Seal the Deal: Perfecting Rubber Dam Placement in Endodontics

because sometimes the contact is very very tight which will prevent the rubber dam from going interdentally and on the other hand sometimes the contact is very open that it will not retain the rubber dam sheet sometimes we'll have to do to work with an older restoration that is bad like we see this with old amalgam restorations all the time the contact is deformed so it will cut the rubber dam sheet while inserting it so i'll have to modify the teeth before placing the rubber dam sheet Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. Today, we're diving into a fundamental yet often underappreciated pillar of successful endodontics, and that's the rubber dam. Our guest is Dr. Robert Milad, a passionate endodontist from Cairo, Egypt, who brings eight years of clinical experience and a deep commitment to education, training both dental students and fellow clinicians in the art and science of rubber dam isolation. He believes the key to mastering rubber dam placement is keeping an open mind, experimenting with different techniques, and eventually developing a system that's both efficient and effective. In this episode, we'll cover it all, from isolation planning and how it ties into whether or not you'll place a core after the root canal, to choosing the right rubber dam clamp, whether it's winged versus wingless, passive versus active. We'll learn all about them. You'll also learn how to test for leakage and what to do when it occurs. of rubber dam thickness and how to communicate with patients who are resistant to having a dam placed on their face. We'll also hear from Dr. Milad about his favorite hand instrument for inverting the rubber dam. And we'll talk to him about dental floss and Teflon and how those things can make all the difference in perfecting your seal. And of course, we'll address the most common mistakes dentists make when placing rubber dams and how you can avoid them. So whether you're new to rubber dam placement or looking to refine your technique, I think this episode is packed with practical pearls and real world insight. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Milad, it's a pleasure to have you on the show. The pleasure is mine. Yeah, we're very happy to have you on the show, Dr. Milad, and thank you for making the time to talk with us. I know you're in Egypt right now, and that's eight hours ahead of where I am now, so I know you had a long day already. So we do appreciate your dedication to doing this podcast episode. So let me begin this episode with a foundational endodontic question, and that is, why is proper isolation so critical during endodontic procedures? Let's take a step back. The whole idea or concept of endodontic treatment is removing as much as we can from the pulp tissue and the associated bacteria and microorganisms that cause the inflammation in the first place. And even if we do everything right, there is no guarantee that we removed everything, which is proven by so many papers. That's why at the end we end up doing, preparing the canal mechanically, then working chemically and removing the pulp remnants and bacteria. And we end up, as Dr. Cohen preferred to say, we end up by entombing the bacteria. so not using the rubber dam is critical because of many reasons first of the arrogant the arrogance we use should not come in contact with the patient mounts first of all the taste it tastes very sour we don't want to give the patient this negative experience but to be honest that the least of our problem we also want to avoid the accidental swelling of sodium hypochlorite and other arrogance as well it can cause chemical burn and i saw it happen before In one of universities I was in, the patient ended up vomiting blood, which was not a fun experience for anyone. Some patients don't tolerate opening their mouths for too long, they can't tolerate the dryness that can happen, or they think that that suction is not working well, so they have to rinse their mouths every once in a mile. How are we supposed to be working in an aseptic condition if the patients keep doing this? If we're working in a pool of saliva, there is nothing to guarantee that nothing will come in contact with the canal and compromise my treatment. In the end, using proper isolation gives me focus and remove the distraction, which is essentially if I'm searching for an MB2 or a middle mesial canal or even dealing with a broken file. Yeah, and also what you did mention, which is also very obvious, is the operator dropping a file down the patient's throat, right? Exactly. Yeah. Again, the sodium hypochlorite coming in contact with soft tissue in the patient's mouth is not a good experience, and it's something that should be avoided at all costs. How has your approach to rubber dam isolation evolved over the years? Now, I know you teach at various places. You teach endodontics and isolation specifically to younger dentists and dental students. What has happened over your teaching career and also your clinical