RUBBER DAM

Rubber dam was introduced byBarnum, a New York dentist in 1863

Advantages of using a rubber dam

• It is raincoat for the teeth
• It helps in improving accessibility and visibility of the working area
• It gives a clean and dry aseptic field while working
• It protects the lips, cheeks and tongue by keeping them out of the way
• It helps to avoid unnecessary contamination through infection control
• It protects the patient from inhalation or ingestion of instruments and medicaments
• It helps in keeping teeth saliva free while performing a root canal so that tooth does not get decontaminated by bacteria present in saliva
• It improves the efficiency of the treatment
• It limits bacterial laden splash and splatter of saliva and blood

• It potentially improves the properties of dental material.
• It provides protection of patient and dentist.

Disadvantages of using a rubber dam

• Takes time to apply 
• Communication with patient can be difficult 
• Incorrect use may damage porcelain crowns/crown margins/ traumatize gingival tissues 
• Insecure clamps can be swallowed or aspirated.Contraindications of use of rubber dam

• Asthmatic patients
• Allergy to latex
• Mouth breathers
• Extremely malpositioned tooth • Third molar (in some cases).

Rubber dam equipment

• Rubber dam sheet• Rubber dam clamp • Rubber dam forceps• Rubber dam frameRubber dam accessories•Lubricant/petroleum jelly• Dental floss• Rubber dam napkin.

Rubber Dam Sheet

  • The rubber dam sheet is normally available in size 5 × 5 or 6 × 6 squares in green or black color
  • It is available in three thicknesses, i.e. light, medium and heavy
  • The middle grade is usually preferred as thin is more prone to tearing and heavier one is more difficult to apply
  • Latex-free dam is necessary as number of patients are increasing with latex allergy
  • Flexi dam is latex-free dam of standard thickness with no rubber smell.

Rubber Dam Clamps

  • Rubber dam clamps, to hold the rubber dam onto the tooth are available in different shapes and sizes.
  • Clamps mainly serve two functions:
    1. They anchor the rubber dam to the tooth.
    2. Help in retracting the gingiva.

Rubber Dam Forceps

  • Rubber dam forceps are used to carry the clamp to the tooth.
  • They are designed to spread the two working ends of the forceps apart when the handles are squeezed together.
  • The working ends have small projections that fit into two corresponding holes on the rubber dam clamps.
  • The area between the working end and the handle has a sliding lock device which locks the handles in positions while the clinician moves the clamp around the tooth.
  • It should be taken care that forceps do not have deep grooves at their tips or they become very difficult to remove once the clamp is in place.

Rubber Dam Frame

Rubber dam frame supports the edges of rubber dam .Frames have been improved dramatically since their old style with the huge ‘butterflies’.Modern frames have sharp pins which easily grip the dam. These are mainly designed with the pins that slope backwards.

• Rubber dam frames are available in either metal or plastic. 

• Plastic frames have advantage of being radiolucent.
• When taut, rubber dam sheet exerts too much pull on the rubber dam clamps, causing them to come loose,especially clamps attached to molars.
• To overcome this problem, a new easy-to-use rubber dam frame (Safe-T-Frame) has been developed that offers a secure fit without stretching the rubber dam sheet. Instead, its “snap-shut” design takes advantage of the clamping effect on the sheet, which is caused when its two mated frame members are firmly pressed together. In this way, the sheet is securely attached, but without being stretched. Held in this manner, the dam sheet is under less tension, and hence, exerts less tugging on clamps—especially on those attached to molars.

SAFE T FRAME

Rubber Dam Punch

  • Rubber dam punch is used to make the holes in the rubber sheet through which the teeth can be isolated.
  • The working end is designed with a plunger on one side and a wheel on the other side.
  • This wheel has different sized holes on the flat surface facing the plunger.
  • The punch must produce a clean cut hole every time.
  • Two types of holes are made, single and multihole.
  • Single holes are used in endodontics mainly.
  • If rubber dam punch is not cutting cleanly and leavingbehind a tag of rubber, the dam will often split as it is stretched out.
  1. Rubber Dam Template
    • It is an inked rubber stamp which helps in marking the dots on the sheet according to position of the tooth.
    • Holes should be punched according to arch and missing teeth.
  1. Rubber Dam Accessories
  2. Lubricant or Petroleum Jelly
  3. It is usually applied on the undersurface of the dam.
  4. It is helpful when the rubber sheet is being applied to theteeth.
  5. dental floss
  6. It is used as flossing agent for rubber dam in tight contact areas.
  7. It is usually required for testing interdental contacts.

Rubber Dam Napkin

• This is a sheet of absorbent materials usually placed between the rubber sheet and soft tissues.
• It is generally not recommended for isolation of single tooth.

REFERENCE – NISHA GARG TEXTBOOK OF ENDODONTICS AND GROSSMAN’S TEXTBOOK OF ENDODONTICS

RUBBER DAM PLACEMENT

  1. Placement of Rubber Dam
  2. Before placement of rubber dam, following procedures should be done:
    • Thorough prophylaxis of the oral cavity.
    • Check contacts with dental floss.
    • Check for any rough contact areas.
    • Anesthetize the gingiva if required.
    • Rinse and dry the operated field.
  • Methods of Rubber Dam Placement.
  • Method I: Clamp placed before rubber dam
  • Select an appropriate clamp according to the tooth size.
  • Tie a floss to clamp bow and place clamp onto the tooth
  • Larger holes are required in this technique as rubber dam has to be stretched over the clamp. Usually two or three overlapping holes are made.
  • Stretching of the rubber dam over the clamps can be done in the following sequence:
  • – Stretch the rubber dam sheet over the clamp
  • – Then stretch the sheet over the buccal jaw and allow tosettle into place beneath that jaw
  • – Finally, the sheet is carried to palatal/lingual side andreleased.
    This method is mainly used in posterior teeth in both adults and children except third molar.

