (CBCT). METHODS: Samples of 180 patients seeking orthodontic treatment at the University of Nevada, Las Vegas School of Dentistry, were included in the study. Pre-treatment multi-slice CBCT scans of these patients were divided into three anteroposterior groups: Class I subjects with ANB angle 0° to 5°; Class II subjects with ANB angle >5°; and Class III subjects with ANB angle <0°. CBCT scans were also divided into three vertical groups: normodivergent subjects with mandibular plane angle 22° to 30°; hyperdivergent subjects with mandibular plane angle >30°, hypodivergent subjects with mandibular plane angle <22°. The masseter was identified and landmarks were placed on the anterior border, at the origin and insertion of the muscle in 3-D mode of the Dolphin Imaging 10.5 Premium software. The Frankfort Horizontal Plane was used as a reference plane and an angular measurement was obtained by intersection of a line produced by the masseter landmarks to calculate the orientation of the muscles. The length of the masseter was measured and data were analyzed using ANOVA and matched pairs test. RESULTS: ANOVA found significant differences in muscle length among the three vertical groups for both the left and right muscles. Paired t test showed significantly shorter muscle length for the hypodivergent group (43.3 ± 4.0 mm) compared to the normodivergent group (45.6 ± 4.5 mm, P < 0.05) and shorter muscle length for the hyperdivergent group (42.3 ± 4.7 mm) compared to the hypodivergent group, P < 0.05. No significant differences were found in muscle length among the three anteroposterior groups. However, significant differences in muscle orientation angle were found among the three anteroposterior groups (P < 0.05). Class II subjects were found to have the most acute orientation angle (67.2 ± 6.6°) and Class III had the most obtuse orientation angle (81.6 ± 6.8°). CONCLUSIONS: These results suggest that certain types of malocclusion may have different masseter lengths and orientations and these differences may have implications for the mechanical advantage in bite force. For example, Class III individuals may have greater bite force than Class II individuals because the muscle fibers are oriented more along the arch of closure.

Anteroposterior relationship of the maxillary central incisors to the forehead in adult white males.

AIM: To evaluate and compare the anteroposterior relationship of the maxillary central incisors to the forehead in white male adults with harmonious profiles and white male adult orthodontic patients. METHODS: Photographs of 101 white male adults with good facial harmony (control sample) were compared with photographs of 97 white male adults seeking orthodontic treatment (study sample). All were profile images with the maxillary central incisors and foreheads in full view. The images were imported into an image editing software program, resized, and rotated to the upright head position. Reference lines were constructed to assess the anteroposterior positions of the maxillary central incisors and forehead inclinations. RESULTS: In the control sample, the maxillary central incisors were positioned between the forehead facial axis (FFA) point and glabella in 91%, posterior to the FFA point in 8%, and anterior to the glabella in <1%. The position of the maxillary central incisors was moderately correlated with forehead inclination (r² = 0.37). In the study sample, the maxillary central incisors were positioned between the FFA point and glabella in 34%, posterior to the FFA point in 59%, and anterior to the glabella in 7%. Maxillary central incisor position and forehead inclination were strongly correlated (r² = 0.53). The anteroposterior maxillary incisor position relative to the forehead between the control and study groups was significantly different (P < .0001). In addition, the forehead inclination between the control and study group was significantly different (P < .05). CONCLUSION: The forehead is an important landmark for anteroposterior maxillary incisor positioning for adult white male patients seeking improved facial harmony.

Identifying the people and factors that influence children's intentions to make lifestyle changes.