career where you have looked at isolation as something that really should be focused on from the educational standpoint? In the beginning, when I was still in dental school and just graduated, I didn't understand rubber dam that much. I only know the four basic clamps, the anterior, the premolar, molar, and B4 clamps. And even then, I couldn't apply them perfectly. I still have leakage in class 1 composite restoration without having any idea why is it leaking. I didn't know about inversion. I didn't know about active clamp. I tried to isolate severely, compromised teeth with a passive clamp, and when I tried to touch the sheet on the frame, the clamp would end up flying in a comedic sense, like a scene from a comedy movie. Sealing leakage, I used to do it with liquid dam, or a gingival barrier. Sometimes I did it with a temporary filling material, because I didn't know better. But with experience, and the more cases I am subjected to, the more interested and invested I became in rubber dam. I started to test the clamp alone before placing the sheet to check the stability. I started to know that there is a thing called inversion to avoid having leaky parts from around the teeth. I started flossing mesial and distal to the clamp, which made a hell of a difference. The most important thing I now understand is the isolation planning. Like the book Seven Habits of Highly Effective People once said, I have to start with the end in mind. Am I trying to achieve isolation for a simple endo, or am I doing the core as well? Am I doing single or multiple isolation? Does the teeth need some sort of modification before placement or all is good? So let me ask you this. When you start talking to a dental student or a new dentist that's out and you kind of relate to them because you know what you didn't learn when you were coming out of dental school and it was really just reach for whatever clamp was on the bracket table and whether it had wings or didn't have wings, whether it was active or passive. The only thing that I learned, when I was in dental school was that if it had wings, you put the rubber dam on as one unit. The wings are to hold the rubber dam so you can place the whole thing on the tooth. And that's what some dentists taught me was the best way. And other dentists said, no, put the clamp on first and then put the rubber dam on. So when you started to see the deficiencies in the clinical knowledge of the people that you were dealing with, the dentists that you were dealing with, what did you see was the big weak point? One of the biggest issues that I often find is not testing the clamp. Because let's get real for a moment. Whether it's an active or a passive clamp, a winged or a wingless clamp, anterior or premolar or molar. In a standard case, they are all interchangeable. It has minute differences between all the cases. So I can use a molar clamp on a molar and it won't be as stable as using a premolar on a molar. So for me, checking the stability of a clamp is the first thing that should be done. We'll be getting right back to our guest in a second, but first, for the optimal bond between zirconia and your resin cement, check out Bisco's Z' Plus. Rated best in class by thousands of top clinicians, Z' Plus, featuring MDP, creates a strong, reliable bond to zirconia. metal, and alumina substrates. And nothing could be simpler. It comes in a single bottle, and it's 100% compatible with both light-cured and dual-cured resin-luting cements. It's time you get the most out of your zirconia restorations. To learn more about Z-Prime Plus and the entire Bisco adhesive product line, visit bisco.com. And what's the best way to check the stability? Let's give an example, a clinical example. You're doing a molar root canal tooth number 30, broken down pretty badly, where it's going to need a post, not necessarily a post, but it's going to need a core, core buildup. What's your process now when you test a clamp before you even start doing the root canal therapy? by experience and by knowledge i know i'm gonna need an active wingless clamp and we're gonna get to that later on i start by applying the clamp alone without a sheet without a frame without even removing the curves i just want to see its stability now my favorite method to check the stability is by applying up an escalating pressure upon the jaw with my fingers. I just insert my finger below the bow and I try to remove the clamp. If the clamp is stable, and I often tell the student this, you can move the whole head of the patient using just one finger. Another thing that I prefer to do is putting my finger distally to the bracket and pulling in a mesial direction. I am imitating the directional and the force that's going to be done by the sheet itself. When you say the sheet, the rubber dam, the rubber dam material. So you put your finger distal to the clamp and you push mesially horizontally along the plane of occlusion? Exactly. Okay, and you're trying to simulate the force that would be created by the actual rubber dam sheet. Exactly. Okay, why