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Isolation techniques in pediatric dentistry

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Isolation techniques in pediatric dentistry

  2. 2. CONTENTS • Introduction • Goals of isolation • Advantage of isolation • Methods of isolation Direct methods Indirect methods • Conclusion
  3. 3. INTRODUCTION • Any operative procedure necessitates the need for adequate control over the operating field. • Proper moisture control, good accessibility and visibility as well as adequate room for instrumentation. • Isolating the working area includes isolation from moisture like saliva, blood and gingival crevicular fluid and isolation from the soft tissues like lips, cheeks, gingiva and tongue.
  4. 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. 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. 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
  7. 7. METHODS OF ISOLATION A) DIRECT METHODS 1. Rubber dam 2. Cotton rolls and Absorbent wafers 3. Evacuator system 4. Gingival retraction cord 5. Mouth props
  8. 8. B) INDIRECT METHODS 1. Comfortable position of the patient and relaxed surroundings 2. Local anaesthesia 3. Drugs: Anti-sialogogues Anti-anxiety drugs
  9. 9. • HISTORY: DR. SANFORD CHRISTIE BARNUM on 15th march 1864, • 1870, Dr. Tees festooned clamps • 1878,Dr.Elliot design clamp forceps • 1879, Ainsworth rubber dam punch • 1880, Dr.Hickman’s lipped clamps • 1890, clamps with holes. • Early 20th century –Rubber dam frame introduced(metal Fernauld’s frame)
  10. 10. ABCD’S OF RUBBER DAM • Adequate access and visibility in the operating field • Better patient protection and management • Control of moisture in the operating field • Decreased operating time
  11. 11. ADVANTAGES OF USING RUBBER DAM DURING ENDODONTIC PROCEDURES: 1. Provides dry and clean operating field. 2. Enhanced access and visibility to the working area. 3. Protects patients from possible aspiration or swallowing of endodontic instruments, medicaments, irrigating solutions and debris 4. Retracts and protects the soft tissues (gingival tissues, tongue, lips and cheeks) against possible trauma from rotary and hand instruments and endodontic medicaments 5. Significantly reduces the microbial content of air turbine aerosols produced during endodontic procedures, thereby reducing the risk of cross-infection. Ballal et al, (2013). Rubber dam in endodontics: An overview of recent advances.
  12. 12. 6. Improves the properties of dental materials by preventing the moisture contamination of restorative materials. 7. Enhances operating efficiency and increased productivity. Patient management is simplified by avoiding need to rinse the mouth of debris. 8. Protects dentists and dental assistants against infections which can be transmitted by the patient’s saliva 9. Minimizes patients conversation during root canal treatment and encourages them to open their mouth 10. Eliminates need for repeated change of cotton rolls due to flooding of saliva or root canal irrigants.
  13. 13. DISADVANTAGES: 1. Minor damage to marginal gingiva & cervical cementum during clamp removal. 2. Metal crown margins show microscopic defects following clamp removal. 3. Ceramic crowns could fracture if clamps are allowed to grip the margins. 4. Time consumption and patient objection
  14. 14. 1.Asthmatic patients 2.Patients with latex allergy 3.Psychological reasons CONTRAINDICATION
  15. 15. Armamentarium
  16. 16. RUBBER DAM SHEET : 1. Size : a) 5”*5” b) 6”*6” 2. Color: Light and dark sheets are available 3. Surfaces: Has a shiny and dull surface, dull side will be facing the occlusal side 4. Thickness: • Thin – 0.15 mm • Medium – 0.20 mm • Heavy – 0.25 mm • Extra-heavy – 0.30 mm • Special heavy – 0.35mm
  17. 17. NON LATEX RUBBER DAM: • Synthetic/silicone • Powder free • Highly elastic
  18. 18. RECENT ADVANCES IN RUBBER DAM SHEETS: • Hygenic dental dam (Coltène/Whaledent, OH, USA) • Derma dam (Ultradent Products. Inc, USA) • Flexi dam (Coltène/Whaledent.
  19. 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. 20. RUBBER DAM PUNCH: • Used to make the holes in the sheet through which the teeth can be isolated • A precision instrument having a rotating metal table and a tapered, sharp pointed plunger which is used to produce clean-cut holes in the rubber dam sheet through which the teeth can be isolated.
  21. 21. RUBBER DAM CLAMPS : • Aid in anchoring the dam to the tooth & in soft tissue retraction
  24. 24. NEWER ADVANCES IN RUBBER DAM CLAMPS Clamp with long guard extension has a larger wing which is used for retraction of the tongue. These clamps retract and protect the cheek and tongue along with isolation. They can be used with gauze or cotton rolls just for the retraction of tongue and cheek Ballal et al, (2013). Rubber dam in endodontics: An overview of recent advances.
  26. 26. • RUBBER DAM FORCEP is necessary to open the clamp and position it around the tooth. • The Ivory forceps are preferable, because they allow the dentist to apply direct pressure toward the gum, which is frequently necessary to position the clamp securely below the bulge of the tooth crown. Sengupta et al 2019, “Newer Advances in Rubber Dam”, International Journal of Current Research
  27. 27. RUBBER DAM HARNESS : • Retracts only sides of RD. • Dam tensors such as those of Woodburg, Cogswell, Mitchell, and Fernald, which are based on the principle of maintaining tension in the dam by the use of clips and elastic bands passing directly over the nape of the neck, are out-dated and have no use in modern Endodontics (Ingle et al., 2002).
  28. 28. 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
  29. 29. PLASTIC FRAME : NYGARD-OSTBY FRAME • Starlite 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
  30. 30. METAL FRAME : YOUNG FRAME • U-shaped metal frame with small metal projections for securing borders of the rubber dam.
