Diabetes education booklet

Introduction to diabetes
Approximately 1.4 million people in the UK have diabetes and it is suggested by Diabetes UK
that there could be another one million people with diabetes and are unaware they have it. The
majority of people with diabetes (85% - 90% will have Type 2 diabetes). The remainder will
have Type 1 diabetes.
Diabetes Mellitus is a condition in which the amount of sugar in the blood is too high. When
we eat a meal the starchy and sugary carbohydrates are changed into sugar (glucose ) during
dijestion and this sugar then passes into the bloodstream. When the pancreas senses that
there is a rising level of glucose in the blood it secretes a hormone called insulin. Insulin
changes glucose into energy which provides fuel for the body. Insulin is vital for life because
without it, the glucose could not be changed into energy and the body could not function
without energy. It is often said that insulin acts like a key – unlocking the cell to allow the
energy in. Obviously, like a car, we only need a certain amount of energy to provide for the
requirements of the body. If we eat more than we need this will be stored as fat.
Signs and symptoms of diabetes
· Excessive thirst
· Frequency in passing of urine
· Blurred vision
· Loss of weight
· Tiredness
· Mood changes
· Frequent infections e. boils, thrush etc
Types of diabetes
There are two main types of diabetes:
· Type 1 ( used to be called insulin dependent ) affecting children and young adults
mostly
· Type 2 diabetes ( used to be called non insulin dependent ) is commoner in the
over 40 year olds although children as young as sixteen and obese are
alsodeveloping Type2 diabetes
Main Aim of treatment
The main aim of treatment of both types of diabetes is to normalise blood glucose levels to
protect against long term damage to the eyes, kidneys, nerves,
heart and all the blood vessels. Some experts call diabetes “a blood vessel disease” because
preventing narrowing of the blood vessels is key to preventing complications.
Type 1 diabetes
The exact cause of Type 1 diabetes is unknown but thought to be due to a viral infection or
environmental factors. In type 1 diabetes there is total destruction of the cells in the pancreas
( beta cells ) that produce the insulin. The onset of type1 diabetes is acute, because as stated
earlier insulin changes glucose into energy but in the absence of insulin, glucose builds up in
the blood and is not turned into energy. In an effort to overcome the lack of fuel for the normal
functioning of the body, fats and proteins are broken down instead. This is why
patients are often underweight at diagnosis.
Once treatment with insulin is started the patient will begin to feel better quickly and will
regain the lost weight.
Treatment for type1 diabetes
People with Type 1 diabetes will need injections of insulin for the rest of their lives. Insulin is
destroyed by the gastric juices so cannot be taken in tablet form.
People with Type1 diabetes will need a minimum of two injections daily and often more. They
will also need to eat a healthy diet and take regular exercise and do regular self blood glucose
testing
If you have been diagnosed with Type 1 diabetes please ask your health professional for the
special section on “ Insulin Ttreatment” which will give you much more specific and detailed
information.
Type 2 diabetes
Type 2 diabetes occurs when the pancreas secretes less insulin than normal or when the
insulin secreted fails to work properly (called insulin resistance). People who are overweight
are five times more likely to develop Type 2 diabetes and four out of five people with Type 2
diabetes are overweight. Excess weight increases your body’s own glucose production and
thus your body’s need for insulin too. At the same time, this extra insulin increases fatty acids
stores and further increases insulin resistance. It becomes a vicious circle.
Type 2 diabetes is particularly associated with central excess weight ( apple shaped rather
than pear shaped). Health risks increase when waist circumference is greater than 37inches
(94cms) in men and 31.5 inches (80cms ) in women. Reducing calorie intake if you are
overweight will help your body use insulin better by reducing insulin resistance.
You will find a whole section of this book devoted to healthy eating, weight control and
exercise.
Type 2diabetes has a gradual onset. You may not feel any symptoms beyond a little tiredness
which is often mistakenly attributed to age and working hard. As Type2 diabetes progresses
you may become aware of some of the signs already mentioned or you may be diagnosed
whilst being investigated for something else. It is suggested by experts that most people have
had Type2 diabetes for at least five years before diagnosis.
