ISOLATION

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ISOLATION
Contents

INTRODUCTION
RUBBER DAM
ARMAMENTARIUM
PROCEDURE
RECENT ADVANCES
COTTON ROLLS AND GAUZE
EVACUVATION SYSTEM
GINGIVAL RETRACTION CORD
INDIRECT METHODS
ISOLATION OF SOFT TISSUES
CONCLUSION


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INTRODUCTION

Operative dentistry cannot be executed properly unless the moisture in the mouth is
controlled.
It is imperative that there should be:-
- Proper moisture control
- Good accessibility & visibility
- Adequate room for instrumentation around the
working area.

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Advantages
Patient related:
A. comfort to the patient
B. It protects from
swallowing or aspirating
foreign bodies
C. Protect soft tissues by
retracting them.
Operator related:

A. A dry clean operative field
B. Infection control
C. Increased accessibility to
operative site
D. Improved properties of dental
materials
E. Improved visibility & less
fogging of mirror
F. Prevents contamination of
tooth preparation.
Phinney and Halstead, 2003
ISOLATION FROM

I) LIQUIDS
1. Saliva
2. Sulcular Fluid
3. Gingival bleeding
4. Irrigants and medicaments
5. Handpiece spray
6. Respiratory moisture


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II) SOLIDS
1. Tissues
A. Mobile- Tongue
Lips & cheeks
Floor of the mouth
Vestibule
Soft palate
Free gingiva
B. Fixed- Periodontium
Hard palate
2. Foreign objects

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ISOLATION FROM MOISTURE

Various aids available for this purpose are:
DIRECT METHODS







INDIRECT METHODS
1. Comfortable position of the patient & relaxed surroundings
2. Local anesthesia
3. Drugs
- Anti sialogogues
- Anti anxiety drugs
- Muscle relaxants


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Rubber Dam
Cotton rolls
Gauze pieces
Absorbent wafers
Suction devices
Gingival retraction cord

RUBBER DAM
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INTRODUCTION
Introduced by DR. S.C. BARNUM in 1864

One of the best methods for providing isolation from saliva & soft tissues.

When dentists is operating on deep carious lesions where the pulp may be exposed
the rubber dam is mandatory to prevent or minimize pulpal contamination.

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RUBBER DAM

BENEFITS OF RUBBER DAM

1.

a) Control of soft tissue & their protection from injury.
b) Prevention of objects being inhaled/ swallowed.
c) Protects from powerful chemicals used in bleaching of
teeth & as irrigants in endodontics.
d) Physical barrier between the operator & oral fluid

2 . Moisture control
a) Physical barrier to moisture.
b) Control of tongue & cheeks.
.

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3 . Patient management is simplified by
a) Avoiding the need to rinse
b) Improving access to & vision of the operating area
c) Gingival retraction & control of gingival hemorrhage
d) Reduction of operating time
e) Provide clean field for endodontic purposes.




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DISADVANTAGES:

1. Time consumption-



2. Patient objection- due to
a. Latex allergy- It is possible but rare
b. Respiratory difficulty
c. Psychological
3. Difficulty in taking radiograph-

.
Incorrect use may damage porcelain crowns/gingival tissues.
Insecure clamps can be swallowed or aspirated.





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Contraindications of rubber dam

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Armamentarium
Rubber dam sheet.
Rubber dam clamps.
Rubber dam forceps.
Rubber dam frame.
Rubber dam punch.
Accessories
Lubricant/Petroleum jelly.
Dental floss.
Rubber dam Napkin.
RUBBER DAM SHEETS
It is made of :-
Latex rubber as it has a good elasticity
Non-latex, elastomeric, powder free materials are also used.
It comes in varied thickness i.e.
a) Light 0.15mm (For endodontic purpose)
b) Medium 0.2mm
c) Heavy 0.25mm
d) Extra heavy 0.35mm (For operative purpose)
Thicker the material
1. Better the isolation.
2. Places high stress on the retainers mainly in molars.

Heavy & extra heavy chairside bleaching.



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It is available in-
Rolls (150mm X 550mm)
Ready cut (150mm X 150mm)
COLOURS
Beige- A light grayish brown or yellowish brown to grayish yellow.
In Endodontics transparent tooth position & axis to be assessed
Grey
Green & blue colour contrast with teeth.

