Presented by: Dr. Piyush Verma Dept of Paedodontics & Preventive Dentistry
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