Introduction
Most texts that discuss operative treatment for children advocate the use of
rubber dam, but it is used very little in practice despite many sound reasons
for its adoption. In the United Kingdom less than 2% of dentists use it
routinely. It is perceived as a difficult technique that is expensive in time
and arduous for the patient.
In fact, once mastered, the technique makes dental care for children easier and a higher standard of care can be achieved in less time than would otherwise be required. In addition, it isolates the child from the operative field making treatment less invasive of their personal space.
The benefits can be divided into three main categories as shown below.
Safety
Damage of soft tissues
The risks of operative treatment include damage to the soft tissues of the mouth from rotary and hand instruments and the medicaments used in the provision of endodontic and other care. Rubber dam will go a long way to preventing damage of this type.
Risk of swallowing or inhalation
There is also the risk that these items may be lost in the patient's mouth and swallowed or even inhaled and there are reports in the literature to substantiate this risk.
Risk of cross-infection
In addition, there is considerable risk that the use of high-speed rotary instruments distribute an aerosol of the patients' saliva around the operating room, putting the dentist and staff at risk of infection. Again, a risk that has been substantiated in the literature.
Nitrous oxide sedation
If this is used it is quite likely that mouth breathing by the child will increase the level of the gas in the environment, again putting dentist and staff at risk. The use of rubber dam in this situation will make sure that exhaled gas is routed via the scavenging system attached to the nose piece. Usually less nitrous oxide will be required for a sedative effect, increasing the safety and effectiveness of the procedure.
Benefits to the child
Isolation
One of the reasons that dental treatment causes anxiety in patients is that the operative area is very close to and involved with all the most vital functions of the body such as sight, hearing, breathing, and swallowing. When operative treatment is being performed, all these vital functions are put at risk and any sensible child would be concerned. It is useful to discuss these fears with child patients and explain how the risks can be reduced or eliminated.
Glasses should be used to protect the eyes and rubber dam to protect the airways and the oesophagus. By doing this, and provided that good local analgesia has been obtained, the child can feel themselves distanced from the operation. Sometimes it is even helpful to show the child their isolated teeth in a mirror. The view is so different from what they normally see in the mirror that they can divorce themselves from the reality of the situation.
Relaxation
The isolation of the operative area from the child will very often cause the child to become considerably relaxed¾always provided that there is good pain control. It is common for both adult and child patients to fall asleep while undergoing treatment involving the use of rubber dam¾a situation that rarely occurs without. This is a function of the safety perceived by the patient and the relaxed way in which the dental team can work with its assistance.
In fact, once mastered, the technique makes dental care for children easier and a higher standard of care can be achieved in less time than would otherwise be required. In addition, it isolates the child from the operative field making treatment less invasive of their personal space.
The benefits can be divided into three main categories as shown below.
Safety
Damage of soft tissues
The risks of operative treatment include damage to the soft tissues of the mouth from rotary and hand instruments and the medicaments used in the provision of endodontic and other care. Rubber dam will go a long way to preventing damage of this type.
Risk of swallowing or inhalation
There is also the risk that these items may be lost in the patient's mouth and swallowed or even inhaled and there are reports in the literature to substantiate this risk.
Risk of cross-infection
In addition, there is considerable risk that the use of high-speed rotary instruments distribute an aerosol of the patients' saliva around the operating room, putting the dentist and staff at risk of infection. Again, a risk that has been substantiated in the literature.
Nitrous oxide sedation
If this is used it is quite likely that mouth breathing by the child will increase the level of the gas in the environment, again putting dentist and staff at risk. The use of rubber dam in this situation will make sure that exhaled gas is routed via the scavenging system attached to the nose piece. Usually less nitrous oxide will be required for a sedative effect, increasing the safety and effectiveness of the procedure.
Benefits to the child
Isolation
One of the reasons that dental treatment causes anxiety in patients is that the operative area is very close to and involved with all the most vital functions of the body such as sight, hearing, breathing, and swallowing. When operative treatment is being performed, all these vital functions are put at risk and any sensible child would be concerned. It is useful to discuss these fears with child patients and explain how the risks can be reduced or eliminated.