is that moving forward? Because when I start applying the sheet on the clamp and I start stretching the sheet on the frame, that's the force that I'm going to face. the frame and the sheet is going to make a mesial force on the clamp. So what determines whether the clamp is stable on the tooth? I mean, does it have to pop off? It doesn't necessarily have to pop off. If it even moves the slightest bit, then I know it's not stable. Because if it moves the slightest bit, there is no guarantee that it's going to be stable for the whole treatment. Right. Now, if you have a tooth that's broken down below the gum line that's very compromised, and there's very little tooth structure that you could work with above the gum line, Which clamps are you going to go with initially for your test? Yeah, initially for my test, I start by using a Brinker clamp. Brinker clamp, I love them, been using them like since eight years ago. I found them to be durable. I found them to be very strong. And among the variable clamps available in the market where I practice, they are the most clamped that exert the maximum force to retract the tissues. I've used them multiple times to retract remaining roots. So tell us more about a brinker clamp. What does it look like physically? Okay, the brinker clamps are wingless, which is very important for my job. To be honest, personally, I don't like the wings at all. It's some sort of distraction for me. But the most important thing is they are active. The beaks and the jaw are inclined epically, so as to engage as much of the tooth structure as we possibly can. I assume you put the clamp on the tooth first and then put the rubber dam sheet over it because there are no... wings to do it in one motion. Exactly. That's my favorite way of doing it. And we talked offline about this, Dr. Milad. You like to use a very limited number of clamps. It saves you time in the whole process of doing this isolation, and you're sticking to the Brinker system. Address that, if you would, for a minute. In my clinic, I have over 20 clamps, but I end up always using the Brinker clamps for 99% of my cases. For me, I like to do the isolation as fast as I can. I'd like to take the... better time to do access or cleaning and shaping and my irrigation protocol. I don't want to spend a lot of time doing isolation. So when using the brinker clamps and active clamps, they reduce my isolation time by so much time. I'm used to them. I know how they work. I know all their tricks. So it's better for me. So as endodontists, which we both are, we all know that we get a lot of cases where there's... curved canals, calcified canals. But one of the challenges that GPs face, and they end up sending the cases out often to us, is when there's no access back there. There's just the opening is very, very limited. What do you do for clamping back in those hard to reach areas? Wingless clamps can be heaven. They can be the difference between success and failures when we're working with upper seven and upper wisdom teeth. we can routinely do restorative treatment on upper seven and upper eight. And if you don't mind, Dr. Milad, I just want to interrupt for a second to clarify to our audience in at least the United States, upper seven, upper eight is upper second and third molars. So we're talking way back. Exactly. Now, the problem with working with upper seven and upper eight that there is sometimes constrained space and no place to put a big clamp because of the prominent mandibular ramus. Now, the wingless clamps are usually smaller, which allow for easier placement. And sometimes in cases like this, we can actually put the rubber dam clamp with the sheet in the same step, something we call the butterfly technique. So once you place the rubber dam over the brinker clamp, how do you assess the quality of the overall isolation? The first thing I like to do, which I also tell all the people that I teach rubber dam, after I complete the isolation process, I remove my hands for 10 seconds. okay i want to see the beauty that i have created and also i want to wait to see if there are any hidden leakages that will show later on that's the first thing i do the second thing i like to do the water test i just filled the rubber dam with water from the triple way syringe and asked the patient if he can feel any cold water in his mouth usually if i'm doing the isolation right the patient doesn't feel a thing and to be honest i like to do the water test because it's better to be water than arrogant If you do notice seepage during that evaluation period, what do you do then? Usually, there are four hidden places that can cause leakage. Sometimes I forget to floss distally, so I'd re-floss distally, or I did it but not enough. Flossing the rubber dam sheet distally means the sheet has to go interdentally between the teeth. So the idea of flossing is to kind of push that dental dam fabric in between the teeth. Exactly. What about the cases where the tooth is broken down? And the contact area is so large that that's not