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We spoke to experts with differing views on rubber dams and isolation for composite restorations.
Resin bonding does not work well in moisture-rich environments. The composite resin materials dentistry presently uses are hydrophobic and require a dry field to be successful, making isolation crucial to prevent bond failure and other problems with composite restorations.
“We want to try to keep it as pristine and as clear a field as we can. These adhesives need it; they require it,” Tim Bizga, DDS, FAGD, a private practice general dentist in Cleveland, OH says. “Nothing good happens if you don’t control the fluid.”
In addition to bond failure, poor isolation leads to sensitivity, contamination, and microleakage. Dr. Bizga compared microleakage to a break in a medieval city wall. If there is a gap in the wall or it is broken down in one area, the city’s enemies can get in. Microleakage follows the same principle on your restoration, but with bacteria.
“If I'm doing a filling and 95 percent of it is clean and dry but there's one little spot that's getting blood on it, well, that's an area that potentially could leak and can undermine the whole thing. That's why it's so critical to isolate,” Dr. Bizga explains. “It's an all-or-nothing-type thing.”
Effective isolation affects the permanency of a restoration as well. When you look at longevity studies around composite in the U.S., Dr. Goodchild says the results are not impressive.
Amalgam restorations last much longer because the material is not as technique sensitive. In his lectures on posterior composite restorations in the U.S., Dr. Goodchild quotes an average longevity of 5.7 years, which he describes as “pretty bad.” The Japanese Dental Science Review suggested in 2011 that only 60 percent of resin composite restorations will last more than ten years.1.
Dr. Goodchild thinks on the clinician’s part, mastering the technique for placing resin composites and all the procedural steps that go into the process are essential to improve the survival rate of your composite restorations. It starts with good isolation-and in his case, a rubber dam.
“What can we do on our side to give that composite restoration its best chance for survival? We can place it in ideal conditions, and, in most cases, that is a well-isolated environment and a rubber dam fits the bill.”
In dental school, students receive instruction on rubber dam isolation. However, as they practice on their own, they begin to branch out to other methods of isolation. These systems have different features that range from mouth props to providing a light to suctioning systems and are designed to be easier-to-use than a rubber dam. They also purport to be as effective as rubber dams, and many clinicians use them to great effect for composite restorations.
We spoke to three experts with differing views on rubber dams. Here’s what they say about isolation and the rubber dam.
The case for rubber dams
Jason Goodchild, DMD, director of clinical affairs for Premier Dental Products Company is also an associate clinical professor at Creighton University School of Dentistry so he uses the rubber dam often in his restorative work. He says it not only helps to ensure good clinical outcomes, but it also helps with the pictures he takes to demonstrate the concepts about the treatment he is presenting to his students.
“From an educator standpoint, there's no better way to get a great picture of a restoration than to isolate it from the cheeks and gums and the tongue and saliva than to use a rubber dam. It’s a wonderful way to highlight it,” Dr. Goodchild says. “From a clinician standpoint, which is much more important, good isolation means you can do better dentistry and when I say better dentistry, I mean you can use materials better.”
Rubber dams are the standard of care for endodontic treatments and have been for many years. So, for root canals, all clinicians should use a rubber dam. If there was ever an issue with the treatment and the case was reviewed to reveal the doctor used something other than a rubber dam for isolation, that could be looked at unfavorably.
“When it comes to endodontics, it’s always been the standard of care,” Dr. Goodchild says. “But from a resin standpoint and as a restorative dentist, I am just a big fan.”
Dr. Goodchild says using rubber dams has become a lost art . However, in recent years he has seen more people returning to rubber dam isolation.
“It's tried and true and we get wonderful results when we do it that way,” Dr. Goodchild says.
Per Dr. Goodchild, there are many techniques to place a rubber dam if you are experienced with them. He says you don’t have to always punch a series of holes so each tooth comes through each hole. He sometimes uses a slit-dam technique, which is two holes with a slit cut between them making it possible to expose a few teeth at once. Then, he would secure the rubber dam down between teeth using floss or Wedjets Dental Dam elastic stabilizing cord.
“So, there's lots of easy ways to place a rubber dam,” Dr. Goodchild says.
Rubber dams are versatile and useful with almost any dental procedure. Dr. Goodchild says they are especially effective with anxious or fearful patients that need sedation.
“We almost always place a rubber dam even for crown preparations because you could keep all the water out of someone's mouth,” Dr. Goodchild says. “It's easy to suction. It's easy to keep the tissue out of the way. I'm a huge supporter of rubber dam for lots of different cases.”
Other ways to isolate work, too
Dr. Ed Kusek, a private-practice dentist in Sioux Falls, SD, recognizes rubber dams are effective for isolation. However, they are also time-consuming, and many clinicians prefer other methods and devices with additional features for their restorative work.
“There is a reason they don’t like them. It takes time and patients don’t like them,” Dr. Kusek says of rubber dams. “There's many different little devices out there now that help suction and illuminate.”
