Moisture Control

and Vitality Testing

Dr. Nessrin Taha
Clinical Doctorate in Endodontics
(Melb), ADC (Sydney),
FRACDS,MFDS (RCSI), Jordanian
Board in Endodontics

Moisture Control
Important during operative and
endodontic procedures
armamentarium includes:
Suction( low and high volume)
Cotton rolls
Rubber dam

Moisture Control
Saliva can block visibility, and interfere
with the setting reaction of dental
materials; therefore affecting their
physical properties
Cotton rolls are placed in the buccal and
lingual sulci
If you work on the lower teeth, you still
need to place a roll on the epsilateral
maxillary buccal sulcus to absorb parotid
saliva

Rubber dam is an essential

component of bacterial
control

Rubber Dam
Its use is mandatory during root
canal treatment even before access
Advantages of rubber dam include:
Biologic rational( most important)
The dam reduces cross contamination
of the root canal system with
microorganisms from saliva

Rubber Dam
Patient and clinician protection
(aspiration,litigation, aerosol)
Soft tissues are retracted and
protected
Visibility is improved
Efficiency is increased

An endodontic file has been inhaled due to no rubber dam barrier

BDJ, 2004;197(9):527-534.

Rubber Dam
Armamentarium:
1-The dam (thin, medium, heavy,
extra heavy)
Two different sizes 5*5, or 6*6 inch
Color: yellow, green, blue, gray
Non latex and latex dam
* Always place the dull side of the dam
toward the operator

Rubber Dam
Armamentarium:
2- the rubber dam frame:
Retracts and stabilize the dam
Both metal and plastic frames are
available
*plastic frames are recommended as
they appear radiolucent; don't mask
areas on the film

Rubber dam

Rubber Dam
Armamentarium:
3-clamps or retainers
Anchor the dam to the tooth
requiring treatment or to the most
posterior tooth in case of multiple
isolation
Aid in soft tissue retraction
Made of stainless steel, consist of a
bow and two jaws, wing or wingless

Rubber Dam
3-clamps or retainers
Wings are extensions of the jaw provide
additional retraction and facilitate
placement of the dam as a single unit
Specific retainers for teeth with minimal
tooth structure (apically inclined jaws)
Serrated jaws( tiger clamps) increases
stabilization of broken down teeth
Universal clamps ( butterfly, 56 )

Fixation of Rubber Dam

I
Clamps- winged or wingless

Rubber Dam
Rubber dam punch, has a series of
wholes on a rotating disk from which you
can select according to the size of the
tooth
Forceps, holds and carries the retainer
during placement and removal
A template may be used to mark the
position of the whole, or just place it in
the center and trim excess over the nose

Rubber Dam Punch

Rubber Dam Placement

1- Placement as a Unit: dam, frame and
clamp all together
2- Placement as a separate units: clamp
then the dam ( tie the clamp with floss)
3- Placement of clamp and dam, then
frame
4- Placement of dam and frame, then
clamp (with butterfly clamps)

Wingless technique

Rubber Dam Placement

The rubber dam is adjusted on the
frame so that the mouth is completely
covered
Slide the dam off the clamp wings
using a plastic instrument, to cover
the holes and constricts around the
tooth neck
Floss the dam through the contacts of
the teeth

Winged technique

Be sure to move the rubber down

to the wing

Rubber Dam Placement

Multiple isolation: when several
teeth require treatment
Multiple holes and the dam is flossed
between the teeth, or single big hole
include all six anteriors and clamp
premolars or use a floss to ligate
around the tooth

Difficult isolation cases

Little remaining tooth structure: use
deep- reaching clamps, clamp adjacent
teeth, clamp the gingiva
Extensive caries in the tooth: build up
with glass ionomer, use an orthodontic
band
Bridges: use a sealant in the seepage
areas
Porcelain restorations: risk of crazing
the porcelain

Tooth is difficult to clamp on

A slit has been cut in the rubber dam
to enable this tooth to be isolated.

BDJ, 2004;197(9):527-534.
*Have to consider the restorability of the tooth, crown lengthening
procedure before RCT
Or for posterior tooth, cement a mental band before RCT.

For mouth breathing

patient

Fixation the rubber dam

II

System of Diagnosis
Medical and Dental History
Examination: subjective & objective
Intensity, spontaneity, duration,
reproduce pain
Periodontal examination (pulpal vs.
periodontal)
Radiographic examination

Diagnostic Outcome
Reversible pulpitis
Irreversible pulpitis
Acute apical periodontitis
Acute apical abscess

Dentinal sensitivity
or
Reversible pulpitis
Chief complaints
Examinations
No spontaneous
Tooth is positive to
pain
vitality with no
lingering pain
Transient pain only
Radiograph no
Recent history of
conclusive finding
restorative dental
on periapical area
procedure

Apical Periodontitis

 Draining sinus

Periodontal Examination

Pulp Vitality Tests

Thermal tests (cold and hot)
Electrical test (EPT)
Direct dentine stimulation
Laser doppler flowmeter
pulsoximeter

Principles of Pulp
Vitality Tests

Test the suspected tooth

Similar tooth controls should be
used
Replicate patients symptoms

Cold Tests
Methods:
Carbon dioxide (dry ice -78 degrees)
Refrigerant (Endo ice -50 degrees)
Ice (0 degree)
Ice-cold water under rubber dam
isolation
Dry the tooth and place cotton roll
In young teeth place the test close to
the incisal one third

Refrigerant Spray

Cold Test
In middle aged and elderly move
close to the cervical one third
Cold test should be applied until the
patient responds: maximum 15
Seconds
Record the nature of response
Normal pulp- gives a brief sharp
pain sensation or tingling from the
tooth

Cold test
Possible mechanism -causes
contraction of the dentinal fluid within
the dentinal tubules, results in rapid
outflow of the fluid and then trigger the
mechanoreceptors on the A delta fibre.
An intense and prolonged response,
lingered >30 seconds (irreversible
pulpitis)- RCT
No response (non-vital pulp)- RCT
False response:
False negative- Atrophic pulp (3%)
False positive- contact gingiva or
transfer to adjacent tooth, multi-rooted

Heat Tests
Not used routinely, only when the major
symptom is heat sensitivity
Might be injurious
Heated gutta percha applied on the labial
surface
Hot instrument
Isolate with rubber dam and use hot
water bath
Possible false negative

Electric pulp testing

Involves a direct current of a high
frequency electricity that can be varied
Dry and isolate the tooth (important)
Apply flouride gel as a conductor on the
electrode
Patient should touch the electrode to
complete the circuit- it gives a digital
reading
Compare the level of response with a
control tooth

Electric Pulp Tester

(EPT)

Fluoride gel is applied on the tip of

electrode

Electric Pulp Tester

Pulp Testing
False negative with cold and EPT can occur
in calcific metamorphesis (trauma cases)
False positive in EPT occur through
salivary contamination of the tested
surface
Results of one test are not conclusive for
the presence or absence of disease
Sharp non lingering response indicates a
vital pulp

Direct Dentin
Stimulation

Exposed dentine may be scratched

with explorer
Absence of a response is not
indicative as its presence
Drilling a test cavity without local
anesthesia is the last resort

Pulp VitalityTesting
All the above tests could indicate the
presence of intact nerve fibers
carrying sensory impulses
However devices that detect pulp
circulation are more indicative of pulp
vitality
Pulse oximeter and laser doppler
flowmetry: expensive and for
experimental work only

THANK YOU

References:
Walton and Torabinejad :Chapter 4 and
Pathways of the pulp: Chapter 1 and 5