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Format for Case Reports Mclindent A compilation of Thesis, Clinical Audit and Clinical Cases Submitted in partial fulfilment of the requirements for the Degree of Clinical Doctorate in Dentistry (Paediatric Dentistry) Eastman Dental Institute University College London Submitted by: MOHD RIDZUAN MOHD RAZI DDS (Malaysia) MFDS RCS (Edinburgh), MPaedDent RCS (England) 2012 1 Contents THESIS ............................................................................................................................. 3 CLINICAL AUDIT ......................................................................................................... 172 2 THESIS 3 EFFECTS OF POLYACRYLIC ACID ON BRUSHITE BONE CEMENT SETTING, MECHANICAL PROPERTIES, DEGRADATION AND CHLORHEXIDINE RELEASE Submitted in partial fulfilment of the requirements for the Degree of Clinical Doctorate in Dentistry (Paediatric Dentistry) Eastman Dental Institute University College London Submitted by: MOHD RIDZUAN MOHD RAZI DDS (Malaysia), MFDSRCS (Edinburgh), MPaedDent RCS (England) 2012 4 DECLARATION OF ORIGINALITY I hereby declare that the work presented in this thesis was carried out by me myself. Information derived from the published and unpublished work of others has been acknowledged in the text and the relevant references are included in this thesis. Mohd Ridzuan Mohd Razi Eastman Dental Institute, University College London September 2012 5 ABSTRACT In the field of Paediatric Dentistry, brushite cement has potential as an endodontic medicament and bone substitute material. Clinical applications however are limited due to their inherent properties, such as rapid setting time and poor mechanical properties. Antimicrobial e.g. chlorhexidine (CHX) could be incorporated into the cement for localised drug release. Aim and objectives: The aim of this study was to assess if partial replacement of citric acid (CA) by polyacrylic acid (PAA) can improve the properties of conventional brushite cements. The objectives were to assess the effects of varying PAA and CHX concentrations in brushite cements on their setting kinetics, final composition, microstructure of the cement, mechanical properties, degradation and CHX release profile. Materials and Methods: The cements consisted of equimolar β- tricalcium phosphate and monocalcium phosphate monohydrate (β-TCP/MCPM) and 6 or 11% (w/w) CHX. The liquid phase consisted of aqueous 800 mM CA and PAA solution at different ratios. Compositions with no CHX and/or PAA were used as control cements. Setting kinetics and final composition were determined using FTIR and Raman spectroscopy respectively. Brushite microstructure was examined using scanning electron microscopy. The cements were tested for microhardness and biaxial flexural strength (BFS). CHX release was quantified with UV spectroscopy and degradation by mass loss. Results: The setting times for compositions with PAA were delayed by up to 12 hours. FTIR indicated formation of dicalcium citrate and polyacrylate complexes could delay brushite formation. High CHX content inhibited the acid retarding effects and complex formation. Raman mapping demonstrated discrete regions of brushite and CHX in all set cements. Microscopically, PAA addition resulted in denser and less porous structure. The BFS ranged from 5.8 ± 1.3 MPa to 11.1 ± 1.2 MPa. CHX incorporation resulted in reduced BFS and modulus whilst PAA addition increased it. The average mass change was significantly different between compositions with and with no chlorhexidine; 12% and 0.2% respectively at the end of study period. The daily degradation rate ranged from 0.1 ± 0.03 wt% to 0.6 ± 0.15 wt%. PAA presence reduced CHX release from more than 90% to less than 20% over 4 weeks. Conclusion: PAA substantially slowed the setting reaction and chlorhexidine release characteristics, altered the final brushite crystal microstructure, increased mechanical properties but did not affect the degradation kinetics. 6 ACKNOWLEDGEMENTS Alhamdulillah, after 3 years, I have managed to obtain the Clinical Doctorate (DDent) in Paediatric Dentistry. First of all, my sincerest gratitude to my parents for their undying support throughout this journey, without which would have not been possible. Also to my beloved family (Along, Pian, Ira, Abang Mahazan, Yasmeen, Arif, Nana and Afiq) who have always been my strength and motivation to keep me going during challenging times. What I had achieved here in Eastman Dental Institute, London is dedicated to them. My deepest gratitude first goes to my supervisors Dr Anne Young and Dr Paul Ashley for their excellent guidance and invaluable assistance which enable me to complete my thesis successfully. A special thanks to Dr Susan Parekh for her continuous support and encouragement throughout the DDent programme. I would also like to thanks Dr Ensanya