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RETAINER/CLAMP
Used to secure dam to the tooth to be isolated.
It has the following parts:
a) Bow
b) Jaws
c) Prongs
d) Wings (optional)
e) Hole

Each retainer consists of four prongs & two jaws connected by bow.



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Retainers are also used for mild degree of gingival retraction. Available in
different sizes & shapes, designed specifically for specific tooth.

When positioned on a tooth, properly selected retainers should contact the
tooth in four areas, two on facial & two on lingual surfaces.

This four-point contact prevents rocking or tilting of the retainer otherwise
such movements can injure tooth & gingiva resulting in postoperative
soreness or sensitivity.


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Clamps are made of :
Steel
Polycarbonate
Plated carbon steel.

The retainers should be tied with a piece of dental floss before carrying
into the tooth to prevent it from being swallowed or aspirated. The tie
should be through both the holes.

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Courtesy The Smile Center, Deerwood, MN.)
RUBBER DAM HOLDER / FRAME

It holds the borders of the dam and position it.
It places extra orally.
It is available in various shapes and sizes and are grouped as:
I- Hanging type II- Strap type
I. HANGING TYPE:
a) Youngs frame- U shaped, metallic. It
has metal projections to hold the dam,

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Young u-shaped frame


b)Nygard Ostby frame- It is a circumferential, contoured, plastic frame with 8
projections to hold the sheet.
c) Fused dam & frame assembly- it has the dam sheet fused with the plastic
frame e.g. instadam, quickdam, handidam etc.



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Nygaard- ostby frame
RUBBER DAM PUNCH
A precision instrument having a rotating metal table (disk) with holes of
varying sizes and tapered sharp pointed plunger. It is used to make clean cut
hole in the rubber dam sheet.



The holes are of different sizes
according to size of different teeth.

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RUBBER DAM TEMPLATE / STAMP
It is a guide to mark the location for the hole
in the rubber dam sheet.
Two types : -Custom made
-Standardized
Custom made sheets are made by dividing the sheet into 6 sections and placing the sheet
over the cast and then marking the hole position on it.
RUBBER DAM STAMP
A rubber dam stamp can be helpful especially when learning to ensure correct positioning of
the holes in the rubber sheet.
This is only suitable for adult & late mixed
dentitions.


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RETAINER FORCEPS

These forceps are used in the placement and removal of the rubber dam
clamp, by engaging its beak in the holes of clamp .
They come with different shapes and sizes of handles and beaks and are
named As :-
- Washington design forcep
- Ivory forcep
- Stokes forcep
Washington design forcep
Provide definite stop.
Resists tilting of the clamp. Washington design forcep
Have flattened area on the outside of the clamp

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STOKES FORCEP
Have notched and pointed tips
Have flattened area on the outside of the clamp




Stokes forcep Tip of stokes forcep

IVORY FORCEP
The stop facilitates manipulation & placement of the clamp with minimizing
the trauma to the gingiva.




Ivory forcep Tip of Ivory forcep



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NAPKIN:
It is a disposable paper which is placed between the patients skin and the
rubber dam sheet.
Uses:
a) Prevents contact of rubber dam sheet to the skin thus preventing any
possible allergic reaction.
b) It absorbs saliva seeping through the corners of the mouth.
c) It acts as a cushion.
LUBRICANTS:-
Soap, Vaseline, petroleum jelly, lubricant aids in passing
the rubber dam over the tooth.

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DENTAL FLOSS
A strand of dental floss should be tied around the retainer
before it is carried into the oral cavity. This is safety measure
to prevent accidental aspiration of the retainer.

Floss should be adequately long .

Dental floss may also be used for passing the rubber dam
sheet through interproximal contact and also serves as a
retainer in place of conventional clamp.
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WEDJET:- This is an elastic cord used to secure the dam
around the teeth farthest away from the clamp
RUBBER DAM APPLICATIONS
Rules:-
Isolate at least three teeth at a time.Single tooth isolation is not
recommended until root canal treatment is to be done.
For working on incisors or mesial aspect of canine: - isolate from
premolar to premolar.
For working on distal aspects of canine,premolars, isolate two teeth
posteriorly and until opposite lateral incisor anteriorly

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For working on molars, isolate till the posterior most tooth on same side
and anteriorly till opposite side lateral incisors.

