Presented by:

Dr. Piyush Verma

Dept of Paedodontics & Preventive Dentistry

Contents Introduction

Goals of isolation

Advantage of isolation

Methods of isolation

Direct methods

Indirect methods

• Conclusion

Introduction

good accessibility and visibility , adequate room for instrumentation

Necessary for easy manipulation and insertion of restorative materials

This control is attained through isolation

Goals of isolation Moisture control

Retraction and access

Harm prevention

Safe and aseptic operating field

Prevent accidental swallowing of restorative materials and instruments

Advantages of isolationPatient related:

A. Provides comfort

B. Protect from swallowing or aspirating foreign bodies

C. Protect soft tissues by retracting them

Operator related:

A. dry clean operative field

B. Infection control

C. Increased accessibility to operative site

D. Improved properties of restorative materials

E. Improved visibility & less fogging of mirror

F. Prevents contamination of tooth preparation

Methods of isolationDirect method :Rubber dam

Cotton rolls & cellulose wafers

Dri-angle

Gauze piece

Suction devices

Gingival retraction cords

Mouth props

Mouth mirror

Rubber dam One of the most effective means of isolating teeth

Developed by SC Barnum in 1864

Advantages of rubber dam

Increases visibility & accessibility

Provides a dry field

Effectively retracts tongue, cheeks away from the field of operation

Saves time

Reduces the chances of injury to soft tissues

Produces calming effect in children

Protects against bad taste of the materials used

Prevents any aspiration or ingestion of dental instruments

Case reports

Panse A et al, 2012 – presented 3 cases of ingestion of dental objects in 3 children in which rubber dam was not used

Case 1

X ray shows a bur at the level of L4 Vertebra in left lumbar region in a 4 yrs child, aspirated during access cavity preparation of 55 with an airoter hand

piece

Case 2

X ray shows a finishing bur at the level of L5 vertebra in left lumbar region in a 6 yrs old male child, aspirated while finishing restoration in his decayed 64, 65

Case 3

X ray shows an airoter cap at the level of L5 vertebra in left lumbar region

Disadvantages of rubber dam

Takes time to be applied

Communication with the patient can be difficult

Incorrect use may damage porcelain crowns/gingival tissues

Insecure clamps can be swallowed or aspirated

Contraindications

child with upper respiratory tract infection, congestion of nasal passage or nasal obstruction

Presence of some fixed orthodontic appliances

recently erupted tooth

Patients with allergy to latex

grossly carious teeth

Armamentarium Rubber dam sheet

Rubber dam template

Rubber dam punch

Rubber dam clamps

Rubber dam forceps

Rubber dam frame

Rubber dam napkin

Waxed dental floss

Scissors

Lubricants

Rubber dam sheet made of latex or non-latex.

Available in 2 sizes- ❶ 5”*5”

❷ 6”*6”

Available in varying thickness

Thin – 0.15 mm

Medium – 0.20 mm

Heavy – 0.25 mm

Extra-heavy – 0.30 mm

Special heavy – 0.35mm

Light and dark sheets are available, may be flavored for the children

Has a shiny and dull surface, dull side will be facing the occlusal side

Rubber dam template

Have positions of the teeth marked on them and are used to transfer them to the rubber dam sheet for holes to be punched

Rubber dam punch

Used to make the holes in the sheet through which the teeth can be isolated

Common hole placement problems

Holes punched too close together – holes pull away from teeth causing leakage

Holes punched too far apart– dam bunches up between teeth

Holes position too low on the dam – dam covers patient’s eyes or nose

Holes position too high on dam – dam does not extend over upper lip

Rubber dam clamps Made of shiny & dull stainless steel

consists of a bow & 2 jaws

Aid in anchoring the dam to the tooth & in soft tissue retraction

2 types :

Winged

Wingless

Wingless

Winged

Frequently used clamps used in pediatric dentistry :

12A clamp -- maxillary left second primary molar and the mandibular right second primary molar

13A clamp -- maxillary right second primary molar and the mandibular left primary second molar.

12A clamp

13A clamp

2A clamp -- first primary molars

14 clamp -- fully erupted permanent molars

14A clamp -- partially erupted permanent molars

2A clamp

14 clamp

14A clamp

Clamps for front teeth

Ivory # 6

Ivory # 15Ivory # 212SIvory # 90N

Ivory # 9

Dental floss

After selecting the appropriate clamp place a 12 inch piece of dental floss on the bow of the clamp to aid in retrieval of the clamp if it is dislodged from the tooth and falls into the posterior pharyngeal area

Rubber dam clamp forceps

Used for placement and removal of retainer from the tooth.

Types of forceps

Brewer 246-046Stockes 246-047

Ivory 246-048

White 246-051 Plamer 246-052

Grooves on their outer surfaces to ensure positive location of the clamp during expansion & placement.