Isolite 3, for example, combines an integrated LED light, suction and retraction functionality to provide isolation for restorative dentistry. Dr. Kusek’s son, Dr. Alex Kusek uses Isolite, which the practice invested in when some dental assistants left the office a while ago.
“He is able to do procedures by himself, without an assistant,” Dr. Kusek says of his son working with Isolite.
When you use a faster form of isolation, it can have positive effects on your productivity. However, it can also improve the experience for patient and dentist alike. Dr. Kusek says particularly it means a less stressful process while you are trying to layer and cure composite.
Dr. Kusek favors Dri-Angle isolation, using a triangular pad that fits into the corner of the mouth well and absorbs fluid. Then, he has his assistant on suction and he handles retraction.
“I like to use the one that has a metal backing and you can conform it. It keeps the buccal cheek back and controls the saliva,” Dr. Kusek says. “Sometimes you have to change it multiple times, though.”
Dr. Bizga also uses rubber dams, but only for endodontic treatments because it is the standard of care. For all other treatments, including composite restorations, he uses something else.
“For me I just limited rubber dams to that one procedure and then I use the DryShield for everything else,” Dr. Bizga says.
When rubber dams won’t work
Some cases exist that are not ideal for rubber dams. They are difficult to use for extractions, or if your patient is claustrophobic or if there isn’t a way to get the dam on properly. Also, in pediatric dentistry getting a rubber dam on a child can prove to be difficult. In those cases, another form of isolation is a good idea, per Dr. Goodchild, whether you use Isolite or IsoDry or any of the other isolation methods, save for one.
“We know cotton roll isolation, although it’s not going away, is not sufficient. A mouthful of cotton rolls is only going to get you so far and probably some other method could be better than that,” Dr. Goodchild says.
“You can do a cotton roll isolation, but with some patients, it’s hard to do. You just can’t keep it dry long enough,” Dr. Bizga says.
“Then the patient’s tongue pops it up and your fighting it all the time,” Dr. Kusek agrees about cotton roll isolation, “and then the patient gets frustrated and it just gets worse.”
Dr. Bizga agrees most people use other methods of isolation for cases where you can’t get a rubber dam on reasonably. For example, when the tooth is broken off at the gum line and there is nothing to grab onto for the dam. If you were to clamp on the gums it could bleed and contaminate the area.
“So that's a case where it's very difficult to get a rubber dam and where these other methods of isolation come in handy,” Dr. Bizga says.
How to improve iIsolation in the operatory
Dr. Kusek says the key to isolation is having very good light and an experienced assistant. He uses a light on his loupes that is battery charged and illuminates nicely in the oral cavity without producing a lot of heat. Also, his assistant and he work well together and have for some time, so she anticipates his needs in the restorative work.
“Sometimes you need to be very efficient and very fast, especially with children” Dr. Kusek says. “If they are getting agitated or whatever and need to be able to move. That’s when it’s great to have an excellent assistant.”
Parents have commented on Dr. Kusek and his assistant’s relationship when observing treatment with their children, noting how the two dental professionals work well together. Dr. Kusek says that’s because they have worked together for a long time and she anticipates his needs.
“I don’t even need to say anything. She just hands me things,” Dr. Kusek says.
For Dr. Bizga, isolation is the foundation of where the composite restoration success begins. Getting the fluids under control is essential, which, in all his cases that aren’t endo, are not handled by the rubber dam.
“I love DryShield because all you have to do is get it in the patient's mouth and then turn it on,” Dr. Bizga says. “It controls the fluid, the suction andit protects airway so if you dropped something it won't go down their throat. So, there's a lot of plusses.”
Dr. Bizga says his composite restorations are stress free once he secures isolation. Everything you do after you isolate you can do to the absolute best of your ability and not worry about managing fluids.
Patients are less stressed, too. With DryShield, the bite block props their mouth open and keeps their tongue moved away. The suction keeps the saliva and water spray under control. Dr. Bizga says when he is using it, patients relax and the dental team can do all the work.
“What I found is a lot of people started dozing off,” Dr. Bizga says. “They get comfortable. They're not worried and at least four out of ten people fall asleep.”
Effective isolation can improve the business-side of your practice as well. It can make things go faster and better than when you are struggling to keep the field dry and clear, which means less chair time for patients. Clinicians can also perform procedures with more predictability and reliability, which improves their reputation, Dr. Bizga explains. Then patients start talking about you to their friends and family.
“So, there’s some elements that are business-oriented as wel,l secondary to the fact you are just trying to do a good job,” Dr. Bizga says. “They go hand in hand. Doing good business means you’re usually being a good healthcare provider as well.”
1.Kubo, Shisei. “Longevity of resin composite restorations.” Japanese Dental Science Review. (2011) 47:1, pp. 43-55. Accessed via Web: www.sciencedirect.com. Web. 30 June 2019. < https://www.sciencedirect.com/science/article/pii/S1882761610000189>.