Spacing between two holes should be adequate if inadequate spacing it
will move thereby injuring the gingiva & will not provide adequate
isolation.

If the holes are over spaced, rubber dam will bunch in between the
teeth.

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PROCEDURES
Comfortable position of patient.
Examine the mouth for calculus deposits & sharp edges of restoration.
Remove any calculus, debris if present before application of rubber dam.
Check for tightness of proximal contacts by passing the floss. Excessive
tight contacts prevent placement of rubber dam & in such cases other
methods of isolation should be used. Correct any rough contact areas.
Anaesthetize the gingiva when
indicated.
Rinse the dry operating field.
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MOLAR TOOTH ISOLATION USING
RUBBER DAM
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ISOLATION OF MULTIPLE TEETH
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RECENT ADVANCES
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OPTADAM INSTADAM
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REMOVAL OF RUBBER DAM
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CONDITIONS WHERE THE RUBBER DAM CANNOT BE PLACED:
1.Grossly destructed tooth where the level of destruction is below the gingival
and cannot be clinically exposed.
2. Severely misaligned tooth.
3. Partially erupted/impacted tooth.

REPAIR OF THE TORN RUBBER DAM:
By patching up with cyanoacrylate.
By placing one more sheet.


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APPLICATIONS IN SPECIAL CONDITIONS

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SPLIT DAM TECHNIQUE
MULTIPLE SEVERELY BROKEN DOWN TEETH
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LIMITED SUPRACRESTAL TOOTH STRUCTURE
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BROKEN DOWN TEETH WITH REMOVAL OF POST AND
SECONDARY CARIES
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GINGIVAL HYPERTROPHY ON MANDIBULAR MOLAR
AND ERUPTING PREMOLAR
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COTTON ROLLS






Cotton rolls are not only moisture absorbents but also aids in minimally
retracting the soft tissue from the operating field.
They are generally isolation alternatives when use of rubber dam
application is not practically possible.
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COTTON ROLLS COTTON PELLETS
Loose cotton can either be rolled manually into cotton roll or prefabricated
cotton rolls are also available

Prefabricated rolls are more compact & can absorb greater amount of
moisture.

Cotton role holders are commercially available devices to position & stabilize
cotton rolls in the mouth.

Advantage:- Slightly more retraction of the lips, cheek & tongue.

Disadvantages:- Have to be removed from mouth for changing the cotton rolls.



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GAUZE PIECE
Gauze sponges are supplied in pieces of 2x2 or large.
They perform the same function as cotton rolls.
They may also be used as throat screens to prevent accidental aspiration of small instrument
when they are used.
Better tolerated due to less chances of adhesion to the mucosa.

ABSORBENT PADS/WAFERS:-
Made of cellulose.
Available in different shapes.
Most common being rounded triangular
shape which adapts to the cheeks.
They are placed in the cheek to cover the
opening of the parotid duct.
More absorbent than cotton rolls and gauze piece.


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EVACAUTION SYSTEM
Vacuum systems are of 2 types
- High vacuum evacuation system
- Low vacuum evacuation system

High vaccum systems is generally operated by dentist or dental assistant.
While the low vaccum system is attached to saliva ejector and may remain in
mouth during the operative procedure.
The high vaccum system is usually stronger than the low vaccum.

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HIGH VOLUME EVACUATORS
In high speed hand piece, both air and
water emerge from the head of the
hand piece to wash the working area and
to act as a coolant for the bur & the tooth.
High volume evacuators are preferred
to remove this collected moisture & debris
in the mouth.

A efficient high volume evacuation has the ability of evacuator tip to clear 150ml
of water in approximately 1sec.
The high volume evacuator tips are usually made up of disposable plastic or
autoclavable metallic tips.
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The tip is usually beveled
This tip should be placed distal to the tooth being prepared.

It has following advantages.
Removes shavings of tooth and restorative material as well as other
debris from the working site.
Toxic material is readily removed
Decreases treatment time as intermittent rinsing and washing is
avoided.