Rubber dam frame

maintains the border of the dam in position

Support the edges of the rubber dam

Retract the soft tissues

Available in metal and plastic

Plastic frame :

Nygard-Ostby frame

U-shaped frame made of plastic

Because of its shape, exerts less tension on the dam

Easier to use

Requires no absorbent napkin, when taking radiographs

Stands away from face

Metal frame :

Young frame

U-shaped metal frame with small metal projections for securing borders of the rubber dam.

ModificationsLe Cadre Articule rubber

dam frame (articulated frame)

Developed in France by Dr. G Saveur

Curved to fit the face and hinged in the middle to fold back

Advantage -- Allows easier access for radiographic film placement

Handidam (Aseptico, Woodenville)

Has a built in foldable radiolucent frame and a plastic tube inserted in prepared holes in rubber dam material to keep the dam open

Available in one size

Advantages

Pre-framed, flexible design facilitates access to the oral cavity for suction, X-ray films, or digital X-ray sensors

Extremely low protein content reduces patient irritation (<50 micrograms)

Saves time–eliminates the need to remove and replace traditional dam during the procedure

Greater patient acceptance

Quick dam

Comes with an attached flexible plastic frame or rim that supports dam intraorally

Effective in saliva control anterior part of the mouth than posterior part

Has a pliable plastic frame around perimeter of the rubber dam

Advantages

Quick & easy placement

No metal clamps or frames

Highly flexible

Instidam (Zirc company)

Simple & effective isolation system

It is a pre punched rubber dam mounted on a frame

Compact design fits outside patient lips

Advantages :

Non threatening & comfortable to patient

Very stretchable

Tear resistant

Provides easy visibility

Radiographs can be taken without removing the dam

Lubricants

Before positioning the dam – lubricate the inner surface well with Vaseline or soap so that sheet will slide better over the contours of the teeth, more easily overcome the contact areas & closely tightly around the cervix

Rubber dam napkins

Prevent direct contact between the rubber sheet & patient’s cheek

Absorb saliva that accumulate beneath the dam by capillary action

Indicated in cases of allergy to the rubber dam

Preparation of the patient for rubber dam

The dam can be presented as a ‘raincoat’ that keeps the tooth dry and held on by a button (clamp) & kept straight by a coat hanger (frame)

Step 1 : Testing and lubricating the proximal contacts

Dental floss is used to test the inter proximal contact and remove debris from the tooth to be isolated

Identifies any sharp edges of restoration or enamel that must be smoothened

Using waxed dental tape may lubricate tight contacts to facilitate dam placement

Step 2 : Punching the holes

Step 3 : Lubricating the dam

lubricate both sides of the rubber

dam in the area of punched hole using a cotton role or gloved finger tip to apply the lubricant

lips and corner of the mouth may be lubricated with petroleum jelly or cocoa butter to prevent irritation

Step 4 : Selecting the clamp

operator receive the rubber dam retainer forceps with the selected retainer and floss tie in position

free end of tie should exit from cheek side of the retainer

Care should be taken not to open the retainer more than necessary to secure it in the forceps

Step 5: Testing the retainers stability and retention

Test the retainers stability and retention by lifting gently in an occlusal direction with a finger tip under the bow of the retainer

An improperly fitting retainer rocks or easily dislodged

Step 6: Placement

3 techniques :

Dam first

Clamp first

Dam & clamp together

Dam first

Finger tip is introduced in the dam opening to better illustrate the patient the functions of this rubber sheet

Assistant’s hands position the dam directly around the tooth to be treated

The dentist positions the clamp

With assistance dentist positions Young’s frame

Disadvantages Procedure is often difficult

Especially in posterior areas or particularly small mouths

Clamp first

Clamp positioned on the tooth

Rubber sheet has been slid below the clamp, already in place

Disadvantages : Difficult procedure

Chances of dislodgement and aspiration of clamp while placing rubber dam

Clamp & dam together

Rubber sheet is punched with a rubber dam punch

Rubber dam is stretched over the wings of selected clamp

Dam & clamp placed in position in patient’s mouth, with the help of an assistant

Young’s frame is positioned to produce tension in the dam

Using an instrument dam is slipped beneath the clamp wings

Advantages :

Not a difficult procedure to perform

Very less chances of dislodgement of the clamp

Most commomly used technique

General rule for limited isolation

Include one tooth posterior & 2 teeth anterior to the tooth being operated on

Limited isolation for operating maxillary left 2nd premolar

Step 7 : Passing the septa through contacts

Use waxed dental tape to pass the

dam through the contacts

Tape is preferred over floss because

wider dimension more effectively carries rubber septa through contacts

not likely to cut the septa

Waxed variety makes passage easier & decreases chances for cutting holes in the septa

