SB 2024 Rubber Dam Placement and Preventive Approaches PDF

Kimberly Patterson DDS MS November 15, 2024  Introduction: Equipment / supplies Please keep area neat, and leave your workplace as you found it Please place all instruments back in cassettes and supplies back in supply area Please take ALL cas...

Kimberly Patterson DDS MS November 15, 2024  Introduction: Equipment / supplies Please keep area neat, and leave your workplace as you found it Please place all instruments back in cassettes and supplies back in supply area Please take ALL cassettes back to Pedo Clinic when done  Key to quality operative dentistry is a clean field McDonald 370  Saves Time ◦ Avg. time to place RD: 1 min 48 sec  Moisture Control  Better Access and Visualization ◦ Better with dark dam material  Safety ◦ Less chance of aspiration ◦ Retracts soft tissues  Behavior Management ◦ Separating barrier – treatment less invasive ◦ If using N2O patients breath through nose McDonald 367 Pinkham 343  Uses 5 x 5 inch medium gauge, dark color  Line rubber dam with frame at upper edge  Punch first molar hole ½ inch above center of frame 1/3 of way across  Additional holes for teeth should be 3-4mm apart at a 45 degree angle Pinkham 344  Hole Selection ◦ Largest Punch  Retainer  Permanent Molars ◦ Medium Punch  Premolars  Primary Molars ◦ Second Smallest Punch  Permanent maxillary incisors ◦ Smallest Punch  Primary Incisors Pinkham 344  Permanent lower incisors  Partially Erupted Permanent Molars ◦ 14 A ◦ 8A  Fully Erupted Permanent Molars ◦ 14 ◦ 8  Second Primary Molars ◦ 14 ◦ 3  Primary incisors and canines ◦ 0 Pinkham 345 Always use a mouth prop / bite block when using a rubber dam – keeps the clamp from popping off due to bite force, and keeps your patients comfortable! Three sizes of Bite Blocks: small – for primary dentition only medium – after 6s erupt, but no permanent 2nd molars erupted large – full permanent dentition, or as the patient tolerates  Select appropriate clamp  Ligate with floss ◦ 18 inches  Place on tooth ◦ Seat lingual first, then engage buccal bulge or height of contour. ◦ Push gingivally with finger pressure to evaluate for sturdy seating  Place rubber dam over clamp ◦ If hitting mandibular ramus have pt shift mandible or close slightly ◦ Do not pull tight on frame – will pop clamp off  Invert Dam  Ligate if necessary Pinkham 245 McDonald 268  Do not have the rubber dam too tight on the frame ◦ It will pull the clamp off the tooth, losing isolation!  Occlusal Restorations ◦ Isolate teeth to be restored  Interproximal restorations ◦ Isolate 1 tooth in front and behind if possible  Rubber Dam Removal ◦ Cut interseptal dam ◦ Check for pieces left behind McDonald 378  Slit Dam ◦ Punch 2 holes ¼ to ½ inch apart ◦ Connect with Scissors  Advantage ◦ Fast ◦ Good for SSC preps ◦ Good for extractions  Disadvantage ◦ Poor moisture control, especially mandible ◦ Use with caution with resins, sealants, and pulpal involvement  Very few times when a rubber dam is not indicated  Assume you will be using a rubber dam for all operative procedures unless faculty says otherwise  Evaluate this Rubber Dam: Use patient friendly terms!! Rubber dam: ‘tooth raincoat’ ‘tooth trampoline’ Clamp: ‘tooth ring’ Bite Block: ‘tooth pillow’ Rubber dam forceps: ‘silver fingers’ “My tooth raincoat’s tooth ring is going to give your tooth a big hug… it will be a tight squeeze, but the tooth raincoat has to be on to keep the sugar bugs from jumping too far. We will slurp the sugar bugs up with our slurpee straw!”  The clamp is a “ring”. Put it on your finger so they can see it doesn’t hurt.  Emphasize the benefits ◦ I’m going to put this on your tooth so you don’t taste anything bad!  Prepare the patient for a “Tight Hug” but no pinches (because they are numb).  