ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10077-3279 |
Comparative Evaluation of Two Isolation Techniques for Proximal Restorations: A Clinical Controlled Study
1,2Department of Paediatric and Preventive Dentistry, Sri Aurobindo College of Dentistry, Sri Aurobindo University, Indore, Madhya Pradesh, India
Corresponding Author: Khushboo Barjatya, Department of Paediatric and Preventive Dentistry, Sri Aurobindo College of Dentistry, Sri Aurobindo University, Indore, Madhya Pradesh, India, Phone: +91 9893523334, e-mail: khushboo.barjatya@gmail.com
Received: 07 August 2023; Accepted: 05 September 2023; Published on: 30 December 2023
ABSTRACT
Introduction: Successful restorations depend on number of factors, but perhaps the most important one is isolation. However, achieving it in a pediatric patient is the biggest challenge. Despite rubber dam being the gold standard for isolation, it is not being used commonly in children. MiniDam by DMG is a comparatively recent advancement that is being used to compare with conventional rubber dam for their isolation efficiency and patient’s attitude.
Materials and methods: A sample size of 30 patients with a minimum of two proximal lesions bilaterally requiring glass ionomer cement (GIC) restorations was selected. Selected patients were treated in two appointments under rubber dam and MiniDam per appointment. They were evaluated for time for placement, isolation efficacy, child’s behavior, and pain perception.
Conclusion: It was concluded that both materials have their merits and demerits, but mini dam has better patient compliance and comparable isolation efficacy.
How to cite this article: Goel A, Barjatya K. Comparative Evaluation of Two Isolation Techniques for Proximal Restorations: A Clinical Controlled Study. J South Asian Assoc Pediatr Dent 2023;6(3):105–108.
Source of support: Nil
Conflict of interest: None
Keywords: Class II restorations, Isolation, Primary tooth, Rubber dam
INTRODUCTION
Caries susceptibility is found to be higher in primary teeth due to broader contact areas as a result of a diminished capacity for self-cleaning and increased plaque buildup.1
For restorations in primary teeth, resin-modified glass ionomer cement (GIC) and composite resin are suitable materials.2 Primary and secondary caries, loss of retention, endodontic problems, and restoration fracture were the main causes for retreating the restored teeth. Several variables affect how well restorations turn out, but moisture control may be the most crucial. Excluding moisture and saliva from the tooth being restored reduces the risk of infection and makes it easier for the restorative material to bond to the tooth.3
Conventional glass ionomers are not advised for proximal restorations in primary molars, as claimed by systematic review, due to flaws like poor anatomical form, mediocre integrity, and inadequate moisture control.4,5
Achieving patient compliance to perform proximal restorations under proper isolation is one of the biggest challenges of pediatric dentistry.6 According to a Cochrane evaluation published in 2016, using rubber dams could prolong the life of dental restorations. However, it is seen that rubber dams are not frequently utilized by dentist, especially in children.3 Sanghvi et al. cited time requirements, patient cooperation, lack of experience, and expense as reasons why dentists do not regularly use the rubber dam.7
Researchers are looking into newer isolation methods and materials that would make the process easier for the patient and the operator while still providing a satisfying level of isolation. Recently, MiniDam (DMG) was developed to help isolate and restore proximal lesions. It is a two-tooth slot system that is clamp-free, latex-free, and stabilized.8 This investigation’s goal is to compare isolation efficiency and patient’s attitude toward mini dam and conventional rubber dam for restoration of class II caries.
MATERIALS AND METHODS
Study Materials
- Rubber dam kit (Hygenic Dental Dam kit, Coltene, Whaledent, United States of America) (Fig. 1A).
- MiniDam (DMG Germany) (Fig. 1B).
Figs 1A and B: (A) Rubber dam; (B) Mini dam
Study Design
The current investigation is a randomized clinical trial following Ethical and Research Committee approval from Sri Aurobindo College of Dentistry SAIMS/IEC/23/22. The study was conducted on 6–8-year-old patients reporting in the OPD of the Department of Pediatric and Preventive Dentistry who required restorations on proximal surface, Sri Aurobindo College of Dentistry, Indore, India from September 2022 to December 2022.
