Isolation from oral fluids Prof. Asaad Javaid Dept of Restorative Dental Sciences College of Dentistry, Zulfi Almajma University

Learning Objectives Narrates significance of isolation Mention various methods of controlling moisture in oral cavity Use saliva ejector effectively Properly position and use High-Volume evacuator Place cotton rolls to effectively isolate operating field

Learning Objectives List demerits of using cotton rolls List advantages and disadvantages of rubber dam Enumerate and identify rubber dam equipment Mention common errors in rubber dam placement and removal

Learning Objectives Define air emphysema Describe how air emphysema can occur during or after dental treatment Narrate the role of electrosurgery in dental procedures

Sources of moisture Saliva: - from salivary glands (parotid, submandibular, sublingual) Blood: - inflamed gingival tissues - iatrogenic damage

Cont. Sources of moisture Gingival crevicular fluid: -inflamed gingival tissues Water: - from rotary instruments - water from triple syringe

Significance of isolation Patient related factors Operator related factors Task /material related factors

Patient related factors Comfort Protects patients swallowing or aspirating foreign bodies Protects patient soft tissues – tongue, cheeks by retracting them from operating field

Detached bur A bur detached from Hand piece and present in bronchus

Swallowed casting Casting present in stomach

Swallowed Crown A cast crown swallowed and present in throat of the patient

Operator related factors Infection control Increased accessibility to operative site, allowing greater convenience and efficiency of operative procedures (e.g. patient’s “need to swallow”) cause fewer problems

Operator related factors Improves visibility of the working field and diagnosis Prevents contamination of cavity preparation/ root canal Haemorrhage from gingiva does not enter operative site

Task/ material related factors Endodontic procedures should be performed in non contaminated dry field for successful accomplishment Dental materials are moisture sensitive, success of adhesion and physical properties relies on a dry field

Methods of moisture control Aspiration Air-Water-Syringe Absorbent materials Rubber dam Pharmacological methods Gingival retraction cord Electrosurgery Tricholoroacetic acid

Aspiration Saliva Ejector High volume aspiration

Saliva ejector Low volume, small diameter tip, usually disposable Flexible plastic tubing with protective flange Routine saliva control Can be placed under rubber dam Best used to remove small amounts of moisture Can be used in conjunction with other methods of moisture control

Saliva ejector: Demerits May cause soft tissue damage; care must be taken not to suck in patients tissues into the tip Active tongues can make placement difficult Low volume aspirators don’t remove solids well

High volume suction High volume vacuum (large diameter tip, autoclavable or disposable) Suitable to remove -large particulate matter -water from high speed drills -air water sprays

High volume evacuation- whilst using a high speed handpiece

Air-Water-Syringe: Air blast is useful to dry tooth or soft tissues during examination or used during operative procedures

Air-Water-Syringe: Demerits Needs greater caution with use as can dehydrate dentine (desiccate) and cause pain and discomfort to patient  Not effective if large volumes of moisture are present

Air- water- syringe Emphysema: A pathological accumulation of air in tissues Through Stenson’s duct

Air emphysema During RCT

Absorbent materials Cotton rolls, pellets, gauze, cellulose wafers. Application: used to absorb saliva and other fluids for short periods of time eg; any examinations, fissure sealants, polishing

Cotton rolls controls small amounts of moisture and also retracts soft tissue

Demerits Only provides short term moisture control Ineffective if high volumes of fluid Active tongues and shallow sulci may make placement and retention difficult

Rubber dam Application: Isolation of one or more teeth from the oral environment Rubber dam eliminates saliva from the working field and also retracts soft tissues

Rubber dam set Rubber dam (green, blue and black)/15cm Rubber dam punch Rubber dam clamps Rubber dam clamp forceps Rubber dam frame/holder Rubber dam stamp for marking the position of tooth Rubber dam lubricant Waxed dental floss Scissors

Rubber Dam: Advantages  Complete, long term moisture control  Maximises access and visibility  Protection for both patient and dentist  Infection control measure  Prevents accidental swallowing or aspiration of foreign bodies  Retracts soft tissues  Increases operator efficiency  Improved properties of dental materials

Rubber Dam: Disadvantages Claimed that it takes time to apply Communication with patient can be difficult Incorrect use may damage porcelain crowns/crown margins/ traumatise gingival tissues Patient may feel discomfort or phobic with it on  Insecure clamps can be swallowed or aspirated

Limitation of use Teeth that are not sufficiently erupted to support a retainer Extremely malpositiond teeth Some 3rd molars

Dental dam punch Notice how the punch plate is a rotary plate form with five or six holes of different sizes cut into the face of the plate. These holes are approximately 1mm deep with sharp edges to accommodate the stylus. Use caution to make sure the holes are cut cleanly. Holes with a ragged edge may tear easily when forced between interproximal spaces of the teeth to be isolated. Ragged edges on the holes may also irritate the gingiva.

Sizes of holes for punching dental dam ( The punch plate holes are numbered one (the smallest) through five (the largest), and fit around different size objects, as follows: 1—mandibular anterior teeth 2—maxillary anterior teeth 3—mandibular and maxillary premolars 4—larger teeth such as molars 5—creates the hole that fits over the dental dam clamp How do you know where to punch the holes on the dental dam material? (The dental dam stamp and template will guide the position of the holes to be punched.)