Glasses should be used to protect the eyes and rubber dam to protect the airways and the oesophagus. By doing this, and provided that good local analgesia has been obtained, the child can feel themselves distanced from the operation. Sometimes it is even helpful to show the child their isolated teeth in a mirror. The view is so different from what they normally see in the mirror that they can divorce themselves from the reality of the situation.
Relaxation
The isolation of the operative area from the child will very often cause the child to become considerably relaxed¾always provided that there is good pain control. It is common for both adult and child patients to fall asleep while undergoing treatment involving the use of rubber dam¾a situation that rarely occurs without. This is a function of the safety perceived by the patient and the relaxed way in which the dental team can work with its assistance.
Shows rubber dam placed in the a child
and with the comfort it provides it is not unusual for children to fall asleep
in the dental chair during treatment under rubber dam.
Benefits
to the dentist
Reduced stress
As noted above, once rubber dam has been placed the child will be at less risk from the procedures that will be used to restore their teeth. This reduces the effort required by the operator to protect the soft tissues of the mouth and the airways. Treatment can be carried out in a more relaxed and controlled manner, therefore lessening the stress of the procedure on the dental team.
Retraction of tongue and cheeks
Correctly placed rubber dam will gently pull the cheeks and tongue away from the operative area allowing the operator a better view of the area to be treated.
Retraction of gingival tissue
Rubber dam will gently pull the gingival tissues away from the cervical margin of the tooth, making it much easier to see the extent of any caries close to the margin and often bringing the cervical margin of a prepared cavity above the level of the gingival margin thus making restoration considerably easier. Interdentally, this retraction should be assisted by placing a wedge firmly between the adjacent teeth as soon as the dam has been placed. This wedge is placed horizontally below the contact area and above the dam, thus compressing the interdental gingivae against the underlying bone. Approximal cavities can then be prepared, any damage from rotary instruments being inflicted on the wedge rather than the child's gingival tissue.
Quite often it can be difficult and time consuming to take the rubber dam between the contacts because of dental caries or broken restorations. It is possible to make life easier by using a 'trough technique', which involves snipping the rubber dam between the punched holes. All the benefits of rubber dam are retained except for the retraction and protection of the gingival tissues.
Moisture control
As mentioned previously, silver amalgam is probably the only restorative material that has any tolerance to being placed in a damp environment, and there is no doubt that it and all other materials will perform much more satisfactorily if placed in a dry field. Rubber dam is the only technique that readily ensures a dry field.
Reduced stress
As noted above, once rubber dam has been placed the child will be at less risk from the procedures that will be used to restore their teeth. This reduces the effort required by the operator to protect the soft tissues of the mouth and the airways. Treatment can be carried out in a more relaxed and controlled manner, therefore lessening the stress of the procedure on the dental team.
Retraction of tongue and cheeks
Correctly placed rubber dam will gently pull the cheeks and tongue away from the operative area allowing the operator a better view of the area to be treated.
Retraction of gingival tissue
Rubber dam will gently pull the gingival tissues away from the cervical margin of the tooth, making it much easier to see the extent of any caries close to the margin and often bringing the cervical margin of a prepared cavity above the level of the gingival margin thus making restoration considerably easier. Interdentally, this retraction should be assisted by placing a wedge firmly between the adjacent teeth as soon as the dam has been placed. This wedge is placed horizontally below the contact area and above the dam, thus compressing the interdental gingivae against the underlying bone. Approximal cavities can then be prepared, any damage from rotary instruments being inflicted on the wedge rather than the child's gingival tissue.
Quite often it can be difficult and time consuming to take the rubber dam between the contacts because of dental caries or broken restorations. It is possible to make life easier by using a 'trough technique', which involves snipping the rubber dam between the punched holes. All the benefits of rubber dam are retained except for the retraction and protection of the gingival tissues.
