Isolation from oral fluids
Prof. Asaad Javaid
Dept of Restorative Dental Sciences
College of Dentistry, Zulfi
Almajma University
slide 1
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
slide 2
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
slide 3
Learning Objectives
• Define air emphysema
• Describe how air emphysema can
occur during or after dental treatment
• Narrate the role of electrosurgery in
dental procedures
slide 4
Sources of moisture
Saliva:
- from salivary glands
(parotid, submandibular, sublingual)
Blood:
- inflamed gingival tissues
- iatrogenic damage
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Cont. Sources of moisture
Gingival crevicular fluid:
-inflamed gingival tissues
Water:
- from rotary instruments
- water from triple syringe
slide 6
Significance of isolation
• Patient related factors
• Operator related factors
• Task /material related factors
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Patient related factors
• Comfort
• Protects patients swallowing or aspirating
foreign bodies
• Protects patient soft tissues – tongue,
cheeks by retracting them from operating
field
slide 8
Detached bur
A bur detached from
Hand piece and
present in bronchus
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Swallowed casting
Casting present in
stomach
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Swallowed Crown
A cast crown
swallowed and
present in throat of
the patient
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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
slide 12
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
slide 13
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
slide 14
Methods of moisture control
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•
•
•
•
•
•
•
Aspiration
Air-Water-Syringe
Absorbent materials
Rubber dam
Pharmacological methods
Gingival retraction cord
Electrosurgery
Tricholoroacetic acid
slide 15
Aspiration
• Saliva Ejector
• High volume aspiration
slide 16
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
slide 17
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
slide 18
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
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High volume evacuation- whilst
using a high speed handpiece
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Air-Water-Syringe:
Air blast is useful to
dry tooth or soft
tissues during
examination or
used during
operative
procedures
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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
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Air- water- syringe
Emphysema:
A pathological
accumulation of air
in tissues
Through Stenson’s duct
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Air emphysema
During RCT
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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
slide 25
slide 26
Cotton rolls
controls small amounts of
moisture and also retracts
soft tissue
slide 27
Demerits
Only provides short term
moisture control
Ineffective if high volumes of
fluid
Active tongues and shallow sulci
may make placement and
retention difficult
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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
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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
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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
slide 33
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
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Limitation of use
• Teeth that are not sufficiently erupted
to support a retainer
• Extremely malpositiond teeth
• Some 3rd molars
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Dental dam punch
Slide 36
Sizes of holes for punching dental dam
(
Slide 37
Dental dam stamp and template
Slide 38
Dental dam forceps
Slide 39
Rubber dam clamps
slide 40
Suggested retainers
Retainer
Tooth #
W56
Most molars
W7
Lower molars
W8
Upper molars
W4
Most premolars
W2
Small premolars
W27
Terminal lower molars requiring
preparation on distal surfac
slide 41
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
slide 42
Ligature
.
Slide 43
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
Elsevier Inc. items and derived items © 2006 by Elsevier Inc.
Slide 44
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
Slide 45
Application/removal errors
• Inappropriate distance between the
holes
• Incorrect arch form of holes
• Inappropriate retainer
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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
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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
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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
slide 49
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
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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
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Cont.
Advantages:
 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
slide 52
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
slide 53
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
slide 54
Cont.
• Advantages:
 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
slide 55
Electrosurgery
Use of high
frequency
electric current
to incise/
coagulate
tissues
slide 56
Electrosurgery: Uses
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•
•
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To access subgingival caries
Gum surgery
Implant placement
Crown lengthening
Coagulating the gum area before
impression taking
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Cont.
Advantages:
 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.
slide 58
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.
slide 59
Trichloroacetic acid
- controls small amounts of bleeding
Hume and Mount 1999
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Suggested reading
• Chapter 10
• Sturdevant’s Arts and Science of
Operative Dentistry
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