various isolating procedures

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GOOD
MORNING

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ISOLATION
DR. SHAKIR HUSSAIN

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Oral environment needs to be
adequately controlled to prevent it
from interfering with the execution
of any dental procedure.

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Goals of Isolation
Moisture control:- To exclude sulcular fluid,
saliva, gingival bleeding in the operating field and to
prevent the hand piece spray and restorative debris.
Retraction and Access:- used to retract
the tongue, maintains mouth opening, lips and cheek.
Harm Prevention:- to prevent swallowing of
instruments , restorative debris and prevents soft tissue
injury

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Need for Isolation in Pediatric Dentistry
 Increased salivation
 Excessive tongue movements
 Better visibility
 Protection from swallowing or aspiration
of foreign elements.
 Aids in behavior management

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Various means of isolation
DIRECT METHOD
Rubber dam
Fluid Absorbents
Saliva Ejectors
Retraction Cord
Mouth Prop
Cotton Holders and Rolls
INDIRECT METHOD
Patient Position
Local Anaesthesia
Pharmacological
Muscle Relaxation

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Rubber Dam
 Developed by S.C.Barnum in 1864
 Usually a latex Rubber
 Used to define the Operating field by
isolating one or more teeth from the oral
environment
 It eliminates saliva from the operating
site and retracts the soft tissues.

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Rationale (Isolation )
 Dry , Clean Operating field.
 Access & Visibility .
 Maintaining(Improved) properties of Dental
Materials.
 Reduced patient conversation
 Tissue retraction
 Operating Efficiency.
 Reduces risk of Cross Contamination
especially to the Root Canal System

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Protection of the Patient and Operator
 Prevents accidental ingestion of
files/reamers
 Prevents injury to soft tissue
 Prevents patient from putting the tongue
into the cavity
 Prevents the irrigating fluid coming in
contact with oral soft tissues

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Contraindications
• Child with upper respiratory tract infection,
congestion of nasal passage or other nasal
obstruction.
• Takes considerable time to be applied.
• Fixed orthodontic appliances
• Recently erupted tooth
• Allergy to latex

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Certain condition which Precludes
the use of rubber dam
 Erupting teeth with insufficient support for
retainer
 Clamp must not impinge on the gingiva nor
traumatize the adjacent teeth.
 Allergy to latex
 Extremely malposition of teeth
 Asthmatic Patient
 Mouth breathers

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Rubber Dam : Material &
Instrument
 Rubber dam sheet
 Rubber dam frame
 Rubber dam punch
 Rubber dam retainer forceps
 Waxed dental floss
 Rubber dam napkin
 Lubricant
 Clamps
 scissors

13. Isolation 13
Rubber Dam Kit

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Rubber Dam
sheet
Rubber Dam Material Various
thickness
Thin (0.006” or 0.5mm)
Medium (0.008” or 0.20mm)
Heavy (0.010” or 0.25mm)
Extra heavy (0.012” or 0.30mm)
Special Heavy (0.014”)
Thicker material resists tear and thinner ones
passes through tight proximal contact easily.

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Various colors
Light / dark colors – contrast
Shiny / dull side
Dull surface should face the occlusal aspect as
it reflects less light
Available in various sizes
Rolls or prefabricated
5 x 5” (12.5 X 12.5cms)- PEDIATRIC
6 x 6” (15 X 15cms)- ADULT

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Rubber Dam frames
Universal U shaped Nygaard Ostby
Sauveor (oval )

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Rubber Dam frame
Rubber Dam Holder
Small metal projections
Youngs U shape

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Rubber Dam Punch
Anisworth
Ash
Ivory

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Lubricants
Water soluble lubricants are applied in the
area of punched holes for easier placement
of the dam.
Easy placement in the tight proximal
regions
e.g.:- Vaseline or soap slurry

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Rubber Dam clamps
Rubber dam Retainer
/clamp
 Shiny or dull stainless
steel
 Consists of a bow and jaws
 Aid in anchoring the dam
to the tooth and soft tissue
retraction.
 Commonly used for
pediatric dentistry are
#2, #4, #8A and #14A.

