“Starting the daily use of the rubber dam is the beginning of wisdom. When the rubber dam comes through the door, slipshod methods go out of the window.
It marks the beginning of better dentistry. “
J.M. Prime (1937)
Isolation: the act of separating something from other things: the act of isolating something.
Isolation in dentistry.
DEFINITION
Isolation of the treatment area from the buccal saliva, thereby protection of the dental tissue from the contamination during the dental treatment.
OBJECTIVE AND METHODS
The objective of the isolation is complex. It provides a dry environment associated with the patient protection, establishment of an absolute visual and manual control as well as it helps improving the treatment efficiency.
Literature divides the methods and tools of isolation into two groups: direct and indirect. Creation of a comfortable posture and relaxes, stress-free environment, the local anesthetic as well as the drug interventions are all considered to be indirect methods serving to reduce saliva production and to ease discomfort. Cotton-rolls, dry angles, retraction cord, lip retractors, different saliva ejectors and rubber dam are known as direct methods.
Originating from the English term “cofferdam” meaning:“…a watertight enclosure … to allow for construction or repairs; safety precaution in tankers …”
Cofferdam (rubber dam) in dentistry.
ABOUT
This is a very thin, usually latex sheet of 12.5 x 12.5 cm in size used for isolating the operating field in the mouth. The places of the teeth to be isolated are marked on the sheet by using a template and are punched with a special punch, and then the sheet is fixed with clamps.
ADVANTAGES
This improved isolation method has many advantages not only for the doctors but the patients. For patients there are two very important advantages: the protection of the oropharynx (aspiration) as well as keeping away and protecting the soft tissues. From the operating side it provides those essential conditions without which only a result with compromises would be reached as regards the treatment quality. Providing clean and dry environment and protection of the operative site from contamination during the entire treatment are some of these conditions, but the reduction of the communication ability of the patient and the protection of the dental personnel are also listed here.
When evaluating it from both sides it is very important to mention the prevention of the cross infection control!
DISADVANTAGES
No real disadvantages can be reported, but still we can recite some we have heard: “extra time”, “extra costs”, “problematic application” as well as “the patient rejects it”.
INDICATIONS – CONTRAINDICATIONS
By examining the indication and contra-indication issue we have experienced that the use of rubber dam has been compulsory only in endodontics so far. We have found only the American official commitment concerning this question.
On the contrary the list of contra-indications is far longer and airy contra-indications like the active orthodontic treatment are also included.
The list of contra-indications is as follows:
– If the patient shows allergic reactions to any components of the material (nowadays non-latex rubber dams are also available!)
– asthma, certain upper respiratory infections and mouth breathing
– psychosomatic intolerance
– transient bacteremia
– certain gingival diseases.
PRECAUTIONS
Application of rubber dam requires precautions; however, the observable rules do not make usage more difficult.
What should we consider while using rubber dam?
– do not block the respiratory organs
– use of rubber dam napkins to eliminate contact dermatitis
– in order to avoid unwanted psychosomatic reactions, such as panic reactions, we should inform the patient about the application of the dam.
TYPES AND FEATURES
Based on thickness a dam can be classified as thin, medium and heavy.
The use of medium dam is the most widespread, but which to use depends mainly on a personal choice. However, the appliance of the thin dam is not recommended for endodontic treatments. I love using heavy dams in critical situation, it is easily adaptable and there is no risk of displacement.
As regards the material the rubber dams are made of we distinguish latex and non-latex rubber dams and within this there are textured and non-textured surface rubber dams.
Main features of the material:
– elasticity
– tearing strength
– easy to clean and dry (tear resistance)
What is it needed for a proper application?
– rubber dam
– a set of clamps
– hole punch
– punching template
– clamp forceps
– frame
– accessories: rubber dam napkins, dental floss, removing scissors, etc.
APPLICATION TECHNIQUES
Different application techniques are available. Its usage is custom-made and depends on the situation as well.
– first the latex
– first the clamp
– the rubber dam and the clamp are placed at the same time.
The successful placement of the later one depends mainly on how handy the operator is. In this case the use of winged clamps is recommended!
When we talk about an “unsuccessful” application, we think about the fact that how the application of the rubber dam affects the result of the treatment or we consider the scope of the treatment.
Common mistakes
– rubber gets nipped with the clamp
– it is not adequately adapted in the sulcus
– rubber tears alongside the perforation
If the failure cannot be corrected, placement of a new rubber means the solution or we just do not take it into account if the failure does not negatively affects the treatment conditions. If it is a case to be published, there is no excuse for placement failure!
I would like to mention in brief about the isolation variations at special situations, since Filippo Cardinali’s article on isolation of the prepared teeth has just been published on the StyleItaliano Endodontics website. He has described special situations in details.
What is considered to be a special situation?
– if the treated tooth is altered as a result of the anatomical/postural conditions or clamps that are not suitable for the given tooth type are used
– the rubber sheet is used in an individual way due to the placement obstacles (split dam technique)
– use of accessories, e.g. liquid rubber dam
– use of altered isolation tools, e.g. OptraGate, OptraDam
HOW SHOULD ISOLATION BE DONE?
