Moisture Control GN PDF

Isolation and Moisture Control Foundations of Clinical Skills and Practice Jacky Hart GDC learning outcomes 1.8.4 Take responsibility for ensuring compliance with current best practice guidelines 1.10.4 Advise on and apply a range of preventive materials and treatment as appropriate Objectives...

Isolation and Moisture Control Foundations of Clinical Skills and Practice Jacky Hart GDC learning outcomes 1.8.4 Take responsibility for ensuring compliance with current best practice guidelines 1.10.4 Advise on and apply a range of preventive materials and treatment as appropriate Objectives By the end of this session students should be able to: Explain why moisture control is necessary Describe the methods of moisture control available to the dental clinician Be able to select the most appropriate moisture control technique for each patient according to the task List the indications, advantages and disadvantages regarding the use of rubber dam Describe three methods of placement of rubber dam Practice moisture control techniques on a fellow student Why is moisture control necessary? Sources of moisture Saliva Blood GCF Instruments Dental Materials Why is moisture control necessary? Saliva is good… until routine dental procedures need to be performed then it’s a problem Saliva/blood/crevicular fluid interfere with placement of all restorative materials(inc fissure sealants) leading to restoration failure Most intra-oral dental procedures can be performed better in a dry field when you can see what you are doing SARS-CoV-2 Methods used for moisture control Methods used for moisture control Compressed Absorbent Retraction Aspiration air materials cord Rubber dam Aspiration High volume suction for use with handpieces and ultrasonic scalers Best for preventing transmission of SARS- CoV-2 Low volume suction, saliva ejector used for smaller volumes of fluid or saliva Aspiration – saliva ejector next to tongue Compressed air The air jet from the 3 in1 tip blows excess moisture from cavities and surfaces of teeth It can also be used to keep water off the mouth mirror to improve vision Use with high volume suction to prevent aerosol transmission during pandemic Absorbent Materials Cotton wool rolls Placed buccal and lingual sulcus to absorb saliva Used for retraction of soft tissues: lips or tongue Soak in water when removing to avoid damage to mucosa Absorbent Materials Dry guards Flat triangular pads of highly absorbent material placed inside cheek over parotid duct to absorb saliva and water Useful for fissure sealants Soak in water when removing to avoid damage to mucosa Absorbent materials DryDent Sublingual Like a Dry guard but for the floor of the mouth Absorbent materials Retraction Cord Used for crown preparations Can be helpful if cavity is near gingival margin Often impregnated with a haemostatic medication Stops gingival bleeding and crevicular fluid oozing Rubber Dam Thin barrier sheet used to isolate teeth; latex or nitrile rubber Only selected teeth are accessible An efficient team – place in 2 minutes Gold standard of moisture control Why do we use rubber dam ? Protection of patient’s airway Patient comfort: physical & psychological barrier Improve operator’s vision, control Retraction of soft tissues Moisture control Protection of operator from SARS-CoV- 2 Indications for use When patient is co-operative and Adhesive restorations informed Complex restorations If they have clear nasal airway Root canal therapy After analgesia has been Pulp capping administered Pulpotomy When there is danger of patient inhaling instruments and Fissure sealant fragments of material When using saliva-sensitive materials Advantages of Rubber Dam Complete Prevents Protection for Visibility isolation inhalation staff Physical & Reduces mouth Reduces time Psychological breathing Disadvantages of Rubber Dam Difficult Patient Excessive Jaw stiffness Latex allergy communication tolerance drying Time & Skill Suitability for Gingival Checking LA needed required clamp trauma occlusion Rubber Dam Equipment  Rubber Dam equipment Rubber dam Stamp/Template Frame Punch Applicator Clamps sheet Caulking agent Scissors Wedjets Gauze Dental floss (Oraseal) Rubber dam hole punch & applicator Select clamp Keep it simple Holes must be clean W8A, 00 (hyg), 212 Parts of a rubber dam clamp 1.1A central arm-helps to engage the rubber dam sheet 2.1B anterior arm-helps to engage the rubber dam sheet 3.Bow-Placed distally 4.Beaks-grip the tooth 5.Contact Points-the point of contact of the clamp with the tooth –circumferential, 6.four point contact. 