Our Familiar Friend
We’re all familiar. A rubber dam is very useful in most phases of dentistry.
It helps create isolation from the oral environment, creates automatic retraction of lips, cheek and tongue, allows for more predictable moisture control, and keeps us from “losing things” down the patient’s throat.
And then there’s this precaution form the American Association of Endodontist’s Website:
Our standards of practice as the dental specialty of Endodontics are very clearly described in those papers as follows: First, when accessing a pulp chamber….
Second, the use of a rubber dam during treatment is mandatory to avoid microbial contamination of the root canal system, limit aerosols, retract tissues, protect the patient from damage by chemicals, and prevent aspiration or swallowing of instruments and materials.
If we’re reasonably serious about getting it placed regularly, most of us have trained and delegated that task to our staff (as it should be).
But, what if we can’t get the #&$@* clamp to stay put?!?! We’d all like to be super docs but what if it just isn’t possible!?
Read on, I might have a solution…
Generally there are two major reasons for a clamp not saying put on the tooth:
- There isn’t enough tooth structure left to clamp on to.
- The tooth is so short and slopey that the clamp can’t be placed below the height of contour.
First off, let me say that I am a fan of isolating the entire quadrant whenever I’m using a rubber dam. I’m just getting better isolation and more information that way.
When performing restorative work it’s usually necessary anyway in order to deal with interproximal areas.
But, it’s also useful when doing endodontics as it gives the doctor a better appreciation as to the orientation of the tooth in the jaw and in relation to the adjacent teeth.
So let’s try to solve this.
Ideas for the first problem:
- Option 1 – Place the clamp distal to the tooth in question and isolate the quadrant.
- Option 2 – Use a clamp with longer, gingivally-facing tines and clamp more apically. Maybe even on the gingiva. The 14a clamp seems to work pretty well for this.
- Option 3 – First build up the tooth a bit and then clamp the build up
One of these options will usually work. For the “slopey short tooth” problem you can try the previous options, but sometimes none of these really gets the job done.
But take heart, there is another possibility. I accidentally discovered this while treating a patient. It will require a fair amount of coordination between you and your assistant but it works only every time.
The Slopey Short Tooth Solution:
(Note: all these directions are for a right-handed doctor. Just reverse them if you’re a lefty)
- Be sure the buccal and lingual surfaces of the tooth to be clamped are clean. I usually use unflavored pumice.
- Place the clamp and hold it in place with your left hand.
- Now etch, rinse, and dry the buccal and lingual surfaces of the tooth.
- Place bonding agent, air dry and cure.
- Place a LARGE amount of composite on the buccal and lingual of the tooth. It should be sufficient to keep the clamp from riding up and over the composite “button.”
- Remove your hand and see how good of a job you’ve done.
- When finished with the procedure, remove the composite buttons with finishing burs.
I did this for years with a standard rubber dam clamp and it worked just fine. However, more recently, I tried grinding off the tines of one of my older clamps so that it wouldn’t take so much composite to create an adequate “button”. Works even better.
Let me know if you have another option for this issue that’s been working well for you.
Next time we’ll talk about the perfect “short tooth” temporary cement that won’t come off till you take it off and even then comes off requiring no clean up.
P.S. If you are looking for more clinical efficiency strategies check out Dr. Nicholas’ online and hands on courses here.