The following people are at an increased risk of developing Type2 diabetes:
Family history of diabetes
Asian or Afro-Caribean origin
Women who have had gestational diabetes
Obese people
People who take little exercise
Older age
People on certain medications eg steroids, and some anti psychotic medications
Treatment for Type2 diabetes
People with Type2 diabetes will be encouraged to eat a healthy balanced diet and take regular
exercise. They will be treated with diet only for the first three months after diagnosis (unless
their blood glucose is very high and they are losing weight). If diet and exercise alone does
not control your blood glucose levels you may also need to take tablets.
Diabetes and Driving in UK
Having diabetes does not mean that you cannot drive as long as you doctor says you are safe
to do so – this is usually when your diabetes becomes stable and controlled. You will
however have to plan in advance before getting behind the wheel of your car if you are on
certain tablets for your diabetes and/or taking insulin.
You must by law inform the Driver and Vehicle Licensing Agency (DVLA) if
Your diabetes is treated with tablets or insulin
If your treatment changes from tablets to insulin or if insulin is added to the
tablets
If there are changes in your health or condition that may affect your ability to
drive safely
If you are applying for a licence for the first time, you must answer YES to the
question about diabetes.
People Treated with Insulin
After you have written to the DVLA informing them of your insulin treatment, you will be sent a
form (called “Diabetic 1”), asking for more information and for the name and address of your
GP/ Hospital Doctor. You will be asked to sign a consent form allowing the DVLA to contact
the doctor directly for more specific information on your diabetes control, eyesight and general
fitness to drive.
This does not mean that you will be refused a licence – it just ensures safety for you and
other drivers. Please answer all questions fully and honestly.
After you have informed the DVLA that you have diabetes, they will send you a letter
explaining your responsibility to re-notify them if you start having insulin or have
“hypos” (low blood sugar), or if you develop any of the complications of diabetes which could
affect your ability to drive.
They will not normally ask you any other questions at this stage and you will normally expect
to keep your “till to” licence.
No restrictions on driving and do not need to inform DVLA.
Restricted Licences
Insulin treated – a driving licence will be issued to you for one, two or three years if you are
treated with insulin. Just before expiry date, you will receive a reminder to renew your licence
and you will be asked to return your current licence. You will be sent another “Diabetic1” form
to confirm your medical condition. Renewals of restricted licences are free.
Tablets or diet treated – usually issued with a “till to” licence. When you reach 70 years of
age, you will be expected (like everyone else in UK) to renew it every one to three years. There
is a charge for this renewal.
Provisional licences – applies to insulin treated only – need to be renewed every one, two or
three years.
When renewing licences, it is always sensible to keep a copy of the old licence or to make a
note of the driver number, before sending to the DVLA. The process takes between six – eight
weeks unless there are complications.
If you drive a motorcycle the rules for informing the DVLA are the same as for a car.
Eyesight Problems
Obviously it is important to have good distance vision and good field of vision (what you can
see side to side when looking straight ahead). There are various tests that an ophthalmologist
can do to carry out to test these factors. Your licence may be revoked if you fail a field of
vision test, but you can appeal against it. There are different types of field of vision tests,
some people do better on one type versus another. The DVLA will accept the results of any
approved type of test.
Large Goods Vehicles (LGV) and Passenger Carrying Vehicles (PCV)
In 1991 the titles of HGV (heavy goods vehicle) changed to LGV
And PSV (public services vehicles) changed to PCV.
People treated with diet alone or diet and tablets are normally allowed to hold LGV and PCV
licences, provided they are otherwise in good health.
People treated on insulin are not allowed to hold these licences. If you currently hold such a
licence and start using insulin you must inform the DVLA and stop driving the vehicle
immediately.
In 1996, the regulation on larger vehicles was extended to include medium sized vehicles.