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Types of clamps
Winged
Wingless
Clamps with jaws inclined
cervically to engage erupting
tooth or severely broken down
tooth

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Types of clamps
 12A:- Maxillary left primary molar and Mandibular
right 2nd primary molar.
 13A:- Maxillary right primary molar and Mandibular
left 2nd primary molar.
 2A:- First Primary molars
 14, 8 clamp:- fully erupted molars
 14A:- Partially erupted permanent molars
 7 Clamp:- Mandibular Molars

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 2, 2A, 207, 208:- 1st primary molars/
cuspids/ bicuspids and permanent
Canines.
 0, 00, 209:- Primary Incisors and
canines
 9, 212:- Anterior teeth

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Rubber Dam clamps

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Rubber Dam clamps

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Need to Ligate the Clamp
All retainers applied before the rubber dam in place
must be ligated.
A 12” or 18” piece of floss should be attached to
the retainer and threaded through both holes
Prevents accidentally swallowing the clamp.
Prevents injury to the dental team from flying
debris caused by an improper seat of the clamp.

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Rubber Dam template

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Rubber Dam Forceps
Used to place and
remove the
retainers or clamps

29. Isolation 29
Rubber Dam Forceps
Placement and
removal

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Rubber Dam Napkin
Prevent skin contact – allergy
Absorb Saliva at corner of mouth
Wiping patients lips

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Rubber Dam Placement
Clamp Placed Prior to rubber dam
Clamp placed along with rubber dam
Clamp placed after the rubber dam

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Method 1
Clamp placed prior to rubber dam
Indication : children & adult (except
3rd molar)
Chances of aspiration is more

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Rubber Dam Placement
method 1
1
2
34

34. Isolation 34
Rubber Dam Placement

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Method 2
Simultaneously placement of retainer &
dam
Advantage :-
Reduce risk of retainer being swallowed or
aspirated before dam is placed
Reduces difficulty of trying to pass the dam
over a previously placed retainer.

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Clamp used :- winged clamp
Disadvantage :- interfere with procedure
due to limited vision .
Indication : 3rd molars

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Method 3
Placement of clamp after dam placement
Use : is restricted to anterior area or till
premolar area

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Rubber Dam removal
Thoroughly cleanse area.
Cut/remove interproximal ligatures.
Stretch rubber dam facially and cut
each interproximal septum with
scissors.
Remove clamp with clamp forceps.

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Remove dam and examine it for any
missing pieces.
Examine site for remaining rubber;
remove with floss or explorer.
Rinse oral cavity, wipe off patient’s lips.

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Selection of rubber dam
Heavy and extra heavy rubber dams are used
for restorative procedures, while medium is
considered ideal for endodontic purposes since
it
- Retracts the tissues better than thin type
- Easier to place than heavier type

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RECENT ADVANCES IN RUBBER DAM
Hat Dam:- it is clear plastic form shaped like a hat
without a top.
It is trimmed and fitted around a clinical crown that
cannot be clamped and it is cemented with glass ionomer
cement.
Cushioning metal clamp jaw:- Ferrite-N is a
material that can be pressed in embrasure area and
material is light cured over which clamp is seated.
Fiber optic clamps:- These are used for high intensity
light transilluminates pulp chamber and canal orifices.

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Cushees:-
Soft thermoplastic cashew shaped nodules placed
on inner surfaces of blade of the clamp.

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Liquid dam:-
 Resinous material is applied on gingival aspect of
tooth surface prior to power bleaching and sand
blasting.
 Kool Dam is the 1st heatless liquid dam

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Fluid absorbents
Used for short periods when absolute
dryness is not required.
During examination, polishing, fluoride
application
Various materials that can be used for
this purpose are:-
- cotton rolls
- gauze or throat shields
- absorbent paper
Cellulose

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Cotton rolls
Available in different diameters variant lengths
Have plain or woven surfaces
Cotton rolls provide the advantage of slightly retracting
the cheeks aiding in visibility and access
They may adhere to dry tissues

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These are stabilized and held sublingually with specific
holders or with an anchoring rubber dam clamp.
They can be applied without holders, over or lateral to
salivary gland orifices.