  31. 31. NEWER ADVANCES IN RUBBER DAM FRAMES • Recently newer frames have been marketed into endodontic practice which has many added advantages. • The articulated rubber dam frame (IRED, France) is made of non-irritant plastic material (polysulfone) currently used in the agro alimentary industry
  32. 32. THE FOLLOWING FEATURES ARE: • A double hinge situated in the vertical axis of the frame, which allows it to be folded in half in the vertical direction. • The articulated frame has an advantage in providing access to the buccal half of the cavity. • In addition to this, it has a reservoir at the bottom of the frame that allows the placement of gauze to compress and an aspiration canula to avoid leakage of fluids such as sodium hypochlorite onto the patient's clothing
  33. 33. • The Safe-T-frame (Sigma Dental Systems)is composed of two hinged frame members whose snap-shut locking mechanism securely clamps the rubber dam sheet in place. • This concept also makes it possible to retain the traditional U-formed frame geometry and dimensions and offers a secure fit without- stretching the rubber dam sheet. • This contributes to greater patient comfort.
  34. 34. RECENT ALTERNATIVES TO RUBBER DAM • Insti dam (Zirc) has an in-built flexible radiolucent nylon frame eliminating the need for a separate one. • It is made of translucent natural latex that is very stretchable, tear-resistant and provides easy visibility. • There is an off-centre pre-punched hole which customizes fit to any quadrant. • Its compact design is just the right size to fit outside the patient‘s lips..
  35. 35. It has the following advantages: • Built-in flexible frame which eliminates the use of separate frame. • Pre-punched hole helps eliminate tearing. • Radiographs may be taken by bending the frame without removing the dam. • Minimal pull on clamp. • Single-use and hence eliminates the need for sterilization
  36. 36. • Handi dam (Aseptico) is a pre-framed rubber dam which eliminates the need for traditional frames. • It is quick and easy to place. It allows easy access to oral cavity during the root canal procedure
  37. 37. • Dry dam is an alternative type of rubber dam which does not require a frame. • It consists of a small rubber sheet set in the centre of an absorbent paper with light elastics on either side to pass over the ears. • It fits like a face mask with an absorbent lining to give patient comfort and reduced risk of allergic reaction. • It is available in medium and thin varieties. • It is useful for quickly isolating anterior teeth but it is not useful for isolation of posterior teeth.
  38. 38. Framed Flexi Dam (Coltène/Whaledent) • The Hygenic non-latex flexi dam is also available with an convenient, built-in-frame. • The dam has good tear resistance and is latex allergy free and odourless. • The smooth surface of the plastic frame helps to maximize patient comfort when positioned against their skin.
  39. 39. • Opti Dam (Kerr) is the first rubber dam with 3-dimensional shape and nipple design. • The 3-dimensional shape of Opti Dam and the anatomical frame shape match the contours of the mouth. • This allows greater access and improved visibility to the working area. • This also allows reduced tension resulting in easier rubber dam application and low risk of clamp displacement. • Opti Dam is available in two versions: anterior and posterior.
  40. 40. • Opti Dam involves much less preparatory work than for conventional rubber dams. • It offers maximum patient comfort and allows them to breath with no pressure around the nasal area.
  41. 41. • Optra Dam (Ivoclar Vivadent, USA) represents the next generation of rubber dams, combining the benefits of a lip and cheek retractor (Optra Gate) • The anatomical shape, high flexibility and patented inner-ring design allows it to be placed without the need for clamps. • Additionally, there is no need for a separate rubber dam frame making it even more time and cost efficient. • It provides optimum isolation as well as it is comfortable for the patient. • Its anatomical shape helps to create a considerably larger treatment field and complete isolation of both arches can be achieved at the same time
  42. 42. • Lubricant Before positioning the dam, it is an advisable to lubricate the inner surfaces well with Vaseline or, more simply, soap, so that the sheet will slide better over the contours of the teeth, more easily overcome the contact areas, and close tightly around the cervix of the tooth (Nidambur Vasudev Ballal et al.)
  43. 43. • Rubber dam napkins prevent direct contact between the rubber sheet and the patient’s cheek. • By absorbing the saliva that accumulates beneath the dam by capillary action, they facilitate treatment. • Their use is not mandatory; however, they are particularly indicated in cases of allergy to the rubber of the dam (de la Vega, 2008).
  44. 44. • Dental floss Apart from preventing the ingestion or aspiration of the clamp, dental floss is particularly useful for assessing the condition of the mesial and distal contact areas, and thus for facilitating the passage of the rubber sheet beneath them (Scardina, 2009)
  45. 45. RECENT ALTERNATIVES TO RUBBER DAM • Kool dam (Pulpdent Corporation) It is a light cured material applied on the gingiva or tooth surfaces prior to power bleaching, sand blasting or other procedures requiring intraoral protection or isolation. • It is also used to block out undercuts prior to taking impressions. Also called as liquid rubber dam. Because of its low exothermic reaction, it eliminates burning and pain, thus assuring patient comfort.
  46. 46. • A similar resin product called as OpalDam is manufactured by Ultradent Incorporation. • It has two disadvantages. Firstly, being resin based, it produces heat when cured, and can thus cause discomfort or pain to the patient. Secondly, some of these products tend to displace and not stay where they are placed
  47. 47. • Anatomically-shaped fast dam is designed to provide a superior means of maintaining a dry quadrant field. • It can be used in place of cotton rolls to retract the cheek and tongue while maintaining a dry field. • Continuous aspiration is achieved by means of 17 suction holes along the perimeter, eliminating the need to change saturated cotton rolls while retracting the cheek and tongue. • Fast dam fits into the valve of all standard saliva ejectors. Fast dam is also suitable when conventional rubber dam is too cumbersome.
  48. 48. • The Isolite is a new dental device that simultaneously delivers continuous throat protection, illumination, retraction and isolation. • It can be particularly useful in young people with incompletely erupted teeth. • Using Isolite, a core buildup during endodontic treatment can be done immediately by placing a matrix or core-former, and thus completing the process in one step. • This reduces the amount of time and number of steps needed as compared to conventional rubber dam.
  49. 49. • A similar device, Isodry, is also available which performs the same function, but requires external lighting.