conducive to do the floss. It's not enough. The fluid is still leaking out between the tooth that you're working on and the adjacent tooth because there's just so much space there. Then comes the teflon. The teflon is one of the best things that I can use in an isolated case in a badly decayed teeth. I can just forcibly put it into the sulcus and it would prevent any contamination and prevent any leakage. I usually place it between the teeth. and the tooth inside the sulcus so it will not only prevent any leakage but will also help inverting the sheet into the sulcus it's basically in the gap it's going to it's going directly into the sulcus and it's with the force of the teflon tape it's it's turning the exposed margin of the rubber dam it's inverting it essentially exactly okay Then do you do another test of spraying the water with the air water syringe just to confirm that it's... Of course. Okay. How long does that whole process take you to put a rubber dam on number 30 with choosing the clamp that you like, which you already know in advance, placing it, placing the rubber dam on... Actually, before you place the rubber dam on, you test the stability of the clamp. So you have to do that. Then you place the rubber dam on and then, again, test for leakage and everything else. What's that whole process? take as far as time relatively it doesn't take usually that much time i once made my assistant shoot a video of me putting a quadrant isolation rubber dam It only took six minutes. Six minutes to do the entire, the tooth is completely isolated with, and that's if there's leakage and you've covered that. Six minutes actually is not a short period of time. I'm assuming, Dr. Milad, you can probably do it faster than that, but you were filming it for a video and you were probably explaining things and showing armamentarium and that's what. took the extra time. And I bet that you would probably do it in half that time on a regular basis. Just curious, Dr. Milad, do you sometimes delegate out to an assistant to place the rubber dam? I usually don't prefer doing this because I like to make sure every step is correct. I'm a meticulous person. And I have so much love for rubber dam that I want to do it myself. Yeah. And I think when we talked earlier, Dr. Milad, I think you emphasize the point that preparing up front Really good isolation will save you a lot of time down the road. Exactly. Yeah, that's important. Do you sometimes clamp multiple teeth just for stability when you're doing endodontics? Or is it only the tooth that you're working on? We'll be right back with our guest. But first, I want to tell you about VOCO's newest composite, Grandioso for You. Top clinicians are calling it the most tooth-like universal composite ever made. Unlike traditional composites that force you to choose between either an anterior aesthetic composite, a stronger layering posterior composite, or a fast but aesthetic compromising bulk fill, Grandioso 4U does it all, simplifying your workflow while delivering superior results in a single material. It cures 4mm in just 10 seconds, looks stunning with 5 cluster shades covering all 16 Vita shades, and handles like a dream with 50% less resin. It's a 91% filled nano hybrid, giving you tooth-like strength, ultra-low shrinkage, exceptional wear resistance, and an amalgam-like high radio opacity. So as they say, seeing is believing. So grab your free sample of Grandioso for you today at voco.dental. Most of the time, if I'm doing the core or the final buildup, I like to do multiple isolation. Give us an example of that. So let's say I'm doing endodontic treatment on the lower right 6. And the lower right 6 has a mesial cavity as well. So I'll end up putting an anchoring clamp on the lower right 7 and extending my isolation to the first premolar. Now, sometimes I put a clamp on the first premolar and sometimes not, according to how tight the contact is. Sometimes when the contact is tight and good, it can retain the rubber dam sheet without having to put any clamp. Sometimes when there is a missing canine or the contact is very bad, I like to put an additional clamp anteriorly. So generally speaking, though, if you're just doing endo, no restorative work, and you're doing tooth number 19, which you call lower right 6, You're going to put the clamp on the actual tooth that you're doing the root canal on and you're not going to use a secondary clamp. It's rare that I use a secondary clamp. If I'm doing a simple class one or a simple endo and the care is with just a class one as well, I do single tooth isolation. There is no need to extend the treatment time to do multiple isolation. Single isolation is enough. So let's talk about the rubber dam fabric itself. Now, I know there are several options regarding color, and there's a reason why rubber dams are black. That's for aesthetic photography, not to get the reflection of the color into the restoration. So they go with black, but you're doing endo. Is there any particular color that you prefer and why? To be honest, in