ISOLATION TECHNIQUES

Need for Isolation

• Increased salivation in child patient

• Excessive tongue movements

• Short attention span which requires shorter duration of treatment

• Decreased danger of aspiration of foreign particles

• Convenience to the operator since it improves visibility

• Improved property of restorative materials.

Goals of isolation

• Moisture control

• Tissue retraction, and

• Harm prevention

Moisture Control

Moisture control refers to excluding sulcular fluid, saliva, and gingival bleeding from the operating field.

It also refers to preventing the handpiece spray and restorative debris from being swallowed or aspirated by the patient.

Harm prevention

• During endodontic procedures, there are chances that paediatric patients may aspirate endodontic files or the tooth debris during the procedure.

• Thus, complete isolation can help to prevent such complications.

Tissue retraction

• Tissues like Cheek, tongue, gingiva are needed to retracted to prevent harm to the tissues during the use of motor handpiece in the dental procedures.

Criteria for isolation techniques:

Be easy to apply and not injure soft and hard tissues.

Be comfortable for the patient.

Provide retraction for better visualization for the operator.

Prevent moisture contamination.

Isolate the area of concern.

Classification of methods available for Isolation

1. Direct Method

• Rubber Dam

• Cotton rolls

• Gauze piece

• Absorbent wafers

• Suction devices

• Gingival retraction cord

2. Indirect Method

• Comfortable position of the patient

• Local anesthesia

• Drugs- Anti sialogogues

• Anti anxiety drugs

• Muscle relaxation

Various means of isolation used routinely in Paediatric Clinic

• Saliva ejectors

• Fluid absorbents

• Rubber dam

• Use of matrices during restorative procedures

A. Saliva EjectorSmall, straw like oral evacuator used during less invasive dental procedures.

Types:

• Metallic: are autoclavable and have rubber tip to avoid irritation to delicate tissues.

• Plastic: are disposable and inexpensive

Saliva Ejector

Indications for use:

Preventive procedures such as a prophylaxis or fluoride treatments.

For control of saliva and moisture accumulation under the dental dam.

During an orthodontic bonding procedure.

Saliva Ejector

Advantages:

• It provides an adequate dry field along with the advantage of washed field.

• There is no dehydration of oral tissues.

Saliva Ejector

Placement of saliva ejector

Bend and shape saliva ejector for placement.

Position under the tongue.

Position saliva ejector opposite the side on which the dentist is working.

Svedopter

A Svedopter is a device that serves as both a saliva ejector and a tongue retractor.

High-Volume Evacuators• High-volume evacuators more powerful suction

devices which are preferred for suctioning water and debris from the mouth during most dental procedures, especially when the dental handpiece is in use.

High-Volume Evacuators

• Cuttings both of tooth and restorative material, as well as other debris, are removed from the operating site.

• A washed operating field improves access and visibility.

• There is no dehydration of the oral tissues.

• Without an anesthetic, the patient experiences less pain.

Precautions

• Ejectors should be disinfected after each use

• Disposable tips should be preferred.

• The child patient must be cautioned not to close his mouth to hold the tip since it may cause backflow of the contaminated solutions into his mouth as a result of pressure changes.

B. Fluid absorbents

• These can be used for short periods when absolute dryness is not required. Eg: Examination

Various materials that can be used for this purpose are:

• Cotton rolls

• Gauze or throat shields

• Absorbent shields

Cotton Roll Isolation and Cellulose Wafers

• These are isolation alternatives when rubber dam application is impractical or impossible.

• Can be used in conjunction with a saliva ejector for maximum efficiency

• Cotton rolls are placed mainly at the openings of major salivary glands.

• Cotton roll holding devices can also be used which may give additional advantage of cheek retraction.

Throat Shields

• It is a gauze sponge (2 x 2 inch [5 x 5 cm]), unfolded and spread over the tongue and the posterior part of the mouth.

• Indicated when there is danger of aspirating or swallowing small objects.

• They are better tolerated by delicate tissues and have less adherence to dry tissues compared to cotton.

• Without a throat shield, it is possible for a small object to be aspirated or swallowed

C. RUBBER DAM ISOLATION

Rubber Dam Isolation

• Introduced in 1864, S.C. Barnum.

• A thin stretchable latex material which becomes a barrier when appropriately applied to selected teeth.

• The rubber dam is used to define the operating field by isolating one or more teeth from the oral environment.

• Gives the most complete control over moisture in the mouth and also retracts the soft tissue.

Advantages of Rubber Dam Isolation

• A dry, clean operating field,

• Improved access and visibility,

• Potentially improved properties of dental materials

• Protection of the patient and operator

• Operating efficiency

Disadvantages

• Cannot be used in patients with latex allergy.