Method II: Placement of rubber dam and clamp together

  • Select an appropriate clamp according to tooth anatomy.
  • Tie a floss around the clamp and check the stability.
  • Punch the hole in rubber dam sheet.
  • Clamp is held with clamp forceps and its wings are insertedinto punched hole.
  • Both clamp and rubber dam are carried to the oral cavityand clamp is tensed to stretch the hole.
  • Both clamp and rubber dam is advanced over the crown.First, jaw of clamp is tilted to the lingual side to lie on thegingival margin of lingual side.
  • After this, jaw of the clamp is positioned on buccal side.
  • After seating the clamp, again check stability of clamp.
  • Remove the forceps from the clamp.
  • Now, release the rubber sheet from wings to lie around thecervical margin of the tooth.
  • Method III: Split dam technique: This method is split dam technique in which rubber dam is placed to isolate the tooth without the use of rubber dam clamp. In this technique, two overlapping holes are punched in the dam. The dam is stretched over the tooth to be treated and over the adjacent tooth on each side. Edge of rubber dam is carefully teased through the contacts of distal side of adjacent teeth.

Split dam technique is indicated:

• To isolate anterior teeth
• When there is insufficient crown structure
• When isolation of teeth with porcelain crown is required. In such cases placement of rubber dam clamp over the crown margins can damage the cervical porcelain.
• Dam is placed without using clamp.
• Here two overlapping holes are punched and dam is stretched over the tooth to be treated and adjacent tooth on each side.

REFERENCE- NISHA GARG TEXTBOOK OF ENDODONTICS

Minimal Invasive Dentistry

current approach in dentistry in Covid state

Amidst the pandemic state with the high transmissibility of the disease through air & droplets and considering that routine dental procedures usually generate aerosols; alterations to dental treatment is of prime concern to maintain a healthy environment for patient & dental team.Here is where the approach of performing minimally invasive dental treatment becomes crucial.

Risks of infection – Human-to-human transmission

What is minimal intervention dentistry?

Minimal intervention dentistry( MID) is a conservative philosophy of professional care concerned with first occurrence,early detection & earliest possible cure of caries at a micro level ; followed by minimally invasive and patient friendly treatment to repair irreversible damage caused by dental caries.

Goals & Principles:

.Early diagnosis of dental caries

.Assessment of individual caries risk

.Disease control by remineralisation of incipient carious lesions.

.Repair rather than replacement of defective restorations

.Minimal invasive treatment

.Periodic follow up.

Caries diagnosis:

Includes early diagnosis & caries risk assessment

Early diagnostic aids
Factors relevant in caries risk assessment

Procedures:

Non invasive procedures: Biological approach

Remineralising agents

Minimal invasive treatments:

1)Air abrasion

Indications-

.for abrading the surface of old composites prior to new restoration ; minimal class I & class II preparations for composites ; for abrading ceramic or cast restorations for bonding ; for widening pits & fissures for sealants.

2) Sono Abrasion

Indications-

.opening pits & fissures for sealant restorations ; minimal preparation of incipient class II cavities

3) Chemicomechanical Caries Removal (CMC)

Carisolv – 2 syringe system ,one containing NaOCl & other with 3 amino acids (glutamic acid,leucine ,lysine); carboxymethylcellulose gel;NaCl,NaOH;Erythrosine.The contents are mixed together to form a pink gel which is applied onto carious dentin and left in place for 30 seconds to allow it to soften & degrade the infected dentin.

Advantages – relatively painless, removes only carious dentin, no vibrations,better substrate for adhesive bonding

Disadvantages- expensive, time consuming

4)Enzymes

5)Laser

2 commonly developed lasers-

.Er:Cr:YSGG(2780 nm)- Erbium,Chromium,Yttrium,Scandium,Gallium,Garnet laser – works by agonizing water droplets as they travel towards the target tissue.

.Er:YAG(2940nm)-Erbium,Yttrium,Scadium,Aluminum,Garnet laser – uses pulses of light energy to micro vaporize water within the target tissues.

6)Ozone

Caries treatment with ozone – based on Niche environment theory .Ozone kit consists of portable apparatus & disposable silicon cups. Follow up 3-6 months.

Disadvantages – can cause porosities or abrade tooth surface ,in case of heavy exposure.

Other techniques (in brief):

7)Atraumatic restorative treatment (ART)

8)Rotary instruments

Cavity designs for minimal tooth preparation:

According to the new classification based on site,size & severity of lesion,following are the designs –

Pit & fissure sealants;Preventive Resin Restorations (PRR)
Tunnel preparations
Slot preparations

Restorative materials used in minimal invasive dentistry :

Conclusion:

Minimal intervention techniques cause less tooth destruction than conventional techniques,thus increasing the long term survival of teeth ,also cause less discomfort to the patient and ensure healing of the disease not only the symptoms. With a reduction in chair side time and simplified techniques there is lesser chances of exposure of the dentist to aerosol contamination,thus maintaining which is the need of the hour.