Sample Size
The sample size was estimated using the software G*Power version 3.1.9.7. Considering the power of the study at 95% and the margin of the error at 5%, the value obtained is 30. So, each study group will comprise 15 samples. For estimation of the effect size and power of the study, values were taken from a review of previous literature.8 A representative of 30 patients with a minimum of two proximal lesions requiring restorations were selected.
Inclusion Criteria
- Patient between 6 and 8 years of age.
- Patients who have more than one proximal carious lesion that needs simple restoration.
- Patients who required multiple appointments.
Exclusion Criteria
Patients who were unwilling to be part of the study.
Procedure
- A total of 30 patients with consent were seen twice for treatment. The rubber dam was utilized before the mini dam in the initial 15 patients. For next 15 patients, the same operator employed the mini dam before the placement of rubber dam. A gap of 1 day was kept between the two appointments. The standardization of technique was done by using a typodont.
- For rubber dam—The adequacy of a winged rubber dam clamp is tested by placing it on the tooth; rubber dam is properly punctured, and the bow of the clamp is pushed through the hole, leaving the clamp’s wings underneath the rubber dam. The clamp’s jaws are then spread open by engaging them with forceps. The entire assembly is moved and put on the tooth. The clamp is then released from the forceps, and the stability of the clamp is rechecked. After that, the clamp is freed from the forceps, its stability is tested once more, and the frame is placed (Fig. 2A).9
- For mini dam—The mini dam was stretched over the tooth of interest. Saliva ejectors and cotton rolls were used as an adjunct to achieve proper isolation (Fig. 2B).
Figs 2A and B: (A) Rubber dam new; (B) Mini dam cropped
After obtaining isolation, restorations were done using conventional glass ionomer cement. During the procedure, all the parameters were recorded.
Outcome Measures
Time of placement was recorded for rubber dam isolation from the point of selection of the clamp till the placement of the frame, whereas for mini dam, it was noted from the point it was stretched over the tooth till placement of saliva ejectors and cotton rolls, and was evaluated using a stopwatch.
Isolation efficacy was graded at the end of the restorative procedure, visually by a trained operator and graded as grade I—adequate; grade II—inadequate.
The child’s behavior was graded according to Frankl’s behavior rating scale during placement of the isolating material and treatment.
Pain perception was set down by pointing out Wong–Baker faces9 pain rating scale during treatment. This is a 10-point scale in which 0 is no hurt and 10 is worst hurt (Fig. 3).
Fig. 3: Wong–Baker faces pain rating scale
Statistical Analysis
The data were analyzed using the Statistical Package for Social Sciences (SPSS) 20.0 version. The data was analyzed for probability distribution using the Kolmogorov–Smirnov test. The distribution of time of placement was normal, and thus, a parametric test of significance (viz paired t-test) was applied for the comparison of time of placement between two methods. The comparison of the child’s behavior and efficacy of isolation between the two methods was done using the Wilcoxon test and McNemar’s test, respectively. Significant p-value < 0.05 and confidence interval was kept at 95%.
RESULTS
The number of patients with definitely positive behavior was more on using mini dam compared to rubber dam, although this difference was statistically nonsignificant. None of the patients showed negative or definitely negative behavior after using the mini dam, whereas 13.3 and 6.7% of patients showed negative and definitely negative behavior, respectively, after using the rubber dam. However, this difference was statistically nonsignificant (p-value > 0.05). There was no difference in the child’s behavior on using the rubber dam or mini dam (p-value > 0.05) (Table 1).
| Rubber dam | Mini dam | Test applied | p-value | ||
|---|---|---|---|---|---|
| Child’s behavior | Definitely positive | 10 (33.3%) | 27 (90.0%) | Wilcoxon test | 0.952 |
| Positive | 14 (46.7%) | 3 (10.0%) | |||
| Negative | 4 (13.3%) | 0 (0.0%) | |||
| Definitely negative | 2 (6.7%) | 0 (0.0%) | |||
| Efficacy of isolation | Leakage present | 2 (6.7%) | 3 (10.0%) | McNemar’s test | 0.655 |
| Leakage absent | 28 (93.3%) | 27 (90.0%) | |||
| Pain perception | No hurt | 4 (13.3%) | 16 (53.3%) | Wilcoxon test | 0.000* |
| Hurts little bit | 18 (60.0%) | 14 (46.7%) | |||
| Hurts little more | 8 (26.7%) | 0 (0.0%) | |||
| Hurts even more | 0 (0.0%) | 0 (0.0%) | |||
| Hurts whole lot | 0 (0.0%) | 0 (0.0%) | |||
| Hurts worst | 0 (0.0%) | 0 (0.0%) | |||
*p-value < 0.05 was considered statistically significant
No significant difference was seen in the efficacy of isolation by the two methods (p-value > 0.05).
