Isolation techniques by A. Thirumagal Anuraaga

1. ISOLATION
TECHNIQUES IN
PEDIATRIC DENTISTRY
By
Dr. A.THIRUMAGAL ANURAAGA
2nd YEAR PG
DEPARTMENT OF PEDODONTICS AND
PREVENTIVE DENTISTRY

2. CONTENTS
• Introduction
• Goals of isolation
• Advantage of isolation
• Methods of isolation
Direct methods
Indirect methods
• Conclusion

3. INTRODUCTION
• Any operative procedure necessitates the need for adequate control
over the operating field.
• Proper moisture control, good accessibility and visibility as well as
adequate room for instrumentation.
• Isolating the working area includes isolation from moisture like
saliva, blood and gingival crevicular fluid and isolation from the soft
tissues like lips, cheeks, gingiva and tongue.

4. GOALS OF ISOLATION
• Moisture control.
• Retraction and access
• Harm prevention
• Safe and aseptic operating field
• Prevent accidental swallowing of restorative materials and
instruments

5. ADVANTAGES OF ISOLATION PATIENT
RELATED:
A.Provides comfort
B.Protect from swallowing or aspirating foreign bodies
C.Protect soft tissues by retracting them

6. 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

7. METHODS OF ISOLATION
A) DIRECT METHODS
1. Rubber dam
2. Cotton rolls and Absorbent wafers
3. Evacuator system
4. Gingival retraction cord
5. Mouth props

8. B) INDIRECT METHODS
1. Comfortable position of the patient and relaxed surroundings
2. Local anaesthesia
3. Drugs:
Anti-sialogogues
Anti-anxiety drugs

10. • HISTORY: DR. SANFORD CHRISTIE BARNUM on 15th march
1864,
• 1870, Dr. Tees festooned clamps
• 1878,Dr.Elliot design clamp forceps
• 1879, Ainsworth rubber dam punch
• 1880, Dr.Hickman’s lipped clamps
• 1890, clamps with holes.
• Early 20th century –Rubber dam frame introduced(metal
Fernauld’s frame)

11. ABCD’S OF RUBBER DAM
• Adequate access and visibility in the operating field
• Better patient protection and management
• Control of moisture in the operating field
• Decreased operating time

12. ADVANTAGES OF USING RUBBER DAM DURING ENDODONTIC
PROCEDURES:
1. Provides dry and clean operating field.
2. Enhanced access and visibility to the working area.
3. Protects patients from possible aspiration or swallowing of endodontic
instruments, medicaments, irrigating solutions and debris
4. Retracts and protects the soft tissues (gingival tissues, tongue, lips and
cheeks) against possible trauma from rotary and hand instruments and
endodontic medicaments
5. Significantly reduces the microbial content of air turbine aerosols
produced during endodontic procedures, thereby reducing the risk of
cross-infection.
Ballal et al, (2013).
Rubber dam in
endodontics: An
overview of recent
advances.

13. 6. Improves the properties of dental materials by preventing the moisture
contamination of restorative materials.
7. Enhances operating efficiency and increased productivity. Patient management is
simplified by avoiding need to rinse the mouth of debris.
8. Protects dentists and dental assistants against infections which can be transmitted by
the patient’s saliva
9. Minimizes patients conversation during root canal treatment and encourages them
to open their mouth
10. Eliminates need for repeated change of cotton rolls due to flooding of saliva or root
canal irrigants.

