2. Contents
Introduction
Goals of isolation
Advantage of isolation
Methods of isolation
Direct methods
Indirect methods
• Conclusion
3. Introduction
good accessibility and visibility
, adequate room for instrumentation
Necessary for easy manipulation and
insertion of restorative materials
This control is attained through
isolation
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
8. Rubber dam
One of the most effective means of isolating teeth
Developed by SC Barnum in 1864
9. Advantages of rubber dam
Increases visibility & accessibility
Provides a dry field
Effectively retracts tongue, cheeks away from the field
of operation
Saves time
Reduces the chances of injury to soft tissues
Produces calming effect in children
Protects against bad taste of the materials used
Prevents any aspiration or ingestion of dental
instruments
10. Case reports
Panse A et al, 2012 – presented 3 cases of ingestion of
dental objects in 3 children in which rubber dam was
not used
11. Case 1
X ray shows a bur at the level of L4 Vertebra in left lumbar region in a 4 yrs
child, aspirated during access cavity preparation of 55 with an airoter hand
piece
12. Case 2
X ray shows a finishing bur at the level of L5 vertebra in left lumbar region in a
6 yrs old male child, aspirated while finishing restoration in his decayed 64, 65
13. Case 3
X ray shows an airoter cap at the level of L5 vertebra in left lumbar region
14. Disadvantages of rubber dam
Takes time to be applied
Communication with the patient can be difficult
Incorrect use may damage porcelain
crowns/gingival tissues
Insecure clamps can be swallowed or aspirated
15. Contraindications
child with upper respiratory tract
infection, congestion of nasal passage or nasal
obstruction
Presence of some fixed orthodontic appliances
recently erupted tooth
Patients with allergy to latex
grossly carious teeth
16. Armamentarium
Rubber dam sheet
Rubber dam template
Rubber dam punch
Rubber dam clamps
Rubber dam forceps
Rubber dam frame
Rubber dam napkin
Waxed dental floss
Scissors
Lubricants
17. Rubber dam sheet
made of latex or non-latex.
Available in 2 sizes- ❶ 5”*5”
❷ 6”*6”
Available in varying thickness
Thin – 0.15 mm
Medium – 0.20 mm
Heavy – 0.25 mm
Extra-heavy – 0.30 mm
Special heavy – 0.35mm
18. Light and dark sheets are available, may be
flavored for the children
Has a shiny and dull surface, dull side will be
facing the occlusal side
19. 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
20. Rubber dam punch
Used to make the holes in
the sheet through which the
teeth can be isolated
21.
22. Common hole placement problems
Holes punched too close together – holes pull
away from teeth causing leakage
Holes punched too far apart– dam bunches up
between teeth
Holes position too low on the dam – dam covers
patient’s eyes or nose
Holes position too high on dam – dam does not
extend over upper lip
23. Rubber dam clamps
Made of shiny & dull stainless steel
consists of a bow & 2 jaws
Aid in anchoring the dam to the
tooth & in soft tissue retraction
2 types :
Winged
Wingless
Wingless
Winged
24. Frequently used clamps
used in pediatric
dentistry :
12A clamp -- maxillary left second
primary molar and the
mandibular right second primary
molar
13A clamp -- maxillary right
second primary molar and the
mandibular left primary second
molar.
12A clamp
13A clamp
26. Clamps for front teeth
Ivory # 6
Ivory # 15
Ivory # 212SIvory # 90N
Ivory # 9
27. Dental floss
After selecting the appropriate
clamp place a 12 inch piece of
dental floss on the bow of the
clamp to aid in retrieval of the
clamp if it is dislodged from
the tooth and falls into the
posterior pharyngeal area
28. Rubber dam clamp forceps
Used for placement and
removal of retainer from the
tooth.
31. Grooves on their outer surfaces to ensure positive location
of the clamp during expansion & placement.
32. 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
33. Plastic frame :
Nygard-Ostby 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
34. Metal frame :
Young frame
U-shaped metal frame with
small metal projections for
securing borders of the
rubber dam.
