References
Kapitan M, Hodacova L, Jagelska J The attitude of Czech dental patients to the use of rubber dam. Health Expect. 2015; 18:1282-1290 https://doi.org/10.1111/hex.12102
Samaranayake LP, Reid J, Evans D. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. ASDC J Dent Child. 1989; 56:442-444
Soldani F, Foley J. An assessment of rubber dam usage amongst specialists in paediatric dentistry practising within the UK. Int J Paediatr Dent. 2007; 17:50-56 https://doi.org/10.1111/j.1365-263X.2006.00796.x
Scottish Dental Clinical Effectiveness Programme. Restricting the use of dental amalgam in specific patient groups: implementation advice. 2018. https://www.sdcep.org.uk/media/f2ooomat/sdcep-dental-amalgam-implementation-advice.pdf (accessed June 2022)
Ammann P, Kolb A, Lussi A, Seemann R. Influence of rubber dam on objective and subjective parameters of stress during dental treatment of children and adolescents – a randomized controlled clinical pilot study. Int J Paediatr Dent. 2013; 23:110-115 https://doi.org/10.1111/j.1365-263X.2012.01232.x
Nara A, Chour R, Narasimman J Effect of rubber dam on arterial oxygen saturation in children. J Int Oral Health. 2015; 7:54-56
Rubber dam techniques in paediatric dentistry
From Volume 49, Issue 7, July 2022 | Pages 606-609
Article
Rubber dam has many applications in paediatric dentistry, yet it is an underused isolation technique in children, particularly within primary care. Rubber dam has obvious advantages in maintaining a dry working field and soft tissue retraction. It protects the airway from foreign bodies, and protects the soft tissues from endodontic irrigation solutions. Disadvantages of rubber dam include difficulties in patient cooperation, lack of operator experience and the perception that it is unnecessary for particular treatments.
This Technique Tip discusses the advantages and disadvantages of rubber dam, behavioural management techniques, useful equipment and examples of rubber dam use in paediatric dentistry. There are numerous isolation techniques in dentistry, with rubber dam being one of the longest established. Its application helps facilitate moisture control, an important consideration when using restorative materials, and mitigates the risk of dental equipment and materials being inhaled or ingested. There are numerous other benefits of rubber dam application listed in Table 1. Use of rubber dam is arguably more important now than it ever has been due to COVID-19. Use of rubber dam reduces the amount of saliva-contaminated aerosol in the environment, thus reducing risk to the dental team.2
| Advantages | Disadvantages |
|---|---|
| Provides moisture control | Lack of patient cooperation |
| Protects the oropharynx by preventing ingestion of dental materials and instruments | Time consuming |
| Protects soft tissues from chemicals, eg sodium hypochlorite | Lack of training |
| Improves vision by retracting soft tissues | Added expense |
| More comfortable for patients due to less liquid and debris in their mouth1 | Damage to soft tissues due to clamp |
| Acts as a psychological barrier for patients separating them from treatment | Reduced communication between operator/patient during treatment |
| Promotes breathing through the nose during inhalation sedation | Patients can feel anxious and/or claustrophobic |
| Improves visual and instrument access | May be difficult/impossible to use in patients who are mouth breathers |
Despite the many advantages of rubber dam, a survey of paediatric specialists in the UK reported a variable level of rubber dam use when undertaking restorative treatment in children.3 The main reasons for not using rubber dam were reported to be lack of patient cooperation and lack of experience of using rubber dam in children. One method to overcome challenges with cooperation is by using the relevant behavioural management techniques (Table 2).
| Language adaptation: speaking ‘childrenese’, ie adapting language so that children can understand. A rubber dam can be described as ‘a raincoat for a tooth’ |
| Tell-show-do: tell the child what you're planning to do, show them the equipment, then carry out the procedure |
| Enhancing control: agree a stop signal such as raising a hand during treatment if breaks are needed |
| Positive reinforcement: praising good behaviours with stickers can help encourage desired behaviours |
In 2018, restrictions on amalgam usage within dentistry were implemented.4 Due to the phase down of amalgam, composite is now the material of choice for the direct restoration of teeth in paediatric patients. Use of rubber dam with other adjuncts, such as dental floss ligatures, helps to achieve a dry working field and, in turn, should make bonding of adhesive materials more predictable. The use of rubber dam has also shown to make treatment less stressful for both the young patient and the operator, and can also reduce overall treatment time.5
Rubber dam is an excellent adjunct for inhalation sedation. The placement of a rubber dam can discourage mouth breathing, which will improve the delivery of the nitrous oxide by promoting nasal breathing only. A drop in oxygen saturation during sedation is a serious safety concern; however, application of rubber dam does not affect oxygen saturation in healthy children.6
Useful equipment for rubber dam application in paediatric patients is summarized in Table 3. Due to differences in the morphology of the primary dentition, paediatric clamps are often useful when isolating primary teeth. The use of DryDam (Directa, Sweden) is a well-tolerated alternative to the conventional rubber dam. DryDam hooks around the ears like a mask and can be secured with rubber dam stabilizing cord such as Wedjets (Coltene, Switzerland). Wedjets are less traumatic to the soft tissues, which can avoid the need to administer local anaesthetic. DryDam is particularly useful when isolating anterior teeth. It is easy to place and arguably more comfortable than a conventional rubber dam. It is therefore very well tolerated in children.
|
|
Dry dam sheet
|
|
|
Paediatric clamps
|
This Tip discusses rubber dam isolation techniques specifically for paediatric patients in a range of clinical circumstances.
