Isolation in 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 isolation
Patient 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 isolation
 Direct 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 anairoter 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 # 15
Ivory # 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 246-046
Stockes 246-047
Ivory 246-048

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.

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

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 ejector
Plastic 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 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)

 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

 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 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

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

Isolation in dentistry

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