14. DISADVANTAGES:
1. Minor damage to marginal gingiva & cervical cementum during
clamp removal.
2. Metal crown margins show microscopic defects following clamp
removal.
3. Ceramic crowns could fracture if clamps are allowed to grip the
margins.
4. Time consumption and patient objection

15. 1.Asthmatic patients
2.Patients with latex allergy
3.Psychological reasons
CONTRAINDICATION

16. Armamentarium

17. RUBBER DAM SHEET :
1. Size : a) 5”*5” b) 6”*6”
2. Color: Light and dark sheets are available
3. Surfaces: Has a shiny and dull surface, dull side will be facing the
occlusal side
4. Thickness:
• Thin – 0.15 mm
• Medium – 0.20 mm
• Heavy – 0.25 mm
• Extra-heavy – 0.30 mm
• Special heavy – 0.35mm

18. NON LATEX RUBBER DAM:
• Synthetic/silicone
• Powder free
• Highly elastic

19. RECENT ADVANCES IN RUBBER DAM SHEETS:
• Hygenic dental dam (Coltène/Whaledent, OH, USA)
• Derma dam (Ultradent Products. Inc, USA)
• Flexi dam (Coltène/Whaledent.

20. 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.

21. RUBBER DAM PUNCH:
• Used to make the holes in the sheet through which the teeth can be
isolated
• A precision instrument having a rotating metal table and a tapered,
sharp pointed plunger which is used to produce clean-cut holes in the
rubber dam sheet through which the teeth can be isolated.

22. RUBBER DAM CLAMPS :
• Aid in anchoring the dam to the tooth & in soft tissue retraction

23. FREQUENTLY USED CLAMPS USED IN PEDIATRIC
DENTISTRY

25. CLAMPS FOR FRONT TEETH

26. NEWER ADVANCES IN RUBBER DAM CLAMPS
Clamp with long guard extension has a larger wing which is used for
retraction of the tongue. These clamps retract and protect the cheek and
tongue along with isolation. They can be used with gauze or cotton rolls
just for the retraction of tongue and cheek
Ballal et al, (2013).
Rubber dam in
endodontics: An
overview of recent
advances.

27. TIGER CLAMP
SUPER CLAMP (DENT
CORP RESEARCH AND
DEVELOPMENT, NY,
USA)
S-G (Silker-Glickman) CLAMP

28. • RUBBER DAM FORCEP is necessary to open the clamp and
position it around the tooth.
• The Ivory forceps are preferable, because they allow the dentist to
apply direct pressure toward the gum, which is frequently necessary to
position the clamp securely below the bulge of the tooth crown.
Sengupta et al
2019, “Newer
Advances in
Rubber Dam”,
International
Journal of Current
Research

29. RUBBER DAM HARNESS :
• Retracts only sides of RD.
• Dam tensors such as those of Woodburg, Cogswell, Mitchell, and
Fernald, which are based on the principle of maintaining tension in the
dam by the use of clips and elastic bands passing directly over the nape
of the neck, are out-dated and have no use in modern Endodontics
(Ingle et al., 2002).

30. 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

31. PLASTIC FRAME : NYGARD-OSTBY FRAME
• Starlite 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

32. METAL FRAME : YOUNG FRAME
• U-shaped metal frame with small metal projections for securing
borders of the rubber dam.

33. NEWER ADVANCES IN RUBBER DAM FRAMES
• Recently newer frames have been marketed into endodontic practice which
has many added advantages.
• The articulated rubber dam frame (IRED, France) is made of non-irritant
plastic material (polysulfone) currently used in the agro alimentary industry

34. THE FOLLOWING FEATURES ARE:
• A double hinge situated in the vertical axis of the frame, which allows
it to be folded in half in the vertical direction.
• The articulated frame has an advantage in providing access to the
buccal half of the cavity.
• In addition to this, it has a reservoir at the bottom of the frame that
allows the placement of gauze to compress and an aspiration canula to
avoid leakage of fluids such as sodium hypochlorite onto the patient's
clothing

35. • The Safe-T-frame (Sigma Dental Systems)is composed of two hinged
frame members whose snap-shut locking mechanism securely clamps
the rubber dam sheet in place.
• This concept also makes it possible to retain the traditional U-formed
frame geometry and dimensions and offers a secure fit without-
stretching the rubber dam sheet.
• This contributes to greater patient comfort.

