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L13 Rubber Dams 2_formatted_text

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Reasons for Using Rubber Dam1

  • a) Infection control

  • b) Patient safety

  • c) Patient comfort

  • d) Moisture control

  • e) Increased visibility

  • Retracts the cheeks, lips, and tongue, offering an unobstructed view.

  • f) Increased access

  • g) Increased efficiency

  • h) “Dento-legal” reasons

Medico-legal Standard of Care

In certain procedures, such as endodontics, the use of rubber dam is considered the standard of care. Failure to use it can be indefensible in a legal situation.

  • i) Improved treatment outcome

Applying Rubber Dam23

Preparation

The key to successful rubber dam application is to use a simple, efficient technique. Punch the required hole(s) in the rubber dam sheet before the patient is in the chair and select a simple, limited range of clamps.

  • Preferred methodRD on a winged clamp

  • Place on tooth together

  • ==Once the clamp is securely in place, use an instrument to flick the rubber dam off the wings of the clamp. An excavator (e.g., a 31L) is the ideal instrument for this task.==

  • Stretch the rubber dam over the frame to complete the isolation.

  • ALWAYS Place a Cotton Roll in Labial / Buccal Sulcus

Safety Precautions456789

  • AVOID  Placing clamp in mouth without RD

Info

With experience, one can select the correct clamp by visually inspecting the tooth or even a radiograph. The winged clamp technique, where the dam is attached, inherently protects the patient, as the dam will catch the clamp if it breaks or slips.

  • If testing a clamp  Use floss on the clamp
  • BUT  Use floss on both sides of the clamp

Critical Safety Detail

The floss must be tied through the holes on both sides of the clamp, looping completely around the bow. Clamps typically fracture at the middle of the bow, and if floss is only tied to one side, the untethered half could be swallowed or inhaled.

  • AND  Remove the floss once RD is placed

Hazard of Leaving Floss

Leaving the floss ligature in place is hazardous:

  • It can get caught in a handpiece, dislodging the clamp.
  • It can be noisy by getting caught in the suction tip.
  • It can act as a wick for saliva, dripping onto the patient or operator.

Rubber Dam Techniques for Endodontics10111213

  • a) Single Tooth Isolation
  • b) Cuff Technique

a) Single Tooth Isolation14

Note

This technique involves isolating only the tooth being treated. It is favored by many for root canal treatment but has significant limitations.

Disadvantages:

  • ==Restricted Access: Severely limits access to the tooth, making it difficult to perform tooth investigation, remove old restorations, or build up interim restorations.==
  • ==Proximal Caries/Cracks: It is not useful when caries, cracks, or restoration margins extend onto the proximal surfaces.==
  • ==Difficult Restorations: Makes it very difficult to place a matrix band and build up an interim or final restoration.==

b) Cuff Technique15

Note

This is the preferred technique. It involves clamping a tooth distal to the one being worked on and creating a

Rubber Dam for Everything !!!

Hole Positions16171819202122

Avoid Pre-made Stamps

The use of a pre-made rubber dam stamp is strongly discouraged. The hole positions on these stamps are often not ideal, placing the working area off-center. The goal is to have the tooth being worked on in the center of the frame, not to have the frame centered on the patient’s face.

Single Tooth Technique23

Anterior TeethPosterior Teeth
LabialMesial
1/41/3

Cuff Technique242526

Creating a Slot

The key to the cuff technique is to create a slot by punching a series of overlapping holes (think of the Audi car logo or Olympic rings). This method is superior to cutting a slit with scissors, as it removes a small amount of material and is simpler. For anterior teeth, punch four overlapping holes in a straight line.

Anterior Teeth

Labial Labial

Anterior TeethPosterior Teeth
Mesial¼⅓
Labial

Anterior Teeth

  • Hole positions are horizontally aligned.
  • Position is approximately 1/4 along the vertical axis from the top edge, towards the Labial direction.

Posterior Teeth

  • Hole positions are vertically aligned.
  • Position is approximately 1/3 along the vertical axis from the top edge, towards the Mesial direction.