35. Modifications
Le Cadre Articule rubber
dam frame (articulated
frame)
Developed in France by Dr. G
Saveur
Curved to fit the face and
hinged in the middle to fold
back
Advantage -- Allows easier
access for radiographic film
placement
36. Handidam (Aseptico,
Woodenville)
Has a built in foldable
radiolucent frame and a plastic
tube inserted in prepared holes
in rubber dam material to keep
the dam open
Available in one size
37. Advantages
Pre-framed, flexible design facilitates access to
the oral cavity for suction, X-ray films, or digital X-
ray sensors
Extremely low protein content reduces patient
irritation (<50 micrograms)
Saves time–eliminates the need to remove and
replace traditional dam during the procedure
Greater patient acceptance
38. Quick dam
Comes with an attached flexible
plastic frame or rim that supports
dam intraorally
Effective in saliva control anterior
part of the mouth than posterior
part
Has a pliable plastic frame around
perimeter of the rubber dam
39. Advantages
Quick & easy placement
No metal clamps or frames
Highly flexible
40. Instidam (Zirc company)
Simple & effective isolation
system
It is a pre punched rubber
dam mounted on a frame
Compact design fits outside
patient lips
41. Advantages :
Non threatening & comfortable to patient
Very stretchable
Tear resistant
Provides easy visibility
Radiographs can be taken without removing the
dam
42. Lubricants
Before positioning the dam
– lubricate the inner surface
well with Vaseline or soap so
that sheet will slide better
over the contours of the
teeth, more easily overcome
the contact areas & closely
tightly around the cervix
43. Rubber dam napkins
Prevent direct contact
between the rubber sheet &
patient’s cheek
Absorb saliva that
accumulate beneath the
dam by capillary action
Indicated in cases of allergy
to the rubber dam
44. 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)
45. Step 1 : Testing and
lubricating the proximal
contacts
Dental floss is used to test the inter
proximal contact and remove
debris from the tooth to be isolated
Identifies any sharp edges of
restoration or enamel that must be
smoothened
Using waxed dental tape may
lubricate tight contacts to facilitate
dam placement
47. Step 3 : Lubricating the
dam
lubricate both sides of the rubber
dam in the area of punched hole
using a cotton role or gloved finger
tip to apply the lubricant
lips and corner of the mouth may
be lubricated with petroleum jelly
or cocoa butter to prevent irritation
48. Step 4 : Selecting the
clamp
operator receive the rubber dam
retainer forceps with the selected
retainer and floss tie in position
free end of tie should exit from
cheek side of the retainer
Care should be taken not to open
the retainer more than necessary
to secure it in the forceps
49. Step 5: Testing the retainers
stability and retention
Test the retainers stability and
retention by lifting gently in an
occlusal direction with a finger tip
under the bow of the retainer
An improperly fitting retainer rocks or
easily dislodged
50. Step 6: Placement
3 techniques :
Dam first
Clamp first
Dam & clamp together
51. Dam first
Finger tip is introduced in the dam opening to better illustrate the patient
the functions of this rubber sheet
64. Advantages :
Not a difficult procedure to perform
Very less chances of dislodgement of the clamp
Most commomly used technique
65. General rule for
limited isolation
Include one tooth
posterior & 2 teeth
anterior to the tooth
being operated on
Limited isolation for operating
maxillary left 2nd premolar
66. Step 7 : Passing the septa
through contacts
Use waxed dental tape to pass the
dam through the contacts
Tape is preferred over floss because
wider dimension more effectively
carries rubber septa through
contacts
not likely to cut the septa
Waxed variety makes passage easier
& decreases chances for cutting
holes in the septa
67. Step 8 : Using a saliva
ejector
Use of saliva ejector is
optional because most
patient usually prefer to
swallow the saliva
Salivation greatly reduced
when profound
anaesthesia is obtained
68. Step 9 : Confirming a
properly applied rubber dam
Properly applied rubber dam is
securely positioned and
comfortable to the patient
69. Step 10 : Checking for accessibilty &
visibilty
Check to see that the completed rubber dam provides
maximal access and visibility for the operative procedure
70. Removal of dam
Step 1 : Cutting the septa
Stretch the dam facially ,
pulling the septal rubber away
from the gingival tissue and
tooth
Protect the under lying tissue