36. RECENT ALTERNATIVES TO RUBBER DAM
• Insti dam (Zirc) has an in-built flexible radiolucent nylon
frame eliminating the need for a separate one.
• It is made of translucent natural latex that is very
stretchable, tear-resistant and provides easy visibility.
• There is an off-centre pre-punched hole which customizes fit
to any quadrant.
• Its compact design is just the right size to fit outside the
patient‘s lips..

37. It has the following advantages:
• Built-in flexible frame which eliminates the use of separate
frame.
• Pre-punched hole helps eliminate tearing.
• Radiographs may be taken by bending the frame without
removing the dam.
• Minimal pull on clamp.
• Single-use and hence eliminates the need for sterilization

38. • Handi dam (Aseptico) is a pre-framed rubber dam which
eliminates the need for traditional frames.
• It is quick and easy to place. It allows easy access to oral
cavity during the root canal procedure

39. • Dry dam is an alternative type of rubber dam which does not require a
frame.
• It consists of a small rubber sheet set in the centre of an absorbent
paper with light elastics on either side to pass over the ears.
• It fits like a face mask with an absorbent lining to give patient comfort
and reduced risk of allergic reaction.
• It is available in medium and thin varieties.
• It is useful for quickly isolating anterior teeth but it is not useful for
isolation of posterior teeth.

40. Framed Flexi Dam (Coltène/Whaledent)
• The Hygenic non-latex flexi dam is also available with an convenient,
built-in-frame.
• The dam has good tear resistance and is latex allergy free and
odourless.
• The smooth surface of the plastic frame helps to maximize patient
comfort when positioned against their skin.

41. • Opti Dam (Kerr) is the first rubber dam with 3-dimensional shape and
nipple design.
• The 3-dimensional shape of Opti Dam and the anatomical frame shape
match the contours of the mouth.
• This allows greater access and improved visibility to the working area.
• This also allows reduced tension resulting in easier rubber dam
application and low risk of clamp displacement.
• Opti Dam is available in two versions: anterior and posterior.

42. • Opti Dam involves much less preparatory work than for
conventional rubber dams.
• It offers maximum patient comfort and allows them to
breath with no pressure around the nasal area.

44. • Optra Dam (Ivoclar Vivadent, USA) represents the next generation of rubber
dams, combining the benefits of a lip and cheek retractor (Optra Gate)
• The anatomical shape, high flexibility and patented inner-ring design allows
it to be placed without the need for clamps.
• Additionally, there is no need for a separate rubber dam frame making it
even more time and cost efficient.
• It provides optimum isolation as well as it is comfortable for the patient.
• Its anatomical shape helps to create a considerably larger treatment field and
complete isolation of both arches can be achieved at the same time

46. • Lubricant Before positioning the dam, it is an advisable to
lubricate the inner surfaces well with Vaseline or, more
simply, soap, so that the sheet will slide better over the
contours of the teeth, more easily overcome the contact
areas, and close tightly around the cervix of the tooth
(Nidambur Vasudev Ballal et al.)

47. • Rubber dam napkins prevent direct contact between the
rubber sheet and the patient’s cheek.
• By absorbing the saliva that accumulates beneath the dam
by capillary action, they facilitate treatment.
• Their use is not mandatory; however, they are particularly
indicated in cases of allergy to the rubber of the dam (de la
Vega, 2008).

48. • Dental floss Apart from preventing the ingestion or
aspiration of the clamp, dental floss is particularly useful for
assessing the condition of the mesial and distal contact
areas, and thus for facilitating the passage of the rubber
sheet beneath them (Scardina, 2009)

49. RECENT ALTERNATIVES TO RUBBER DAM
• Kool dam (Pulpdent Corporation) It is a light cured material
applied on the gingiva or tooth surfaces prior to power
bleaching, sand blasting or other procedures requiring
intraoral protection or isolation.
• It is also used to block out undercuts prior to taking
impressions. Also called as liquid rubber dam. Because of its
low exothermic reaction, it eliminates burning and pain,
thus assuring patient comfort.