Anyone passing their driving test after 31 st December 1996 will only be given a licence to
drive vehicles up to 3.5 tonnes.
Vehicles weighing 3.5 tonnes – 7.5 tonnes (Category CI ) and mini buses (DI) are now treated
as Group 2 vehicles – normally there is a complete ban on insulin users obtaining a group 2
licence. However some CI licence holders can now apply for a medical assessment and can
regain ability to drive these vehicles whilst on insulin. Please write to the DVLA for more
information.
Taxis
The law does not bar insulin users from driving taxis, provided they are less than nine seats.
As local councils issue licences the policy may vary in different parts of the UK. Some taxi
authorities issue blanket restrictions. Please contact Diabetes UK and DVLC for more
information.
Diabetes in Pregnancy (Gestational Diabetes)
If you need to commence insulin in pregnancy, you should notify DVLA immediately.
You will normally be allowed to continue driving but are recommended to stop if your control
becomes unstable or if you do not have good warning signs of hypoglycaemia. You should re
notify the DVLA six weeks after delivery if you are still on insulin, as your licence will need to
be reassessed.
If you have problems relating to your driving licence, please discuss it with your diabetes
team, who will be able to advise you. DVLA wish to issue licences, not to take them away –
you can help by giving as much information as possible.
DO NOT DRIVE IF
· You have difficulty recognising early signs of hypoglycaemia (Section )
· You have started on insulin and your diabetes is not yet controlled.
· You have problems with eyesight not corrected by glasses
· You have numbness or weakness in your feet caused by nerve damage or circulation
(neuropathy or ischaemia)
· You have been drinking alcohol.
Precautions before Driving
Long journeys need careful planning, allowing for regular stops if you are on
specific tablets for diabetes and insulin.
Normally it is wise to have something to eat every two to three and half hours if you are on
insulin and not to miss meals and not to delay meals if you are on tablets and insulin.
Test your blood sugar before driving and regularly during a long drive or if at
work before you drive home at the end of the day or shift.
·Always carry quick acting glucose and slow release carbohydrate in the car at all
times if you are on insulin or specific diabetes tablets.
Always carry identification on your person and in the car stating your name, how
your diabetes is treated and the name of your GP.
At the first sign of Hypoglycaemia
· Stop driving as soon as it is safe to do so
· Remove ignition key and move into passenger seat.
· Immediately take glucose tablets or sugary drink (both may be required)
· Follow this with slow release carbohydrate i.e sandwich, crisps, biscuits etc.
· Wait for at least 15 – 20 minutes until you feel better, recheck blood if possible, if you
do not feel better, take more glucose and biscuits and wait a further 15 minutes.
· If you continue to feel unwell – call for help and do not drive – if considering using
motorway emergency assistance, please remember you may be unsteady on your feet, so
take extra glucose before walking.
Car Insurance
The main potential danger of diabetes and driving is the possibility of having a hypoglycaemic
episode which could impair your judgement and lead to an accident.
Since the Disability Discrimination Act came into effect at the end of 1996, insurers can only
refuse cover if they have evidence of increased risk.
It is virtually important to inform your motor insurance that you have diabetes.
Your motor insurance may become invalid if
· You fail to update them on changes to your treatment or physical condition
· You fail to notify the DVLA as mentioned previously
· You fail to comply with DVLA restrictions or recommendations
Diabetes UK Services has an exclusive service that will search through a panel of insurers for
the best quote, - freephone 0800 731 7431.
Life Assurance / Insurance
Some people experience difficulty getting life cover. It is important that you declare your
diabetes when applying for a new policy. Any life policy you hold at the time of diagnosis is
unaffected.
Any difficulties ring Diabetes UK Careline 0845 120 2960
Or write to Diabetes UK Careline, 10, Parkway, London, NW1 7AA (operates a translation
service also)
Travel Insurance
Many travel insurance policies exclude pre-existing medical conditions such as diabetes, you
must check carefully if your policy includes or excludes diabetes.