Step 8 : Using a saliva ejector

Use of saliva ejector is optional because most patient usually prefer to swallow the saliva

Salivation greatly reduced when profound anaesthesia is obtained

Step 9 : Confirming a properly applied rubber dam

Properly applied rubber dam is securely positioned and comfortable to the patient

Step 10 : Checking for accessibilty & visibilty

Check to see that the completed rubber dam provides maximal access and visibility for the operative procedure

Removal of dam

Step 1 : Cutting the septa

Stretch the dam facially , pulling the septal rubber away from the gingival tissue and tooth

Protect the under lying tissue by placing the finger tip beneath the septum

Step 2 : Removing the retainer

Engage the retainer forceps with retainer &

remove it

Step 3 : Removing the dam

After the retainer is

removed ,release the

dam from the anterior

anchor tooth and remove

the dam and frame

simultaneously

Step 4 : Wiping the lips

Wipe the patient lip with the napkin immediately after the dam and frame are removed

Prevents saliva from getting on to the patient’s face

Step 5: Rinsing the mouth & massaging the tissues

Rinse the teeth and the high volume evacuator

Massage the tissues around the anchor teeth to enhance the circulation

Step 6 : Examining the dam

Lay the teeth of rubber dam over a light -colored flat surface or hold it up to the operating light to determine that no portion of the rubber dam has remained between or around the teeth

Such a remnant would cause gingival inflammation

Cleaning of clamps after use

Cleaning –Clamps should be rinsed & cleaned immediately after

the procedure

Failure to clean will decrease the life of the clamp & can result in staining & corroding

Rinse & remove excess material before ultrasonic cleaning

Allow clamps to dry

Sterilization –

Important to remove excess restorative material from the clamp before sterilization as it may damage the clamp

Autoclave – 15 min at 130°C/266°F

• Inspection –

Inspect the clamp for wear, distortion or damage

Discard if distorted

Care –

Do not bend or distort the clamp

Do not let clamps get scratched by other clamps or instruments

When using obturation techniques involving sodium hypochlorite, immediately rinse clamps with water after the clamp is removed

Errors in application & removal of rubber dam

Off center arch form

May not adequately shield the patient’s oral cavity, allowing foreign matter to escape down patient’s throat

May result in an excess dam material superiorly that may occlude patient’s nasal airway

Superior border of dam may me folded or cut from around patient’s nose

Inappropriate retainer

May be :

Too small resulting in occasional breakage when the jaws are overspread

Unstable on the anchor tooth

Impinge on soft tissues

An appropriate retainer should maintain a stable four point contact with the anchor tooth

Retainer pinched tissue

Jaws & prongs of the retainer usually slightly depress the tissues but should never pinch or impinge on it

Shredded or torn dam

care should be taken to prevent tearing the dam during hole punching or passing the septa through contact

Incorrect technique for cutting the septa

May result in cutting soft tissues or tearing of septa

Stretching the septa away from gingiva, protecting the lip & cheek with an index finger, using curved beak scissors decreases the risk

Precautions :

Rubber dam should not obstruct patient’s airway thus

should not cover his nose

Holes should be prepared in rubber dam for patients with upper respiratory tract obstruction

Patients with allergy to latex –

Latex free rubber dam should be used

Rubber dam napkin can be used

Latex allergy Latex – products made from the milky fluid of the

rubber tree ‘Hevea brasiliensis’

Caused by continuous contact with the natural rubber latex products

E.g.- rubber gloves, rubber dam, bite blocks, ortho elastics, rubber stoppers, prophy cups

It is essential that dental health care professionals are aware of the warning signs & keep a watchful eye for those signs in patients & themselves

Types of latex reactions :

Type 4 reaction

Contact dermatitis

Thought to be caused by chemicals added to the latex during processing

Reactions take up 2 days to develop

Symptoms : swelling & redness of skin, cracked, itchy & dry skin

Type 1 reactions :

Appear to be caused by protein found in natural rubber latex

Generally takes pace within seconds to minutes after exposure

Can cause life threatening anaphylaxis, low blood pressure, cardiac arrhythmia, difficulty in breathing & even death

Symptoms : Hives, Wheezing, Running nose, itchy eyes, tingling of the lips, swelling of eyelids, light headedness, difficulty in breathing

Case report Raggio DP et al, 2010 –

9 yr old female patient

First contact with latex happened on her first birthday party with a balloon, resulting in swelling on body

According to mother’s report – presented strong reaction after contact with latex gloves during laboratory blood test, proved NRL allergy

Vinyl gloves were used

Vinyl gloves as an alternative to rubber dam

metallic saliva ejector

Identification of clients at risk

Clients who have experienced rash, itching, swelling, nose or eye irritation or shortness of breath after contact with any latex product ( balloons, erasers, gloves, rubber dam)