  50. 50. RECENT ACCESSORY TO RUBBER DAM • Cushees: These are soft thermoplastic cashew shaped nodules which are grooved on their inner surface and act as rubber dam clamp cushions. • It increases patient comfort through elimination of contact of steel clamp with gingiva or tooth enamel, and thus helps to protect the natural tooth structure and costly restorations. • It also enhances rubber dam seal to limit leaking from above or below the dam and reduces clamp slippage. • They are available in two sizes: yellow for anterior and bicuspid clamps and blue for molar clamps.
  51. 51. • Wedjets (Hygenic) These are stretchable elastic stabilizing cords made from natural latex rubber and used as a rubber dam retainer. • These are a faster and easier method of retaining the rubber dam than using conventional clamps. • It is placed like dental floss over the rubber dam in the interproximal areas of the teeth, holding the rubber dam in position. • It is available in extra small, small and large sizes. • It reduces patient trauma and discomfort caused by metal clamps. They are especially used in the isolation of anterior teeth.
  52. 52. 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)
  53. 53. PLACEMENT OF RUBBER DAM 3 METHODS 1. Dam first technique 2.Clamp first technique 3.Clamp and dam together technique
  54. 54. DAM FIRST
  55. 55. DISADVANTAGES: • Procedure is often difficult • Especially in posterior areas or particularly small mouths
  56. 56. CLAMP FIRST
  57. 57. DISADVANTAGES: • Difficult procedure • Chances of dislodgement and aspiration of clamp while placing rubber dam
  59. 59. ADVANTAGES : • Not a difficult procedure to perform • Very less chances of dislodgement of the clamp • Most commomly used technique
  62. 62. • Inappropriate distance between the holes • Incorrect arch form of the holes Inappropriate retainer Shredded/ torn dam Sharp tips on No. 212 retainer Incorrect technique of cutting septa • Shredded or torn dam • care should be taken to prevent tearing the dam during hole punching or passing the septa through contact ERRORS IN APPLICATION & REMOVAL
  63. 63. • 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
  64. 64. 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
  65. 65. CASE REPORTS Nabeeh PK et al Accidental ingestion of endodontic instrument in child patient: A case report,2020.
  66. 66. • Accidental Ingestion and Uneventful Retrieval of an Endodontic File in a 4 Year Old Child: A Case Report Prashant Bondarde
  67. 67. • Vanhée et al., A. Behavior of Children during Dental Care with Rubber Dam Isolation: A Randomized Controlled Study. Dent. J. 2021 • This study aims to determine the behavioral and physiological indicators of stress in children during dental care with or without a rubber dam • The results obtained in this study show that the use of the rubber dam allows to reduce the stress in young patients during dental cares.
  68. 68. • Pediatric Dental Patients’ Attitudes to Rubber Dam , A McKay et al., J Clin Pediatr Dent (2013) • To explore young patients’ experiences of rubber dam (RD) and determine how personal and clinical factors may influence opinions. • The use of RD appears acceptable physically and psychologically to most pediatric patients, however, visibility of the RD to others was a potential concern to some children.
  69. 69. • The accidental ingestion or aspiration of the dental instrument is the potential life-threatening complication. In such cases, “prevention is better than cure” is applicable. • Rubber dam isolation should be strictly applied, and dentist should be aware of handling such situation by having the knowledge of diagnosis, immediate retrieval measures and providing emergency treatment to the patient. TAKE HOME MESSAGE
  71. 71. DIRECT METHODS • Rubber dam • Absorbent materials (Cotton rolls and cellulose wafers) • Low-volume evacuator • High-volume evacuator • Air-water syringe • Throat shield • Cheek retractor • Mouth prop
  72. 72. PHARMACOLOGICAL METHODS • Antisialogogues • Antianxiety drugs • Muscle relaxants METHODS USED FOR GINGIVAL TISSUE MANAGEMENT • Physicomechanical • Chemical • Chemomechanical
  74. 74. COTTON ROLLS: • Manually rolled Pre-fabricated Smooth Woven. • Cotton rolls are usually placed in buccal or lingual sulcus specially where salivary gland ducts exit so as to absorb saliva
  75. 75. Cellulose wafers are used in addition to cotton rolls and are placed in the buccal sulcus to retract the cheek. 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. • Comes in two types: plain and silver coated
  76. 76. ADVANTAGES • Effective to control small amounts of moisture for short time periods • Retract soft tissues at same time. DISADVANTAGES • Provide only short-term moisture control • Ineffective if high volumes of fluid are present • Shallow sulci and hyperactive tongue may make placement and retention difficult
  77. 77. HOLDERS:
  78. 78. ADVANTAGES: • Provide slightly more retraction • Improve accessibility and visibility of working area. DISADVANTAGES • They have to be removed from the mouth for changing cotton rolls • Relatively time consuming
  80. 80. LOW VOLUME EVACUATORS: • Low volume evacuators are basically saliva ejectors • Saliva ejector is best used to remove small amounts of moisture and saliva collected in the oral cavity during clinical procedure. • It can be used in conjunction with other methods of moisture control. • Tip of saliva ejector should be smooth to prevent any tissue injury. • It is better to have small diameter disposable tip.
  82. 82. ADVANTAGES: • Economical • Easy to use • Can be held by patient • Can be placed under rubber dam • Some have flanges attached which help in retraction of tongue and floor of mouth.
  83. 83. DISADVANTAGES: • Hyperactive tongues can make its placement difficult • Low volume aspirators do not remove solids well • If used inappropriately, can be uncomfortable for patient • May cause soft tissue damage by sucking in soft tissues into the tip.
  84. 84. SVEDOPTOR (E.C.MOORE) • It is a saliva ejector which not only removes saliva but also protects the tongue and floor of the mouth. • A mirror like vertical blade is attached to the evacuator tube so that it holds the tongue away from the field of operation. • Several sizes of vertical blades are supplied by the manufacturer
  85. 85. HYGOFORMIC • This coiled saliva ejector is used in the same way as the svedoptor, but it does not have a reflective blade, rather it has a retracting coil. • It must be reformed before use. • The coil should be loosened or partially uncoiled so that it extends posteriorly enough to hold the tongue away from the operating field.