Rubber dam applications
There are many indications for rubber dam use in paediatric dentistry. Outlined below are some cases where rubber dam has been used.
Single tooth isolation
Rubber dam should be applied when restoring teeth with composite to ensure adequate moisture control. Rubber dam can promote nasal breathing during inhalation sedation, which is an added bonus. Figure 1 shows rubber dam isolation of the upper left central incisor to facilitate root canal treatment while the patient is under inhalation sedation.
Some patients experience hypersensitivity, for example patients with amelogenesis imperfecta or patients with molar incisor hypomineralization (MIH). Cold water from the fast handpiece can elicit a painful response due to this sensitivity. Placing a rubber dam when restoring a tooth can protect the rest of the dentition from the cold stimulus and reduce peri-operative sensitivity, making treatment more comfortable.
Isolation using DryDam
Rubber dam application is imperative when undertaking endodontic treatment. The rubber dam protects the oropharynx, preventing ingestion of materials and instruments. It also protects the soft tissues from the irrigation solutions used during endodontic treatment, such as sodium hypochlorite. The rubber dam also serves to prevent oral contaminants entering the canal system during treatment, thereby aiding in disinfection and improving the sterilization of the root canal system. For anterior teeth, DryDam is the rubber dam of choice, and can be used to isolate a single tooth or multiple teeth.
The treatment of certain traumatic injuries requires placement of a rubber dam. For example, if a patient presents with a complicated enamel–dentine fracture, the patient may require a pulpotomy or pulpectomy. Figure 2 shows isolation of incisors during a pulpotomy procedure in UL1. Placing a rubber dam before treatment ensures that the tooth is shielded from saliva, and prevents bacteria entering the pulp.
Split dam technique
It is beneficial to minimize the number of appointments when treating paediatric patients, such as through practising quadrant dentistry, where all necessary treatment in a quadrant is carried out in one visit. This is useful when executing an extensive treatment plan.
The split dam technique can be used when restoring multiple teeth in one quadrant. It can also facilitate isolation when splinting teeth after traumatic injury. The technique involves creating a trough (Figure 3) and stretching the rubber dam over several teeth in that quadrant. The rubber dam can be secured at either end using clamps or Wedjets (Figure 4).
Double dam technique
Restorative work can be carried out under general anaesthesia (GA) in certain circumstances. This is most common in paediatric dentistry and special care dentistry.
Rubber dam isolates the working area and can offer some retraction of soft tissues and intubation tubes.
Children who are placed on comprehensive care GA lists may require extensive restorative work in multiple quadrants. In these circumstances, the ‘double dam’ technique can be used. This involves the simultaneous isolation of two quadrants (Figure 5), allowing the clinician to complete all necessary work on one side of the mouth in a time-efficient manner, without the need to adjust the rubber dam after each restoration.
Challenges in the developing dentition
There are multiple challenges involved in the placement of rubber dam in the developing dentition. Teeth may be partially erupted and the dentition may be spaced or crowded, which can affect placement, retention and stability of the rubber dam. The soft tissues, specifically the tongue, can be particularly active in children. This can further reduce the stability of the rubber dam. In the mixed dentition, there may be mobile teeth that are close to exfoliation. These teeth may be in close proximity to the tooth being isolated, which can affect the stability of the rubber dam and potentially impede the placement of dam stabilizing cord or clamp in this region. These issues can be addressed by stretching the rubber dam over a more stable posterior tooth, which can then be clamped or secured with Wedjets. A combination of clamps, floss ligatures and Wedjets can further improve the retention and stability of the rubber dam in these cases.
Conclusion
Rubber dam is an excellent tool which has many applications in paediatric dentistry. It facilitates treatment by providing moisture isolation, increased visibility and reducing treatment time. It also promotes patient safety by reducing the risk of aspiration and soft tissue damage.
Adopting behavioural management techniques will increase the likelihood of paediatric patients cooperating for rubber dam application and subsequent treatment. There are additional technical challenges involved in the placement of rubber dam in the developing dentition, due to partially erupted teeth, spacing, crowding and potential mobility of primary teeth. Clinicians must be able to adapt their isolation approaches accordingly, depending on the clinical picture. The use of clamps, stabilizing cord and floss ligatures can facilitate effective isolation and improve stability of the rubber dam in these patients.