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LOW VOLUME EVACUATORS
Low volume evacuators are basically
saliva ejectors which are meant to
remove the saliva that collects on the
floor of the mouth.
These can be left in the mouth
during operative procedure.
They are also available with disposable plastic tips or autoclavable metallic
tips.
It should be placed with their tips on the floor of the mouth directed
backwards and not directly in contact with the tissue.


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GINGIVAL RETRACTION CORD

These are readymade cotton on synthetic fibers woven in the form of
cords. Various types of cords are available
e.g.
- Braided or Non braided
- Plain or impregnated.

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Gingival retraction cord is used when the use of rubber dam is not practical
or appropriate.
Its use should be accompanied with other isolation methods.
A properly impregnated cord causes.
Displacement of the free gingiva laterally by few tenth of mm thus
opening the sulcus.
Apical positioning of the gingival crest although no attempt is made to
force the gingival retraction cord apically.
Transient dehydration of gingiva.
Decreased bleeding when cord is impregnated with vasoconstrictors like
adrenaline or styptic like haemodent.
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A Gingival retraction cord :
- Provides improved access and visibility.
-Protects gingiva from abrasion during cavity preparation.
-Restricts excess restorative material from pushing into the sulcus.
-Everts the gingival tissue thus exposing margins of the cavity.



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PLACEMENT OF CORDS
Insert cord only after anaesthetizing the area

Choose cord that can be gently inserted into the sulcus without causing
ischemia.

The diameter of cord should be such that it does not blanch the tissue

The length of the cord should be such that it extends 1 mm beyond the gingival
width of the cavity on extend around the whole circumference of tooth.



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A blunt packing instrument is used and the cord should be packed slowly &
progressively.

Never remove dry cord otherwise it may pull the epithelium and cause its
abrasion.

After removal check for pieces of gingival restoration cord that my have
been left in gingival environment.
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INDIRECT METHOD
These are the measures that actually reduces the amount of salivation and
hence aid in isolation indirectly.

1. COMFORTABLE AND RELAXED POSITION OF THE PATIENT
The patient should be comfortable seated in the dental chair. He/ she should
not be tensed.
The surrounding should also be pleasant and relaxing.
The attitude of dental staff should be good.
All these factors aids in reducing salivation.

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2. LOCAL ANAESTHESIA
Using a local anesthetic helps in reducing. The discomfort associated with
treatment in addition to control moisture by decreasing salivation.
Another advantage is vasoconstriction caused by local anesthetic which
helps in reducing hemorrhage at the operating site.
The salivation is less as the patient is comfortable, less anxious and less
sensitive to stimuli.


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3. DRUGS - Drugs can also reduces salivation but are rarely indicates. These
includes
Antisialoguogues premeditation may be indicated using an anticholinergic
agent to depress salivation. Atropine can be given half an hour before the
appointment.
Contraindication:-- Patient with high ocular pressure,
- cardiovascular problem.
Antianxiety agent & barbiturates sedatives
- These are helpful in apprehensive patient
-Diazepam 5-10mg 24 hours before appointment
-Barbiturates-
Muscle relaxants:-Can be tried

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ISOLATION FOR THE SOFT TISSUES (SOFT
TISSUE MANAGEMENT)

The soft tissues like cheeks, lips, tongue & gingiva should be protected from injury
during operative procedures.
Their isolation is necessary for proper cavity preparation & restoration .
Various methods of isolation are.
RETRACTION OF THE LIPS, CHEEKS & TONGUE
The method includes-
Rubber dam (most efficient)
Cotton rolls & holder
Mouth mirrors
Tongue guards-
Tongue depressor.
Cheek & lip retractor


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TONGUE GUARD
They protect tongue against injury.
They create a wall between the tongue and the operating field.
They can be made up of Plastic (disposable) or Metal (Autoclavable)

TONGUE DEPRESSOR-
It lowers tongue to avoid interference
with any operative procedure.
Cheek can also be retracted.
Disposable wooden tongue depressor is
most popular.

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CHEEK & LIP RETRACTOR-



Used mainly for working on anterior teeth & for photographic purposes.

They fit around upper and lower lip & pull them outward & backward
exposing facial surfaces of maxillary & mandibular teeth.