my restorative work and in the dental treatment, I use blue or a light blue rubber dam sheet. I like it because it's better for my eyes. It's more relaxing. But if I'm cementing a crown and I need that extra edge while photographing my work, I usually go for the black rubber dam sheet. Okay. So it's good to have both colors on hand. And as far as taste, you're not, I talked to you earlier about that, and that's not a big thing for you, like mint flavored or anything like that. You go with a, you don't go with any particular. flavored rubber dam? I don't care about the taste. My patients never care about the taste. I had never heard a complaint about the taste. So it's one less thing to worry about. Yes. No, that's true. Because some people may not like mint or may not like whatever. Yeah. No, totally, totally get you there. So I also want to ask you, Dr. Milad, about the thickness of the rubber dam sheet. Obviously, a thinner sheet is more flexible. A thicker one may be more resistant to tearing, but it's more rigid. What do you typically prefer for your endo cases? to be honest i've tried all the thicknesses there is to the rubber dam sheet and i've reached to the stage that most of my cases if i'm doing quadrant isolation i'm going to use the heavy thickness i'm a meticulous person i don't want to risk the sheet breaking or being cut when i'm working so i may as well put the heavy sheet Because of the thickness of the actual rubber dam sheet, Dr. Milad, are you finding that when you stretch it, it's putting more force on the clamp and in some cases dislodging it? Although, of course, you're getting the benefit of the stronger and tear resistant material. I have this problem with some brands of the rubber dam sheet, but not all of them. I never use a thin sheet. So in light of the fact we've been talking about... rubber dams for 20 minutes or so. What is your go-to brand? And actually, the brand you mentioned may not be available in the States, but I'm sure our audience is curious to know which brand of rubber dam you're currently using. I like sanctuary rubber dam sheets. In the old times, I used to work with a company called Nickton. I used the rubber dam sheet, but I find them very rigid. You said very rigid? Yes. Now, with the Sanctuary rubber dam sheets, the heavy thickness is just as flexible as the medium and the thin. This is a point of strength. And to reiterate that brand name, it's called Sanctuary? Yeah. Okay, is that sold in North America? I assume it is, but... I assume it is as well. And I'm checking that out as we speak. They're available in the United States, and they're latex-free, so that's even better. And when it comes to the rubber dam clamps, I know when I practiced endo, Coltine were the ones that I used. They owned the whole market. are you a fan of the coltine brand clamps i love them i use them for 99 of my cases so you talked about earlier the brinker style clamp exactly they are made by coltine okay so they're brinker clamps that are made by coltine okay so let me pivot a little bit to some pushback that you might get from a dentist that you're teaching for instance um or is attending one of your lectures and they raise their hand and say i can't spare the time to put a rubber dam on it's just too time consuming and I could isolate with cotton rolls and other ways. You mentioned six minutes with the video that you produced, but I'm sure, like I mentioned, I think you can probably get that down to half that if you were, especially if you didn't spring a leak somewhere and you had to repair it with Teflon or whatever, or floss or both, and it went fairly smoothly, which probably a lot of cases do, you probably could do it in two minutes. But when a dentist responds to you saying, I don't have the time and my dental assistant is not skilled to do it, so I can't delegate it to him or her. What do you say to that? I say that anything in dentistry can be time consuming if you're not trained enough. Like, we as endodontists, when we first started, it could take us three visits to complete a molar. But with enough practice and equipment, we can now do one-hour molar endo, sometimes with the core as well. The problem is that rubber dam is not hard in itself. It's the lack of experience. Or inherently, some dentists are not totally convinced about using it, so they don't do the effort. Yeah, I can't agree with you more on that, Dr. Milad. That's true. I never thought I would do a molar root canal in an hour when I started my career. But over time with the right training, that's how it turned out. So I do agree with that. And the more you use a rubber dam and the more you become familiar with all the tricks of the trade, like, you know, you've talked about some of them, it will become easier. So let's pivot a bit and talk about the use of anesthesia. So obviously, we're getting the patient numb. We're giving them local anesthetic to perform the endodontic procedure. What are you doing additionally, if anything, to make sure they're comfortable with the rubber dam? If