Some insurance companies charge an extra £10 - £15 to include diabetes. It is worth having a
letter to this effect from the insurers
Diabetes UK are continually expanding the service they offer. Please see relevant telephone
lists at the back of this booklet.
Diabetes and Employment
An employer cannot by law refuse to employ you or dismiss you purely because you have
diabetes, according to the Disability Discrimination Act (DDA1995).
Although most people with diabetes do not consider themselves to have a disability, diabetes
is covered by the Act.
Certain professions are exempt from the DDA and can refuse to employ someone with diabetes,
especially if they are treated with insulin, these include
· Air line crew
· Armed services
· Off shore workers
· Train drivers
· Any work requiring LGV and PCV
· Police force
However, if diabetes is diagnosed whilst in this employment, it may be possible to continue
with some negotiable changes in your duties.

How to Write a Research Proposal

Framework of the Research Proposal
A research proposal is a written document that includes the following information:
– Summary of prior literature.
– Identification of research topic and research questions.
– Specification of procedure to be followed to answer research questions.
The purpose of your proposal is to sell your idea by showing you have thought it through very
carefully and have planned a good research study.
There are three major sections of a research proposal, although the exact headings can vary:
I. Introduction
II. Method
III. Data Analysis
Two examples of Tables of Contents for a research proposal are shown in Table 4.1 (see your
textbook).
• Notice that the headings can vary.
• When you write a proposal, check with your committee or funding agency to determine
if they have a preferred layout of headings.
I. The introduction section of your proposal.
• The purpose of this section is to introduce your research idea, establish its importance
(i.e., you want to “sell” it to your reader), and explain its significance.
• Flow of the introduction:
– Start with a general introduction that
• defines the research topic.
• demonstrates its importance.
– Then review the relevant literature.
– This review should lead directly into a statement of the purpose of the study and your
research questions.
II. The method section of your proposal.
• This provides a written description of the specific actions, plan, or strategy you will
take to answer your research questions.
• It includes information about your proposed
– Research participants
– Design
– Apparatus or instruments, and
– Procedure.
Participants
The subsection of the method section entitled participants should provide a written
description of the individuals who will participate in your research study and how they will be
recruited.
Be sure to specify the following
Their demographic characteristics such as age and gender.
Inclusion and exclusion criteria you will use.
Any inducements for participation you plan to use.
Where they are located.
Design
In this subsection of the method section, entitled “Design, you present your plan or strategy
to be used to investigate your research questions.
• You must include a separate design section if your design is complicated; otherwise you
can put in your procedure section.
• The following is included in the design section:
– Type of design and design layout of your study (e.g., you might use a pretest-posttest
control-group design).
– Description of all the variables being examined in your study.
– Description of how your variables are to be combined.
– Description of the points of measurement and manipulation in the design.
Apparatus and/or Instruments
In this subsection of the method section you describe any apparatus and or instruments you
propose to use in your research study.
The following information should be included:
– General description of the apparatus or instruments.
– Variables measured by instruments.
– Reliability and validity of instruments.
– Why the instruments or apparatus are used.
– Reference indicating where apparatus or instruments can be obtained.
Procedure
In this subsection of the method section of your proposal, you carefully describe how your
study will be executed.
• The following information should be included in the procedure section:
– A description of the design if it was not previously described.
– A detailed step-by-step description of how the study will be executed.
The reader should know exactly what you intend to do after reading this description. It should
include enough information to tell the reader how to do the study if he or she wanted to
replicate it.
III. The data analysis section of your proposal describes exactly how you propose to analyze
the data you plan on collecting.
In a quantitative study, you will use some type of statistical analysis. You need to specify
those analyses.
In a qualitative study, there is no one or “right” way of analyzing the data. You must explain
the approach you propose to use and justify its use. In general, qualitative analysis will
involve coding and searching for relationships and patterns in qualitative data.
An abstract is required in completed research studies; it is an optional section in a research
proposal. You will need to determine if one is needed in your case.