Childhood obesity and health behavior programs are increasingly a focus within literature and individual provider practices. This study was designed to inform "best practices" for establishing effective programs in the medical setting by identifying persons and factors that influence children's willingness to be active, eat healthy, and lose weight when medically appropriate. A total of 342 child and parent dyads living in a rural setting participated in this study. Child and parent report of theory of planned behavior constructs and child intentions to lose weight, eat healthier, and increase own exercise was established as the study outcomes. Parent and child perceptions and child characteristics (e.g., weight status) were associated with children's intentions to lose weight and obtain more exercise whereas only child perceptions were associated with children's intentions to eat healthier. Incorporating children as young as 10 years of age in conversations and planning for diet and physical activity lifestyle changes is essential for the success of the treatment option.

Stability of Class II treatment with an edgewise crowned Herbst appliance in the early mixed dentition: Skeletal and dental changes.

INTRODUCTION: The objectives of this research were to assess skeletal and dental changes in patients with Class II malocclusion treated with the edgewise crowned Herbst appliance in the early mixed dentition and to measure the stability of treatment after a second phase of fixed appliance therapy. METHODS: Twenty-two patients (ages, 8.4 ± 1.0 years) with Class II Division 1 malocclusion treated consecutively with the edgewise crowned Herbst appliance in the early mixed dentition were studied. Lateral cephalograms were taken before Herbst treatment, immediately after Herbst treatment, and after a second phase of fixed appliance therapy. The results were compared with a control group of untreated Class II subjects selected from the Bolton-Brush study, matched by age, sex, and craniofacial morphology. A total of 37 sagittal, vertical, and angular cephalometric variables were evaluated. Changes in overjet and molar relationship were calculated. Changes due to growth were subtracted to obtain the net changes due to treatment. The data were analyzed by using analysis of variance (ANOVA) and the t tests. RESULTS: Overcorrection with the Herbst appliance resulted in an average reduction in overjet of 7.0 mm and a change in molar relationship of 6.6 mm. Several factors contributed to the change in overjet: restraint of the forward movement of the maxilla (0.4 mm), forward movement of the mandible (2.0 mm), backward movement of the maxillary incisors (3.7 mm), and forward movement of the mandibular incisors (0.9 mm). Skeletal changes together with a 3.1-mm backward movement of the maxillary molars and a 1.1-mm forward movement of the mandibular molars contributed to the changes in molar relationship. After the second phase of fixed appliance therapy, the change in overjet was reduced to 2.8 mm. Most of the remaining overjet corrections were contributed by the restraint of maxillary growth (2.8 mm). The mandible moved posteriorly by 1.6 mm, and the mandibular incisors moved forward by 0.2 mm. Change in molar relationship was reduced to 2.2 mm. The maxillary molars moved backward by 0.2 mm, and the mandibular molars moved forward by 0.8 mm. CONCLUSIONS: Overcorrection of Class II malocclusion with the edgewise crowned Herbst appliance in the early mixed dentition resulted in a significant reduction in overjet and correction of the molar relationship. A portion of the correction was maintained after a second phase of fixed appliance therapy because of the continuous restraint of maxillary growth and the dentoalveolar adaptations.

Class III camouflage treatment: what are the limits?

INTRODUCTION: The purpose of this study was to determine the skeletal, dental, and soft-tissue changes in response to camouflage Class III treatment. METHODS: Thirty patients (average age, 12.4 + or - 1.0 years) with skeletal Class III malocclusions who completed comprehensive nonextraction orthodontic treatment were studied. Skeletal, dental, and soft-tissue changes were determined by using published cephalometric analyses. The quality of orthodontic treatment was standardized by registering the peer assessment rating index on the pretreatment and posttreatment study models. The change in the level of gingival attachment with treatment was determined on the study casts. The results were compared with a group of untreated subjects. Data were analyzed with repeated measures analysis and paired t tests. RESULTS: The average change in the Wits appraisal was greater in the treated group (1.2 + or - 0.1 mm) than in the control group (-0.5 + or - 0.3 mm). The average peer assessment rating index score improved from 33.5 to 4.1. No significant differences were found for the level of gingival attachments between the treatment and control groups. The sagittal jaw relationship (ANB angle) did not improve with camouflage treatment. A wide range of tooth movements compensated for the skeletal changes in both groups. The upper and lower limits for incisal movement to compensate for Class III skeletal changes were 120 degrees to the sella-nasion line and 80 degrees to the mandibular plane, respectively. Greater increases in the angle of convexity were found in the treated group, indicating improved facial profiles. Greater increases in length of the upper lip were found in the treated group, corresponding to the changes in the hard tissues with treatment. CONCLUSIONS: Significant dental and soft-tissue changes can be expected in young Class III patients treated with camouflage orthodontic tooth movement. A wide range of skeletal dysplasias can be camouflaged with tooth movement without deleterious effects to the periodontium. However, proper diagnosis and realistic treatment objectives are necessary to prevent undesirable sequelae.