I'm giving an inferior abular nerve buck, I will end up doing buccal infiltration as well. If I'm working with upper teeth, then I will end up giving palatal infiltration as well. One of the things, Dr. Milad, that we discussed prior to the podcast was interesting to me. Now, I know we practice in different parts of the world. You're in Cairo, Egypt, and most of our listeners are North America. We do have listeners in probably over 40 countries right now on this show. But one of the things that surprised me was that some of the pushback you get from dentists that you teach specifically on rubber dam isolation is that it costs too much. The cost of the rubber dam material is too expensive. That could be that in your country, it's very hard to get this material and it's very, very pricey. And maybe if they would use it on every patient, if they're doing restorative, endo, whatever, it adds up. But it seems to me that would be not a big concern here in North America. But I do think it's interesting for you to elaborate on that. Like you said, sometimes I hear dentists say to me that rubber dam is expensive. But let's look at it this way. How much is the rubber dam sheet, which is the only consumable thing? Every other thing in the rubber dam armamentarium is autoclavable and reusable. So the only consumable thing is the rubber dam sheet. And put that in contrast with how much does it cost for a drop of bond? Or how much is the endodontic treatment cost when you have to do it for free because it's your mistake, you didn't isolate it well? Or how much, which is the most important thing I'm going to talk about, how much for the bad reputation that a patient can give you because your feelings routinely debond and endo fails? Right. So you're talking about rubber dam placement on not only endodontics, but all restorative procedures, correct? Exactly. Yeah. So when you give them that response to their argument saying that it costs too much for the rubber dam material, what do they say? Actually, some dentists are convinced. And the people who are not convinced, I usually break it down to them financially. If I can't convince them, is there... It's their choice. I won't force anyone to do anything. But for me, I prefer to do the right thing. I prefer to work with proper isolation. It's better for my peace of mind. Yeah. And, you know, the expression goes, you can't save your way to prosperity. You can't save your way to prosperity by cutting corners on materials that are crucial to the procedure, which is absolutely, to me, non-negotiable as far as rubber dam and endodontics. As far as restorative work, I could see how some dentists use other forms of isolation for restorative work. But again, based on the conversations I've had with you, Dr. Milad, and your expertise with isolation, I think you're way ahead of the curve here. Thanks so much. Yeah. So I do want to touch upon the use of gingival barrier regarding leakage of a rubber dam. You have your opinion on it. I'd like to hear it. And also, you know, what our options are. i usually don't use gingival barrier material unless i absolutely have to or i am in a hurry i'm just doing an emergency case and i just have to open an access between appointments then i will use it but as a general rule i wouldn't trust gingival barrier as much some clinicians even use it to build the whole walls which is used later on as a reference point which is not the best thing to do as it can break any time making us repeat whole steps The whole point of having a reference point is having a standard and a stable point on which I build all my work. If you find yourself needing to do this, then the tooth needs buildup before starting the endotreatment. Also, gingival barrier material doesn't adhere to the tooth like composite. Personally, I am used to working with microscope and I often I see leakage from under the gingival barrier. So essentially, Dr. Milad, you obviate the need to use a gingival barrier by doing a deep margin elevation. Exactly. And by doing so, once that margin is brought up higher occlusally, then when you put your rubber dam system on, most of the time you don't even have any leakage problems. Is that correct? Exactly. So what's the order in your procedure as far as access, deep margin elevation? What do you do first and so forth? Expand on that if you would. Actually, I do the access first and then I do the pre-endodontic buildup. According to how much time will it take? is the decisive factor in which will I do the endodontic procedure at the same time or not because let's say if I'm doing a deep margin elevation on a premolar usually it doesn't take that much time and premolar usually doesn't take much time if they are single or a double canal so I may do the premolar and complete the endodontic treatment till the end. But sometimes I'll have to deal with a lower six or a lower seven MOD cavity, and I have to do margin elevation, both mesial and distal. The patient can tolerate all that time. I'll have to do the margin elevation and then