51. • A similar resin product called as OpalDam is manufactured
by Ultradent Incorporation.
• It has two disadvantages. Firstly, being resin based, it
produces heat when cured, and can thus cause discomfort or
pain to the patient. Secondly, some of these products tend to
displace and not stay where they are placed

52. • Anatomically-shaped fast dam is designed to provide a superior means
of maintaining a dry quadrant field.
• It can be used in place of cotton rolls to retract the cheek and tongue
while maintaining a dry field.
• Continuous aspiration is achieved by means of 17 suction holes along
the perimeter, eliminating the need to change saturated cotton rolls
while retracting the cheek and tongue.
• Fast dam fits into the valve of all standard saliva ejectors. Fast dam is
also suitable when conventional rubber dam is too cumbersome.

53. • The Isolite is a new dental device that simultaneously delivers
continuous throat protection, illumination, retraction and
isolation.
• It can be particularly useful in young people with incompletely
erupted teeth.
• Using Isolite, a core buildup during endodontic treatment can be
done immediately by placing a matrix or core-former, and thus
completing the process in one step.
• This reduces the amount of time and number of steps needed as
compared to conventional rubber dam.

56. • A similar device, Isodry, is also available which performs the
same function, but requires external lighting.

57. RECENT ACCESSORY TO RUBBER DAM
• Cushees: These are soft thermoplastic cashew shaped nodules which are
grooved on their inner surface and act as rubber dam clamp cushions.
• It increases patient comfort through elimination of contact of steel clamp
with gingiva or tooth enamel, and thus helps to protect the natural tooth
structure and costly restorations.
• It also enhances rubber dam seal to limit leaking from above or below the
dam and reduces clamp slippage.
• They are available in two sizes: yellow for anterior and bicuspid clamps and
blue for molar clamps.

58. • Wedjets (Hygenic) These are stretchable elastic stabilizing cords made
from natural latex rubber and used as a rubber dam retainer.
• These are a faster and easier method of retaining the rubber dam than
using conventional clamps.
• It is placed like dental floss over the rubber dam in the interproximal
areas of the teeth, holding the rubber dam in position.
• It is available in extra small, small and large sizes.
• It reduces patient trauma and discomfort caused by metal clamps.
They are especially used in the isolation of anterior teeth.

59. 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)

63. PLACEMENT OF RUBBER DAM 3 METHODS
1. Dam first technique
2.Clamp first technique
3.Clamp and dam together technique

64. DAM FIRST

68. DISADVANTAGES:
• Procedure is often difficult
• Especially in posterior areas or particularly small mouths

69. CLAMP FIRST

71. DISADVANTAGES:
• Difficult procedure
• Chances of dislodgement and aspiration of clamp while
placing rubber dam

72. CLAMP & DAM TOGETHER

77. ADVANTAGES :
• Not a difficult procedure to perform
• Very less chances of dislodgement of the clamp
• Most commomly used technique

78. SPILT DAM TECHNIQUE

79. REMOVAL OF RUBBER DAM

80. • Inappropriate distance between the holes
• Incorrect arch form of the holes Inappropriate retainer
Shredded/ torn dam Sharp tips on No. 212 retainer
Incorrect technique of cutting septa
• Shredded or torn dam
• care should be taken to prevent tearing the dam during hole
punching or passing the septa through contact
ERRORS IN APPLICATION &
REMOVAL

81. • 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

82. 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

83. CASE REPORTS
Nabeeh PK et al Accidental ingestion of endodontic instrument in
child patient: A case report,2020.

84. • Accidental Ingestion and Uneventful Retrieval of an Endodontic File in
a 4 Year Old Child: A Case Report Prashant Bondarde

85. • Vanhée et al., A. Behavior of Children during Dental Care with Rubber
Dam Isolation: A Randomized Controlled Study. Dent. J. 2021
• This study aims to determine the behavioral and physiological
indicators of stress in children during dental care with or without a
rubber dam
• The results obtained in this study show that the use of the rubber dam
allows to reduce the stress in young patients during dental cares.