  86. 86. SWEFLEX SALIVA EJECTORS: • Flexible, curved Efficient, comfortable, reduces aerosols with superior suction capability.
  87. 87. PRECAUTIONS TO BE TAKEN WHILE USING SALIVA EJECTOR: • Floor of mouth should not directly contact the tip so as to avoid trauma. • Sides of saliva ejector should not rub against surface of mouth to avoid injury. • When rubber dam is used, always make a hole so that ejector can pass through the dam instead of placing it under the dam. • Always protect floor of mouth beneath the ejector using cotton rolls or gauze piece to avoid tissue injury.
  88. 88. HIGH VOLUME EVACUATORS: • When using a high speed hand piece, both air and water emerges from the head of the hand piece to wash the working area and to act as a coolant for the bur and the tooth. • High volume evacuators are preferred to remove this collected moisture and debris in the mouth
  89. 89. • The tip usually beveled and is placed intermittently in the mouth during the operative procedure by the dental assistant. • The tip of the evacuator should be placed distal to the tooth being prepared & it should not interfere with the operator’s access or vision
  90. 90. ADVANTAGES: • Large particulate matter • Water from high speed drills • Air-water spray • Since clean field is achieved in less time, quadrant dentistry is made easy • Added advantage of double-ended aspiration tip is that if by chance one end gets clogged, another end can keep on aspirating.
  91. 91. AIR-WATER SYRINGE By air-water syringe an air blast can be useful to dry tooth or soft tissues during examination or used during operative procedures ADVANTAGE: Easy to use DISADVANTAGES: • Can dehydrate dentin and cause pain and discomfort to patient • Not effective if there are large volumes of moisture • Does not remove the moisture from oral cavity, it can just transfer moisture from one tooth to the next.
  92. 92. THROAT SHIELDS: • Throat shield is especially important when the maxillary tooth is being treated. • In this, an unfolded gauze sponge is stretched over the tongue and posterior part of the mouth. • It is useful in recovering a restoration (inlay or crown), if it is dropped in the oral cavity.
  93. 93. ADVANTAGES: • Avoids aspiration of restorations • Economical • Easy to use. DISADVANTAGE: • Not well tolerated by some patients as it can cause gagging
  94. 94. CHEEK RETRACTORS • They are used to expand the mouth opening more in the vertical rather than horizontal direction. • This makes them ideal for use when working on the gingival border of upper and lower front teeth and for the adjustment of orthodontic bands.
  95. 95. MOUTH PROP • A potential aid to restorative procedures on posterior teeth (for a lengthy appointment) is a mouth prop . • A prop should establish and maintain suitable mouth opening. Its use may also help relieve masticatory muscle fatigue.
  96. 96. A MOUTH PROP SHOULD HAVE FOLLOWING FEATURES: I. Adaptable to all mouths. II. Easily positioned, without causing discomfort to the patient. III. Readily adjusted, if necessary, to provide the proper mouth opening or improve its position in the mouth. IV. Stable once applied. V. Rapidly removed in case of emergency. VI. Sterilizable or disposable.
  97. 97. • Mouth props are generally available as either a block type or a ratchet type. • Although the ratchet type is adjustable, its size and cost are disadvantages.
  98. 98. PHARMACOLOGICAL MEANS • In this method, drugs are usually used to reduce the salivation. • Commonly used drugs are antisialologues, antianxiety drugs, muscle relaxants and sedatives, etc.
  99. 99. ANTISIALOLOGUES: • In this anticholinergic agents like atropine is used half an hour before procedure to reduce the salivation. • But it should be avoided in nursing mothers and patients with cardiovascular problems
  100. 100. DRUGS USED AS ANTISIALOLOGUES: • Atropine (Saltropine) – 0.05 mg
  101. 101. • Al Jeraisy et al. BMC Pediatrics (2020) Efficacy of scopolamine transdermal patch in children with sialorrhea in a pediatric tertiary care hospital RESULTS: STP use showed significant reduction in severity of drooling (p < 0.001), wiping of the child’s mouth (p < 0.001), bibs or clothing changes (p < 0.001), choking and aspiration of saliva (p = 0.001). The Relative Risk Reduction of the drooling-related ED and RA visits were 86% and 67% respectively. Nearly two-thirds (60%) of caregivers were satisfied with using STP.
  102. 102. GLYCOPYRROLATE (ROBINUL) • Franko and Lunsford (1960) found glycopyrrolate (Robinul) • To be a potent, long-acting anticholinergic agent and more recently it has been recommended as a suitable alternative to atropine. • BR.J. ANAESTH ET AL ., GLYCOPYRROLATE-NEOSTIGMINE MIXTURE FOR ANTAGONISM OF NEUROMUSCULAR BLOCK: COMPARISON WITH ATROPINENEOSTIGMINE MIXTURE
  103. 103. • Zanon et al. Italian Journal of Pediatrics (2021) Compounded glycopyrrolate is a compelling choice for drooling children: five years of facility experience • A retrospective observational study on 21 patients who received a custom- formulated galenic glycopyrrolate syrup for sialorrhea for an average period of 14.3 months. • Overall, 16 out of 21 patients (76.2%) reported a significant improvement in sialorrhea and QoL. In 14 subjects (66.7%), there was a remarkable decrease in the drooling severity; 10 individuals (47.6%) reported a reduction in drooling frequency
  104. 104. ANTIANXIETY AGENTS AND SEDATIVES: • Antianxiety drugs and sedatives like diazepam and barbiturates are used in apprehensive patients 24 hours before appointment. • Since these drugs result in psychological dependence, patient selection is done carefully MUSCLE RELAXANTS: • Muscle relaxants can also be used to reduce salivation
  105. 105. Oral Sedation in Pediatric Dentistry: The Growing Wave of Chemical Restraint Gino Gizzarelli,
  106. 106. METHODS USED FOR GINGIVAL TISSUE MANAGEMENT • In this, different methods are used, which mechanically displace the gingiva both laterally and apically away from the tooth surface. • Before using these methods following requirements should be fulfilled: 1. Normal and healthy gingiva with good vascular supply. 2. Adequate zone of attached gingiva 3. Adequate amount of healthy bone without the sign of tooth resorption
  107. 107. METHODS FOR PHYSICOMECHANICAL MEANS 1. Rubber dam: • Various type of rubber dam sheets such as heavy and extra heavy sheets provide adequate type of mechanical displacement of gingival tissue. • For additional retraction, Clamp No. 212 (cervical retainer) can also be used. 2. Wooden wedges: • They are used interdentally to displace the gingival tissue, thus helping in retraction. • Care should be taken while using wooden wedge as it can damage the interproximal tissue if inserted forcibly
  108. 108. GINGIVAL RETRACTION CORDS: • Different types of retraction cords are available in the market, which displace the gingiva both laterally and apically away from the tooth surface. • Retraction cord can be of cotton or synthetic and braided/ nonbraided type. Garg, et al.: Fluid absorbancy of retraction cords
  109. 109. INDICATIONS OF GINGIVAL RETRACTION: • Control of gingival flow or gingival bleeding—especially when the margins of restoration are close to gingiva, for example, restoration of class V preparation. • To provide esthetics for final restoration of fixed prosthesis by exposing the finish line • To increase retention in case of indirectrestorations where crown height is inadequate
  110. 110. • To extend the margins subgingivally in case of cervical caries extending below the gingiva • For accurate recording of preparation margins while taking impressions • For removing the hypertrophied gingiva, interfering with placement of preparation margins.