The elements of the abstract will include the following:
Concise statement of research hypothesis or research questions.
Statement of expected number and characteristics of participants.
Brief summary of procedure or way data will be collected.
Brief statement of how will analyze results.
Abstract is optional in proposals.
Sample Research Proposal
Resident: John Smith, PGY2
Research Mentor: Jane Doe, MD, Section of General Internal Medicine
Date of Proposal: February 5, 2009
I. Title of Proposed Research Project Medical Students as Mediators of Change in Tobacco
Use  
II. Specific Aims
In conducting this study, we will accomplish the following specific aims:
Specific Aim 1. Compare the effectiveness of the stage specific smoking cessation
counseling intervention with the control intervention by evaluating the impact on the
following patient outcomes at 1, 3, 6 and 12 months: a) quit rate, b) stage of change, c)
desire to quit, d) motivation to quit, e) confidence in quitting (self-efficacy), and f) nicotine
dependence.
Hypothesis 1. Patients counseled by students initially trained in stage specific smoking
cessation counseling will have higher quit rates, improve their stage of change, increase
their desire to quit, be more motivated to quit, have higher confidence in quitting, and have
less nicotine dependence at 12 months.
Specific Aim 2. Compare the effectiveness of the stage specific smoking cessation
counseling intervention with the control intervention by evaluating the impact on the
following processes of care rated by patients at 1, 3, 6 and 12 months: a) satisfaction with
the quality of care in general, and b) satisfaction with the quality of care related to smoking
cessation counseling.
Hypothesis 2. Patients counseled by students initially trained in smoking-specific
behavioral counseling will have greater satisfaction with both measures of quality of care at
12 months.
III. Background
Tobacco is the only legally sold product known to cause death in one half of its regular
users.(1) Thus, of the estimated 1.3 billion people in the world who smoke, nearly 650
million will die prematurely as a consequence.(1) In the United States, approximately 25% of
men and 20% of women, or 46 million adults, smoke.(2) The financial toll of tobacco use in
the U.S. is substantial. Estimated costs include $75 billon per year in medical expenditures
and $80 billion from lost productivity.(3) The personal health risks of smoking are even
more significant with respect to morbidity and mortality. Although the role of physicians in
cessation efforts has been demonstrated, many physicians fail to counsel patients. The
most common reasons cited for lack of counseling include inadequate training and time
pressures. Our intervention will target medical students in the early stages of training. The
proposed intervention will provide a foundation for medical learners in stage specific
counseling and will aid physicians in primary practice to help their patients stop smoking.
The rationale for this program is that providing education early and allowing students to use
these skills with patients in the community can help: 1) future physicians with confidence in
smoking cessation counseling, 2) physicians in the community who may not have adequate
time to counsel patients, and 3) patients whose health may be at risk from smoking.
IV. Research Methods
Study Design : Randomized cross-over trial consisting of two smoking cessation
counseling interventions: 1) counseling intervention including patient education, written
material and follow-up by students who have been trained in stage specific tobacco
cessation techniques, and 2) counseling intervention that includes patient education, written
material and follow-up by students who have been trained in non-smoking cessation
techniques (exercise counseling).
Setting : Community practice sites in internal medicine, family medicine and pediatrics
throughout Connecticut where medial students attend weekly continuity sessions with
physician preceptors.
Study Subjects : 80 first-year medical students and 308-350 patients aged 16 years or
older in the students’ community practice sites who are seeing the students’ physician
preceptor for any reason and meet criteria of smoking one or more cigarette daily in the
previous week.
Randomization: Students will be randomized by the day they attend their Principles of
Clinical Medicine Course and trained in stage specific tobacco cessation counseling or
exercise counseling. After 6 months, students will receive training in the other behavioral
counseling technique.
Main Outcome Measures: patients’ quit rate, stage of change, desire to quit, motivation
to quit, confidence in quitting (self-efficacy), and nicotine dependence at 1, 3, 6, and 12
months.