by placing the finger tip
beneath the septum
71. Step 2 : Removing the retainer
Engage the retainer forceps with retainer &
remove it
72. Step 3 : Removing the
dam
After the retainer is
removed ,release the
dam from the anterior
anchor tooth and remove
the dam and frame
simultaneously
73. Step 4 : Wiping the lips
Wipe the patient lip with the napkin immediately
after the dam and frame are removed
Prevents saliva from getting on to the patient’s
face
74. Step 5: Rinsing the mouth & massaging the tissues
Rinse the teeth and the high volume evacuator
Massage the tissues around the anchor teeth to
enhance the circulation
75. Step 6 : Examining the
dam
Lay the teeth of rubber dam
over a light -colored flat
surface or hold it up to the
operating light to determine
that no portion of the rubber
dam has remained between or
around the teeth
Such a remnant would cause
gingival inflammation
76. Cleaning of clamps after use
Cleaning –
Clamps should be rinsed & cleaned immediately after
the procedure
Failure to clean will decrease the life of the clamp &
can result in staining & corroding
Rinse & remove excess material before ultrasonic
cleaning
Allow clamps to dry
77. Sterilization –
Important to remove excess restorative material
from the clamp before sterilization as it may
damage the clamp
Autoclave – 15 min at 130°C/266°F
• Inspection –
Inspect the clamp for wear, distortion or damage
Discard if distorted
78. Care –
Do not bend or distort the clamp
Do not let clamps get scratched by other clamps or
instruments
When using obturation techniques involving
sodium hypochlorite, immediately rinse clamps
with water after the clamp is removed
80. Off center arch form
May not adequately shield the
patient’s oral cavity, allowing
foreign matter to escape down
patient’s throat
May result in an excess dam
material superiorly that may
occlude patient’s nasal airway
Superior border of dam may
me folded or cut from around
patient’s nose
81. Inappropriate retainer
May be :
Too small resulting in occasional breakage when
the jaws are overspread
Unstable on the anchor tooth
Impinge on soft tissues
An appropriate retainer should maintain a stable
four point contact with the anchor tooth
82. Retainer pinched tissue
Jaws & prongs of the retainer usually slightly
depress the tissues but should never pinch or
impinge on it
83. Shredded or torn dam
care should be taken to prevent tearing the dam
during hole punching or passing the septa through
contact
84. 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
85. 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
86. Latex allergy
Latex – products made from the milky fluid of the
rubber tree ‘Hevea brasiliensis’
Caused by continuous contact with the natural rubber
latex products
E.g.- rubber gloves, rubber dam, bite blocks, ortho
elastics, rubber stoppers, prophy cups
It is essential that dental health care professionals are
aware of the warning signs & keep a watchful eye for
those signs in patients & themselves
87. Types of latex reactions :
Type 4 reaction
Contact dermatitis
Thought to be caused by chemicals
added to the latex during
processing
Reactions take up 2 days to develop
Symptoms : swelling & redness of
skin, cracked, itchy & dry skin
88. Type 1 reactions :
Appear to be caused by protein found in
natural rubber latex
Generally takes pace within seconds to minutes
after exposure
Can cause life threatening anaphylaxis, low
blood pressure, cardiac arrhythmia, difficulty in
breathing & even death
Symptoms : Hives, Wheezing, Running
nose, itchy eyes, tingling of the lips, swelling of
eyelids, light headedness, difficulty in
breathing
89. Case report
Raggio DP et al, 2010 –
9 yr old female patient
First contact with latex happened on her first birthday
party with a balloon, resulting in swelling on body
According to mother’s report – presented strong
reaction after contact with latex gloves during
laboratory blood test, proved NRL allergy
90. Vinyl gloves were used
Vinyl gloves as an alternative to rubber
dam
metallic saliva ejector
91. Identification of clients at risk
Clients who have experienced rash, itching, swelling, nose or
eye irritation or shortness of breath after contact with any
latex product ( balloons, erasers, gloves, rubber dam)
Clients with spina bifida, eczema, banana, chestnut or
avocado allergies
Clients with frequent or prolonged hospital treatment or
multiple surgeries
Clients with frequent occupational exposure to latex products
92. Precautions for the latex sensitive patients
