1. Isolation from oral fluids
Prof. Asaad Javaid
Dept of Restorative Dental Sciences
College of Dentistry, Zulfi
Almajma University

2. 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

3. 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

4. Learning Objectives Define air emphysema
Describe how air emphysema can occur during or after dental treatment
Narrate the role of electrosurgery in dental procedures

5. Sources of moisture Saliva: - from salivary glands
(parotid, submandibular, sublingual)
Blood:
- inflamed gingival tissues
- iatrogenic damage

6. Cont. Sources of moisture
Gingival crevicular fluid:
-inflamed gingival tissues
Water:
- from rotary instruments
- water from triple syringe

7. Significance of isolation
Patient related factors
Operator related factors
Task /material related factors

8. Patient related factors
Comfort
Protects patients swallowing or aspirating foreign bodies
Protects patient soft tissues – tongue, cheeks by retracting them from operating field

9. Detached bur
A bur detached from Hand piece and present in bronchus

10. Swallowed casting
Casting present in stomach

11. Swallowed Crown
A cast crown swallowed and present in throat of the patient

12. 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

13. 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

14. 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

15. Methods of moisture control
Aspiration
Air-Water-Syringe
Absorbent materials
Rubber dam
Pharmacological methods
Gingival retraction cord
Electrosurgery
Tricholoroacetic acid

16. Aspiration
Saliva Ejector
High volume aspiration

17. 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

18. 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

19. 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

20. High volume evacuation- whilst using a high speed handpiece

21. Air-Water-Syringe:
Air blast is useful to dry tooth or soft tissues during examination or used during operative procedures

22. 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

23. Air- water- syringe
Emphysema: A pathological accumulation of air in tissues
Through Stenson’s duct

24. Air emphysema
During RCT

25. 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

27. Cotton rolls controls small amounts of moisture and also retracts
soft tissue

28. Demerits Only provides short term moisture control
Ineffective if high volumes of fluid
Active tongues and shallow sulci may make placement and retention difficult

29. 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

30. 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

33. 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

34. 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

35. Limitation of use
Teeth that are not sufficiently erupted to support a retainer
Extremely malpositiond teeth
Some 3rd molars

36. Dental dam punch
Notice how the punch plate is a rotary plate form with five or six holes of different sizes cut into the face of the plate.
These holes are approximately 1mm deep with sharp edges to accommodate the stylus.
Use caution to make sure the holes are cut cleanly. Holes with a ragged edge may tear easily when forced between interproximal spaces of the teeth to be isolated. Ragged edges on the holes may also irritate the gingiva.

37. Sizes of holes for punching dental dam (
The punch plate holes are numbered one (the smallest) through five (the largest), and fit around different size objects, as follows:
1—mandibular anterior teeth
2—maxillary anterior teeth
3—mandibular and maxillary premolars
4—larger teeth such as molars
5—creates the hole that fits over the dental dam clamp
How do you know where to punch the holes on the dental dam material? (The dental dam stamp and template will guide the position of the holes to be punched.)

38. Dental dam stamp and template
The dental dam stamp and inkpad are used to mark the dental dam with predetermined markings for the average adult and pediatric arches.
The template provides flexibility when one or more teeth in the arch are out of alignment.

39. Dental dam forceps
Notice how the hand of the operator is stretched prior to squeezing the forceps.
After squeezing the spring-action forceps, the operator holds the forceps in position with the sliding bar.
The operator will squeeze the handles again to release the dental dam clamp.
Notice the position of the beaks, which prevents the operator from having to rotate the forceps to place the clamp in position.

40. Rubber dam clamps
, and improve visibility

41. Suggested retainers Retainer Tooth # W56 Most molars W7 Lower molars
Upper molars W4
Most premolars W2
Small premolars
W27
Terminal lower molars requiring preparation on distal surfac

42. 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

43. Ligature
The slide shows an example of ligating the dental dam clamp.
Always cut a long enough piece so it can readily be grabbed if needed.
Tie the other end of the ligature to the frame of the dental dam to ensure you can easily find the end. .

44. 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
Applications:
Maxillary arch application: Punch the holes one inch down from the upper edge of the dam.
Mandibular arch application: Punch the holes two inches from the edge.
Curve of the arch: It may be necessary to make adjustments to accommodate an extremely narrow or wide arch.
Use the one-step or the two-step method to place the dam. The main difference in the methods is the sequencing in the placement of the clamp and dental dam.
Elsevier Inc. items and derived items © 2006 by Elsevier Inc.

45. 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
Why is it important to evaluate the dental material after removal? (Fragments of the dental dam left behind under the gingiva can cause gingival irritation.)

46. Application/removal errors
Inappropriate distance between the holes
Incorrect arch form of holes
Inappropriate retainer

47. 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

48. 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

49. 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

50. 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

51. 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

52. Cont. Advantages: Disadvantages:
 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

53. 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

54. 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

55. Cont. Advantages: Disadvantages:
 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

56. Electrosurgery coagulate tissues
Use of high frequency electric current to incise/
coagulate tissues

57. Electrosurgery: Uses To access subgingival caries Gum surgery
Implant placement
Crown lengthening
Coagulating the gum area before impression taking

58. Cont. Advantages: Disadvantages:
 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.

59. 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.

60. Trichloroacetic acid controls small amounts of bleeding
Hume and Mount 1999

61. Suggested reading Chapter 10 Sturdevant’s Arts and Science of
Operative Dentistry

62. Thank you