Process Measures : patient satisfaction with the quality of care in general, and
satisfaction with the quality of care related to smoking cessation counseling.
Analyses: patient level analyses of main outcome and process measures comparing
patients who received counseling from students trained in smoking cessation counseling
and patients who received counseling from students trained in exercise counseling adjusting
for potential confounding factors. We will use logistic regression for dichotomous outcomes
and linear regression for continuous outcomes. We will use generalized estimating
equations (GEE) and random effects modeling to allow us to adjust for time-dependent
covariates
V. Timeline of Research Project
Month
Activity 1 2 3-4 5 6-9
10-12 13-14
Student randomization X
Train standardized patient X
Assess student behavioral counseling skills X
Train student in smoking or exercise counseling X
Assessment of office practice sites X
Train medical assistants to recruit patients X
Recruit patients X X
Patient counseling in-person
X X
Patient counseling by phone
X X
Data collection X X
Data analysis
X X
Prepare publication
(s) X
Present research at scientific
meetings X
VI. Literature Cited
1. World Health Organization Website: WHO tobacco Treaty set to become law, making
global public health history. WHO . 2005. 1-17-2005.
2. Cigarette smoking among adults--United States, 2001. MMWR Morb Mortal Wkly Rep
2003; 52(40):953-956.
3. Centers for Disease Control. Targeting Tobacco Use, the Nation's Leading Cause of Death
2004. CDC. 2005. 1-19-2005.

RUBBER DAM - Benifits for the patient and dentist, technique

Introduction
Most texts that discuss operative treatment for children advocate the use of rubber dam, but it
is used very little in practice despite many sound reasons for its adoption. In the United
Kingdom less than 2% of dentists use it routinely. It is perceived as a difficult technique that is
expensive in time and arduous for the patient.
In fact, once mastered, the technique makes dental care for children easier and a higher
standard of care can be achieved in less time than would otherwise be required. In addition, it
isolates the child from the operative field making treatment less invasive of their personal
space.
The benefits can be divided into three main categories as shown below.
Safety
Damage of soft tissues
The risks of operative treatment include damage to the soft tissues of the mouth from rotary
and hand instruments and the medicaments used in the provision of endodontic and other
care. Rubber dam will go a long way to preventing damage of this type.
Risk of swallowing or inhalation
There is also the risk that these items may be lost in the patient's mouth and swallowed or
even inhaled and there are reports in the literature to substantiate this risk.
Risk of cross-infection
In addition, there is considerable risk that the use of high-speed rotary instruments distribute
an aerosol of the patients' saliva around the operating room, putting the dentist and staff at
risk of infection. Again, a risk that has been substantiated in the literature.
Nitrous oxide sedation
If this is used it is quite likely that mouth breathing by the child will increase the level of the
gas in the environment, again putting dentist and staff at risk. The use of rubber dam in this
situation will make sure that exhaled gas is routed via the scavenging system attached to the
nose piece. Usually less nitrous oxide will be required for a sedative effect, increasing the
safety and effectiveness of the procedure.
Benefits to the child
Isolation
One of the reasons that dental treatment causes anxiety in patients is that the operative area
is very close to and involved with all the most vital functions of the body such as sight,
hearing, breathing, and swallowing. When operative treatment is being performed, all these
vital functions are put at risk and any sensible child would be concerned. It is useful to
discuss these fears with child patients and explain how the risks can be reduced or
eliminated.
Glasses should be used to protect the eyes and rubber dam to protect the airways and the
oesophagus. By doing this, and provided that good local analgesia has been obtained, the
child can feel themselves distanced from the operation. Sometimes it is even helpful to show
the child their isolated teeth in a mirror. The view is so different from what they normally see
in the mirror that they can divorce themselves from the reality of the situation.
Relaxation
The isolation of the operative area from the child will very often cause the child to become
considerably relaxed¾always provided that there is good pain control. It is common for both
adult and child patients to fall asleep while undergoing treatment involving the use of rubber
dam¾a situation that rarely occurs without. This is a function of the safety perceived by the
patient and the relaxed way in which the dental team can work with its assistance.
