isolation

ISOLATION OF THE ISOLATION OF THE OPERATING FIELDOPERATING FIELD

Dr shabeel pnDr shabeel pn

Royal Dental CollegeRoyal Dental College

INTRODUCTIONINTRODUCTION

The basic principles underlying an The basic principles underlying an operative treatment are operative treatment are

An aseptic techniqueAn aseptic techniqueDebridement of the woundDebridement of the woundProper drainage andProper drainage andGentle treatment of the tissues with Gentle treatment of the tissues with

both instruments and drugsboth instruments and drugs

MAGNIFICATION OF OPERATING MAGNIFICATION OF OPERATING FIELDFIELD

1.1. Proper patient positionProper patient position2.2. Proper isolationProper isolation3.3. Fluids and debris evacuation by Fluids and debris evacuation by

sucking instruments and equipmentssucking instruments and equipments4.4. Tissue retractionTissue retraction5.5. Use of mouth props to stabilize the Use of mouth props to stabilize the

operating fieldoperating field6.6. Use of pre medication for better co-Use of pre medication for better co-

operation for patientoperation for patient

IsolationIsolation

Isolation is very important for Isolation is very important for controlling moisturecontrolling moistureRetraction andRetraction andHarm preventionHarm prevention

Goals of IsolationGoals of Isolation

Moisture controlMoisture controlRetraction and accessRetraction and accessHarm preventionHarm preventionSafe and aseptic operating fieldSafe and aseptic operating fieldPrevent accidental swallowing of Prevent accidental swallowing of

restorative materials and instrumentsrestorative materials and instrumentsBacterial contamination from salivaBacterial contamination from salivaLocal anesthesiaLocal anesthesia

Methods for IsolationMethods for Isolation

1.1. Rubber Dam IsolationRubber Dam Isolation

2.2. Cotton roll isolation and Cellulose wafersCotton roll isolation and Cellulose wafers

3.3. Throat ShieldsThroat Shields

4.4. High volume evacuator and saliva High volume evacuator and saliva ejectorejector

5.5. Retraction cordsRetraction cords

6.6. Mirror and Evacuator tip retractionMirror and Evacuator tip retraction

7.7. Mouth PropsMouth Props

8.8. drugsdrugs

Rubber DamRubber Dam

“ “ It’s hard to believe that a sheet of rubber can It’s hard to believe that a sheet of rubber can make u feel more comfortable about dental make u feel more comfortable about dental treatment and allow us to do better dentistry treatment and allow us to do better dentistry but, rubber dam can” but, rubber dam can”

S C Barnum 1864 – New York cityS C Barnum 1864 – New York city The Rubber Dam is a flat, thin sheet of latex or The Rubber Dam is a flat, thin sheet of latex or

non latex that is held by a clamp(retainer) and a non latex that is held by a clamp(retainer) and a frame that is perforated to allow the teeth that frame that is perforated to allow the teeth that will be worked on to protrude through the will be worked on to protrude through the perforations in the sheet while all the other teeth perforations in the sheet while all the other teeth are covered and protected by the rubber dam.are covered and protected by the rubber dam.

Rubber DamRubber Dam

A tooth bathed in salivaA tooth bathed in saliva A tongue that insists on obstructing A tongue that insists on obstructing

visionvision Bleeding gingivaBleeding gingiva Bacteria laden saliva reinfecting areasBacteria laden saliva reinfecting areas

it also ensures:it also ensures: Improve the quality of operation Improve the quality of operation To define the operating fieldTo define the operating field

AdvantagesAdvantages

1.1. Isolation of the operating fieldIsolation of the operating field2.2. Improved access and visibilityImproved access and visibility3.3. Improved properties of dental materialsImproved properties of dental materials4.4. Protection of patient’s airwayProtection of patient’s airway5.5. Protection of patient’s soft tissuesProtection of patient’s soft tissues6.6. High patient acceptance – Allow to RelaxHigh patient acceptance – Allow to Relax7.7. No gag reflexNo gag reflex8.8. Keep the tongue Keep the tongue 9.9. Time savingTime saving10.10. Operating efficiencyOperating efficiency

DisadvantagesDisadvantages

Time consumptionTime consumption Patient’s objectionPatient’s objectionConditions where rubber dam not used:Conditions where rubber dam not used: partially erupted teethpartially erupted teeth Some third molarsSome third molars Extremely malpositioned teethExtremely malpositioned teeth Asthma patientsAsthma patients Psychological reasonsPsychological reasons Latex allergyLatex allergy