  111. 111. Placement and Removal of Retraction Cord
  112. 112. CHEMICAL MEANS • Chemical means is one of the oldest methods of retraction of gingival • Commonly used chemicals for this method are trichloroacetic acid and sulfuric acid.
  113. 113. TRICHLOROACETIC ACID • Itis used for chemical means of gingival retraction, though now a days its use has been reduced. ADVANTAGE • Effectively controls the bleeding site. DISADVANTAGE • Caustic in nature—can cause soft tissue damage if accidently dropped on tissues.
  114. 114. CHEMICOMECHANICAL METHODS: Different Chemicals used are: Vasoconstrictors: 1. Epinephrine 2. Norepinephrine Astringents: 1. Alum (100%) 2. Aluminum chloride (15%–25%) 3. Tannic acid (15%–25%) 4. Ferric sulphate (15%–15.5%). Tissue coagulants: 1. Zinc Chloride 2. Silver nitrate
  115. 115. VASOCONSTRICTORS: • As the name indicates, these cause local vasoconstriction, reduce the blood supply and gingival fluid seepage. • Epinephrine and norephinephrine are included in this category. • But nowadays, their use has been declined because of systemic adverse effects.
  116. 116. ADVANTAGE • Used as an adjunct to gingival retraction cord when gingival bleeding is present. DISADVANTAGES • Invasive procedure • Contraindicated in patients with cardiovascular disease, diabetes mellitus • Not effective if profuse bleeding is present.
  117. 117. ASTRINGENTS (BIOLOGIC FLUID COAGULANTS) • As compared to vasoconstrictors, these chemicals are considered to be safe and have no systemic effects. • These chemicals coagulate blood and gingival fluid in the sulcus, thus forms a surface layer which seals against blood and fluid seepage. • Alum, aluminum chloride, tannic acid and ferric sulphate are included in this category.
  118. 118. TISSUE COAGULANTS • These agents usually act by coagulating the surface layer of sulcular and gingival epithelium. • These chemicals form a nonpermeable film for underlying fluids. • Zinc chloride and silver nitrate are included in the tissue coagulants. • If applied for prolonged time, coagulants can cause: 1. Ulceration 2.Local necrosis 3.Change in contour, size and position of free gingiva.
  119. 119. CONCLUSION • Even though the concept of absolute isolation was developed more than 150 years ago and despite its widely acknowledged benefits, a number of clinicians refuse to use absolute isolation in routine endodontic practice (Marshall and Page, 1990). • The time it takes to achieve good isolation will pay itself forward exponentially in time as well as in quality of treatment and reduction of stress. • Good isolation will preserve tooth structure, prevent contamination of the field, provide better visibility, and prevent iatrogenic misadventures (Anabtawi et al., 2013).
  120. 120. REFERENCES • Grossman’s Endodontic practice • Shobha tandon. Textbook of Peadodontics • Sturdevants’ art and science of operative dentistry. • Text book of endodontics- Nishagarg • Ballal et al, (2013). Rubber dam in endodontics: An overview of recent advances • Sengupta et al 2019, “Newer Advances in Rubber Dam”, International Journal of Current Research.
  121. 121. • Accidental Ingestion and Uneventful Retrieval of an Endodontic File in a 4 Year Old Child: A Case Report Prashant Bondarde • Vanhée et al., A. Behavior of Children during Dental Care with Rubber Dam Isolation: A Randomized Controlled Study. Dent. J. 2021 • Nabeeh PK et al Accidental ingestion of endodontic instrument in child patient: A case report,2020 • Pediatric Dental Patients’ Attitudes to Rubber Dam , A McKay et al., J Clin Pediatr Dent (2013)

Notas do Editor

  • Such an environment is necessary for easy manipulation and insertion of restorative materials.. It is imperative that there should be proper moisture control, good accessibility and visibility as well as adequate room for instrumentation around the working area.
  • Moisture Control. Operative dentistry cannot be executed properly unless the moisture in the mouth is controlled. Moisture control refers to excluding sulcular fluid, saliva, and gingival bleeding from the operating field. It also refers to preventing the hand piece spray and restorative debris’ from being swallowed or aspirated by the patient. The rubber dam, suction devices, and absorbents are variously effective in moisture control. • Retraction and Access. The details of a restorative procedure cannot be managed without proper retraction and access. IT provides maximal exposure of the operating site.The rubber dam, high-volume evacuator, absorbents, retraction cord, and mouth prop are used for retraction and access. arm Prevention. An axiom taught to every member of the health profession is "Do no harm," and an important consideration of isolating the operating field is preventing the patient from being harmed during the operation. As with moisture control and retraction, a rubber dam, suction devices, absorbents, and occasional use of a mouth prop contribute not only to harm prevention, but also to patient comfort and operator efficiency.
