Rubber dam techniques in paediatric dentistry

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

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).

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.

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.