– as far as possible the teeth holding the clamps should be anesthetized
– the amalgam fillings should always be removed in isolation
– it is useful the application of anesthetic gel on the rest of the teeth because of the invagination (adaptation into sulcus)
HOW MANY TEETH SHOULD BE ISOLATED?
– Isolation of a single tooth is accepted in case of an endodontic treatment or in case of treating a class I. cavity
– Isolation of three or more teeth is a must in case of class II. cavity
– Isolation of a full quadrant is compulsory when it is a case-presentation or publication
Recommendation:
– In case of FRONT teeth the isolation of the entire frontal area is recommended, in most of the case I isolate teeth from 4 to 4. When I bond veneers, the clamp is always placed on the tooth which is treated in order to have the rubber adequately placed in the cervical area.
– In case of PREMOLAR teeth isolation of only 2 teeth is rare when treating MO or OD cavities. In such cases the clamps should be chosen very carefully to prevent the placement of the sectional matrix. Basically, I prefer to work in quadrant isolation.
– In case of MOLARS, the isolation of the entire molar area is the minimum isolation requirement! If it is not prepared for publication, isolation from 4 is enough!
ISOLATION IN TAKING PHOTOS VS TAKING PHOTOS IN ISOLATION
Basic requirements:
– rubber dam should always be clean
– replacement of rubber dam after sandblasting
– acid, primer, bond cleaning with alcoholic cotton roll!
The usage of contrastors has highly improved the aesthetic results of the dental photos. They enable the achievement of artistic level by a detailed focus on the optical characteristics and coloring effect. Their use in rubber dam isolation is sometimes difficult. The color of rubber dam and the black contrastor slightly bends the visual effect in the photos.
But the contrast is very important!
And PHOTODAM was born……
Fig.1
HISTORICAL BACKGROUND
-1836 Rich uses a gold band that is placed around the tooth for isolation. This is described as “cofferdam” method.
-1864 It has been used in dentistry since this year. Sanford Christie Barnum came up with the idea of using a punched sheet of rubber and pulling it over the treated tooth. In May of the same year in the course of a meeting at the Cooper Institute the solution to the problem of sustaining a “dry working area” is announced.
-1867 Barnum’s method is described as “widespread”.
-1882 S.S. White develops the cofferdam punch.
– In the same year Dr. Delous Palmer launches a set of 32 clamps, a tool very similar to the one used nowadays.
-1920 with the promotion of silver amalgam and the development of the suction methods, the demand for the rubber dam technique declines
– The interest for rubber dam was reborn in the1990s.
The use of rubber dam, unfortunately, is still not routine-like.
Fig.2
Official American commitment.
Fig.3
Active orthodontic is not a real contraindication
Fig.4
Different thicknesses.
Fig.5
Different materials.
Fig.6
Non-textured and textured rubber dam surfaces.
Fig.7
Elasticity testing tools.
Fig.8
The weight of the apple, 184 grams.
Fig.9
Different stretch degrees.
Fig.10
Al2O3 residues remaining on the surface.
Fig.11
Accesories.
Fig.12
APPLICATION
Method no. 1, rubber dam first.
Fig.13
Method no. 2, clamp first.
Fig.14
Method no. 3, rubber dam and wingless clamp at the same time.
Fig.15
Method no. 4, rubber dam and winged clamp at the same time.
Fig.16
Common mistakes.
Fig.17
Special anatomical/postural conditions.
Fig.18
Split dam technique.
Fig.19
Indication for use of light curing gingival dam.
Fig.20
Altered isolation tools.
Fig.21
Altered isolation in fashion.
Fig.22
Extension of isolation.
Fig.23
Isolation in frontal region.
Fig.24
Isolation for veneer bonding.
Fig.25
Isolation for crown luting.
Fig.26
Isolation in premolar region.
Fig.27
Isolation in molar region.
Fig.28
Always clean the rubber dam for photos!
Fig.29
Rubber dam and contrastor.
Fig.30
The importance of contrast.
Conclusions
Isolation of the treatment area provides the ability to create an aseptic and dry environment and improves manual control together with efficiency. Whichever color, thickness, elasticity or application technique, the rubber dam improves both the patient’s experience and comfort and the practitioner’s performance.
Bibliography
1. American Association Of Endodontists: Appropriateness Of Care And Quality Assurance Guidelines. 3rd Ed., 1998, P16.
2. Beaudry, R.J.: Prevention Of Rubber Dam Hypersensitivity. J. Endod. 10:544, 1984.
3. Cochran, M.A., Miller, C.H., Sheldrake, M.A.: The Effi- Cacy Of The Rubber Dam As A Barrier To The Spread Of Microor- Ganisms During Dental Treatment. J. Am. Dent. Assoc. 119:141, 1989.
4. Israel, H.A., Leban, S.G.: Aspiration Of An Endodontic In- Strument. J. Endod. 10:452, 1984.
5. Reuter, J.F.: The Isolation Of Teeth And The Protection Of The Patient During Endodontic Treatment. Int. Endod. J., 16:173, 1983.
