Rubber Dam Isolation in Dentistry

• Isolation in the operative field ensures a clean and dry working environment for dental procedures.

Rubber Dam Isolation Application Steps

• Step 1: Testing and lubricating the proximal contacts to facilitate dam placement.
• Step 2: Punching holes in the rubber dam:
• Punch an identification hole in the upper left of the dam to easily locate that corner when applying to the holder.
• Isolation of at least three teeth is recommended.
• Only the tooth being treated is isolated when endodontic therapy is needed.
• Isolation pattern determined by the number of teeth being treated and their surface.
• The distance between holes should equal the distance between the centers of adjacent teeth, measured at the gingival tissue level.
• Excessive distance between holes leads to excessive dam material and wrinkles between teeth.
• Insufficient distance between holes causes stretching, resulting in space around teeth and leakage.
• The dam should intimately adapt to the teeth and covers and retracts the interdental tissue when the distance is correct.
• Smaller holes are needed for adequate seal when using a thinner rubber dam owing to its greater elasticity.
• For operating on incisors and mesial surfaces of canines, isolate from first premolar to first premolar.
• Metal retainers aren't usually required; retainers can be positioned over the dam if extra access is needed.
• For operating on canines, isolate from the first molar to the opposite lateral incisor.
• Should a Class V lesion on a canine be treated, isolate posteriorly to include the first molar to provide access for placement of the cervical retainer
• When operating on molars, punch holes as far distally as possible and isolate anteriorly to include the lateral incisor on contrasting arch.
• Anterior teeth included in the isolation provide finger rests for the operator and assistant, which also helps with access and visibility.
• When operating on premolars, punch holes to include one to two teeth distally, and extend anteriorly to include the opposite lateral incisor.
• When applying the rubber dam to maxillary teeth:
• Punch the first holes for the central incisors approximately 1 inch (25 mm) from the dam's superior border.
• For patients with a large upper lip or mustache, position holes more than 1 inch from the edge.
• For children or adults with a small upper lip, position holes less than 1 inch from the edge.
• The remaining holes are punched after the holes for the incisors are located.
• When applying the rubber dam to mandibular teeth:
• The first hole should be made for the posterior anchor tooth that is receiving the retainer.
• To find the correct placement:
• The rubber dam should be mentally divided into three vertical parts: left, middle, and right.
• If the anchor tooth is the mandibular first molar, punch the hole half way from the upper to lower edge and at the point where right (or left) and middle thirds join.
• Step 3: Lubricating the dam:
  • Apply a water-soluble lubricant to the punched holes.
  • Avoid oil-based lubricants.
• Step 4: Selecting the retainer:
  • Winged clamps as opposed to wingless clamps.
  • Passive clamps as opposed to active clamps.
  • Retentive clamps.
  • Retraction clamp selection.
• Step 5: Testing retainer's stability and retention.
  • To test an improperly fitting retainer, lift gently in an occlusal direction with a fingertip under the bow.
  • An improperly fitting retainer rocks or dislodges easily
• Step 6: Positioning the dam over the retainer.
  • The dam and retainer can be applied at the same time.
• Step 7: Applying the napkin.
• Step 8: Positioning the napkin.
• Step 9: Attaching the frame.
  • Adjust curvature so it's concentric with the patient's profile.
• Step 10: Passing the dam through the posterior contact.
• Step 11: Passing septa (the part of the dam between holes) through the contacts:
  • Stretch septal dam faciogingivally and lingogingivally with forefingers.
• Step 12: Passing the septa through the contacts with tape.
  • Use waxed tape because its wider dimension effectively carries the rubber septa.
• Step 13: Inverting the dam.

Rubber Dam Isolation Removal Steps

• Cutting the septa.
• Removing the retainer.
• Removing the dam.
• Examining the dam.

Errors in Rubber Dam Application and Removal

• Off-Center Arch Form can lead to foreign objects escaping down the patient's throat.
• Excess dam material may occlude the patient's nasal airway.
• Inappropriate Retainers are retainers that:
• Are too small leading to breakage when jaws are overspread
• Are unstable on the anchor tooth.
• Impinge on soft tissue.
• Impede wedge placement.
• Retainer-Pinched Tissue: The jaws/prongs of the retainer depress the tissue but not pinch or impinge on it.
• Inappropriate Distance between the Holes.

Other Isolation Techniques

• Cotton Roll Isolation:
• Absorbents serve as alternatives to rubber dams when rubber dams are not practical or possible.
• Used along with anesthesia and saliva ejectors to provide acceptable moisture control for most clinical procedures.
• Replace cotton rolls when saturated with saliva.
• Cotton rolls placed in the facial vestibule isolate maxillary teeth.
• Cotton rolls placed in the vestibule and between teeth and tongue isolate mandible.
• Throat shields are indicated when the risk of aspirating or swallowing small objects is present. if a rubber dam is not being used.
• Particularly important when treating teeth in the maxillary arch.
• Gauze 2x2 inch (5x5cm) works well unfolded and put on the tongue and posterior part of the mouth. Can recover a small object.
• High-Volume Evacuators and Saliva Ejectors:
• High-volume evacuators are preferred for suctioning water and debris since saliva ejectors remove water slowly and are limited to picking up solids
• Place evacuator tip tip close to the prepared tooth but without obstructing access.
• Saliva ejectors aren't usually required for saliva removal if the operating site is profoundly anesthetized.
• Mouth Props:
• Assist restorative posterior teeth procedures (lengthy appointments)
• Establish and maintain mouth opening, which relaxes the patient's muscles and reduces fatigue/pain.
• A major benefit to relief of maintaining adequate mouth opening and of muscle fatigue/pain
• Allows steady mouth opening and multiple/extended procedures
• Retraction cord:
• Can isolate and retract during access subgingival direct procedures and during gingival margin indirect procedures when applied correctly.
• Drugs:
• Rarely needed to control salivation. Atropine is generally limited to drug use. Be familiar with signs, adverse effects, and contraindications (nursing mothers, patients with glaucoma).