Fluid Control Flashcards
what is fluid control
controlling water and saliva during tooth preparation
what happens when you have too much water and too little water
- too much water: you cant see and patient is drowning
- too little water: you can heat tooth and cause pulpal necrosis
what is gingival control
saliva and crevicular fluid management is crucial for making a quality impression and for proper cementation
what is soft tissue management good for
preparation, impression and cementation
how is soft tissue managed
lasers, electrosurge or a scalpel to re countour the gingiva as well as move or remove it from the operative environment
what are the uses for rubber dam
- still the gold standard for isolation and moisture control
- caries control 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 provides _____ for resin cement procedures
necessary isolation
is the dam removed to check occlusion
yes
primary way to manage fluid during preparation is with:
high speed suction
what are the other products to manage fluids
- cotton roll isolatio n
- releaf hands free suction device
- dry angle cheek guards
- nu-bird suction and mirror in one device
- dentopop
describe isovac and isolite and what it does
- 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
what is used in clinics as alternative to rubber dam
isovac
what are the medications used to reduce saliva
- GI anticholinergics
- clonidine
describe GI anticholinergics
- Robinul
-Pro- Banthine - decreases stomach acid and other secretions including saliva
- contraindicated in patients with heart disease/glaucoma/asthma
describe clonidine (anti-hypertensive drug)
- safer than anticholinergics but have side effects like sedation, blurred vision, allergic reactions
- caution for hypertensive patients
the health and biotype of the gingiva needs to be evaluated:
prior to, during and after restorative treatment
what parts of poorly contoured restorations are responsible for inflammatory reactions
- roughness and porosity of materials
- inaccessibility for patient OH
- lack of patient OH
- defective crown margins
- invasion of biological width
describe periodontal health management with gingival control
- use the provisional to re-create or maintain proper gingival contours
- SRP may be needed to remove foreign substances and kickstart the healing process
- pre-placement of retraction cord and careful final marginal preparation
- chlorhexidine 0.12% for two weeks prior to crown preparation can be useful in more significant inflammation situations
what makes up the biologic width
junctional epithelium and connective tissue attachment in the gingival sulcus
describe the radiographic evaluation with biologic width
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 sulucs
- usually 0.5-1mm sub gingival
what kind of ginginva are more susceptible to damage and recession
thin,scalloped
what type of gingiva is more stable, responds better to treatments and more resistant to recession
thick, flat gingiva
why is gingival control so critical to restorative treatment
rapid marginal recession may occur as soon as 2 weeks
what can marginal recession occur from
- damage during tooth preparation
- over contoured provisional
- over contoured final crowns
- injury caused by cord packing
- poor OH resulting in inflammation
what is the purpose of tissue retraction
- to displace the gingiva for margin exposure
- as a cutting guide during tooth preparation
- displacement of gingival tissue for impression
- control of crevicular fluids
what is the purpose of tissue retraction as a cutting guide during tooth preparations
- tissue protection during margin placement
- visualization of the finish line
what is the purpose of displacement of gingival tissue for impression
- when margin is at or below the gingival contour
- for impression and die trimming
what is the purpose of placement of retraction cord prior to preparation
- improves visibility
- reduced tissue trauma
- acts as a guide for margin placement
what is the order of placing the margin then packing cors
begin with a rough preparation supragingival to start then pack cord and proceed to finalization of preparation and margin
what is the goal of cord placement
- cord causes vertical displacement of tissues to visualize the margin placement
- allows subgingival margins without significant damage to tissues
cord can be left in place for final impression using:
the 2 cord technique
cord placement aims for a depth of:
no deeper than half the depth of the sulcus
what does packing cord do
- provides space for enough impression material to record this anatomy
- removes fluids and anatomy to accurately record the crown margins
- helps arrest heme
- aids in cleanliness and dryness prior to impression
what are the 3 techniques for gingival control
- mechanical
- chemo-mechanical
- surgical
what are the mechanical techniques for gingival control
- rubber dam
- retraction cord
- cordless materials - pastes, gels, compoundsw
what are the chemo-mechanical techniques for gingival control
- retraction cord and chemicals for hemostasis
what are the surgical methods for gingival control
- electrosurgery
- laser
- scalpel
how does the retraction cord work
- produced enlargement of the gingival sulcus
- stretches circumferential fibers to displace tissue laterally and vertically
what are the types of retraction cord
- braided, twisted, knitted
- sizes #000- #3
what cord is used at UMKC
ultradent knitted cord
using a retraction cord and a hemostatic agent what should be considered
- 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 placementwh
what are the advantages and disadvantages of retraction cord soaked in epi
- A: can be kind to tissues, sulcus not overly harmed and left clean, no additional tissue loss
-D: extra epi systemically for pt
why is retraction cord soaked in epi not used at UMKC
unpredictability in the exposure of epi to patients