Moisture control
As mentioned previously, silver amalgam is probably the only restorative material that has any tolerance to being placed in a damp environment, and there is no doubt that it and all other materials will perform much more satisfactorily if placed in a dry field. Rubber dam is the only technique that readily ensures a dry field.
'Trough technique' of rubber dam
placement.
Technique
Most texts on operative dentistry demonstrate techniques for the use of rubber dam. It is not intended to duplicate this effort, but it would seem useful to point out features of the technique that have made life easier for the authors when using rubber dam with children.
Analgesia
Placement of rubber dam can be uncomfortable especially if a clamp is needed to retain it. Even if a clamp is not required the sharp cut edge of the dam can cause mild pain. Soft tissue analgesia can be obtained using infiltration in the buccal sulcus followed by an interpapillary injection. This will usually give sufficient analgesia to remove any discomfort from the dam. However, more profound analgesia may be required for the particular operative procedure that has to be performed.
Method of application
There are at least four different methods of placing the dam, but most authorities recommend a method whereby the clamp is first placed on the tooth, the dam stretched over the clamp and then over the remaining teeth that are to be isolated. Because of the risk of the patient swallowing or inhaling a dropped or broken clamp before the dam is applied, it is imperative that the clamp be restrained with a piece of floss tied or wrapped around the bow. This adds considerable inconvenience to the technique and the authors favour a simpler method whereby the clamp, dam, and frame are assembled together before application and taken to the tooth in one movement. Because the clamp is always on the outside of the dam relative to the patient there is no need to use floss to secure the clamp.
A 5-inch (about 12.5 cm) square of medium dam is stretched over an Ivory frame and a single hole punched in the middle of the square. This hole is for the tooth on which the clamp is going to be placed and further holes should be punched for any other teeth that need to be isolated. A winged clamp is placed in the first hole and the whole assembly carried to the tooth by the clamp forceps. The tooth that is going to be clamped can be seen through the hole and the clamp applied to it. The dam is then teased off the wings using either the fingers or a hand instrument. It can then be carried forward over the other teeth with the interdental dam being 'knifed' through the contact areas. It may need to be stabilized at the front using either floss, a small piece of rubber dam, a 'Wedjet', or a wooden wedge.
Most texts on operative dentistry demonstrate techniques for the use of rubber dam. It is not intended to duplicate this effort, but it would seem useful to point out features of the technique that have made life easier for the authors when using rubber dam with children.
Analgesia
Placement of rubber dam can be uncomfortable especially if a clamp is needed to retain it. Even if a clamp is not required the sharp cut edge of the dam can cause mild pain. Soft tissue analgesia can be obtained using infiltration in the buccal sulcus followed by an interpapillary injection. This will usually give sufficient analgesia to remove any discomfort from the dam. However, more profound analgesia may be required for the particular operative procedure that has to be performed.
Method of application
There are at least four different methods of placing the dam, but most authorities recommend a method whereby the clamp is first placed on the tooth, the dam stretched over the clamp and then over the remaining teeth that are to be isolated. Because of the risk of the patient swallowing or inhaling a dropped or broken clamp before the dam is applied, it is imperative that the clamp be restrained with a piece of floss tied or wrapped around the bow. This adds considerable inconvenience to the technique and the authors favour a simpler method whereby the clamp, dam, and frame are assembled together before application and taken to the tooth in one movement. Because the clamp is always on the outside of the dam relative to the patient there is no need to use floss to secure the clamp.
A 5-inch (about 12.5 cm) square of medium dam is stretched over an Ivory frame and a single hole punched in the middle of the square. This hole is for the tooth on which the clamp is going to be placed and further holes should be punched for any other teeth that need to be isolated. A winged clamp is placed in the first hole and the whole assembly carried to the tooth by the clamp forceps. The tooth that is going to be clamped can be seen through the hole and the clamp applied to it. The dam is then teased off the wings using either the fingers or a hand instrument. It can then be carried forward over the other teeth with the interdental dam being 'knifed' through the contact areas. It may need to be stabilized at the front using either floss, a small piece of rubber dam, a 'Wedjet', or a wooden wedge.