Shows rubber dam placed in the a child and with the comfort it provides it is not unusual for
children to fall asleep in the dental chair during treatment under rubber dam.
Benefits to the dentist
Reduced stress
As noted above, once rubber dam has been placed the child will be at less risk from the
procedures that will be used to restore their teeth. This reduces the effort required by the
operator to protect the soft tissues of the mouth and the airways. Treatment can be carried out
in a more relaxed and controlled manner, therefore lessening the stress of the procedure on
the dental team.
Retraction of tongue and cheeks
Correctly placed rubber dam will gently pull the cheeks and tongue away from the operative
area allowing the operator a better view of the area to be treated.
Retraction of gingival tissue
Rubber dam will gently pull the gingival tissues away from the cervical margin of the tooth,
making it much easier to see the extent of any caries close to the margin and often bringing
the cervical margin of a prepared cavity above the level of the gingival margin thus making
restoration considerably easier. Interdentally, this retraction should be assisted by placing a
wedge firmly between the adjacent teeth as soon as the dam has been placed. This wedge is
placed horizontally below the contact area and above the dam, thus compressing the
interdental gingivae against the underlying bone. Approximal cavities can then be prepared,
any damage from rotary instruments being inflicted on the wedge rather than the child's
gingival tissue.
Quite often it can be difficult and time consuming to take the rubber dam between the
contacts because of dental caries or broken restorations. It is possible to make life easier by
using a 'trough technique', which involves snipping the rubber dam between the punched
holes. All the benefits of rubber dam are retained except for the retraction and protection of
the gingival tissues.
Moisture control
As mentioned previously, silver amalgam is probably the only restorative material that has any
tolerance to being placed in a damp environment, and there is no doubt that it and all other
materials will perform much more satisfactorily if placed in a dry field. Rubber dam is the only
technique that readily ensures a dry field.
'Trough technique' of rubber dam placement.
Technique
Most texts on operative dentistry demonstrate techniques for the use of rubber dam. It is not
intended to duplicate this effort, but it would seem useful to point out features of the
technique that have made life easier for the authors when using rubber dam with children.
Analgesia
Placement of rubber dam can be uncomfortable especially if a clamp is needed to retain it.
Even if a clamp is not required the sharp cut edge of the dam can cause mild pain. Soft tissue
analgesia can be obtained using infiltration in the buccal sulcus followed by an interpapillary
injection. This will usually give sufficient analgesia to remove any discomfort from the dam.
However, more profound analgesia may be required for the particular operative procedure that
has to be performed.
Method of application
There are at least four different methods of placing the dam, but most authorities recommend a
method whereby the clamp is first placed on the tooth, the dam stretched over the clamp and
then over the remaining teeth that are to be isolated. Because of the risk of the patient
swallowing or inhaling a dropped or broken clamp before the dam is applied, it is imperative
that the clamp be restrained with a piece of floss tied or wrapped around the bow. This adds
considerable inconvenience to the technique and the authors favour a simpler method whereby
the clamp, dam, and frame are assembled together before application and taken to the tooth in
one movement. Because the clamp is always on the outside of the dam relative to the patient
there is no need to use floss to secure the clamp.
A 5-inch (about 12.5 cm) square of medium dam is stretched over an Ivory frame and a single
hole punched in the middle of the square. This hole is for the tooth on which the clamp is
going to be placed and further holes should be punched for any other teeth that need to be
isolated. A winged clamp is placed in the first hole and the whole assembly carried to the
tooth by the clamp forceps. The tooth that is going to be clamped can be seen through the
hole and the clamp applied to it. The dam is then teased off the wings using either the fingers
or a hand instrument. It can then be carried forward over the other teeth with the interdental
dam being 'knifed' through the contact areas. It may need to be stabilized at the front using
either floss, a small piece of rubber dam, a 'Wedjet', or a wooden wedge.