The number of patients reporting “no hurt” on using mini dam (53.3%) was significantly more compared to those using the rubber dam (13.3%). The number of patients reporting “hurts little more” on using mini dam (0.0%) was significantly less compared to those using rubber dam (26.7%).
The mean time of placement for the mini dam (1.4543 ± 0.72329 minutes) was significantly less than the mean time of placement of the rubber dam (5.23 ± 0.96209 minutes) (p-value < 0.05) (Table 2).
| Rubber dam | Mini dam | Test applied | p-value | ||
|---|---|---|---|---|---|
| Time of placement | Mean | 5.23 | 1.4543 | Paired t-test | 0.000* |
| Standard deviation | 0.96209 | 0.72329 | |||
*p-value < 0.05 was considered statistically significant
DISCUSSION
Rubber dam has many benefits, including antisepsis,10 moisture control11 and protection of soft tissues,12 protection from endodontic instrument aspiration or toxic materials,13 prevents cross infection, and shields the operator’s licit liability in the event of any mishaps.14,15 Additionally, it improves the effectiveness of the treatment by preventing the buildup of fluids in the oral cavity, especially those with a disagreeable taste, and making it easier to do four-handed dentistry.14,15 However, due to the cost and difficulty in placement, general dentists and specialists do not favor the use of rubber dams. Recently, mini dam was developed to help isolate and, in particular, restore proximal lesions.7 Its two-tooth slot design, lack of latex, and ability to be stabilized without the need for clamps.8
In the present study, the duration for placement of the mini dam was less in contrast with the rubber dam, which is explained as placing the rubber dam has multiple processes, whereas placing mini dam is a single-step process. It is worth noting that both isolation techniques were technique-sensitive, and skill must be developed through practice.
Pain perception was found to be better in patients with mini dam compared to rubber dam. During placement of rubber dam, patient experiences discomfort due to the pressure from the rubber dam clamp. Also, placing its frame and sheet enhanced younger patients’ fear and anxiety, whereas placing mini dam was hassle-free.
Although more leaks were found in mini dam isolation, no statistically significant difference was noted in their isolation efficacy.
It is worth noting that as mini dam has a two-slot system, it also helps in better proximal wall buildup.
As it is well established in the literature that the rubber dam provides good isolation efficacy with additional benefits, including antisepsis, moisture control, retraction and protection of soft tissues, and protection against aspiration of endodontic instruments.10-13 Whereas the mini dam provides additional advantages like better proximal wall buildup, less chair time, less pain perception, and better behavior management, which makes it a preferable choice for pediatric patients. In a study done by Priyanka et al.,8 efficacy of isolation was evaluated by recording the presence or absence of seepage of gingival blood or fluid. Seepage was absent in 93.3% of the teeth in the rubber dam group, whereas this percent was found to be 86.7% in the mini dam group. Child’s behavior was seen to be statistically similar, and the patient-evaluated pain perception score was found to be marginally worse in the mini dam group compared to that in the rubber dam group.8 Their findings with respect to isolation were aligned with our findings, whereas contrasting results were noted with respect to the factors like child’s behavior and pain perception.
CONCLUSION
Within the constraints of the investigation, it can be stated that although the placement of the mini dam is technique- and skill-sensitive and does not provide superior isolation when compared with conventional rubber dam, but due to its characteristics like the ease in placement, better behavior management, comparable isolation efficacy, reduced pain perception and chair time makes it a better choice for proximal lesions, especially in pediatric patients.
Limitations
The sample size of the study was very small to draw any conclusion. Also, for recording isolation efficacy, a subjective method was used, which can cause operator bias.
DISCLOSURE STATEMENT
The present study has no financial relationships to disclose. None of the authors have any conflicts of interest.
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