what are astringents
substances that cause constriction of soft tissues
what do astringents do
bleeding control in various dental proceudres such as impression making in fixed pros, class V restorations and root surface restorations
what are astrignents made of
-buffered aluminmum chloride (20% hemodent)
- ferric sulfate (15%) astringedent
what are the advantages and disadvantages of astringents made from buffered aluminum chloride (20% hemodent)
- A: moderate hemostasis and tissue shrinkage, precipitates protein, contracts blood vessels, extracts fluid from tissues, leaves sulcus clean, sulcus not overly harmed, does not inhibit PVS polymerization
- D: nasty taste
what are the advantages and disadvantages of astringents made from ferric sulfate (15%) astringedent
A: stypic (clotting agent), applied to cut tissue for best hemostasis
- D:leaves a dark residue, causes dentin discoloration (dont use with veneers or esthetic cases), inhibits setting of PVS impression materials, leads to inaccurate impressions
what is the mechanism of dentin darkening in ferric sulfate astringedent
possible high acidity of gingival retraction fluids 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:
- provide adequate thickness or impression material and access to the preparation marin
- reduced tears and distortions of impression material
- sulcus is opened in a cone shape
what is the single cord technique
- 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
what is the double cord technique
- # 000-#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
- must remove first cord after ipression before patient goes home
what happens if you dont remove cord before patient leaves
inflammation and pain
what is considered the gold standard for impression taking
double cord technique
what is the tissue retraction procedure
- use of local is mandatory
- moisture control is mandatory
- place cord near crevice
- place looped cord around tooth with cotton forceps
- start in deepest part of sulcus ( usually interproximal)
- use blunt instrument
- use gentle pressure to avoid stripping attachment
- placement is parallel to the root
why is moisture control mandatory
prevents dilution of hemostatic agents, cotton rolls to displace tongue and cheek. other isolation techniques can be used
why is the use of local anesthesia mandatory
patient comfort, also aids in reduced salivary flow and some heme control
what is the angle of the cord placement at the tooth
approximately 45 degrees
straight downward pressure causes cord to:
not seat and creates tissue trauma and further bleeding
packing cord towards starting point will:
keep cord in place
packing cord away from starting point will:
pull cord out
what are the common problems with cord placement
- 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
what is step 1 of cord placement procedure
- determine # of cord to use (2 cord techqniue is the default)
- select largest cord you believe will fit appropriate for your technique
- cut cord into anticipated length plus a little extra
what is step 2 of the cord procedure
- place cord segments into hemostatic solution
- 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 patients gingiva will be bleeding some astringedent can be drawn into syringe and placed on cart
what is step 3 of cord procedure
- 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
what is step 4 in cord procedure
- 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
what is step 5 of cord placement
- allow cord to site and be isolated for 3-5 minutes
- remove top cord
- air dry the tooth and cervicular area
- place light body material into sulcus circumferentially
- below the impression material down into the sulcus with lots of air
- start again to place light body impression material
- palce in impression tray with medium, hard, or rigid impression material
- remove any remaining smaller cord prior to temporizing
what are the cautions for cord placement
- do not remove a dry cord it will tear the gingiva creating bleeding and an inflamamtory reaction
- double cord technique- always make sure you took out both cords
what do you do if cord has been placed and does not overflow the sulcus but you still have bleeding from your preparation or patients gingiva is unhealthy
- sub astringent on tissue until bleeding stops
- remove dark debris from astringent by using hemodent and cotton pellet
- dry thoroughly
- check for bleeding and repeat if needed
what do you do if bleeding cannot be controlled well enough for a final impression that day
temporize, send pt 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
what are the retraction pastes
- traxodent: 15% aluminum chloride
- magic foam cord (PVS)- material expands in sulcus, no hemostatic agent
if using a paste best to combine with:
a small cord and add pressure with a cotton cap
traxodent works best with
narrow cord in sulcus and retraction paste placed coronally
what does soft (kaolin paste) do
produced gently pressure on sulcus while absorbing excess fluid
what does aluminum chloride fo
creates astringent effect without irritating or discoloring surrounding tissue
traxodent rinses without:
leaving a film
describe electrosurge
- burns tissue away
- burnt tissue odor
- cauterizes (no bleeding after)
- tissue heals quickly
- predictability of final tissue contour or location is unpredictable
- inexpensive
- easy to use
describe the laser
- 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
- available at UMKC clinic
describe rotary
- intentional use of a handpiece to remove excess gingiva
- hemorrhage can be a problem here
- tissues will heal, but may have some discomfort to patient
- healing contour and levels is unpredictable
- final impression not lilkely to happen same day
healthy predictable gingiva can be managed and maintained with:
proper pre treatment assessment, management, selection of appropriate armamentarium and care