Clients with spina bifida, eczema, banana, chestnut or avocado allergies

Clients with frequent or prolonged hospital treatment or multiple surgeries

Clients with frequent occupational exposure to latex products

Precautions for the latex sensitive patients

Take thorough medical history

Refer the patient to physician for latex sensitive testing

Emergency medical kit with non latex airway bags, mask, bandages & tape should be available

Schedule latex sensitive patients as the first patient of the day

Use glass syringes over plastic or pre-filled or single use syringes since plunger may contain rubber

Use non latex devices (gloves, dams ,etc) & rubber dam napkins

If a reaction occurs, discontinue the treatment & observe the

patient for at least 20 min, medical intervention may be needed

Cotton rolls & cellulose wafers

Available in different diameters, cut to variant lengths & have plain or woven surfaces

Stabilized & held sublingually with specific holders or with an anchoring rubber dam clamp

Can be applied without holders, over or lateral to salivary gland orifices

Cellulose wafers provide additional absorbency

Advantage – Slight retraction of cheeks aiding in visibility & access

Precaution:

Moisten the cotton rolls & cellulose wafers while removing to prevent inadvertent removal of epithelium from cheeks, floor of mouth or lips

Gauze piece or throat shields

Indicated when there is danger of aspirating or swallowing small objects, when rubber dam is not being used

Used in pieces of 2”x2” or larger

Particularly important when treating teeth in maxillary arch

Gauze sponge unfolded & spread over the tongue& posterior part of the mouth

Advantage –

Better tolerated by delicate tissues

Less adherence to dry tissues compared to cotton

Dri – angle A thin, absorbent, cellulose triangle

Unique replacement on the cotton roll in

the parotid area

Covers the parotid or Stensen's duct and effectively restricts the flow of saliva

Provides the required Dri-Field for

Composites

Bonding

Cementing

Comes in two types: plain and silver coated

Saliva ejector & high volume evacuating equipment

Saliva ejector prevent pooling of saliva in the floor of the mouth

High volume evacuating equipment removes solid debris along with water

Saliva ejector

High volume evacuator

Types of saliva ejectors :

Metallic –

Autoclavable

Rubber tip to avoid irritating delicate tissues on floor of the mouth

Plastic – Disposable & inexpensive

Metallic saliva ejectorPlastic saliva ejector

Requirements :

Tip should always be molded to face backwards with a slight upward curvature

Floor of the mouth under the tip should be covered with gauze to prevent injury to soft tissues

Should not interfere with instrumentation

Advantages

Provides an adequate dry field

No dehydration of oral tissues

Precautions

Should be disinfected after each use

Child patient- cautioned not to close his mouth

Retraction cords Used for isolation & retraction in direct

procedures of treatment of accessiblesub gingival area

Diameter of cord should be selectedsuch that it is gently inserted intogingival sulcus, producing lateraldisplacement of the free gingiva withoutblanching

Cord may be moistened with a noncaustic styptic before insertion(Hemodent)

3 sizes :

Sizes Quality Diameter

Size 0 Super thin 0.45

Size 1 Thin 0.55

Size 2 Medium 0.8

Advantages –

May help restrict excessive restorative materials from entering the gingival sulcus

Provide better access for contouring & finishing the restorative material

Prevent abrasion of gingival tissue during tooth preparation

Used primarily to push the gum tissue away from the prepared margins of the tooth, in order to create an accurate impression of the teeth

Mouth props

Can be potential aid for lengthy appointment on posterior teeth

Should maintain suitable mouth opening

Types –

Block

Ratchet

Block type Ratchet type

Ideal characteristics -Should be adaptable to all mouths

Should be easily positioned & removed with no patient discomfort

Should be stable once applied

Should be either sterilizable or disposable

Mouth mirror

Secondary function -- Helps to retract cheeks, lip & tongue in the absence of rubber dam

Indirect methods :

Local anaesthesia

Drugs –

Anti sialogogues (Atropine)

Anti anxiety ( Diazepam)

Conclusion

A thorough knowledge of the preliminary proceduresreduces the physical strain on the dental teamassociated with the daily dental treatment, reducespatient’s anxiety associated with dental procedures &enhance moisture control thereby improving thequality of operative dentistry

ReferencesSturdevant’s Art and Science of Operative Dentistry

Grossman’s Endodontic practice

Shobha tandon. Textbook of Peadodontics

MS Muthu. Pediatic Dentistry, Principles & Practice

Vimal K Sikri. Textbook of operative dentistry

Raggio DP et al. Latex allergy in dentistry: clinical casesreport. J Clin Exp Dent. 2010;2(1):55-9

Panse E et al. Accidental ingestion of instruments inPediatric dental patients : Report of 3 cases. JADA2012;1(2): 79-81