Take thorough medical history
Refer the patient to physician for latex sensitive testing
Emergency medical kit with non latex airway bags, mask,
bandages & tape should be available
Schedule latex sensitive patients as the first patient of the day
Use glass syringes over plastic or pre-filled or single use
syringes since plunger may contain rubber
Use non latex devices (gloves, dams ,etc) & rubber dam
napkins
If a reaction occurs, discontinue the treatment & observe the
patient for at least 20 min, medical intervention may be
needed
93. Cotton rolls & cellulose wafers
Available in different diameters, cut to
variant lengths & have plain or woven
surfaces
Stabilized & held sublingually with specific
holders or with an anchoring rubber dam
clamp
Can be applied without holders, over or
lateral to salivary gland orifices
Cellulose wafers provide additional
absorbency
94. Advantage – Slight retraction of cheeks aiding
in visibility & access
Precaution:
Moisten the cotton rolls & cellulose wafers while
removing to prevent inadvertent removal of
epithelium from cheeks, floor of mouth or lips
95. Gauze piece or throat
shields
Indicated when there is danger
of aspirating or swallowing
small objects, when rubber
dam is not being used
Used in pieces of 2”x2” or larger
Particularly important when
treating teeth in maxillary arch
96. Gauze sponge unfolded & spread over the tongue&
posterior part of the mouth
Advantage –
Better tolerated by delicate tissues
Less adherence to dry tissues compared to cotton
97. 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
Provides the required Dri-Field for
Composites
Bonding
Cementing
Comes in two types: plain and silver
coated
98. Saliva ejector & high
volume evacuating
equipment
Saliva ejector prevent
pooling of saliva in the floor
of the mouth
High volume evacuating
equipment removes solid
debris along with water
Saliva ejector
High volume evacuator
99. Types of saliva ejectors :
Metallic –
Autoclavable
Rubber tip to avoid irritating delicate tissues on
floor of the mouth
Plastic – Disposable & inexpensive
101. Requirements :
Tip should always be molded to face backwards
with a slight upward curvature
Floor of the mouth under the tip should be
covered with gauze to prevent injury to soft tissues
Should not interfere with instrumentation
102. Advantages
Provides an adequate dry field
No dehydration of oral tissues
Precautions
Should be disinfected after each use
Child patient- cautioned not to close his mouth
103. Retraction cords
Used for isolation & retraction in direct
procedures of treatment of accessible
sub gingival area
Diameter of cord should be selected
such that it is gently inserted into
gingival sulcus, producing lateral
displacement of the free gingiva without
blanching
Cord may be moistened with a non
caustic styptic before insertion
(Hemodent)
105. Advantages –
May help restrict excessive restorative materials from
entering the gingival sulcus
Provide better access for contouring & finishing the
restorative material
Prevent abrasion of gingival tissue during tooth
preparation
Used primarily to push the gum tissue away from the
prepared margins of the tooth, in order to create an
accurate impression of the teeth
106. Mouth props
Can be potential aid for lengthy
appointment on posterior teeth
Should maintain suitable
mouth opening
Types –
Block
Ratchet
108. Ideal characteristics -
Should be adaptable to all mouths
Should be easily positioned & removed with no patient
discomfort
Should be stable once applied
Should be either sterilizable or disposable
109. Mouth mirror
Secondary function -- Helps to retract cheeks,
lip & tongue in the absence of rubber dam
110. Indirect methods :
Local anaesthesia
Drugs –
Anti sialogogues (Atropine)
Anti anxiety ( Diazepam)
111. Conclusion
A thorough knowledge of the preliminary procedures
reduces the physical strain on the dental team
associated with the daily dental treatment, reduces
patient’s anxiety associated with dental procedures &
enhance moisture control thereby improving the
quality of operative dentistry
112. References
Sturdevant’s Art and Science of Operative Dentistry
Grossman’s Endodontic practice
Shobha tandon. Textbook of Peadodontics
MS Muthu. Pediatic Dentistry, Principles & Practice
Vimal K Sikri. Textbook of operative dentistry
Raggio DP et al. Latex allergy in dentistry: clinical cases
report. J Clin Exp Dent. 2010;2(1):55-9
Panse E et al. Accidental ingestion of instruments in
Pediatric dental patients : Report of 3 cases. JADA
2012;1(2): 79-81