86. • Pediatric Dental Patients’ Attitudes to Rubber Dam , A McKay
et al., J Clin Pediatr Dent (2013)
• To explore young patients’ experiences of rubber dam (RD) and
determine how personal and clinical factors may influence opinions.
• The use of RD appears acceptable physically and psychologically to
most pediatric patients, however, visibility of the RD to others was a
potential concern to some children.

87. • The accidental ingestion or aspiration of the dental
instrument is the potential life-threatening complication. In
such cases, “prevention is better than cure” is applicable.
• Rubber dam isolation should be strictly applied, and dentist
should be aware of handling such situation by having the
knowledge of diagnosis, immediate retrieval measures and
providing emergency treatment to the patient.
TAKE HOME
MESSAGE

89. ISOLATION
TECHNIQUES IN
PEDIATRIC DENTISTRY- II
By
Dr. A.THIRUMAGAL ANURAAGA
2nd YEAR PG
DEPARTMENT OF PEDODONTICS AND
PREVENTIVE DENTISTRY

90. DIRECT METHODS
• Rubber dam
• Absorbent materials (Cotton rolls and cellulose wafers)
• Low-volume evacuator
• High-volume evacuator
• Air-water syringe
• Throat shield
• Cheek retractor
• Mouth prop

91. PHARMACOLOGICAL METHODS
• Antisialogogues
• Antianxiety drugs
• Muscle relaxants
METHODS USED FOR GINGIVAL TISSUE MANAGEMENT
• Physicomechanical
• Chemical
• Chemomechanical

92. DIRECT METHODS
ABSORBENT MATERIALS (COTTON ROLLS & CELLULOSE
WAFERS):

93. COTTON ROLLS:
• Manually rolled Pre-fabricated Smooth Woven.
• Cotton rolls are usually placed in buccal or lingual sulcus specially
where salivary gland ducts exit so as to absorb saliva

94. Cellulose wafers are used in addition to cotton rolls and are
placed in the buccal sulcus to retract the cheek.
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.
• Comes in two types: plain and silver coated

95. ADVANTAGES
• Effective to control small amounts of moisture for short time
periods
• Retract soft tissues at same time.
DISADVANTAGES
• Provide only short-term moisture control
• Ineffective if high volumes of fluid are present
• Shallow sulci and hyperactive tongue may make placement and
retention difficult

96. HOLDERS:

97. ADVANTAGES:
• Provide slightly more retraction
• Improve accessibility and visibility of working area.
DISADVANTAGES
• They have to be removed from the mouth for changing cotton rolls
• Relatively time consuming

98. EVACUATOR SYSTEM

99. LOW VOLUME EVACUATORS:
• Low volume evacuators are basically saliva ejectors
• Saliva ejector is best used to remove small amounts of moisture
and saliva collected in the oral cavity during clinical procedure.
• It can be used in conjunction with other methods of moisture
control.
• Tip of saliva ejector should be smooth to prevent any tissue
injury.
• It is better to have small diameter disposable tip.

100. TYPES OF SALIVA EJECTORS :

101. ADVANTAGES:
• Economical
• Easy to use
• Can be held by patient
• Can be placed under rubber dam
• Some have flanges attached which help in retraction of tongue
and floor of mouth.

102. DISADVANTAGES:
• Hyperactive tongues can make its placement difficult
• Low volume aspirators do not remove solids well
• If used inappropriately, can be uncomfortable for patient
• May cause soft tissue damage by sucking in soft tissues into
the tip.