Tooth whitening effects on bracket bond strength in vivo.

OBJECTIVE: To test the hypothesis that there is no difference between the bracket survival rate of brackets bonded to bleached and unbleached teeth. MATERIALS AND METHODS: Thirty-eight patients who required comprehensive orthodontic treatment were included in the study. A split mouth technique was used with one arch exposed to in-office whitening gel containing 38% hydrogen peroxide for 30 minutes, while the unbleached arch served as the control. Patients were divided into two groups: Brackets bonded within 24 hours after bleaching and brackets bonded 2-3 weeks after bleaching. The bracket survival rate was computed using the log-rank test (Kaplan-Meier Analysis). RESULTS: A significantly higher rate of bracket failure was found with bleached teeth (16.6%) compared with unbleached teeth (1.8%) after 180 days. Brackets bonded within 24 hours of bleaching resulted in significantly higher clinical failure (14.5%) compared with those bonded after 3 weeks (2.1%). Adhesive Remnant Index scores of failed brackets revealed that the majority of failure in bleached teeth occurred in the enamel/resin interface. CONCLUSIONS: The hypothesis was rejected. Brackets bonded within 24 hours after bleaching have a significantly higher risk for bond failure. Orthodontic bonding should be delayed for 2-3 weeks if patients have a history of in-office bleaching with 38% hydrogen peroxide.

Effects of sealant and self-etching primer on enamel decalcification. Part II: an in-vivo study.

INTRODUCTION: A self-etching primer (SEP) saves valuable time by eliminating the many steps required to etch, rinse, and place a sealant before application of the adhesive and placement of the bracket. The purpose of this study was to compare the effects of a conventional etch and sealant (CES) and a SEP on enamel decalcification in vivo. METHODS: Twenty-five patients who required comprehensive orthodontic treatment were included in this study. Before bonding, enamel surfaces were treated with either a CES (Light Bond, Reliance Orthodontic Products, Itasca, Ill) or a SEP (Transbond Plus, 3M Unitek, Monrovia, Calif) by using a split-arch technique. At the end of the observation period (18-24 months), the O'Leary plaque index was used to determine patients' oral-hygiene compliance, and enamel decalcification around the orthodontic bracket was scored based on the amount and severity of decalcification. Scanning electron microscopy images and x-ray spectrum analysis were performed to examine the etched pattern of the 2 bonding systems. Data were analyzed by using analysis of variance (ANOVA) and the Tukey-Kramer test; the confidence level was set at a significant level of P = 0.05. RESULTS: Significantly higher decalcification scores were found in the SEP group (27.5%) compared with the CES group (13.9%, P <0.001). No significant differences were found in the decalcification scores for teeth in the maxillary and mandibular arches. Significant differences were found between level of hygiene and decalcification (P <0.0001). Patients with fair or poor hygiene compliance had higher decalcification scores in the SEP group than in the CES group. CONCLUSIONS: Using a SEP might save chair time and improve cost-effectiveness, but it provides less resistance to enamel decalcification than a CES, especially in patients with poor oral hygiene.

Reactivation of herpes zoster (shingles) infection associated with an increased risk of death in immunocompetent older persons.