7.Notch 8.Clamp Holes-help in positioning the clamp over the tooth with the help of forceps.1 Select clamp to have 4 point contact on tooth Place floss on clamp Safety Necessary unless rubber dam placed first Prevent accidental inhalation Mark up and punch rubber dam holes Line up sheet with teeth and then mark up to get holes in correct place Or use template Use rubber dam punch to create clean holes Three methods of application of rubber dam Clamp first then Dam & Clamp Dam first then dam (together) clamp Rubber dam videos Please refer to Moodle Clamp placement for anterior teeth Next stage (applies to all methods) ‘Knife’ through contact points with floss Place napkin between dam and patient’s face Attach frame Inversion of the dam Wedjets if necessary ‘Knife’ through contacts points with floss Inversion of the dam Dry tooth with compressed air Pull dam first buccally and then palatally to invert edges If that doesn’t work, use air jet combined with flat plastic Floss interdentally Wedjet used for stability Important points to check Are edges inverted? Check seal distal to clamped tooth May need Oraseal (Ultradent) Check patient can breathe Saliva ejector for patient Removal Remove any wedjets Pull dam buccally Cut interdentally with scissors Remove clamp, dam and frame ALL IN ONE with forceps Check all rubber accounted for especially interproximally Check occlusion if applicable Rubber dam – Problems and solutions  Positioning errors Usually due to holes not being punched in correct place. Positioning errors Must protect airway. Patient must be able to breathe. What’s the problem? Patient safety with rubber dam Latex-free rubber dam (nitrile) Can the patient breathe through their nose? May need ‘air hole’. Have scissors ready before you start. Ensure frame doesn’t injure eyes Explain to get consent – stop signal Problems with clamp Tooth / restoration damage Gingival trauma – use clamp of correct shape Clamp fracture – use correct size clamp Swallowing / inhalation – floss clamp before application Difficult contact points Check for clear contacts before punching holes Floss through all contacts to identify difficult sites Consider trough technique ‘Knife’ the rubber through contacts Carry through easy contacts first Attach frame Return to difficult areas once dam stable generally Problems with saliva Reassure patient that they can swallow without closing their mouth. This is easier if dam creates lip seal Optional - place saliva ejector under or through hole in the dam to rest freely in the mouth Use Oraseal to seal leaks around rubber dam Breathing difficulties Cut a small hole in the dam in the region of the palate away from area of operation Ensure rubber dam cut away from nose Defer treatment Use other forms of isolation Rubber dam for specific situations Anterior Teeth Usually all 6 anterior teeth exposed 3 – 3 or premolar to premolar 00 clamps or wedjets to secure Single tooth endodontics, cervical cavities, class III and IV Clamps not always necessary Posterior Teeth Isolate one tooth posterior to tooth being treated if possible Extend to central incisor at least 8 teeth for optimum stability 3 – 4 teeth minimum requirement Buccal restorations Rubber dam can get in the way of restorations near the buccal gingival margin Try Optragate Doesn’t stop gingival crevicular fluid oozing up Paedodontics ▪ Minimal isolation ▪ Normally only two or three teeth ▪ Trough technique for SSC ▪ DW clamps useful for primary molars/ first molars ▪ Good communication with patient and carer e.g. safety, relaxing, quality of result ▪ Must be able to breathe through nose Paedodontics continued Tell, show, do Child friendly language: e.g. ‘tooth button’; ‘raincoat’; ‘stops bugs getting into tummy’ Show child clamp (‘clip’) on demo model Spend time teaching child how they can communicate, swallow and breathe through their nose Give child control – stop signals etc Could try dry dam for work on anterior teeth Matrix bands Avoid trapping rubber dam between band and tooth – pre-wedge Can’t place circumferential band on clamped tooth – remove clamp before placing matrix, or try different/sectional matrices Summary Explained why moisture control is necessary Described the methods of moisture control available to the dental clinician Listed the indications, advantages and disadvantages regarding the use of rubber dam Described three methods of placement of rubber dam Practical sessions in phantom head and on clinic to consolidate learning Further information Mackenzie L, Waplington M, Bonsor S. Restorative dentistry: Splendid Isolation: a Practical Guide to the Use of Rubber Dam Part 1. Dent Update 2020; 47: 548-558. Mackenzie L, Waplington M, Bonsor S. Restorative dentistry: Splendid Isolation: a Practical Guide to the Use of Rubber Dam Part 2. Dent Update 2020; 47: 633-642. Baughan S, Casaus A. Technique tips – Moisture Control in Children. Dent Update 2019; 46: 291-293.