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Disadvantages:-
 It doesn’t provide proper isolation.
 It doesn’t protect the patient from debris getting
into the mouth.
 It is difficult to use in children's with gag reflex
 If removed improperly, a dry cotton roll may stick
to the oral mucosa and results in cotton roll
stomatitis

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Gauze or throat shields
A gauze sponge is unfolded and spread over the tongue
and the posterior part of the mouth.
Used in pieces of 2”X 2” or larger
Indicated when there is danger of aspirating or
swallowing small objects.
Important when treated maxillary arch

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Absorbent paper pads
Different shapes to fit various locations in
mouth
More absorbent than any of the above
absorbents

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Saliva ejectors and high
volume evacuating equipment
Saliva ejector prevent pooling of saliva in the floor
of mouth
High volume evacuating equipment removes solid
debris along with water unlike the saliva ejectors

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Saliva ejectors and high volume
evacuating equipment
Types
- Metallic –
Autoclavable and have rubber tip to
avoid irritating the
delicate tissues on the floor of the mouth
- Plastic – Disposable and Inexpensive

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Saliva ejectors and high volume
evacuating equipment
Precautions:-
- Care should be taken to avoid cross
contamination. Thus,
Should be disinfected after each use
Disposable tips are preferred
Child patient is cautioned not to close his
mouth to hold the tip since it may cause
backflow of contaminated solutions into his
mouth as a result of pressure changes

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Saliva ejectors and high
volume evacuating equipment
Requirements
- Floor of the mouth under the tip should be
covered with gauze to prevent injury to soft tissue
- Should not traumatize the lip or cheek mucosa
- Should not interfere with instrumentation
- Needs to be used with other adjuncts like Cotton
Rolls and Gauze

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Other alternative aids
Retraction cord
Insert cord after anaesthetizing the area
- usually used for cervical lesions
Mirror and evacuator tip
- help in retraction of oral soft tissues, specially in
absence of rubber dam

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Other alternative aids
Svedopter
 Tongue retraction and saliva ejector.
 Used for preparation and cementation in fixed
Prosthesis.

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Mouth prop
- benefits both operator and the
patient
- maintain mouth opening
during various procedures
- prevent muscle fatigue in
patients
Cheek and lip retractor

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Drugs
 Anti sialagogues can be used to decrease
excessive salivation
e.g:- atropine
 Local anesthesia decreases pain in addition to the
vasoconstrictor it bring about a reduction in
salivation.

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REFRENCES
 Olatosi OO, Nzomiwu CL, Erinoso OA, Oladunjoye AA.
Undergraduate dental students' perception, educational satisfaction,
and attitude regarding the use of rubber dam. J Clin Sci
2018;15:13-7.
 Damle SG. Textbook of pediatric dentistry. 5th edition.
 Ahmad. IA. Rubber dam usage for endodontic treatment: a review.
International Endodontic Journal, 2009; 42: 963–972.
 Nikhil Marwah. Textbook of pediatric dentistry. 3rd edition.
 Gilbert. GH. et al. Rubber dam use during routine operative
dentistry procedures. Operative Dentistry; 2010: (35-5)491-499.

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 Roger J. Smales, Thomas L. Berekally. Long-term Survival of
direct and indirect restorations placed for the treatment of
advanced tooth wear. Eur. J. Prosthodont. Rest. Dent; 2007 :15
(1);2-6.
 BM Owens. Alternative rubber dam isolation technique for the
restoration of class V cervical lesions. Operative Dentistry; 2006,
31:2, 277-280.
 Marlus Cajazeira et al. Influence of the operatory field isolation
technique on tooth-coloured direct dental restorations. Am J Dent.
2014; 27(3):155-159.
 Arnalod Casterllucci. Tooth Isolation: the Rubber Dam.

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