delay the endodontic treatment for another visit. And you mentioned to me earlier, Dr. Milad, you take a very interesting step to prevent a mishap in the chamber. with material that you're using for the deep margin elevation and you certainly don't want that ever to happen. Tell us about what you do to prevent composite from getting into the chamber. First, I want to remove all cares and then I want to open the access to accurately decide about the size of the pulp chamber so I can put Teflon in the pulp chamber to avoid having any composite that can block any of the canals. So for those of us who use rubber dams, every so often we encounter a patient that doesn't like rubber dams for whatever reason. Maybe they had a bad experience in the past or they just have rubber dam anxiety. They can't have this thing framed around their mouth for an hour. What do you do to get patients to accept rubber dam placement so you can move forward with your endodontic therapy? I've been practicing for eight years now. In eight years, I only had one patient who absolutely refused. rubber dam actually what i found to be more beneficial is patient education if i explain rubber dam as thorough as i can and explain that this is for their benefit actually and usually they agree on the spot and the most importantly if you know how to do it fast the patient will trust that you know what you're doing if the patient can sense and believe me they can sense that you're having trouble putting it on and you keep repeating steps they will ask you not use it In their mind, they will say, this doctor is not good at this step. Let's skip it and save ourselves some time. Yeah, I can't agree with you more on many of the things you just said, especially the fact that the patient knows when a dentist is fumbling during a procedure. They could sense the lack of skill that reduces confidence between the dentist and the patient, which is the last thing we want, because that affects everything going forward. So I think it's really important, like you said, education, training, do it fast, do it well. And the meticulousness that you practice endodontics under is really respectable and honorable because it's so important to isolate everything when you're doing that kind of work, especially if you're including a deep margin elevation. You want to make sure that everything is isolated. And I think it's great that you practice this way and teach this to your students and dentists where you are in Egypt and elsewhere. So over the years, with all the interaction you've had with the students and dentists you teach, what do you find to be the most common pitfall, pain point that dentists are falling into related to the placement of the rubber dam? The most prominent mistake that I see is that some dentists are... flexible enough they know that this more this is a molar clamp i should place it on a molar this is a pre-molar clamp i should place it on a pre-molar but rubber dam isolation is very dynamic clamps are interchangeable how many times i've placed pre-molar clamps on molars or anterior clamps on pre-molar so many times more than i can count sometimes i check the stability of a clamp before starting the treatment and then while working i decide to change the clamp because i've seen something That requires me to change the clamp. Sometimes it's the accessibility, sometimes it's not comfortable for the patient, and I don't want to increase the anesthesia. I think it's admirable, Dr. Milad, that you don't necessarily have to follow the rules to a T. When I say that, I mean following the manufacturer's instructions saying that this clamp fits on this tooth. It's obviously your call based on your experience, and it certainly seems to be working for you. And I think that's a great way to approach dentistry is to have an open mind, experiment, and think out of the box. And another example, actually, of how you think out of the box, based on our offline discussion, Dr. Milad, is typically we use a passive clamp when we have the natural contour of a crown remaining. So we're doing our access through the occlusal surface of the tooth, and the clamp is passively sitting in the undercut of the crown, whether it's a natural crown or artificial crown. But either way, you're going with an active clamp, generally wingless. Tell us why. I'd like to use an active wingless clamp as well because it will help me later on when I'm doing the core and I have to place a matrix and a ring. It will not interfere with all of my equipment and armamentarium. So we talked about it earlier how much you rely on the Brinker clamps. Tell us what that set is made up of. Now they have six clamps that go from B1 up to B6. And they are very selective like B1 and B2 and B3 are for molars. B4 is for retracting upper interiors and lower interiors. B5 and B6 which can be used for all anterior teeth. That's the set I use for most of my work. Now for frames, in the old times I used to use the metal frames a lot. But what I noticed is sometimes it's not comfortable for the patient