Materials and Materials and InstrumentsInstruments

1.1. Rubber dam materialRubber dam material2.2. Rubber dam holderRubber dam holder3.3. Rubber dam retainer(clamp)Rubber dam retainer(clamp)4.4. Plastic tray for holding the clampPlastic tray for holding the clamp5.5. Retainer forcepsRetainer forceps6.6. PunchPunch7.7. NapkinNapkin8.8. LubricantLubricant9.9. Modelling compoundModelling compound

1.1. Dam materialDam material

•Available in 5x5 inches or 6x6inchesAvailable in 5x5 inches or 6x6inches•Thin --------------- 0.15mmThin --------------- 0.15mm•Medium------------0.2mmMedium------------0.2mm•Heavy--------------0.25mmHeavy--------------0.25mm•Special heavy----0.35mmSpecial heavy----0.35mm•Shiny surface and dull surface.Shiny surface and dull surface.•Dull surface in occlusalDull surface in occlusal

2. Holder or frame2. Holder or frame

Maintains the borders in positionMaintains the borders in positionTwo types:- 1.plasticTwo types:- 1.plastic

2. stainless steel2. stainless steel

3. Retainers3. Retainers

Two types:Two types: 1. wingless 1. wingless 2. winged2. winged Anchor the dam to the teethAnchor the dam to the teeth Retract the gingival tissuesRetract the gingival tissues

Upper central incisors and all cuspids:– Ivory no. 9Upper central incisors and all cuspids:– Ivory no. 9 Upper laterals and all lower incisors:- HF no. 211Upper laterals and all lower incisors:- HF no. 211 For all premolars:- HF no. 27For all premolars:- HF no. 27 For all molars:- HF no. 26For all molars:- HF no. 26 Not completely erupted young anterior maxillary Not completely erupted young anterior maxillary

teeth:- HF no. 27teeth:- HF no. 27

4. Plastic tray for 4. Plastic tray for holding clampholding clamp5.5. Retainer ForcepsRetainer Forceps

for placing and removal of retainerfor placing and removal of retainer

6. Punch6. Punch

For producing holes in the rubber dam for the teethFor producing holes in the rubber dam for the teeth It is an instrument having a rotating metal table with It is an instrument having a rotating metal table with

six holes of varying sizes and a tapered sharp pointed six holes of varying sizes and a tapered sharp pointed puncherpuncher

Larger holes-MolarsLarger holes-Molars Medium sized holes-premolars , canines and upper Medium sized holes-premolars , canines and upper

incisorsincisors Smallest hole –lower incisors.Smallest hole –lower incisors.

Rubber dam punchRubber dam punch

7.Napkin7.Napkin

Between rubber dam and patients skinBetween rubber dam and patients skin Reduce allergic reactionReduce allergic reaction Absorbs salivaAbsorbs saliva

8. lubricant8. lubricant

Liquid soap Liquid soap Petroleum and cocoa butter should not be Petroleum and cocoa butter should not be

usedused

9.Modelling compound9.Modelling compound

Prevent the movement of retainerPrevent the movement of retainer

Hole size and positionHole size and position

holes punched by following the archholes punched by following the arch Hole should be approximately over the centre of Hole should be approximately over the centre of

incisal or occlusal surface of teethincisal or occlusal surface of teeth Guide Holes- along the upper border of rubber damGuide Holes- along the upper border of rubber dam -for identification of upper surface of dam-for identification of upper surface of dam For conservative treatment – 3 holes For conservative treatment – 3 holes For endodontic treatment – 1 holeFor endodontic treatment – 1 hole

Placement of rubber damPlacement of rubber dam

3 methods3 methods

1.1. Dam first techniqueDam first technique

2.2. Clamp first techniqueClamp first technique

3.3. Clamp and dam together techniqueClamp and dam together technique

Removal of rubber damRemoval of rubber dam

Cutting the septaCutting the septaRemoving the retainerRemoving the retainerRemoving the damRemoving the damWiping the lipsWiping the lipsRinsing the mouth Rinsing the mouth Massaging the tissue andMassaging the tissue andExamining the damExamining the dam

Alternative methodsAlternative methods

Cervical retainer replacementCervical retainer replacementFixed bridge isolation Fixed bridge isolation Substitution of retainer with a matrixSubstitution of retainer with a matrix

Variations with ageVariations with age

For younger - change the hole sizeFor younger - change the hole size

- smaller sheet- smaller sheetPrimary teeth- HF no.27 retainerPrimary teeth- HF no.27 retainerYoung permanent teeth – Ivory no. Young permanent teeth – Ivory no.