Rubber Dam for Everything !!!27282930

  • ALL Restorative Dentistry

  • ✓ ALL Restorative Dentistry – including posts

Supporting Evidence

A study was cited showing a statistically significant higher rate of favorable outcomes for post placement when a rubber dam was used.

!!

Figure 7. Reaming of canal.Figure 8. Try-in post.Figure 9. Placement of adhesive into canal.
Figure 10. Placement of cement into canal.Figure 11. Post cementation (Incorrect/Not Recommended).Figure 12. Injecting core material into post.
  • ALL Restorative Dentistry + impressions !!

Info

While it may seem extreme, it is possible to take impressions (especially with digital CAD/CAM scanners) with the dam in place. At a minimum, the entire preparation can be done under isolation, with the dam removed only for the final impression.

  • ✓ Trauma Management - Emergency + Subsequent

Example

Invaluable in emergency situations. It helps manage the patient, control the environment, and allows for repositioning teeth, starting endodontic treatment, building up restorations, and placing splints, all in one session.

  • ✓ Orthodontics - e.g. Extrusion

  • ✓ Surgery - e.g. Hemisection & Mes. root extraction

Example

The dam provides isolation during both the endodontic and surgical phases of a procedure like a hemisection, where a tooth is sectioned and a root is removed.

  • Pre-op.
  • RCF
  • 15 mths R/C
  • Post-op.

Additional Tricks, Hints & Equipment31323334

Equipment353637

  • Orashield - Rubber Dam Napkins

  • Clamps

  • ==Disposable Plastic Clamps: Can be used on teeth with porcelain crowns to avoid chipping the margin. However, they are not reliably radiopaque, so meticulous record-keeping is essential.==

Other Hints383940

  • Orthodontic brackets / arch wires

  • ==It is usually possible to work around fixed orthodontic archwires. Place the dam over the wires and use a cotton roll in the sulcus. If minor leakage occurs, it can be sealed with Oraseal.==

  • ==Sealing Gaps: Oraseal is an excellent material for sealing any small gaps where saliva may leak, ensuring complete isolation.==

  • If the RD is not well adapted to the tooth

  • If the dam isn't adapting well, gently open the clamp beaks with forceps to allow the rubber dam to slip underneath. When released, the clamp will hold the dam tightly against the tooth.

  • Be sure to isolate the correct tooth!!

Case Example

Mistakes can happen, especially with similar-looking teeth like lower incisors. A case was presented where a dentist began root canal treatment on the wrong incisor. The cuff technique helps prevent this by exposing adjacent teeth for reference.

  • ==Protect Interim Restorations: For multi-visit treatments, continue to use the cuff technique by clamping the tooth behind the one being treated. This prevents the clamp from dislodging or damaging the large interim restoration.==
  • ==Anterior Cuff Technique Trick: For upper or lower anteriors, loop the dam between the canine and first premolar, then place the clamp over the top of the rubber dam on the premolar. This presses the dam tightly against the palatal or lingual tissue, creating an excellent seal.==

Record Keeping41

Clamp numbers:002A2T4912A13A
Wedjets used:W
Cuff technique used:Shows teeth cuff extended over
Vertical line indicates no clamp, held in place by contact point
OraSeal used:On Li of lowers -//////////On Bu of lowers -//////////(Can reverse for uppers)

Charting and Notes

Use the chart to visually record the isolation method by drawing the clamp used on the anchor tooth and a line to indicate a cuff. In electronic records, write a detailed note (e.g.,

There is NO Excuse !!!42

“Improvisation” - in Vietnam 2000 Rubber Glove !!

The Attitude of the Dentist

The use of rubber dam ultimately comes down to the attitude of the dentist. If you want to use it, you will find a way. Seeing procedures like post placement performed without isolation is evidence of poor dentistry. Patients appreciate the benefits, and it makes the operator’s work significantly easier.

Conclusion43

**It’s

Summary

There are numerous compelling reasons to use rubber dam, centered on infection control, patient safety, and achieving superior clinical results. It is the medico-legal standard of care for endodontics and is a critical tool for anyone who wishes to pursue excellence in their dental practice.

“Dam” Easy !!**

In the pursuit of excellence the rubber dam is a tool of the achiever

Footnotes

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