103. SVEDOPTOR (E.C.MOORE)
• It is a saliva ejector which not only removes saliva but also
protects the tongue and floor of the mouth.
• A mirror like vertical blade is attached to the evacuator tube
so that it holds the tongue away from the field of operation.
• Several sizes of vertical blades are supplied by the
manufacturer

105. HYGOFORMIC
• This coiled saliva ejector is used in the same way as the
svedoptor, but it does not have a reflective blade, rather it
has a retracting coil.
• It must be reformed before use.
• The coil should be loosened or partially uncoiled so that it
extends posteriorly enough to hold the tongue away from the
operating field.

107. SWEFLEX SALIVA EJECTORS:
• Flexible, curved Efficient, comfortable, reduces aerosols with
superior suction capability.

108. PRECAUTIONS TO BE TAKEN WHILE USING SALIVA
EJECTOR:
• Floor of mouth should not directly contact the tip so as to avoid
trauma.
• Sides of saliva ejector should not rub against surface of mouth to avoid
injury.
• When rubber dam is used, always make a hole so that ejector can pass
through the dam instead of placing it under the dam.
• Always protect floor of mouth beneath the ejector using cotton rolls or
gauze piece to avoid tissue injury.

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

110. • The tip usually beveled and is placed intermittently in the mouth
during the operative procedure by the dental assistant.
• The tip of the evacuator should be placed distal to the tooth being
prepared & it should not interfere with the operator’s access or vision

111. ADVANTAGES:
• Large particulate matter
• Water from high speed drills
• Air-water spray
• Since clean field is achieved in less time, quadrant dentistry is
made easy
• Added advantage of double-ended aspiration tip is that if by
chance one end gets clogged, another end can keep on aspirating.

112. AIR-WATER SYRINGE
By air-water syringe an air blast can be useful to dry tooth or soft tissues
during examination or used during operative procedures
ADVANTAGE:
Easy to use
DISADVANTAGES:
• Can dehydrate dentin and cause pain and discomfort to patient
• Not effective if there are large volumes of moisture
• Does not remove the moisture from oral cavity, it can just transfer
moisture from one tooth to the next.

113. THROAT SHIELDS:
• Throat shield is especially important when the maxillary
tooth is being treated.
• In this, an unfolded gauze sponge is stretched over the
tongue and posterior part of the mouth.
• It is useful in recovering a restoration (inlay or crown), if it
is dropped in the oral cavity.

114. ADVANTAGES:
• Avoids aspiration of restorations
• Economical
• Easy to use.
DISADVANTAGE:
• Not well tolerated by some patients as it can cause gagging

115. CHEEK RETRACTORS
• They are used to expand the mouth opening more in the
vertical rather than horizontal direction.
• This makes them ideal for use when working on the gingival
border of upper and lower front teeth and for the adjustment
of orthodontic bands.

116. MOUTH PROP
• A potential aid to restorative procedures on posterior teeth
(for a lengthy appointment) is a mouth prop .
• A prop should establish and maintain suitable mouth
opening. Its use may also help relieve masticatory muscle
fatigue.

117. A MOUTH PROP SHOULD HAVE FOLLOWING FEATURES:
I. Adaptable to all mouths.
II. Easily positioned, without causing discomfort to the patient.
III. Readily adjusted, if necessary, to provide the proper mouth
opening or improve its position in the mouth.
IV. Stable once applied.
V. Rapidly removed in case of emergency.
VI. Sterilizable or disposable.

118. • Mouth props are generally available as either a block type or
a ratchet type.
• Although the ratchet type is adjustable, its size and cost are
disadvantages.

119. PHARMACOLOGICAL MEANS
• In this method, drugs are usually used to reduce the
salivation.
• Commonly used drugs are antisialologues, antianxiety
drugs, muscle relaxants and sedatives, etc.

