Fluid control Flashcards
Fluid Control -
-Too much water –
-Too little water –
Controlling water and saliva during tooth preparation
you can’t see and patient is drowning
you can heat tooth and cause pulpal necrosis
Gingival Control
Saliva and crevicular fluid management is crucial for making a
Soft tissue management, such as gingival displacement, is important for
the (3)
quality impression and for proper cementation
preparation, impression, and cementation
Soft tissue management
Managed with (3) to re-contour the
gingiva as well as move or remove it from the operative environment
lasers, Electrosurge, or a scalpel
Uses for Rubber Dam:
(6)
-Still the gold standard for isolation and
moisture control
-Caries, O&R, removing old restorations
-Placing a Core
-During Post and Core procedures
-Root Canal Treatment
-When tissue retraction is difficult
(hypertrophied tissue or a pseudopocket)
Rubber Dam can be used during
preparation and cementation of
(2)
-Rubber Dam provides necessary
isolation for —
-Rubber Dam used during
preparation for Inlay/Onlay.
Then, Dam is removed to check
(2)
Inlays and Onlays.
resin cement procedures.
occlusion and clearance.
Primary way to manage fluid during
preparations is with —
There are tons of products out there to help
manage this in other ways.
high-speed suction.
Fluid Control
(5)
Cotton roll isolation
Dry Angle cheek guards
Dentopop
Nu-Bird. Suction and
mirror in one device
Releaf hands free
suction device
Fluid Control - Isovac
Isovac and Isolite
(5)
-Isolates both Max and Mand at the same time.
-Retracts tongue and cheek
-Continually aspirates fluids and oral debris
-Obturates throat – prevents aspiration of material
**Used in clinics at UMKC as alternative to Rubber Dam
Fluid control with Medication
Medications can be used to reduce saliva (anti-sialagogues)
(3)
-Not very commonly used for this purpose
-GI Anticholinergics (Robinul / Pro-Banthine)
-Clonidine (anti-hypertensive drug)
-GI Anticholinergics (Robinul / Pro-Banthine)
(2)
-Decreases stomach acid and other secretions
including saliva
-Contraindicated in patients with heart disease /
glaucoma/ asthma
-Clonidine (anti-hypertensive drug)
(2)
-Safer that anticholinergics but have side effects like
sedation, blurred vision, allergic reactions
-Caution for hypertensive patients.
Periodontal health is critical in the preparation and
design process of a crown or bridge.
-The health and biotype of the gingiva needs to be
evaluated
prior to, during, and after restorative
treatmen
Poorly contoured restorations are responsible for
inflammatory reactions:
(5)
-Roughness and porosity of materials
-Inaccessibility for patient OH
-Lack of patient OH
-Defective crown margins
-Invasion of biological width
Periodontal health management:
-Use the provisional to —
-SRP may be needed to —
-Pre-placement of —
- — for two weeks prior to crown
preparation can be useful in more significant
inflammation situations.
re-create or maintain
proper gingival contours.
remove foreign
substances and kickstart the healing process.
retraction cord and careful
final marginal preparation
Chlorhexidine 0.12%
Biologic Width:
(5)
-Gingival Sulcus
-Junctional Epithelium
-Connective Tissue Attachment
-Radiographic Evaluation
-Crown Finish line ideally no deeper than half
the depth of the sulcus.
-Radiographic Evaluation
-PA/BW – Determine if crown lengthening
is advisable or needed to avoid impinging
on Biological width.
-Crown Finish line ideally no deeper than half
the depth of the sulcus.
-Usually —
0.5 – 1.0mm sub gingival
Thin, scalloped gingiva–
More
susceptible to damage and
recession.
Thick, flat gingiva–
More stable.
Responds better to treatments and
more resistant to recession
Why is gingival control so critical to
restorative treatment?
Rapid marginal recession may occur as
soon as
2 weeks. (results in
unpredictable tissue levels).
Why is gingival control so critical to
restorative treatment?
Rapid marginal recession may occur as
soon as 2 weeks. (results in
unpredictable tissue levels).
How?
(5)
-Damage during tooth preparation
-Over contoured provisional
-Over contoured final crowns
-Injury caused by cord packing
-Poor OH resulting in inflammation
Tissue displacement must be gentle.
Purpose of Tissue Retraction –
(4)
-To Displace the Gingiva for margin exposure
-As a cutting guide during tooth preparation
-Displacement of gingival tissue for impression
-Control of crevicular fluids
-As a cutting guide during tooth preparation
(2)
-Tissue protection during margin placement
-Visualization of finish line
-Displacement of gingival tissue for impression
(2)
-When margin is at or below the gingival contour
-For impression and die trimming
-Control of crevicular fluids
(3)
-water, saliva, blood
Placement of retraction cord prior to
preparation.