Dental dam stamp and template The dental dam stamp and inkpad are used to mark the dental dam with predetermined markings for the average adult and pediatric arches. The template provides flexibility when one or more teeth in the arch are out of alignment.

Dental dam forceps Notice how the hand of the operator is stretched prior to squeezing the forceps. After squeezing the spring-action forceps, the operator holds the forceps in position with the sliding bar. The operator will squeeze the handles again to release the dental dam clamp. Notice the position of the beaks, which prevents the operator from having to rotate the forceps to place the clamp in position.

Rubber dam clamps , and improve visibility

Suggested retainers Retainer Tooth # W56 Most molars W7 Lower molars Upper molars W4 Most premolars W2 Small premolars W27 Terminal lower molars requiring preparation on distal surfac

Types of clamps Winged clamps have extra extensions to help retain the dental dam Posterior clamps are for the maxillary and mandibular posterior teeth Anterior clamps retract the gingiva on the facial surface

Ligature The slide shows an example of ligating the dental dam clamp. Always cut a long enough piece so it can readily be grabbed if needed. Tie the other end of the ligature to the frame of the dental dam to ensure you can easily find the end. .

Dental Dam Application Area of mouth examined for placement Dam is punched Clamp selected, legated, and positioned on forceps Placement of clamp Placement of dam Placement of frame Dam secure and inverted Applications: Maxillary arch application: Punch the holes one inch down from the upper edge of the dam. Mandibular arch application: Punch the holes two inches from the edge. Curve of the arch: It may be necessary to make adjustments to accommodate an extremely narrow or wide arch. Use the one-step or the two-step method to place the dam. The main difference in the methods is the sequencing in the placement of the clamp and dental dam. Elsevier Inc. items and derived items © 2006 by Elsevier Inc.

Dental Dam Removal Remove any ligatures Using crown and bridge scissors, cut each hole creating one slit Position forceps in clamp Remove dam and frame as one unit Evaluate patient Evaluate dam Why is it important to evaluate the dental material after removal? (Fragments of the dental dam left behind under the gingiva can cause gingival irritation.)

Application/removal errors Inappropriate distance between the holes Incorrect arch form of holes Inappropriate retainer

Little distance b/w holes Too little distance between holes precludes adequate isolation b/c the hole margins in the RD are stretched and will not fit snugly around the necks of the teeth

Much distance b/w holes Too much distance results in excess septal width causing the dam to wrinkle between teeth, interfere with proximal access, and not provide adequate tissue retraction

Incorrect arch form of holes If the punched arch form is too small (incorrect arch form), the holes will be stretched open around the teeth, permitting leakage If the punched arch form is too large, the dam will wrinkle around the teeth and thus may interfere with access

Inappropriate retainer May be too small, resulting in breakage when the jaws are overspread May be unstable on the anchor tooth May impinge on soft tissue May impede wedge placement

Pharmacological methods Use of local anaesthetic with a vasoconstrictor eg Adrenaline: causes transient vasoconstriction of blood vessels in site of injection. May control haemorrhage in some situations

Cont. Advantages: Disadvantages:  Used as an adjunct to control gingival bleeding when use of retraction cord is not sufficient Disadvantages:  Invasive, patient may not want LA needle  Will be numb for a while  Not effective if profuse bleeding

Gingival retraction cord Special type of cord either knitted or twisted that is placed gently into the gingival sulcus and stretches the circumferential gingival fibres

Gingival retraction cord Provides isolation and retraction of the gingival tissues eg when doing restorations in cervical area or when unable to apply rubber dam Absorbs gingival crevicular fluid and can also be soaked or impregnated with vasoconstrictors and thus be useful in controlling minor amounts of gingival bleeding

Cont. Advantages: Disadvantages:  Effective in control gingival haemorrhage or gingival crevicular fluid and at same time retracting gingival tissues Can be used as adjunct to other methods Disadvantages:  Only effective if small amounts of gingival crevicular fluid  May need local anaesthetic prior to placement.  Can be difficult to insert  Can cause gingival damage if not inserted correctly

Electrosurgery coagulate tissues Use of high frequency electric current to incise/ coagulate tissues

Electrosurgery: Uses To access subgingival caries Gum surgery Implant placement Crown lengthening Coagulating the gum area before impression taking

Cont. Advantages: Disadvantages:  Can be used to control small amount of bleeding. Disadvantages:  Potentially can cause tissue damage if not used properly.  Can’t use if patient has a pacemaker.  Unpleasant odour.  Can’t use with metal instruments.

Tricholoroacetic acid Chemical method of controlling haemorrhage in local areas of tissue trauma. Advantages:  Effective control of bleeding site. Transient. Disadvantages:  Caustic; need to use with care as can cause soft tissue damage if accidentally dropped on tissues.

Trichloroacetic acid controls small amounts of bleeding Hume and Mount 1999

Suggested reading Chapter 10 Sturdevant’s Arts and Science of Operative Dentistry

Thank you