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RETRACTION OF GINGIVA
It is done be
Physiomechanical means
Chemical means
Electrochemical means
Surgical means

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A. PHYSIO-MECHANICAL MEANS

The method involves forcing the gingiva away from tooth surface in lateral &
apical direction.
Indications-
It should be used only when gingiva is healthy with good vascular supply.
Zone of attached gingiva apical to free gingiva
Bone support should be sufficient without signs of resorbtion.
Various method includes-
Rubber dam- It provides modest mechanical displacement of gingiva tissue.
Gingival retraction cord & rolled cotton twills.
They are introduced into gingival sulcus. They cause apical & lateral deflection
of gingiva & isolation from gingival circular fluid.
Wooden Wedges
When placed interdentally depress gingival tissue.

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Cotton rolls combined with fast setting zinc oxide eugenol cement
It is an effective method for minimum 48 hrs & should not be placed for more than
7 days.

Procedure- Procedure involves
Mixing of ZOE to a thin creamy consistency & rolling cotton along with these cement.
Rolls are dried with paper towel to remove excess liquid & gain a compactness.
Operative field is dried & isolated cotton rolls are placed in base of gingival sulcus.
They compress laterally rather than apically
Pack is held in position due to fast setting ZOE.

Disadvantages:-
Time consuming
Extended period of placement causes loss of periodontal attachment.

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B. CHEMICAL MEANS

Chemical are used with pressure packing which leads to enlargement of
gingival sulcus as well control of fluids from sulcus.
Gingival retraction cord soaked in chemical will provide better gingival
retraction. Also cotton rolls cotton pallets are used.

CHEMICALS USED.
Vasoconstrictor They cause vasoconstriction by epinephrine & nor
epinephrine
Reduce blood supply of the area
Decrease hemorrhage
Decrease tissue fluid seepage & hence reduce size of gingiva.

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Contraindications:-
CVS disease
Hypertension
Diabetes
Hyperthyroidism


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ASTRINGENTS & STYPTICS-
These include biologic tissue coagulants .
Biologic tissue coagulants coagulate blood & tissue fluids locally creating surface
layer which seals against blood & sulcular fluid seepage. e.g.

Alum (100%)
Alum potassium sulphate (10%)
Aluminum Chloride (15-25%)
Tannic acid (15-25%)
Zn chloride, Silver nitrate

Prolong use causes ulceration, local necrosis, changes contour of free gingiva.
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C.ELECTROSURGICAL MEANS

It denotes surgical reduction of sulcular epithelium using an electrode to
produce gingival retraction.
It is a high frequency radio transmitter that uses a vaccum tube to deliver a
high frequency electric current.
Indications-
Use in areas of inflamed gingival tissue where not possible to use
retraction cord.
When access to working area is not available by conservative means.
Contraindications:
Patients with cardiac pacemaker


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Advantages-
Sophisticated technique
Can be done in gingival in inflammation
Produces little to no bleeding
Quick procedure

Disadvantages:-
Very technique sensitive
Application of excessive pressure procedure severe tissue damage
Difficult to control lateral heat dissipation.

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Four actions can be seen
Cutting this is possible when minimal energy is produced by controlled
use.
Coagulation- Due to greater heat generation, there occurs coagulation of
tissues oozed fluids & blood
Fulguration It has deeper tissue involvement always associated with
carbonization.
Desiccation Most dangerous action because of uncontrolled & unlimited
nature caused massive tissue destruction

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Rules for using electrosurgical unit for isolation purposes-
Proper isolation of working site with minimum moisture present

Adequate current should pass at the site of surgery

Use of fully rectified, undammed filtered current with minimum energy
output.

Use unipolar electrode for cutting. Avoid damage to free gingival crest

For coagulation bulky unipolar electrodes are used with a partially rectified,
partially dampened energy output.





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SURGICAL MEANS

Removal of interfering & unneeded gingival tissue surgically by a sharp
knife.
It is also used for placing periodontal attachment apparatus apically to
create a healthy retracted free gingival tissue.


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CONCLUSION

In summary all operative procedures are best done on a dry and non
contaminated tooth surfaces so that the material can provide dentist with
their optimal physical properties on the other hand the operators eye can
see clearly and have non distorted images when the area is dry.

Rubber dam is the most effective means of isolating teeth and protecting
the patient throat during endodontic treatment its use simplifies
endodontic treatment which can be completed to a high standard in less
time that when it is not used.

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