  • Thickness mm inch Thin 0.15 0.006 Medium 0.20 0.008 Heavy 0.25 0.010 Extra heavy 0.30 0.012 Special heavy 0.35 0.014
  • Hygenic dental dam (Coltène/Whaledent, OH, USA) – It is a non-latex rubber dam for patients with latex allergies. This powder-free, synthetic dam comes in one size (6 × 6 inches). It has a shelf life of 3 years and has the same tensile strength of a latex dam.
    Derma dam (Ultradent Products. Inc, USA) - It is also a nonlatex and powder-free rubber dam. It has a low content of surface proteins and has an advantage of having low dermatitis potential, reduced allergic reactions and greater tear resistance
    Flexi dam (Coltène/Whaledent)- It is an elastic nonlatex dental dam made from an elastic plastomer and can be elongated more than 1000 % before tearing. It is more tenacious than latex dam and is simple to place. It needs to be stretched before use. It is available in blue and violet colour. These colours provide a good contrast to the working area and may have a calming effect on the user. This has an advantage while performing aesthetic treatment procedures.
  • 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
  •  2 types :  Winged  Wingless Wingless Winged
  • 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
  • 2A clamp -- first primary molars  14 clamp -- fully erupted permanent molars  14A clamp -- partially erupted permanent molars
  • Tiger clamps are clamps with serrated jaws. These serrations increase the stabilization of the clamp on the partially erupted or broken down teeth.
    S-G (Silker-Glickman) clamp
    is a clamp with anterior extension which allows for retraction of the dam around a severely brokendown tooth, and the clamp itself is placed on a tooth proximal to the one being treated. It is made from durable cast stainless steel, which is autoclavable, corrosion-resistant, flexible and long lasting. It is ideal clamp for molar isolation. Its extended wings allows for rubber dam placement around the teeth with minimal tooth structure.
    Super Clamp (Dent Corp Research And Development, NY, USA)
    Super clamp (Fig 3.4) comes with a pre-cut rubber dam material designed to fit the clamp. It is very simple to use, quick and easy to place. It allows for easy evacuation of oral fluids with a saliva ejector or a high-volume evacuator, and also can be used without the rubber dam to protect only the tongue and soft tissues. The clamp is made out of a thin, flexible stainless steel. It can be sterilized by autoclave, chemiclave or even dry heat. However, it has one disadvantage that, it cannot be used for anterior teeth. It comes in three sizes: L- large clamp for molars, M- medium clamp which can also be used for molars and S- small clamp which can be used for premolars (Scardina, 2009
    Gold colored clamp Gold colored clamps (Fig 3.5) have diamond grit on their jaw to improve the retention of the clamp
  • The older frames have numerous disadvantages such as, requiring more time for positioning, they completely cover the patient‘s nose and mouth, giving the patient unpleasant sensation of suffocation and they do not cause retraction of the lips or cheeks.
  • This accessibility facilitates proper positioning of the radiographic film, administration of additional local anaesthetic, and evacuation of therapeutic liquids, which may have accidentally entered the buccal cavity
  • It has an added disadvantage of not being useful in a bleaching procedure due to the absorbent nature of the paper surrounding it
  • with the total isolation of a rubber dam (Figure 8). It is available in both regular and small sizes. The soft flexible material allows patients to maintain full mobility of their jaw along with added comfort throughout the procedure. Due to the enhanced flexibility of the plastic rings, it can be placed more easily in the patient's mouth.
  • It remains flexible after curing and has good tear resistance. It stacks on itself smoothly and evenly and is easy to remove. It is moisture friendly and works well in the oral environment and is a rubber dam substitute
  • It has a unique soft, flexible mouthpiece which isolates maxillary and mandibular quadrants simultaneously, retracts and protects the soft tissues from accidental damage from high speed turbines, delivers shadow less illumination and continuously aspirates fluids and prevents the aspiration of foreign objects.
  • It has the following disadvantages: (a) It is significantly more expensive than the rubber dam. (b) It does not provide the color contrast with the teeth that some practitioners find helpful when using rubber dam. (c) It may cause damage to the gingiva, since Isolite does not seal the gingiva from irrigants or intra canal medicaments
  • They are sterilizable and reusable. It can be applied to one or both the jaws of rubber dam clamps
  • The operator receives dental floss from the assistant to test the interproximal contacts and remove debris from the teeth to be isolated. Passing (or attempts to pass) floss through the contacts identifies any sharp edges of restorations or enamel that must be smoothed or removed to prevent tearing the dam. Using waxed dental tape may lubricate tight contacts to facilitate dam placement. Step 2: Punching the Holes. Step 3: Lubricating the Dam.This facilitates passing the rubber dam through the contacts. The lips and especially the corners of the mouth may be lubricated with petroleum jelly or cocoa butter to prevent irritation. Step 4: Selecting the Retainer.
    Step 5: Testing the Retainer’s Stability and Retention. If during trial placement the retainer seems acceptable, remove the forceps. Test the retainer’s stability and retention by lifting gently in an occlusal direction with a fingertip under the bow of the retainer. An improperly fitting retainer will rock or be easily dislodged.
    Step 6: Positioning the Dam Over the Retainer. • Be applying the dam, the floss tie may be threaded through the anchor hole, or it may be left on the underside of the dam. With the forefingers, stretch the anchor hole of the dam over the retainer (bow first) and then under the jaws. The lip of the hole must pass completely under the jaws. The septal dam must always pass through its respective contact in single thickness. If it does not pass through readily, it should be passed through with dental tape later in the procedure.