• Time consumption and patient objection are the most frequently quoted disadvantages of the rubber dam.

Contraindications

• Conditions that may preclude the use of the rubber dam are:

• Partially erupted teeth

• Extremely malpositioned teeth

• Some third molars

• Patients suffering from asthma or with nasal obstructions

Rubber Dam Equipment

• Rubber dam sheets

• Template/stamp

• Holder or Frame

• Rubber dam punch

• Clamps/ retainers

• Clamp forceps

• Dental floss

• Lubricant

• Scissors

Rubber dam sheets

Made of either latex or latex-free material.

Available in a continuous roll or in two precutsizes (6x6 or 5x5).

Has a shiny and a dull side.

Available as scented and flavored sheets.

Dam thicknesses (gauges) are:• Thin (0.006 inch [0.15 mm]),

• Medium (0.008 inch [0.2 mm]),

• Heavy (0.010 inch [0.25 mm]),

• Extra Heavy (0.012 inch [0.30 mm]),

• Special Heavy (0.014 inch [0.35 mm]).

Rubber dam sheets

• Because the dull side is less light reflective, it is generally placed facing the occlusal of the isolated teeth

• A thicker dam is more effective in retracting tissue and more resistant to tearing; it is especially recommended for isolating Class V lesions.

• Thinner material is particularly helpful when contacts are tight.

• Generally, dark, heavy, 6 X 6 inch sheets are recommended.

Rubber dam template/stamp

• This inked stamp/paper produces a series of dots on the rubber corresponding to the average positions of the teeth.

• the top edge of the rubber sheet should be just below the patient’s nose, thus covering the mouth but not the nose

Rubber dam punch• A precision instrument having a rotating metal table

(disk) with six holes of varying sizes and a tapered, sharp-pointed plunger.

• It is used to make round holes of different diameters (0.7 – 2 mm).

• The largest hole being for molars and the smallest for mandibular incisors.

Rubber dam clamps/retainers

• These are metal clips which fit the neck of the tooth and hold the rubber dam in position.

• Parts of the clamp:

– Bow: Rounded portion of the clamp.

– Jaws: Prongs that seat around the tooth create the extension and balance necessary to stabilize the clamp.

• Available as:– Wingless

– Winged

TYPES

OF

CLAMPS

Rubber dam clamp forceps

• An instrument for placing, adjusting, and removing clamps.

Rubber dam (equipment)

• Lubricant. A water-soluble lubricant applied in the area of the punched holes facilitates the passing of the dam septa through the proximal contacts.

• Dental dam napkin: Increases patient comfort by absorbing moisture between the patient's face and the dam.

• Waxed dental floss or tape. This can be used to carry the rubber past a tight contact point.

– Used for clamp ligature as well- An important safety step to retrieve a dislodged/swallowed clamp

Rubber dam (equipment)

• Rubber Dam Holder (Frame): This holds the free edges of the rubber and prevents them from falling into the mouth or back against the patient’s face.

• Stabilizes and stretches the dam so it fits tightly around the teeth and out of the operator's way.

• Available in plastic and metal frames.– U-shaped frame.

– Young’s frame.

– Otsby frame

Rubber Dam Application

• Steps in preparation and placement– Dental dam equipment and supplies readied.– Introduce the materials to the child.– Dam is punched. – Clamp selected, ligated, and positioned on

forceps.– Tie a length of floss to the clamp.– Placement of clamp.– Placement of dam.– Placement of frame.– Dam secure

Rubber Dam removal

• Steps in removal

– Remove any ligatures that are stabilizing the dam.

– Using crown and bridge scissors, cut each hole creating one slit.

– Position forceps in clamp.

– Remove everything as one unit.

– Evaluate patient.

– Evaluate dam.

Additional Isolation Aids

• Retraction cord: used for cervical lesions when the use of rubber dam is impractical.

• Mirror and evacuator tip: Help in retraction of oral soft tissues.

• Mouth Prop: It maintains mouth opening during various procedures and prevents muscle fatigue in patients.

• Drugs: 1. Antisialagogues can be used to decrease excessive

salivation. Eg: Atropine2. Local Anaesthesia- in addition to vasoconstriction, it

brings about a reduction in pain and salivation.

Chair position

• A comfortable chair position for both the patient and the operator is required for the maintenance of all the above discussed isolation techniques.

References

• TEXTBOOK OF PEDIATRIC DENTISTRY- NIKHIL

MARWAH.

• TEXTBOOK OF PEDIATRIC DENTISTRY-

SHOBHA TANDON.

Thank you