1414

Errors in application and Errors in application and removalremoval

Prevent adequate moist controlPrevent adequate moist control Reduce access and visibilityReduce access and visibility Cause injury to patientCause injury to patient1.1. off centre arch formoff centre arch form2.2. Inappropriate distance between holesInappropriate distance between holes3.3. Incorrect arch form of holesIncorrect arch form of holes4.4. Inappropriate retainerInappropriate retainer5.5. Shredded or torn DamShredded or torn Dam6.6. Sharp tips of no 212 retainerSharp tips of no 212 retainer

Cotton roll isolation and cellulose Cotton roll isolation and cellulose waferswafers

They are absorbentsThey are absorbents Provide moisture control with saliva ejectorProvide moisture control with saliva ejector Isolation of maxillary teethIsolation of maxillary teeth - cotton roll in facial vestibule- cotton roll in facial vestibule - simple method- simple method Isolation of mandibular teethIsolation of mandibular teeth - medium sized cotton in vestibule and - medium sized cotton in vestibule and large one between teeth and tonguelarge one between teeth and tongue - difficult method- difficult method Cellulose wafers - retraction and additional Cellulose wafers - retraction and additional

absorbencyabsorbency

Throat shieldsThroat shields

Prevent aspiration and swallowingPrevent aspiration and swallowingMainly maxillary teethMainly maxillary teeth

High volume evacuator and High volume evacuator and saliva ejectorsaliva ejector

For suctioning water and debrisFor suctioning water and debris AdvantagesAdvantages -both solid and liquid-both solid and liquid -improve access and visibility-improve access and visibility -prevent dehydration of oral tissues-prevent dehydration of oral tissues -less pain for patient-less pain for patient

Retraction cordsRetraction cordsControl sulcular fluidControl sulcular fluidVasoconstrictor (epinephrine) along thisVasoconstrictor (epinephrine) along thisPrevent aberration of gingival tissuesPrevent aberration of gingival tissuesPrevent excess restorative materials from Prevent excess restorative materials from

entering the gingival sulcusentering the gingival sulcus

Mirror and evacuator tip Mirror and evacuator tip retractionretraction

Cheek , lip and tongue retractionCheek , lip and tongue retractionSecondary functionSecondary function

Mouth propsMouth props

For lengthy appointments For lengthy appointments For relieving patients mouth musclesFor relieving patients mouth muscles2 types2 types 1. block type- low cost1. block type- low cost

2. ratchet type- large size and high cost2. ratchet type- large size and high cost

DrugsDrugs Rarely indicatedRarely indicated Atropine(antisialogogues)-5mg,30min Atropine(antisialogogues)-5mg,30min

before the procedures-reduce salivationbefore the procedures-reduce salivation Antianxiety drugs like valium-5 to 10mg Antianxiety drugs like valium-5 to 10mg

30min before30min before Muscle relaxantsMuscle relaxants Medication for controlling gingival bleedingMedication for controlling gingival bleeding Pain control medicationPain control medication Contraindication- Contraindication- nursing mothers and nursing mothers and

Glaucoma patientsGlaucoma patients

DISCUSSIONDISCUSSION

You notice during an endo that saliva You notice during an endo that saliva is creeping through your rubber dam is creeping through your rubber dam hole. What should you do ?hole. What should you do ?

A) Put on a new piece with a smaller holeA) Put on a new piece with a smaller holeB) Put in a new piece using thicker damB) Put in a new piece using thicker damC) Use caulking paste to seal the leakC) Use caulking paste to seal the leakD) Use a curved saliva ejector in the D) Use a curved saliva ejector in the mouth under the dam mouth under the dam

When doing an MO restoration When doing an MO restoration under dam on an upper first under dam on an upper first premolar, you should apply the premolar, you should apply the

dam clamp to thedam clamp to the

A) CanineA) Canine

B) First premolarB) First premolarC) Second premolarC) Second premolarD) Any of theseD) Any of theseE) None of these - you must use wedgesE) None of these - you must use wedges

It is essential to lubricate dam It is essential to lubricate dam before applying it. Which of these before applying it. Which of these

is NOT a suitable lubricant?is NOT a suitable lubricant?

A) Shaving creamA) Shaving creamB) Liquid soapB) Liquid soapC) HibiscrubC) HibiscrubD) VaselineD) Vaseline

When doing an endo, how many When doing an endo, how many teeth would you normally have teeth would you normally have

coming through the dam?coming through the dam?

A) Just the one being root treatedA) Just the one being root treated B) 2 B) 2 C) 3 C) 3 D) As many as possible and practical D) As many as possible and practical

You have problems with the dam You have problems with the dam tearing. What might you consider tearing. What might you consider

??

A) Using thinner damA) Using thinner damB) Using thicker damB) Using thicker damC) Making the holes closer togetherC) Making the holes closer togetherD) Making the holes further apartD) Making the holes further apart

Which of these will make the Which of these will make the dam most likely to tear?dam most likely to tear?

