Medicaid and privately financed orthodontic patients have similar occlusal and psychosocial outcomes

Objective: This study compares occlusal and psychosocial outcomes from comprehensive orthodontic treatment in Medicaid (MC) and privately financed (private pay, PP) patients. Methods: Two cohorts received comprehensive orthodontics: MC (n = 66); PP (n = 60). A calibrated, blinded examiner scored dental casts at baseline (pretreatment, T1) and after completing 2 years of treatment (posttreatment, T2) using the Peer Assessment Rating (PAR) and the Index of Complexity, Outcome, and Need (ICON). The prevalence of patients in the validated ICON categories for treatment need, complexity, and improvement were calculated. Questionnaires to assess body image (BI) and expectations/experiences were administered. Occlusal measures at T2 were compared after adjustment for baseline characteristics. Psychosocial measures were compared between and within groups. Occlusal and psychosocial associations were evaluated. Results: MC was 1.3 years younger (P < 0.001) and had worse malocclusions at baseline (PAR 32 versus 25; P < 0.001); (ICON 64 versus 56; P = 0.06). After adjustment for age and initial severity, estimated average differences between groups at T2 (MC‐PP) were slight: 1.5 [95 percent confidence interval (CI) ?2.9, 5.9] and 2.4 (95 percent CI ?4.4, 8.9) for PAR and ICON, respectively. More PP completed treatment under 2 years (85 percent versus 62 percent; P = 0.03). At baseline, both groups needed treatment, but MC malocclusions were more complex (P = 0.05). At T2, both groups were acceptable and there were no differences in ICON improvement categories. Group differences in psychosocial measures and associations between psychosocial and occlusal measures were evident in the “teeth” domain but weak or lacking elsewhere. Conclusions: Occlusal and psychosocial outcomes from orthodontics in MC and PP were comparable, despite worse MC malocclusions at baseline.     

Surgical treatment of complex spinal cord lipomas

Purpose

This paper shows the long-term benefits of total/near-total resection of complex spinal cord lipomas and meticulous reconstruction of the neural placode, and specifically, its advantage over partial resection, and over non-surgical treatment for the subset of children with asymptomatic virgin lipomas.

Methods

The technique of total resection and placode reconstruction, together with technical nuances, are described in detail. We added 77 patients with complex lipomas to our original lipoma series published in 2009 and 2010, to a total of 315 patients who had had total or near-total resection and followed for a span of 20 years. Long-term outcome is measured by overall progression-free survival (PFS) with the Kaplan–Meier analysis, and by subgroup Cox proportional recurrence hazard analysis for the influence on outcome of 4 predictor variables of lipoma type, presence of symptoms, prior surgery, and post-operative cord–sac ratio. These results are compared to an age-matched, lesion-matched series of 116 patients who underwent partial lipoma resection over 11 years. The results for total resection is also compared to two large published series of asymptomatic lipomas followed without surgery over 9 to 10 years, to determine whether prophylactic total resection confers better long-term protection over conservative treatment for children with asymptomatic lipomas..

Results

The PFS after total resection for all lipoma types and clinical subgroups is 88.1 % over 20 years versus 34.6 % for partial resection at 10.5 years (p?<?0.0001). Culling only the asymptomatic patients with virgin (previously unoperated) lipomas, the PFS for prophylactic total resection for this subgroup rose to 98.8 % over 20 years, versus 67 % at 9 years for one group of non-surgical treatment and 60 % at 10 years for another group of conservative treatment. Our own as well as other published results of partial resection also compare poorly to non-surgical treatment for the subset of asymptomatic virgin lipomas. Multivariate subgroup analyses show that cord–sac ratio is the only independent variable that predicts outcome, with a 96.9 % PFS for ratio <30 % (loosest sac), 86.2 % for ratio between 30 and 50 %, and 78.3 % for ratio >50 % (tightest sac), and a threefold increase in recurrence hazard for high ratios (p?=?0.0009). Pre-operative patient profiling using multiple correspondence analysis shows the ideal patient for total resection is a child less than 2 years old with a virgin asymptomatic lipoma, who, with a PFS of 99.2 %, is virtually cured by total resection.