OBJECTIVES: To determine whether cutaneous herpes zoster infection in immunocompetent older people is correlated with an increased risk for death. SETTING: Primary care clinics associated with West Virginia University, Morgantown West Virginia. DESIGN: Case-control study PARTICIPANTS: Immunocompetent outpatients born from 1903 through 1931, seen from 1994 through 2001; 102 patients diagnosed with herpes zoster (HZV) infection and 201 controls. The median age of both groups was 75 and the sample size was approximately 5,000. MEASUREMENTS: Three-year mortality, risk, and age of death after first clinic visit for herpes zoster. RESULTS: Fourteen deaths occurred in the control group with a mean age of death of 83.4 and 26 deaths among the subjects with HZV with a mean age of death of 79.6. This age difference was not statistically significant, however the age adjusted risk of dying in three years after reactivation of HZV was 4.9 times the adjusted odds of dying without HZV, controlling for age. (95% confidence intervals for the ratio of adjusted odds: 2.4-10.44) CONCLUSION: In this study reactivation of herpes zoster infection was associated with an increased risk for death in the three years following an infection; deaths were not directly correlated with such an infection, but occurred for various other reasons. This suggests that herpes zoster infections may be a marker for early mortality.

Modified tarsal resection operation for congenital ptosis with fair levator function.

PURPOSE: There are many options for surgical repair of congenital ptosis with fair levator function. The authors review their 10-year experience with an en bloc resection of tarsus, Müller muscle, and conjunctiva in conjunction with graded levator aponeurosis advancement (a variation of the tarsectomy operation). METHODS: This is a retrospective case series that reviews all cases of ptosis repair performed at West Virginia University from 1994 to 2004 using the "modified tarsal resection method." Thirty patients with congenital ptosis and fair levator function were identified. Follow-up ranged from 6 weeks to 8 years. Charts were reviewed for type of ptosis, pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Müller muscle resection, postoperative eyelid symmetry, and postoperative complications. RESULTS: In patients with congenital ptosis and fair levator function, the average preoperative upper eyelid margin to reflex distance was 0.0 mm and the average postoperative upper eyelid margin to reflex distance was 2.8 mm. Twenty-five of 30 (83%) patients were deemed to have a "good" surgical outcome. The amount of tarsus-Müller muscle resection reliably predicts the amount of eyelid elevation. The only complications to date have been transient lagophthalmos with exposure keratitis. CONCLUSIONS: In the authors' hands, an en bloc resection of tarsus, Müller muscle, and conjunctiva combined with levator aponeurosis advancement reliably produces excellent results in the treatment of fair levator function congenital ptosis, superior to their previous experience with isolated maximal levator aponeurosis advancement.

Perceptions of professionalism vary most with educational rank and age.

The purpose of this study was to assess whether the perception of what constitutes professionalism varies with age, discipline, gender, or educational level among students and faculty at the major academic health sciences center in West Virginia. This exploratory descriptive survey study asked participants to classify behaviors described in a survey as professional, unprofessional, or unrelated to professionalism. Results were analyzed using contingency tables. For 2 x 2 contingency tables, test of independence of homogeneity was carried out by using Fisher's exact test. For tables of higher dimensions, chi square test was used. The survey yielded a 45 percent return rate and demonstrated that the perception of professionalism varied most with the level of education and age and, to a lesser extent, with gender and health care discipline. Undergraduates, females, the youngest age group (< or = 26), nursing students, and faculty other than dental or medical were more likely to label behavior depicted in the survey statements as unprofessional. The findings of this study underscore the complexities of the genesis of professionalism. Further study in regard to the teaching of professionalism is warranted.