120. ANTISIALOLOGUES:
• In this anticholinergic agents like atropine is used half an
hour before procedure to reduce the salivation.
• But it should be avoided in nursing mothers and patients
with cardiovascular problems

121. DRUGS USED AS ANTISIALOLOGUES:
• Atropine (Saltropine) – 0.05 mg

122. • Al Jeraisy et al. BMC Pediatrics (2020) Efficacy of scopolamine
transdermal patch in children with sialorrhea in a pediatric tertiary
care hospital
RESULTS: STP use showed significant reduction in severity of drooling
(p < 0.001), wiping of the child’s mouth (p < 0.001), bibs or clothing
changes (p < 0.001), choking and aspiration of saliva (p = 0.001). The
Relative Risk Reduction of the drooling-related ED and RA visits were
86% and 67% respectively. Nearly two-thirds (60%) of caregivers were
satisfied with using STP.

123. GLYCOPYRROLATE (ROBINUL)
• Franko and Lunsford (1960) found glycopyrrolate (Robinul)
• To be a potent, long-acting anticholinergic agent and more
recently it has been recommended as a suitable alternative
to atropine.
• BR.J. ANAESTH ET AL ., GLYCOPYRROLATE-NEOSTIGMINE MIXTURE FOR ANTAGONISM OF
NEUROMUSCULAR BLOCK: COMPARISON WITH ATROPINENEOSTIGMINE MIXTURE

124. • Zanon et al. Italian Journal of Pediatrics (2021) Compounded glycopyrrolate
is a compelling choice for drooling children: five years of facility experience
• A retrospective observational study on 21 patients who received a custom-
formulated galenic glycopyrrolate syrup for sialorrhea for an average period
of 14.3 months.
• Overall, 16 out of 21 patients (76.2%) reported a significant improvement in
sialorrhea and QoL. In 14 subjects (66.7%), there was a remarkable decrease
in the drooling severity; 10 individuals (47.6%) reported a reduction in
drooling frequency

125. ANTIANXIETY AGENTS AND SEDATIVES:
• Antianxiety drugs and sedatives like diazepam and
barbiturates are used in apprehensive patients 24 hours
before appointment.
• Since these drugs result in psychological dependence,
patient selection is done carefully
MUSCLE RELAXANTS:
• Muscle relaxants can also be used to reduce salivation

126. Oral Sedation
in Pediatric
Dentistry: The
Growing Wave
of Chemical
Restraint
Gino
Gizzarelli,

127. METHODS USED FOR GINGIVAL TISSUE
MANAGEMENT
• In this, different methods are used, which mechanically displace the
gingiva both laterally and apically away from the tooth surface.
• Before using these methods following requirements should be fulfilled:
1. Normal and healthy gingiva with good vascular supply.
2. Adequate zone of attached gingiva
3. Adequate amount of healthy bone without the sign of tooth
resorption

128. METHODS FOR PHYSICOMECHANICAL MEANS
1. Rubber dam:
• Various type of rubber dam sheets such as heavy and extra heavy sheets
provide adequate type of mechanical displacement of gingival tissue.
• For additional retraction, Clamp No. 212 (cervical retainer) can also be used.
2. Wooden wedges:
• They are used interdentally to displace the gingival tissue, thus helping in
retraction.
• Care should be taken while using wooden wedge as it can damage the
interproximal tissue if inserted forcibly

129. GINGIVAL RETRACTION CORDS:
• Different types of retraction cords are available in the
market, which displace the gingiva both laterally and
apically away from the tooth surface.
• Retraction cord can be of cotton or synthetic and braided/
nonbraided type.
Garg, et al.:
Fluid
absorbancy of
retraction
cords

130. INDICATIONS OF GINGIVAL RETRACTION:
• Control of gingival flow or gingival bleeding—especially
when the margins of restoration are close to gingiva, for
example, restoration of class V preparation.
• To provide esthetics for final restoration of fixed prosthesis
by exposing the finish line
• To increase retention in case of indirectrestorations where
crown height is inadequate

131. • To extend the margins subgingivally in case of cervical caries
extending below the gingiva
• For accurate recording of preparation margins while taking
impressions
• For removing the hypertrophied gingiva, interfering with
placement of preparation margins.

