Q&A  Rubber Dam  in Pedodontics  -Dr.Thomas Manjooran

Q, Do you recommend the application of rubber dam in day to day  pratice of pediatric dentistry. I feel it is a waste of time and makes it more difficult for the child. Does rubber dam really help?
A, Saliva is teaming with micro organisms and it is preferable to exclude this extraneous infection from all cavities. In addition salivary contamination must be avoided in certain techniques; for example, pulp capping and root canal treatment. Rubber dam has the effect of psychologically and physically separating the patient from the dental procedure and this tends to relax the patient abundantly. Rubber dam makes paediatric dental treatment more efficient.
To say that rubber dam is of little usage in paediatric dentistry despite many sound reasons for its adoption may seem a little odd. It is perceived as a difficult technique and expensive in time. In fact if once mastered, the technique makes dental care for children easier and a high 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

1,Safety

Prevention of damage to soft tissues
The risks of operative treatments include damage to the soft tissues of the mouth from rotary and hand instruments and the medicaments used in the provision of endodontics 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.

Risk of cross-infection
The use of high-speed rotary instruments distribute an aerosol of the patients' saliva, around the operating room, putting the dentist and the staff at the risk of infection.

Nitrous oxide isolation
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 the dentist and staff at risk. The use of rubber dam in this situation will make sure that exhaled gas is routed via a 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.

2, 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 as sight, hearing, breathing and swallowing. When operative procedure 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 paediatric 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 anaesthesia has been obtained, the child can feel themselves distanced from the operation. Sometimes it is even good 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 relaxed always 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 dam; a situation that rarely occurs without. This is function of the safety perceived by the patient and the relaxed way in which the dental team can work with its assistance.

3, Benefits to the clinician
Reduced stress
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 clinician to protect the soft tissues of the mouth and airways. Treatment can carried out in a more relaxed and controlled manner, therefore lessening the stress of the procedure on the dental team.

Retraction of tongue and cheek
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 tissues
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 tissues. 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 the rubber dam are retained except for the retraction and protection of the gingival tissues.

Moisture control
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.