Medication utilization patterns and methods of suicidality in borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a psychiatric disorder characterized by suicidal thoughts/attempts and instability of mood, interpersonal relationships, and self-image. Patients with BPD engage in manipulative acts in apparent attempts to exert control in their interpersonal relationships. This issue of control may also be exhibited in their manner of self-medication. OBJECTIVE: To examine the medication utilization patterns of patients with BPD versus patients without personality disorders in a control group and to compare methods of suicidality between the groups. METHODS: A randomized, retrospective, chart review study was conducted at an academic medical center psychiatric hospital. The study examined the medication utilization patterns and methods of suicidality displayed over a one-year period for 29 patients hospitalized with BPD versus 29 patients in a control group. RESULTS: The number of psychotropic, non-psychotropic, and total drugs on admission and discharge was significantly greater for patients with BPD compared with patients in the control group. There was no significant difference between the 2 groups with respect to overdose and cutting methods of suicidality. The mean number of Axis III discharge diagnoses in the control group upon discharge was significantly less than that in the study group. Approximately 25% of patients with BPD considered overdosage as a means to end their life. CONCLUSIONS: As patients with BPD receive more medications than patients without the disorder and often exhibit suicidal thoughts/attempts, clinicians should closely monitor the use of all medications.

Evaluation of a required statewide interdisciplinary rural health education program: student attitudes, career intents and perceived quality.

INTRODUCTION: A shortage of healthcare providers in West Virginia led to the creation of a statewide, community-based program with a required three-month rural experience for most state-sponsored health professions students. Project description: Initiated using funding from the W. K. Kellogg Foundation and expanded using both state funds and Area Health Education Center support, the West Virginia Rural Health Education Partnerships (WVRHEP) program impacts institutions of higher learning, 50 counties, and 332 training sites, and all students in state-funded health professions schools. A longitudinal database has been constructed to study program effects on students' reported attitudes, service orientation, and career intents. METHODS: Baseline data are collected from medical students, and students in all disciplines provide feedback on rotations and information about career intents, social responsibility, and attitudes towards rural practice. RESULTS: Data indicate an association between perceived quality of the rural experience and increased interest in rural health, social responsibility and confidence in becoming part of the community. Medical students may tend to rate social responsibility higher after completion of the first rural rotation. Students who anticipate practice in smaller towns also tend to rate the quality of the rotation higher, to anticipate careers in primary care, and to acknowledge social responsibility. CONCLUSION: As WVRHEP program graduates who have completed these surveys enter practice, both personal and community-specific program characteristics may be identified which strengthen interest in rural practice. The predictive validity of intermediate outcomes of attitudes and career intents in forecasting the ultimate outcomes of recruitment and retention may be studied.

Cephalometric variables to predict future success of early orthopedic Class III treatment.

BACKGROUND: The objective of this study was to select a model of cephalometric variables to predict future Class III growth patterns based on the results of early orthopedic treatment with a protraction facemask. MATERIAL: Sixty-four patients with Class III malocclusion were treated with a protraction facemask. Cephalometric radiographs were taken before treatment and a minimum of 3 years after treatment. The sample was divided into 2 groups: successful and unsuccessful according to overjet and molar relationships. Eleven linear and 5 angular measurements were made on the pretreatment radiograph. A logistic regression model was used to identify the dentoskeletal variables most responsible for the prediction of successful and unsuccessful outcomes in subjects receiving treatment. RESULTS: Stepwise variable selection generated 4 variables significant in predicting successful treatment outcomes: position of the condyle with reference to the cranial base (Co-GD, P = .02), ramal length (Co-Goi, P = .03), mandibular length (Co-Pg, P = .01), and gonial angle (Ar-Goi-Me, P < .0001). The gonial angle was found to be significantly larger in the unsuccessful group. Controlling for other variables, the probability of successful treatment is an increasing function of Co-GD and Co-Goi, and a decreasing function of Co-Pg and Ar-Goi-Me. A logistic equation was established that is accurate in predicting successfully treated Class III patients 95.5% of the time and unsuccessful ones 70% of the time. CONCLUSIONS: These results suggest that Class III growing patients with forward position of the mandible, small ramal length, large mandibular length, and obtuse gonial angle are highly associated with unsatisfactory treatment outcomes after pubertal growth.