(3)
-Improves visibility
-Reduces tissue trauma
-Acts as a guide for margin placement
-Most often, begin with a
rough
preparation supragingival to start. Then
pack cord. Proceed to finalization of
preparation and margin
Gingival Control – Tissue Retraction
Cord causes — displacement of tissues to …
Allows subgingival margins without significant …
Can be left in place for final impression using —
Aiming for no deeper than …
vertical, visualize the margin placement
damage to tissues
2 Cord technique
half the depth of the sulcus.
Tissue covering subgingival margins must be
retracted or displaced horizontally. Packing Cord:
-Provides space for enough …
-Removes (2) to accurately record the crown margins.
-Helps arrests —
-Aid in (2) prior to impression.
impression material to record this anatomy.
fluids and anatomy
heme
cleanliness and dryness
Techniques for gingival control:
(3)
Mechanical
Chemo-mechanical
Surgical
Mechanical
(3)
-Rubber dam
-Retraction cord
-Cordless materials (pastes, gels, compounds)
Chemo-mechanical
(1)
Retraction cord AND chemicals for hemostasis
Surgical
(3)
Electrosugery
Laser
Scalpel
Retraction Cord –
Produces …
Stretches circumferential fibers to …
Types – (3)
Sizes -
— cord used at UMKC
enlargement of the gingival sulcus
displace tissue laterally and vertically
Braided, twisted, knitted
#000 - #3
Ultradent knitted
Gingival Control
There is a — in the cap of the
cord container.
Stretch out how much you need and…
blade
snap the cap down to cut the cord.
Using Retraction Cord AND a Hemostatic agent:
(3)
-Hemostatic medicaments control crevicular fluids
and seepage
-Retraction cord can be purchased impregnated
with a chemical for this purpose
-Non-impregnated cord can be soaked in heme
controlling agents prior to placement.
Retraction Cord soaked in Epinephrine
Advantages:
(3)
-Can be kind to tissues
-Sulcus not overly harmed and left clean
-No additional tissue loss
Retraction Cord soaked in Epinephrine
Disadvantages:
(1)
-Extra epinephrine systemically for patient
Retraction Cord soaked in Epinephrine
*Not used in UMKC clinic due to the
unpredictability of the
epinephrine exposure to patients.
Astringents are substances that cause
constriction of soft tissues. They have a massive use in
bleeding control in various dental procedures such as impression making in fixed prosthodontics,
class V restorations and root surface restorations, etc.
Astringents:
Buffered Aluminum Chloride (20% Hemodent)
Advantages:
(3)
-Moderate hemostasis and tissue shrinkage
-Sulcus not overly harmed
-Does not inhibit PVS polymerization
-Moderate hemostasis and tissue shrinkage
-Precipitates —
-Contracts —
-Extracts — from tissues
-Leaves sulcus —
protein
blood vessels
fluid
clean
Astringents:
Buffered Aluminum Chloride (20% Hemodent)
Disadvantages:
(1)
-Nasty taste
Astringents:
Ferric Sulfate (15%) Astringedent
Advantages:
(2)
-Stypic (clotting agent)
-Applied to cut tissue for best hemostasis
Astringents:
Ferric Sulfate (15%) Astringedent
Disadvantages:
(3)
-Leaves a dark residue (esthetic issue)
-Causes dentin discoloration (delayed)
-Inhibits setting of PVS impression materials
-Causes dentin discoloration (delayed)
-don’t use with
veneers or esthetic
anterior cases.
-Inhibits setting of PVS impression materials
-leads to
inaccurate impressions
Dentin Darkening:
Possible high acidity of gingival retraction fluids (GRFs) and the high
affinity of iron for hard tooth tissues, resulting in an interaction with
bacterial byproducts and precipitation of insoluble ferric sulfide in
the porous demineralized dentin
For proper exposure of your finish line (margin) cord aims to:
(3)
Provide adequate thickness of impression material and access to the
preparation margin.
Reduces tears and distortions of impression material
Sulcus is opened in a cone shape
Single Cord Technique
(4)
-Use of single cord for entire circumference
-In deeper sulcus, a second cord could be
used in select area
-Remove all cords for impression
-Best used in shallow sulcus
Double Cord Technique
(4)
-#000 or #00 pre-packed into sulcus.
-Second cord placed over the top of existing cord
-For impression, top cord is removed. Second cord
(lower, smaller cord is left in place for the
impression).
-If smaller cord is picked up in impression, it is cut off
prior to pouring up in stone
Double Cord Technique
-Remember – must
remove first cord after impression
and before patient goes home! Severe
inflammation and pain can occur.
— is considered the gold
standard for impression taking. All other
techniques are compared to this.
Double Cord technique
Tissue retraction procedure:
Mandatory (2)
Use of Local is mandatory
Moisture control is mandatory
Use of Local is mandatory
(2)
-Patient comfort
-Also aids in reduced salivary flow and some
heme control.
