Isolation in dentistry

Success of any dental procedure is determined by a good isolation. Here is a seminar on how to isolate the oral cavity from fluids and maintain a good dry field while working on a patient

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

2. Contents Introduction Goals of isolation Advantage of isolation Methods of isolation Direct methods Indirect methods Conclusion

3. Introduction good accessibility and visibility , adequate room for instrumentation Necessary for easy manipulation and insertion of restorative materials This control is attained through isolation

4. Goals of isolation Moisture control Retraction and access Harm prevention Safe and aseptic operating field Prevent accidental swallowing of restorative materials and instruments

5. Advantages of isolation Patient related: Provides comfort Protect from swallowing or aspirating foreign bodies Protect soft tissues by retracting them

6. Operator related: dry clean operative field Infection control Increased accessibility to operative site Improved properties of restorative materials Improved visibility & less fogging of mirror Prevents contamination of tooth preparation

7. Methods of isolation Direct method : Rubber dam Cotton rolls & cellulose wafers Dri-angle Gauze piece Suction devices Gingival retraction cords Mouth props Mouth mirror

8. Rubber dam One of the most effective means of isolating teeth Developed by SC Barnum in 1864

9. 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

10. 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

11. 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

12. 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

13. Case 3 X ray shows an airoter cap at the level of L5 vertebra in left lumbar region

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Rubber dam punch Used to make the holes in the sheet through which the teeth can be isolated

21. 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

22. 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

23. 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

24. 2A clamp -- first primary molars 14 clamp -- fully erupted permanent molars 14A clamp -- partially erupted permanent molars 2A clamp 14 clamp 14A clamp

25. Clamps for front teeth Ivory # 6 Ivory # 15 Ivory # 212S Ivory # 90N Ivory # 9

26. 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

27. Rubber dam clamp forceps Used for placement and removal of retainer from the tooth.

28. Types of forceps Brewer 246-046 Stockes 246-047 Ivory 246-048

29. White 246-051 Plamer 246-052

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

31. 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

32. 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

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

34. Modifications Le 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

35. 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

36. 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

37. 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

38. Advantages Quick & easy placement No metal clamps or frames Highly flexible

39. Instidam ( Zirc company) Simple & effective isolation system It is a pre punched rubber dam mounted on a frame Compact design fits outside patient lips

40. Advantages : Non threatening & comfortable to patient Very stretchable Tear resistant Provides easy visibility Radiographs can be taken without removing the dam

41. 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

42. 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

43. 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)

44. 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

45. Step 2 : Punching the holes

46. 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

47. 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

48. 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

49. Step 6: Placement 3 techniques : Dam first Clamp first Dam & clamp together

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

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

52. The dentist positions the clamp

53. With assistance dentist positions Young’s frame

54. Disadvantages Procedure is often difficult Especially in posterior areas or particularly small mouths

55. Clamp first Clamp positioned on the tooth

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

57. Disadvantages : Difficult procedure Chances of dislodgement and aspiration of clamp while placing rubber dam

58. Clamp & dam together Rubber sheet is punched with a rubber dam punch

59. Rubber dam is stretched over the wings of selected clamp

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

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

62. Using an instrument dam is slipped beneath the clamp wings

63. Advantages : Not a difficult procedure to perform Very less chances of dislodgement of the clamp Most commomly used technique

64. General rule for limited isolation Include one tooth posterior & 2 teeth anterior to the tooth being operated on Limited isolation for operating maxillary left 2 nd premolar

65. 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

66. 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

67. Step 9 : Confirming a properly applied rubber dam Properly applied rubber dam is securely positioned and comfortable to the patient

68. Step 10 : Checking for accessibilty & visibilty Check to see that the completed rubber dam provides maximal access and visibility for the operative procedure

69. 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

70. Step 2 : Removing the retainer Engage the retainer forceps with retainer & remove it

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

77. 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

78. Errors in application & removal of rubber dam

79. 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

80. 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

81. Retainer pinched tissue Jaws & prongs of the retainer usually slightly depress the tissues but should never pinch or impinge on it

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

83. 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

84. 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

85. 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

86. 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

87. 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

88. 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

89. Vinyl gloves were used Vinyl gloves as an alternative to rubber dam metallic saliva ejector

90. 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

91. 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

92. 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

93. 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

94. 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

95. 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

96. 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

97. 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

98. Types of saliva ejectors : Metallic – Autoclavable Rubber tip to avoid irritating delicate tissues on floor of the mouth Plastic – Disposable & inexpensive

99. Metallic saliva ejector Plastic saliva ejector

100. 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

101. 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

102. Retraction cords Used for isolation & retraction in direct procedures of treatment of accessible sub gingival area Diameter of cord should be selected such that it is gently inserted into gingival sulcus, producing lateral displacement of the free gingiva without blanching Cord may be moistened with a non caustic styptic before insertion (Hemodent)

103. 3 sizes : Sizes Quality Diameter Size 0 Super thin 0.45 Size 1 Thin 0.55 Size 2 Medium 0.8

104. 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

105. Mouth props Can be potential aid for lengthy appointment on posterior teeth Should maintain suitable mouth opening Types – Block Ratchet

106. Block type Ratchet type

107. 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

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

109. Indirect methods : Local anaesthesia Drugs – Anti sialogogues (Atropine) Anti anxiety ( Diazepam)

110. Conclusion A thorough knowledge of the preliminary procedures reduces the physical strain on the dental team associated with the daily dental treatment, reduces patient’s anxiety associated with dental procedures & enhance moisture control thereby improving the quality of operative dentistry

111. References Sturdevant’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 cases report. J Clin Exp Dent. 2010;2(1):55-9 Panse E et al. Accidental ingestion of instruments in Pediatric dental patients : Report of 3 cases. JADA 2012;1(2): 79-81