Names for Dam ◦ Trampoline ◦ Raincoat  Tell-Show-Do ◦ Behavior guidance technique of explaining procedures in age appropriate and non-threatening terms, showing the appropriate equipment and completing the procedure Recommended Reading: ◦ Nowak Chapter 33 – Excellent Review of Sealants!  Occlusal surfaces are 12.5% of total surfaces but account for 60% of decay! 80% if count lingual and buccal surfaces.  Does not receive the same protection from fluoride as smooth surfaces Nowak p 468  Procedure  Clean ◦ Rotating dry bristle brush or dry toothbrush ◦ Air abrasion ◦ Mechanical preparation does not improve retention  Procedure  Isolation ◦ Rubber Dam - ideal ◦ Cotton Rolls ◦ Cheek Shields ◦ Suction ◦ Isolite  Procedure  Etch ◦ 30-50% acid solution ◦ Etch the whole surface, ALL grooves (buccal, lingual) ◦ 20 seconds ◦ Still have to etch with an air abrasion preparation  Procedure  Etch ◦ 30-50% acid solution ◦ Etch the whole surface, ALL grooves (buccal, lingual)  Procedure Wash – Rinse 20-40 seconds – Dry with compressed air – Tooth should appear chalky, frosty white Nowak ch. 33  Procedure  Bonding Agent ◦ Helps if complete isolation is not possible ◦ Beneficial for Buccal and Lingual Pits ◦ Increases time must keep isolated and cost ◦ Apply according to manufacturer’s instructions (cure before sealant placement)  Sealant Application ◦ Confine sealant to pits and fissures – seal ALL grooves ◦ Less is best! ◦ Can use microbrush to remove excess, Dycal instrument or explorer to manipulate uncured sealant mat’l  Procedure  Sealant Application ◦ Cure to manufacturer’s instructions ◦ *** dental materials like composite and sealant GO TOWARDS THE LIGHT when cured… ◦ *** when curing an occlusal sealant, cure from lingual/buccal first, then buccal/lingual, and FINALLY cure occlusal… draws sealant INTO grooves, not out of them!!!  Procedure  Sealant Application ◦ Example: ◦ To seal tooth #19: ◦ Seal occlusal, buccal groove, and distobuccal groove ◦ Cure from LINGUAL first (does not have a groove that needs to retain the sealant), then buccal, and finally occlusal…  Procedure  Check with explorer aggressively! ◦ Should feel smooth and glassy, no margins  Rinse tooth – tastes nasty!  Adjust Occlusion (?) ◦ Usually not necessary with children with minimally filled sealants and proper application technique ◦ Adults more sensitive to occlusal interferences  Emphasize need for reevaluation and repair at subsequent recalls!  Procedure  Procedure  Procedure  Sealing Over Caries  Need to diagnose the tooth first clinically and radiographically  Do not place over caries that has progressed into dentin*  Intact sealants are effective at arresting decay ◦ 99% reduction in microorganisms  Resin Infiltration:  Interproximal ‘sealants’… https://www.dmg-america.com/solutions/prevention-and- early-intervention/infiltration/icon-proximal#c12854  Resin Infiltration:  Interproximal ‘sealants’… https://www.dmg-america.com/solutions/prevention-and- early-intervention/infiltration/icon-proximal#c12854  Resin Infiltration:  Interproximal ‘sealants’… https://www.dmg-america.com/fileadmin/dmg- america/Products/Prevention_and_early_interventio n/Infiltration/Icon_Proximal/IFU_Icon_Proximal.pdf *AAPD Policy on Minimally Invasive Dentistry 2023 https://www.aapd.org/globalassets/media/policies_guidelines/p_minimallyinvasivedentistry.pdf  Resin Infiltration:  Interproximal sealants… https://www.aapd.org/globalassets/media/policies_ guidelines/p_minimallyinvasivedentistry.pdf  Resin Infiltration:  Interproximal sealants… https://pages.ada.org/hubfs/DMG-ebook-v9.pdf  Resin Infiltration:  Icon – resin infiltration technique Apply drying solution 30s Cure all sides 40s each Apply resin 3 min Gently agitate to