132. Placement and Removal of Retraction Cord

134. CHEMICAL MEANS
• Chemical means is one of the oldest methods of retraction
of gingival
• Commonly used chemicals for this method are
trichloroacetic acid and sulfuric acid.

135. TRICHLOROACETIC ACID
• Itis used for chemical means of gingival retraction, though
now a days its use has been reduced.
ADVANTAGE
• Effectively controls the bleeding site.
DISADVANTAGE
• Caustic in nature—can cause soft tissue damage if accidently
dropped on tissues.

136. CHEMICOMECHANICAL METHODS:
Different Chemicals used are:
Vasoconstrictors:
1. Epinephrine
2. Norepinephrine
Astringents:
1. Alum (100%)
2. Aluminum chloride (15%–25%)
3. Tannic acid (15%–25%)
4. Ferric sulphate (15%–15.5%).
Tissue coagulants:
1. Zinc Chloride
2. Silver nitrate

137. VASOCONSTRICTORS:
• As the name indicates, these cause local vasoconstriction,
reduce the blood supply and gingival fluid seepage.
• Epinephrine and norephinephrine are included in this
category.
• But nowadays, their use has been declined because of
systemic adverse effects.

138. ADVANTAGE
• Used as an adjunct to gingival retraction cord when gingival
bleeding is present.
DISADVANTAGES
• Invasive procedure
• Contraindicated in patients with cardiovascular disease,
diabetes mellitus
• Not effective if profuse bleeding is present.

139. ASTRINGENTS (BIOLOGIC FLUID COAGULANTS)
• As compared to vasoconstrictors, these chemicals are
considered to be safe and have no systemic effects.
• These chemicals coagulate blood and gingival fluid in the
sulcus, thus forms a surface layer which seals against blood
and fluid seepage.
• Alum, aluminum chloride, tannic acid and ferric sulphate
are included in this category.

140. TISSUE COAGULANTS
• These agents usually act by coagulating the surface layer of
sulcular and gingival epithelium.
• These chemicals form a nonpermeable film for underlying fluids.
• Zinc chloride and silver nitrate are included in the tissue
coagulants.
• If applied for prolonged time, coagulants can cause:
1. Ulceration
2.Local necrosis
3.Change in contour, size and position of free gingiva.

141. CONCLUSION
• Even though the concept of absolute isolation was developed more than 150
years ago and despite its widely acknowledged benefits, a number of
clinicians refuse to use absolute isolation in routine endodontic practice
(Marshall and Page, 1990).
• The time it takes to achieve good isolation will pay itself forward
exponentially in time as well as in quality of treatment and reduction of
stress.
• Good isolation will preserve tooth structure, prevent contamination of the
field, provide better visibility, and prevent iatrogenic misadventures
(Anabtawi et al., 2013).

142. REFERENCES
• Grossman’s Endodontic practice
• Shobha tandon. Textbook of Peadodontics
• Sturdevants’ art and science of operative dentistry.
• Text book of endodontics- Nishagarg
• Ballal et al, (2013). Rubber dam in endodontics: An overview of recent
advances
• Sengupta et al 2019, “Newer Advances in Rubber Dam”, International
Journal of Current Research.

143. • Accidental Ingestion and Uneventful Retrieval of an Endodontic File in
a 4 Year Old Child: A Case Report Prashant Bondarde
• Vanhée et al., A. Behavior of Children during Dental Care with Rubber
Dam Isolation: A Randomized Controlled Study. Dent. J. 2021
• Nabeeh PK et al Accidental ingestion of endodontic instrument in child
patient: A case report,2020
• Pediatric Dental Patients’ Attitudes to Rubber Dam , A McKay
et al., J Clin Pediatr Dent (2013)