Conclusion

Total/near-total resection of complex lipomas and complete reconstruction of the neural placode achieves far better long-term protection against symptomatic recurrence than partial resection for all lesions; and for the subset of asymptomatic virgin lipomas, also better than non-surgical treatment. Partial resection in many cases produces worse outcome than conservative treatment for asymptomatic lesions.     

Social media basics for orthodontists

One of the most common buzz words in today's online world is "social media." This article defines social media, explains why it is important to practicing orthodontists, and provides information about how doctors can incorporate it into their practices. Five of the most useful social media tools are described in detail, outlining the strengths, weaknesses, opportunities, and risks inherent in each.     

Comparison of 2-Ethyl-Cyanoacrylate and 2-Butyl-Cyanoacrylate for Use on the Calvaria of CD1 Mice

Short-chain cyanoacrylates (SCCA), such as ethyl-2-cyanoacrylate (KrazyGlue, Aron Alpha, Columbus, OH) are commonly used as commercial fast-acting glues. Although once used in clinical medicine as skin adhesives, these products caused tissue toxicity and thus their use in live tissue was discontinued. SCCA were replaced by longer-chain versions (LCCA), such as butyl-cyanoacrylate (Vetbond, 3M, St Paul, Minnesota), which were found to be less toxic than the short-chain formulations. Some researchers prefer to use SCCA due to the belief that they create a stronger bond than do the longer-chain counterparts. In survival surgeries, we compared the bone thickness, bone necrosis, fibrosis, inflammation, and bone regeneration in the calvaria of control (naïve), surgery-only, SCCA-treated, and LCCA-treated mice (n = 20 per group). At 1 and 14 d after surgery, all mice except those treated with SCCA showed statistically similar bone measurements to those of the naive control group. The SCCA group had significantly less bone regeneration than did all other groups. These results suggest that the application of SCCA causes bone damage resulting in the loss of bone regeneration. This finding may assist investigators in choosing a tissue glue for their studies and may support the IACUC in advocating the use of pharmaceutical-grade tissue glues.Abbreviations: LCCA, long-chain cyanoacrylates; SCCA, short-chain cyanoacrylatesCyanoacrylates have been used as tissue adhesives since their synthesis in 1949.⁶ Synthetic cyanoacrylate adhesives belong in the family of liquid monomers formed by alkyl esters of 2-cyanoacrylic acid. The basic formula of the cyanoacrylate adhesive (alkyl-2-cyanoacrylate) has been manipulated to form different cyanoacrylate adhesives with different properties.²⁹ Several 2-cyanoacrylate esters have been synthesized by changing the length of the alkyl chain attached.⁴² The first cyanoacrylates were short-chained, poorly manufactured, and toxic to animals at pharmacologic doses.²⁴ Short-chain cyanoacrylates (SCCA), such as methyl-2-cyanoacrylate and ethyl-2-cyanoacrylate (KrazyGlue [Aron Alpha, Columbus, OH]), continue to be used as fast-acting adhesives.⁵ Although appropriated as tissue glues soon after their discovery, these early SCCA caused tissue toxicity and thus were discontinued in the clinical arena.⁴ Research showed that changing the type of alcohol in the compound to one with a longer molecular chain reduced tissue toxicity. Over time, nontoxic, longer-chain cyanoacrylates (LCCA), such as butyl-cyanoacrylate (Vetbond [3M, St Paul, Minnesota]) and octylcyanoacrylate, were manufactured, leading to their use once again in clinical medicine³³ (Figure 1).Open in a separate windowFigure 1.Trade names for different types of cyanoacrylates.Many researchers contend that SCCA is superior to LCCA in regard to the strength and tenacity of the bond when used to create cranial windows and as an application prior to an overlay of acrylic for cranial implants. However, SCCA is not pharmaceutical-grade, as mandated by the USDA in Policy 3² and the Guide for the Care and Use of Laboratory Animals,²² and therefore can only be used after specific review and approval by an institution''s IACUC. The determination for substitution is generally based on scientific necessity or compound availability.In this study, the effects of applying an SCCA product to mice calvaria were compared with those of an LCCA glue. Specifically, we evaluated bone regeneration, osteocyte numbers, inflammation, and bone remodeling at 2 time points after application. We hypothesized that mice calvaria treated with the SCCA product would show signs of toxicity, compared with skulls treated with the LCCA glue.