distribute https://www.dmg-america.com/fileadmin/dmg- america/Products/Prevention_and_early_intervention/Infiltration/Icon_Proximal/IFU_Icon_Proximal.pdf  Resin Infiltration:  Icon – resin infiltration technique https://www.dmg-america.com/fileadmin/dmg- america/Products/Prevention_and_early_intervention/Infiltration/Icon_Proximal/IFU_Icon_Proximal.pdf  Resin Infiltration:  Icon – resin infiltration storage and patient information https://www.dmg-america.com/fileadmin/dmg- america/Products/Prevention_and_early_intervention/Infiltration/Icon_Proximal/IFU_Icon_Proximal.pdf Resin Infiltration: Courtesy Dr. Rob Delarosa 41 Resin Infiltration: Courtesy Dr. Rob Delarosa 42 Resin Infiltration: Courtesy Dr. Rob Delarosa 43  Resin Infiltration:  Teen - Soda / Poor Oral Hygiene  Icon – resin infiltration of demineralized areas ◦ works interproximally (between teeth) ◦ Radiographic appearance of resin-treated lesion improves over time Orthodontic separator on Etchant acid pre-treatment Resin infiltration prior to floss to place between teeth – light curing create space (~15 min) https://pages.ada.org/hubfs/DMG-ebook-v9.pdf  Resin Infiltration:  Primary teeth – poor oral hygiene  Icon – resin infiltration of demineralized areas ◦ works interproximally (between teeth) ◦ Radiographic appearance of resin-treated lesion improves over time https://pages.ada.org/hubfs/DMG-ebook-v9.pdf  Resin Infiltration:  Primary teeth – poor oral hygiene  Icon – resin infiltration of demineralized areas https://pages.ada.org/hubfs/DMG-ebook-v9.pdf Resin Infiltration: 47  Resin Infiltration: 1. early non-invasive treatment of enamel-based lesions in a vulnerable population 2. educates residents and students on preventive therapies 3. promotes evidence-based preventive practice  Resin Infiltration: CDT code: D2990 – unable to bill NY Medicaid, however can bill for Fluoride Varnish Application recovering $168.97 per encounter https://ebusiness.ada.org/Assets/docs/85994.pdf  Resin Infiltration: https://www.aetna.com/content/dam/aetna/pdfs/aon/platinum-dmo.pdf  Conservative (Preventive) Resin Restoration  Introduced by Simonsen in 1978  Alternative to traditional Class I prep  Excavate areas of minimal decay  Choice of restoration depends on depth of decay ◦ Typically posterior resin in area of decay  Seal entire tooth to prevent future decay  Conservative (Preventive) Resin Restoration  Not a substitute for diagnosis! ◦ Is there decay? ◦ Where is it?  Enamel  Dentin ◦ What type of Isolation? ◦ Local Anesthetic?  Just because you open a fissure with a handpiece does not mean you can bill for a resin  Sealant ◦ mechanical or chemical preparation in enamel  Resin ◦ must be in dentin  Do not commit insurance fraud!  Behavior Guidance  Etch and Sealant can seem threatening ◦ show it to them, say it’s not a shot ◦ Demonstrate on your gloved hand/finger ◦ put a sealant on your/their fingernail so they can see how everything works  Keeping chin up helps improve isolation! ◦ Work with patient supine  Sealants taste BAD! ◦ Rinse everything off well before taking off rubber dam or cotton rolls  Use wet 2X2 instead of powerwash…  New York Medicaid Coverage  6-year molar sealant – under 10 years of age  12-year molar sealant – 10 through 15 years of age  No reimbursement for sealants on premolars  No reimbursement for sealants on lingual surfaces of anterior teeth  No reimbursement for sealants on primary teeth  No reimbursement for sealants before age 5y or after age 15y  Reapplication reimbursable after 5 yrs  If you feel a sealant is indicated you still should recommend it – an educated parent will likely pay for the preventive service https://www.emedny.org/providermanuals/dental /pdfs/dental_policy_and_procedure_manual.pdf References