Isolation in Clinical Practice
The isolation of clinical sites influences the efficacy, efficiency and safety of care, as well as patient comfort. Options include cotton rolls and suction, dry angles, orthodontic elastomers, rubber dams, and the Isolite System.
Cotton rolls are easy and fast to place and, together with suction, may often provide sufficient isolation for restorative and preventive care. However, this method may be insufficient for some patients, including those with high salivary flow, and does not protect patients from accidental aspiration or ingestion of small objects or endodontic irrigants. The same advantages and disadvantages apply to triangular cellulose-based dry angles, although these more readily absorb saliva and adhere to the mucosa, which helps protect it from the high-volume evacuation (HVE). Using orthodontic elastomers (separators) has also been recommended as a user-friendly, easy technique to retract gingival tissue and isolate clinical sites prior to the placement of resin composite crowns in primary teeth. Additional methods would still be necessary for thorough isolation and safety. Both rubber dams, which are considered the clinical reference for isolation, and the Isolite System provide for greater procedural efficiency and safety in comparison to the methods described above.
A rubber dam is recommended during restorative, endodontic and pit-and-fissure sealant procedures. It is traditionally placed first, followed by the rubber dam clamps or floss ligatures, although the placement first of modified clamps and then the rubber dam is another option. Rubber dam use appears nonetheless to be rather limited, based on 2 surveys in the Dental Practice-Based Research Network. In the restorative procedures survey, 63% of 229 respondents reported never using a rubber dam, and just 12% of restorations (n=9,890) in 5,810 patients were placed under rubber dam. There was also wide variability in rubber dam use during endodontic therapy in the second study with 729 respondents, including 524 general dentists.
This may be due to perceptions of potential time lost because of rubber dam placement, or patient dislike of rubber dams. In reality, expert rubber dam placement may save chairside time due to the ease of isolation once it has been placed. Patient reactions are variable, with pediatric patients in a sealant study finding it less stressful than the use of cotton rolls, while patients in another study reported that rubber dam use caused them more discomfort than cotton rolls and suction. From the perspective of clinical experience and outcomes, reports are conflicting. Some small studies have reported no differences under test conditions in clinical outcomes for restorations placed under rubber dam or with cotton rolls and suction. Failure to use a rubber dam may also influence the choice of root canal irrigant,due to concerns about the irrigant flowing into the patient?s mouth, and may have a negative impact on treatment outcomes. Short-term gingival recession has been observed with rubber dam use.
The Isolite System was introduced to provide incremental benefits compared to other isolation methods, while still isolating the clinical site and providing for patient safety. The Isolite System mouthpiece is designed with plastic flexible flanges buccally and lingually that isolate unilateral upper and lower quadrants simultaneously. Visualization is improved with an LED light with 5 levels of illumination and a cure-safe mode. Other design elements also enhance procedures for dental professionals and patients (Table 1). As with a rubber dam, aerosolized bacteria and spatter are reduced and the Isolite System helps to prevent the inhalation or ingestion of small foreign objects. Unlike rubber dams, the Isolite System can also be used during all imaging procedures and can be used during nonsurgical periodontal therapy.
The Isolite System reduces chairside time and has good patient acceptance. In a study of pediatric patients (n=48, mean age 9 years), 340 seconds was required for sealant placement using the Isolite System compared to 398 seconds using cotton rolls and suction. Furthermore, patients found both methods to be equally acceptable.
Considerations in the selection of an isolation method include the clinical procedure, efficacy of the isolation method, safety, patient comfort and preference, and chairside time. While rubber dams provide for excellent isolation and contribute to patient safety, they are inconsistently used. In contrast, cotton rolls and suction are quicker and easier to use, but do not provide for thorough isolation or aid patient safety. The Isolite System provides traditional and innovative benefits to meet the needs and preferences of dental professionals and patients alike.
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