Abou Neel, Dr Graham Palmer and Dr Nicky with their help in my experimental works, for which I am much obliged.. Then to my all DDent colleagues, Mashael, Mohammed, Naz, Terry, Omar, Ibtesam, Nabilah, Jehan, Abeer, Sanaa, Mazlina, Azlina, Nadaa, Elly and Hussain. Not to forget Hillary, Sonia, Amal and dearest Sumathy. All of you will always be on my mind. Thanks for making this 3 years of my life enjoyable and less stressful with all the laughter. Thank you so much guys!!! I would also like to honour all the people that I have met throughout my time here in Unit of Paediatric Dentistry, Eastman Dental Institute/Hospital for their lovely companionship. A special thank you goes to all my Malaysian friends that I met in London and United Kingdom. Last but not least, thank you to Dr Ganasalingam Sockalingam and Dr Jamilah Omar for who have always inspired me to specialise in this field. Finally, to my sponsor the Ministry of Health Malaysia for scholarship and study leave, both are gratefully acknowledged. 7 Table of Contents DECLARATION OF ORIGINALITY .................................................................................. 5 ABSTRACT....................................................................................................................... 6 ACKNOWLEDGEMENTS ................................................................................................. 7 TABLE OF CONTENTS ................................................................................................... 8 LIST OF FIGURES ......................................................................................................... 11 LIST OF TABLES ........................................................................................................... 15 ABBREVIATIONS .......................................................................................................... 16 CHAPTER 1 .................................................................................................................... 19 1.0: INTRODUCTION ..................................................................................................... 20 1.1 STATEMENT OF THE PROBLEM .......................................................................... 20 CHAPTER 2 .................................................................................................................... 22 2.0 LITERATURE REVIEW ............................................................................................ 23 2.1 INTRODUCTION ........................................................................................................ 23 2.2 SEQUEALAE OF DENTAL TRAUMA .............................................................................. 23 2.2.1 Loss of vitality ............................................................................................................. 27 2.2.2 Arrested root development .......................................................................................... 27 2.2.3 Replacement resorption .............................................................................................. 29 2.2.4 Premature tooth loss ................................................................................................... 29 2.2.5 Alveolar bone resorption ............................................................................................ 30 2.3 MANAGEMENT OF THE TRAUMATISED TOOTH ............................................................. 31 2.3.1 Management of crown fracture ................................................................................... 31 2.3.2 Management of immature teeth with non- vital pulp .................................................. 32 2.3.3 Management of replacement resorption ..................................................................... 33 2.3.4 Management of alveolar bone preservation. .............................................................. 34 2.4 PROBLEMS WITH CURRENT TECHNIQUES FOR MANAGING TRAUMA .............................. 36 2.4.1 Calcium Hydroxide ..................................................................................................... 36 2.4.2 Mineral trioxide aggregate ......................................................................................... 37 2.4.3 Alveolar bone loss preservation and grafting technique ............................................ 38 2.5 BRUSHITE CEMENT AS A POSSIBLE ENDODONTIC OR BONE GRAFT MATERIAL ............... 40 2.6 BRUSHITE CEMENT.................................................................................................. 41 2.6.1 Calcium orthophosphate ............................................................................................. 41 2.6.2 Calcium Phosphate ceramics.....................................................................................
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