A) A large toothA) A large toothB) A large clampB) A large clampC) A small holeC) A small holeD) A rusty dam punchD) A rusty dam punch

You are having trouble getting You are having trouble getting the dam between the contact the dam between the contact points for four anterior teeth. points for four anterior teeth.

What might you NOT do?What might you NOT do?

A) Punch the holes closer togetherA) Punch the holes closer togetherB) Push it through with flossB) Push it through with flossC) Use lubricantC) Use lubricantD) Use wooden wedges for a short while D) Use wooden wedges for a short while to separate the teethto separate the teethE) Use an abrasive finishing strip to E) Use an abrasive finishing strip to reduce the contact pointsreduce the contact pointsF) Use an abrasive finishing strip to F) Use an abrasive finishing strip to smooth off rough interproximal fillings smooth off rough interproximal fillings

Where does the metal dam Where does the metal dam frame go?frame go?

A) Under the damA) Under the damB) Over the damB) Over the dam

Which is true?Which is true?

A) The curved parts of the clamp A) The curved parts of the clamp beaks should rest on the toothbeaks should rest on the toothB) The pointed parts of the clamp B) The pointed parts of the clamp beaks should rest on the toothbeaks should rest on the tooth

Which of these medical Which of these medical conditions is not relevant conditions is not relevant when considering use of when considering use of

dam?dam?

A) Latex allergyB) Sleep apnoeaC) ClaustrophobiaD) SinusitisE) Emphysem

You are unable to apply dam to an You are unable to apply dam to an upper molar that requires upper molar that requires

endodontic treatment. What should endodontic treatment. What should you do?you do?

A) Advise extractionB) Dress the pulp with a mummifying paste and provide a good coronal sealC) Continue without damD) Refer the patient to an endodontic specialist

Which is NOT a function of dam Which is NOT a function of dam in endodontics in endodontics

A) Preventing saliva contaminationB) Improving visibilityC) Confining excess irrigantsD) Making access to the pulp chamber easierE) Improving patient comfortF) Reducing medicolegal liability

If you can't get dam onto a tooth If you can't get dam onto a tooth for root treatment, which for root treatment, which solution is unacceptable?solution is unacceptable?

A) Restore the tooth first to enable A) Restore the tooth first to enable dam placement, then drill access dam placement, then drill access through the new restorationthrough the new restorationB) Crown lengthening by electrosurgeryB) Crown lengthening by electrosurgeryC) Working without damC) Working without damD) Restoring with a copper bandD) Restoring with a copper bandE) Placing the dam clamp beaks E) Placing the dam clamp beaks directly onto the gingivadirectly onto the gingiva

You are providing anterior You are providing anterior composite tip restorations, but composite tip restorations, but the dam clamp is in the way. the dam clamp is in the way.

What is the best option?What is the best option?

A) Proceed without damA) Proceed without damB) Use rubber or wooden wedges B) Use rubber or wooden wedges instead to hold the dam in placeinstead to hold the dam in placeC) Use adhesive to fix the dam to the C) Use adhesive to fix the dam to the gingiva gingiva

Which is the WRONG way to Which is the WRONG way to apply dam using a apply dam using a winglesswingless

clamp?clamp? A) Put the clamp on the tooth, then pull the A) Put the clamp on the tooth, then pull the

dam over itdam over itB) Place the dam on the tooth with fingers, B) Place the dam on the tooth with fingers, then position the clamp over itthen position the clamp over itC) Attach the dam to the clamp and frame C) Attach the dam to the clamp and frame outside the mouth, then put the assembly outside the mouth, then put the assembly over the tooth using clamp holders over the over the tooth using clamp holders over the damdamD) Attach the dam to the clamp and frame D) Attach the dam to the clamp and frame outside the mouth, then put the assembly outside the mouth, then put the assembly over the tooth using clamp holders under the over the tooth using clamp holders under the damdam

When the dam is in place, When the dam is in place, which of these will further which of these will further

improve the seal to the improve the seal to the tooth?tooth?

A) Placing vaseline round the tooth marginsA) Placing vaseline round the tooth marginsB) Inverting the edge of the dam around B) Inverting the edge of the dam around the tooth with a small plastic instrumentthe tooth with a small plastic instrumentC) Leaving strips of floss interproximallyC) Leaving strips of floss interproximallyD) Coating the assembly with cavity varnishD) Coating the assembly with cavity varnish

ReferencesReferences 1.1. Art and Science of Operative Dentistry- Art and Science of Operative Dentistry-

Theodore M RobersonTheodore M Roberson2.2. Operative Dentistry- GrossmanOperative Dentistry- Grossman3.3. www.dentalindia.comwww.dentalindia.com4.4. www.jada.ada.orgwww.jada.ada.org5.5. www.dentalgentlecare.comwww.dentalgentlecare.com6.6. www.aseptico.comwww.aseptico.com