  • Step7: Applying the Napkin. • The operator now gathers the rubber dam in the left hand while the assistant inserts the fingers and thumb of the right (or left) hand through the napkin’s opening and grasps the bunched dam held by the operator.
    Step 8: Positioning the Napkin. The assistant then pulls the bunched dam through he napkin and position it on the patient’s face. The operator helps by positioning the napkin on the patient’s right side. The napkin reduces skin contact with the dam. Step 9: Attaching the Frame: The operator unfolds the dams. \Simultaneously, the operator stretches and attaches the dam on the right side. The frame is positioned outside the dam. The curvature of the frame should be concentric with the patient’s face. The dam lies between the frame and napkin. Attaching the dam to the frame at this time controls the dam to provide access and visibility. Secure free ends of the floss tie to the frame.Step 11: Passing the Dam through Posterior contact. If there is a tooth distal to the retainer, the distal edge of the posterior anchor hole should be passed through the contact to ensure a seal around the anchor tooth. Step 13: Applying the Anterior Anchor (If Needed) • The operator passes the dam over the anterior anchor tooth, anchoring the anterior portion of the rubber dam. Usually, the dam passes easily through the mesial and distal contacts of the anchor tooth. When the contact farthest from the retainer is minimal (“light”), an anchor may be required in the form of a double thickness of dental tape or a narrow strip of dam material that is stretched, inserted, and released. Step 14: Passing the Septa through the Contacts without Tape. The operator passes the septa through as many contacts as possible without the use of dental tape by stretching the septal dam faciogingivally and linguogingivally with the forefingers. Passing the dam through as many contacts as possible without using dental tape is urged because the use of tape always increases the risk of tearing holes in the septa. Slight separation (wedging) of the teeth is sometimes an aid when the contacts are extremely tight. Pressure from a blunt hand instrument (e.g., beaver-tail burnisher) applied in the facial embrasure gingival to the contact usually is sufficient to obtain enough separation to permit the septum to pass through the contact.

  • Step 15: Passing the Septa through the Contacts with Tape. Use waxed dental tape to pass the dam through the remaining contacts. Tape is preferred over floss because its wider dimension more effectively carries the rubber septa through the contacts. Also, tape is not as likely to cut the septa.. The waxed variety makes passage easier and decreases the chances for cutting holes in the septa or tearing the edges of the holes. The tape should be placed at the contact on a slight angle. With a good finger rest on the tooth, the tape should be controlled so that it slides (not snaps) through the proximal contact, thus preventing damage to the interdental tissues. Step 17: Inverting the Dam Interproximally. Invert the dam into the gingival sulcus to complete the seal around the tooth and prevent leakage. Often, the dam inverts itself as the septa are passed through the contacts as a result of the dam being stretched gingivally. The operator should verify that the dam is inverted interproximally. Inversion in this region is best accomplished with dental tape.
    Step 18: Inverting the Dam Faciogingivally. • With the edges of the dam inverted interproximally, complete the inversion facially and lingually using an explorer or a beaver-tail burnisher while the assistant directs a stream of air onto the tooth. This is done by moving the explorer around the neck of the tooth facially and lingually with the tip perpendicular to the tooth surface or directed slightly gingivally. A dry surface prevents the dam from sliding out of the crevice. Alternatively, the dam can be inverted facially and lingually by drying the tooth while stretching the dam gingivally and then releasing it slowly Step 20: Confirming a Properly Applied Rubber dam. The properly applied rubber dam will be securely positioned and comfortable to the patient. The patient should be assured that the rubber dam does not prevent swallowing or closing the mouth (about halfway) when there is a pause in the procedure.
    Step 21: Checking for Access and Visibility Check to see that the completed rubber dam provides maximal access and visibility for the operative procedure.
    Step 22: Inserting the Wedges. For proximal surface preparations (Classes II, Ill, and IV), many operators consider the insertion of interproximal wedges as the final step in rubber dam application. Wedges are generally round toothpick ends about half inch (12.7 mm) in length that are snugly inserted into the gingival embrasures from the facial or ling embrasure, whichever is greater, using No. 110 pliers. • To facilitate wedge insertion, first stretch the dam slightly by fingertip pressure in the direction opposite wedge insertion, and then insert the wedge while slowly releasing the dam.
  • Finger tip is introduced in the dam opening to better illustrate the patient the functions of this rubber sheet
  • Assistant’s hands position the dam directly around the tooth to be treated
  • The dentist positions the clamp
  • vWith assistance dentist positions Young’s frame
  • Clamp positioned on the tooth
  • Rubber sheet has been slid below the clamp, already in place
  • Rubber sheet is punched with a rubber dam punch
  • Rubber dam is stretched over the wings of selected clamp
  • Dam & clamp placed in position in patient’s mouth, with the help of an assistant
  • Young’s frame is positioned to produce tension in the dam
  • Using an instrument dam is slipped beneath the clamp wings
  • Used in case of fractured crowns or anteriors with ceramic crown or veneers to prevent chipping of the crown margins.  Two overlapping holes are punched on the dam or slit cut between the holes made for the two adjacent teeth.  The dam is stretched over the tooth to be treated & one adjacent tooth on each side.  It is essential that the sealing material is applied to prevent leakage and contamination.
  • thoroughly cleanse area.  Cut/remove inter proximal ligatures.  Stretch rubber dam facially and cut each inter proximal septum with scissors.  Remove clamp with clamp forceps.  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.
  • A four year old, male child, reported to the Department of Pedodontics & Preventive dentistry with the chief complaint of pain on his lower right back tooth since 2 weeks. As the patient exhibited discomfort with the placement of the rubber dam, the procedure was carried out without rubber dam isolation. During the cleaning and shaping of the root canal, the patient suddenly moved his head, due to which an endodontic instrument (Pro Taper hand file, Dentsply) slipped from the operators hand. The procedure was stopped immediately and measures were taken to retrieve the file from the posterior region of oral cavity but were not visible in the oral cavity. The patient didn’t have choking or cough with no obvious signs of respiratory distress.