A retrospective comparison of remifentanil versus methohexital for anesthesia in electroconvulsive therapy.

The electroconvulsive therapy (ECT) service at West Virginia University conducted a retrospective analysis of 24 patients who received bilateral ECT between November 1998 and December 2003. Patients were treated with a standard methohexital-based anesthetic. Twenty-four patients became completely or relatively refractory to maximum settings on the ECT device and were then switched to remifentanil as the sole induction agent. Seizure threshold was established by stimulus dose retitration. Stimulus dose in total charge (mC) and dynamic energy (J) was significantly lower with the remifentanil anesthetic versus methohexital. (P < 0.0001) Resulting motor and EEG seizure duration in patients was significantly longer receiving the remifentanil anesthetic versus methohexital. (P < 0.0001) Previous reports describe a rise in seizure threshold in patients for repeated ECT. Although this rise occurred during the treatment course using a methohexital anesthetic, this effect was greatly diminished when remifentanil was used as the sole anesthetic agent. We conclude that remifentanil can provide improved seizure response to ECT in patients who are refractory to seizure induction after a standard methohexital anesthetic. We also conclude that the increase in stimulus dose typically required with repeated treatments is related to the anesthetic regimen.

Comparison of bond strength between a conventional resin adhesive and a resin-modified glass ionomer adhesive: an in vitro and in vivo study.

The objectives of this study were (1) to compare the in vivo survival rates of orthodontic brackets bonded with a resin-modified glass ionomer adhesive (Fuji Ortho LC; GC America, Alsip, Ill) after conditioning with 10% polyacrylic acid and a conventional resin adhesive (Light Bond; Reliance Orthodontic Products, Itasca, Ill) bonded with 37% phosphoric acid, (2) to compare the in vitro bond shear/peel bond strength between the 2 adhesives, (3) to determine the mode of bracket failure in the in vivo and in vitro tests according to the adhesive remnant index (ARI), and (4) to compare the changes in surface morphology of enamel surface after etching or conditioning with 10% polyacrylic acid, with scanning electron microscopy. In the in vitro study, 50 extracted premolars were randomly divided into 4 groups: brackets bonded with Fuji Ortho LC or Light Bond adhesive that were debonded after either 30 minutes or 24 hours. Bond strengths were determined with a testing machine at a crosshead speed of 1 mm/min. Data were analyzed with analysis of variance and a paired Student t test. The in vivo study consisted of 398 teeth that were randomly bonded with Fuji Ortho LC or Light Bond adhesive in 22 subjects with the split-mouth technique. Bracket survival rates and distribution were followed for 1.3 years. Data were analyzed with Kaplan-Meier product-limit estimates of survivorship function. The in vitro study results showed significant differences (P <.05) among the adhesives and the debond times. Light Bond had significantly greater bond strengths than Fuji Ortho LC at 24 hours (18.46 +/- 2.95 MPa vs 9.56 +/- 1.85 MPa) and 30 minutes (16.19 +/- 2.04 MPa vs 6.93 +/- 1.93 MPa). Mean ARI scores showed that Fuji Ortho LC had significantly greater incidences of enamel/adhesive failure than Light Bond adhesive (4.9 vs 4.1). For the in vivo study, no significant differences in failure rate, sex, or location in dental arch or ARI ratings were found between the 2 adhesives. These results suggest that, compared with conventional resin, brackets bonded with resin-modified glass ionomer adhesive had significantly less shear bond strength in vitro. However, similar survival rates of the 2 materials studied after 1.3 years indicate that resin-reinforced glass ionomers can provide adequate bond strengths clinically. The weaker chemical bonding between the adhesive and the enamel might make it easier for clinicians to clean up adhesives on the enamel surface after debonding.