Moisture control is mandatory
(3)
-Prevents dilution of hemostatic agents
-Cotton rolls to displace tongue and cheek
-Other isolation techniques can be used
Gingival Control – Cord Placement
–Place cord near —
–Place looped cord around tooth with
–Start in — part of sulcus (usually —)
–Use — instrument
–Use gentle pressure to avoid —
–Placement is — to the root
crevice
cotton forceps
deepest, interproximal
blunt
stripping attachment
parallel
Gingival Control – Cord Placement
Note angle toward tooth at approximately – degrees.
Straight downward pressure caused cord to
Packing toward starting point will
Packing away from starting point will
45
not seat and creates tissue trauma and further bleeding.
keep cord in place
pull cord out
Gingival Control – Cord Placement
Common problems:
(4)
Insufficient tissue retraction leading to impression
material being too thin.
Cord could be too small vertically or horizontally
Retraction cord too small – Bottleneck of tissue
Top of cord needs to be fully visible with no tissue
overlap at the top of the sulcus.
Gingival Control – Cord Placement
Step 1 –
(3)
Determine # of cords to use (2 cord technique is the default)
Select largest cord you believe will fit appropriate for your technique
Cut cord into anticipated length plus a little extra
Step 2 –
(4)
Place cord segments into hemostatic solution. In clinic, we use small clear cups for this.
Recommend Hemodent as primary astringent.
After soaking cord, dab off excess leaving cord still wet just prior to placement in the mouth.
If you know your patient’s gingiva will be bleeding, some Astringedent can be drawn into a
syringe and placed on your cart.
Step 3 –
(3)
Pack smaller (#000 or #00) cord (now moistened with Hemodent) into the sulcus with
smooth blade instrument.
Cut off excess length.
The margin should be visible ABOVE the cord.
Step 4 –
(3)
Pack larger (#0 or larger) cord (now moistened with Hemodent) into the sulcus with
smooth blade instrument.
Do not cut off excess length. Leave some cord hanging out to grab later.
The margin should be visible ABOVE the cord.
Step 5 –
(8)
Allow cord to sit and be isolated (dry and heme free) for 3-5 minutes.
Remove top cord
Air dry the tooth and crevicular area
Place light body material into sulcus circumferentially
Blow the impression material down into sulcus with LOTS of air. (Circular motion around
the tooth multiple times with lots of air)
Start again to place light body impression material
Place impression tray with medium, hard, or rigid impression material
Remove any remaining smaller cord prior to temporizing
Do not remove a — cord. This – the gingiva creating bleeding
and an inflammatory reaction.
dry
tears
Double Cord Technique. Always check for
the smaller cord’s removal
prior to the patient being dismissed! This will create pain and inflammation!
Has cord been placed gently and does not overflow the sulcus BUT you still have bleeding from
your preparation or patients gingival unhealth?
Rub Astringedent on tissue until bleeding stops.
Remove dark debris from Astringedent by using Hemodent and cotton pellet.
Dry thoroughly
Check for bleeding and repeat if necessary
REMEMBER – Astringedent will inhibit the setting of your PVS impression material. — may allow you to get an adequate impression
A
thorough wash and dry
*There are some situations where the bleeding cannot be controlled well enough for a final
impression that day. In this case, you
temporize, send the patient home, and have them back
in a week to remove the temp, pack cord and take a new impression after healing has
occurred. Can also prescribe Chlorhexidine to help reduce inflammation etc.
Retraction Pastes –
(2)
Traxodent (Expasyl, Dryz)
Magic Foam Cord (PVS)
Traxodent (Expasyl, Dryz)
-15% aluminum Chloride
Magic Foam Cord (PVS)
(2)
-Material Expands in sulcus
-**Does not have a hemostatic agent
**If using a paste, best to combine with a
single small cord and add pressure with a
cotton cap
Electrosurge
(7)
-Burns tissue away
-Burnt tissue odor
-Cauterizes (no bleeding after)
-Tissues heal quickly
-Predictability of final tissue contour or location is
unpredictable
-Inexpensive! (maybe $500 versus $5,000 for laser)
-Easy to use
Laser
(6)
Vaporizes tissue
”Cut” around the tooth is usually ragged
Laser can be slow to cut. Best for fine detail work. If there
is a lot of tissue to contour or remove, use Electrosurge.
Hemorrhage is not a problem
Tissue heals well
Laser available in UMKC Clinic
Rotary
(5)
Intentional use of a handpiece to remove excess gingiva
Hemorage can be a problem here
Tissues will heal, but may have some discomfort to patient
Healing contour and levels is unpredictable
Final impression not likely to happen same day. Patient
will have to come back for assessment of healing
results and of tooth preparation and impression.