  • A 4-year-old male patient reported to the department of pediatric and preventive dentistry, Annasaheb Chudaman Patil Memorial Dental College, Dhule with pain in his lower left back tooth. On radiographic examination, pulpectomy was planned for the tooth 74. On the same day, access opening was done with tooth 74 under local anesthesia, pulp was extirpated, working length was determined and bio-mechanical preparation was in progress when patient suddenly moved his head due to which endodontic instrument (size Sx Pro Taper hand file, Dentsply) slipped from operator’s hand and patient swallowed it.
  • Even though ingestion of dental instrument is rare in pediatric dental practice, standard protocols of patient safety has to be followed.
  • Cotton rolls, pellets, gauze, and cellulose wafers absorbents are helpful for short period of isolation, for example, in examination, polishing, pit and fissure sealant placement.
    Absorbents play an essential role in isolation of the teeth especially when rubber dam application is not possible.
  • 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.
    Comes in two types: plain and silver coated
    Provides the required Dri-Field for  Composites  Bonding  Cementing 
  • Cotton rolls can be placed into position and stabilized with commercial holding devices known as Cotton roll holders
  • Vacuum systems can be high volume and low volume.
  • To avoid any interference with working, it can be bent to place in the required area of mouth.
  • Metallic : Autoclavable  Rubber tip to avoid irritating delicate tissues on floor of the mouth  Plastic – Disposable & inexpensive
    They are available with disposable plastic tips or auto clavable metallic tips.
  • A mirror like vertical blade is attached to the evacuator tube so that it holds the tongue away from the field of operation.
    Several sizes of vertical blades are supplied by the manufacturer
    It is designed so that the vacuum evacuator tube passes anterior to the chin and over the incisal edges of mandibular anterior teeth and down to the floor of the mouth.
    An adjustable horizontal chin blade is attached to the evacuation tube so that it will clamp under the chin to hold the apparatus in place.
  • Floor of mouth should not directly contact the tip so as to avoid trauma.
    Sides of saliva ejector should not rub against surface of mouth to avoid injury.
    When rubber dam is used, always make a hole so that ejector can pass through the dam instead of placing it under the dam.
    Always protect floor of mouth beneath the ejector using cotton rolls or gauze piece to avoid tissue injury.
  • because low volume saliva ejectors are slow at work and poor at clearing solids.
  • Its tips are usually made up of disposable plastic or auto clavable metallic tips
  • It facilitates fast removal of: •
  • Can dehydrate dentin and cause pain and discomfort to patient
    Not effective if there are large volumes of moisture
    Does not remove the moisture from oral cavity, it can just transfer moisture from one tooth to the next.
  • Mouth props. (A) Block-type prop maintaining mouth opening. (B) Ratchet-type prop maintaining mouth opening. (C) Block-type prop. (D) Ratchet-type prop. (E) Foam-type disposable prop
    The most outstanding benefits to the patient are relief of responsibility of maintaining adequate mouth opening and relief of muscle fatigue and associated discomfort. For the dentist, the prop ensures constant and adequate mouth opening and permits extended or multiple operations, if desired.
  • Competitive antagonists • Compete with acetylcholine • Block acetylcholine at the muscarinic receptors in the PSNS • Reversible blockade of acetylcholine at muscarinic receptors by competitive binding • (reversal by increasing acetylcholine or agonist ----> decreased blockade) • Once these drugs bind to receptors, they inhibit nerve transmission at these receptors
  • A main disadvantage of atropine is its short duration of action (Wangeman and Hawk, 1942 Both atropine, being tertiary amines, cross the blood-brain barrier and thus have some central effects
  • The usual hospital practice of managing patients with excessive salivation is to start them on glycopyrrolate for a week, if there is no response [non-response was defined as no change in the frequency of salivation as mentioned by the child’s parent/caregiver], then to switch to STP, starting with ¼ patches (0.375 mg) then gradually increased to full patches (1.5 mg), or to the maximum tolerated dose of their medication. STPs were placed on cleaned skin behind the ear once daily
  • ). Its main advantages are that it has an onset of action similar to that of neostigmine and, being a quaternary compound, it does not cross the blood-brain barrier. It has been shown also to be a more effective antisialogogue than is atropine
  • Glycopyrrolate oral solution is usually prescribed initially at 0.02 mg/kg three times daily and titrated in 0.02 mg/kg increments every 5–7 days, based on therapeutic response and adverse reactions. The maximum recommended dose is 0.1 mg/kg three times a day, not to exceed 1.5–3 mg per dose based on weight. Glycopyrrolate is recommended to be administered at least 1 h before or 2 h after meals
  • Different sizes of retraction cords available in the market: o size showed more absoribung thbicker cord
  • (Anesthetize the area. • Select the appropriate size of cord which can be placed into gingival sulcus without causing any injury/ischemia. Take the length of cord so that it extends 1 mm beyond the gingival width of the preparation or extends around the whole circumference of the tooth. • Take an instrument for packing the cord.It should be blunt hatchet or hoe shaped. Apply slight force laterally and slightly angulated towards the tooth surface. Avoid application of apical pressure as it may harm the junctional epithelium. Insert one endofthe cord, stabilize itwithbluntinstrument and pack the rest of the cord. Avoid putting ends of the cord interproximally for better grip of the cord. . • Remove the cord slowly and take care that it should not be dry. A dry cord may adhere to epithelium and on removal it may cause its abrasion. • Check for any pieces of retraction cord immediately after its removal and remove if any, to avoid gingival irritation.
  • Application of chemical agent for management of gingival tissus
  • This is the most common and popular technique used for gingival retraction and has been considered safe, also it provides adequate amount of gingival tissue displacement.
  • The effect of the drug is to: 1-increase the duration of the local anesthesia by producing vasoconstriction at the site of injection, thereby allowing the local anesthetic to persist at the injection site before being absorbed into the circulation and metabolized. 2-Very weak solutions of epinephrine (1:100,000) can also be used topically to vasoconstrict mucous membranes to control oozing of capillary blood.
  • These chemicals or coagulants are not preferred because of its side effects