Isolation and Moisture Control

• Jacky Hart presents Isolation and Moisture Control within the Foundations of Clinical Skills and Practice.
• This presentation aligns with GDC learning outcomes 1.8.4 and 1.10.4.
• Objective is to take responsibility for best practice compliance and advise/apply preventive materials and treatments.
• By the session's end, students should understand moisture control necessity, available methods, technique selection, rubber dam indications, advantages/disadvantages, three placement methods, and moisture control practice on a fellow student.

Necessity of Moisture Control

• Saliva, blood, and crevicular fluid are sources of moisture.
• Routine dental procedures interfere with restorative materials if moisture is present.
• Intra-oral procedures are better performed in dry condition to gain better vison.

Methods for Moisture Control

• Available methods include: aspiration, compressed air, absorbent materials, retraction cord, and rubber dam.

Aspiration

• High-volume suction is used with handpieces and ultrasonic scalers, preventing SARS-CoV-2 transmission.
• Low-volume suction, like a saliva ejector, is used for smaller fluid amounts.
• Remove saliva ejector when next to tongue.

Compressed Air

• 3-in-1 tip air jet removes excess moisture from cavities and tooth surfaces.
• Keep water off the mouth mirror to improve vision.
• Use in conjunction with high-volume suction to prevent aerosol transmission.

Absorbent Materials

• Cotton Wool Rolls: Placed in buccal and lingual sulcus to absorb saliva and retract lips or tongue, soak in water before removing to prevent damage to mucosa.
• Dry Guards: Flat, triangular pads placed over the parotid duct to absorb saliva and water, useful for fissure sealants.
• DryDent Sublingual: functions like a dry guard, but for the floor of the mouth.
• Retraction Cord: For crown preparations and near gingival margins, often with hemostatic medication, to stop gingival bleeding and crevicular fluid.

Rubber Dam

• It is a thin barrier, made of latex or nitrile rubber, to isolate teeth.
• Only selected teeth can be accessed.
• Placed in 2 minutes by an efficient team is considered the gold standard of moisture control.
• It provides patient airway protection and physical/psychological comfort.
• It also improves operator vision and control, retracts soft tissues, and offers moisture control, also providing SARS-CoV-2 protection.
• It is indicated when the patient is cooperative and informed, with clear nasal airway, also after analgesia, and when there is a risk of patient inhaling instruments or materials. Also used during salviva-sensitive materials.
• Can use when wanting: Adhesive and complex restorations, root canal therapy, pulp capping and polpotomy, and fissure sealants.

Advantages

• Complete isolation, visibility, prevents inhalation, and provides staff protection.
• The dam reduces both time, mouth breathing, and physical & psychological stress.

Disadvantages

• Difficult to communicate, patient tolerance, jaw stiffness, excessive drying, and potential for latex allergy.
• Requires time and skill, local anesthesia and also consideration to both clamp suitability and to gingival trauma and checking occlusion

Rubber Dam Equipment

• Essential items include the rubber dam sheet, stamp/template, frame, punch, applicator, and clamps.
• Other tools include scissors, Wedjets, gauze, dental floss, and caulking agent (Oraseal).
• The rubber dam hole punch and applicator are used together for efficient placement.

Clamps

• Selection should keep it simple and maintain clean holes.
• Examples include W8A, 00 (hyg), and 212.
• A central arm engages the rubber dam sheet, anterior arm engages the dam sheet, placed distally.
• Beaks grip the tooth, offering a four-point circumferential contact.
• A notch is present and clamp holes help placement of clamp.
• Select a clamp for 4 point contact on the tooth.

Floss Placement

• Place floss on clamp for safety and to prevent accidental inhalation, unless the rubber dam is placed first.

Hole Marking and Punching

• Line up sheet with the teeth and mark where get the wholes in the correct place, use template as alternative.
• Use rubber dam punch to correctly create clean holes.

Methods of Rubber Dam Application

• Three methods include, clamp first then dam, dam and clamp (together), and dam first then clamp.
• Knife through all contact points with floss.
• Place napkin between the dam and the patients face, then attach frame.
• Inversion the dam.
• Use Wedjets if necessary.
• Ensure edges are inverted.
• Check seal distal to clamped tooth, and use Oraseal (ultradent) if necessary and saliva ejector if necessary.
• Check patient can breathe.

Removal

• Remove all wedjets first
• Pull dam buccally and cut interdentally with scissors
• Remove clamp,dam, and frame. all in one with forceps.
• Check is all robber has been accounted for.
• Check occlusion if applicable.

Problems and Solutions

• Avoid positioning errors to ensure effective isolation, with no positioning where mask is interfering.
• Ensure patient safety with latex-free dams, confirming breathability through the nose (cut 'air hole' if needed), frame not injuring eyes, and explaining a stop signal to patient.
• Manage clamp problems by using the correct clamp size and flossing the clamp before application.
• Address difficult contact points by checking for clear contact, floss, consider trough technique, knife technique, carrying through contacts, and attaching frame. Returning to difficult areas once stable.
• Manage saliva issues, reassure patient to swallow and or place optional saliva elector, using Oraseal if seals are making leaks.
• Manage breathing difficulties by cutting a small hole in dam on the palate away from the operation area and ensure the dam is not obstructing the nose.

Specific situations

• Anterior teeth: Expose usually all 6 anterior teeth, from 3-3 (or premolar to premolar), using 00 clamps/Wedjets.
• Use for single tooth endodontics, cervical cavities, class III/IV; clamps not always necessary.
• ** Posterior teeth:** Isolate one tooth posterior to the tooth being treated. Exposed extends to the central incisor, with eight teeth required for optimum stability, or a minimum of 3-4 teeth.
• Buccal restoration: Rubber dam can get in away of restorations near the buccal gingival margin, you may need to use Optragate.
• Paedodontics: requires minimal isolation, normally only two or three teeth and you need to use a trough technique for SSC. Also use DW clamps because they are useful to Molars. Important t communicate well with patent and reassure them that everything will be safe and relaxing. And that you are there to get a good quality result and most importantly that they are able to breath through there nose.
• Have child friendly language, and show chilf clamps to the children of demo model. Have to spend time to teach how to swallow and breath through their noses. And give child control-stop signals etc.
• Matrix bands: - Avoid traping robber dam between band and tooth-pre-wedge. Cannot place circumference band on clamp tooth-remove clamp before placing matrix, or try different/ sectional matrices.

Summary

• Moisture controls necessity
• Methods of moisture control.
• Indicates, advantages and disadvantages of use of rubber dam.
• Practical sessions on a phantom head and clinic, which consolidates what has been learnt.