having a metal frame in contact with their skin for so much time. So when I switched to the plastic frames, it made that much difference for me and for the patient as well. And also radiographs, right? And when you take radiographs, you benefit from having a plastic frame, of course. So when you teach dentists, young dentists that are coming out of school or dentists that have been out that don't use rubber dams, what's your key message to them as far as recommendations? I say to them, please invest in more equipments and clamps. It's going to be worth it. And always use rubber dam, even if you do it bad. Just practice. Practice makes perfect. And the last thing, which we just said minutes earlier, be open to change your isolation plan according to each patient's specific case. In addition to endodontics, you also use rubber dam placement on all of your restorative work? Exactly. I use rubber dam for my endodontic procedure, restorative. Sometimes I cement crowns with rubber dam as well. And once the rubber dam is placed, what do you use for suction for the patient? I always use the high suction. But to be honest, if I'm doing a good rubber dam isolation, the patient rarely asks for me to suction anything in their mouth. So you rely on the patient to swallow themselves to clear the fluid in their mouth. Yes, and it's very natural for them. Yeah, and the reason for that is because you're not getting any fluid leaking down through the rubber dam. Exactly. So you mentioned... the importance, Dr. Milad, about planning, isolation planning. We normally don't talk about isolation planning as much. If we're going to use a rubber dam, we put it on and that's it. Tell us about your thoughts about isolation planning before starting a root canal. To be honest, for me, a correct planning is also important to maximize the isolation effectiveness and reducing the possible operative time. For me, the competent practitioner should place the dam in a few minutes and with the outmost care. And this actually will increase the patient compliance toward the isolation techniques. For me, the isolation planning comes in multiple steps. First, I have to determine the extension of my isolation. Am I doing the endodontic treatment alone or doing the filling as well or the final buildup? Am I doing single tooth isolation or multiple teeth isolation? Is it a class 1 or a class 2 or a MOD? Okay, usually for me, and this is very important and I usually teach it a lot. If the planned restorative treatment affect interproximal surface, then the isolation will have to be multiple isolation. I'll have to involve more teeth. If I'm working with a mesial box, I have to extend the clamp one tooth beyond the one I'm working with. And if there is a distal box and distal caries, I extend the clamp two teeth beyond the one I'm working with. Are you saying in these cases you use more than one clamp? I just use one anchoring clamp and do the rest with ligature floss. Also, there's... a very important thing that we have to do in planning before testing the clamp we actually have to floss between the teeth to accurately determine if the contact between teeth is good or it does need some sort of modification because sometimes the contact is very very tight which will prevent the rubber dam from going interdentally and on the other hand sometimes the contact is very open that it will not retain the rubber dam sheet Sometimes we'll have to do to work with an older restoration that is bad. Like we see this with old amalgam restorations all the time. The contact is deformed, so it will cut the rubber dam sheet while inserting it. So I'll have to modify the teeth before placing the rubber dam sheet. So what happens if there, let's talk about the tight contact. There's absolutely no room, barely to get floss between those teeth. What do you do there? Sometimes I lubricate the underside of the rubber dam before. placing the rubber dam sheet. In other times, it depends on the case. If between the teeth, there is a caries, and I'm planning to go ahead and remove the caries and do class two restoration, sometimes I use finishing strip to just move the contact and reduce it like a bit. Right, so you do very minor interproximal reduction with a finishing strip. And if the contact is too large? Then I'll have to use accessory clamps to get the stability that I want. So as we get to the end of this podcast episode, if you would, Dr. Milad, provide us with some clinical tips, tricks of the trade that really would help our listeners improve their rubber dam placement. The first thing that not only will be helpful in rubber dam isolation is always take photo of your work. Take photos of your isolation. I usually take photos of all my work. When I go back and edit the photos, sometimes I find some mistakes that I couldn't see during working. So I'll know how to fix them later on. The second thing is a double flat instrument is your best friend while doing the rubber dam isolation. You can use it to invert the sheet into the sulcus. You can use it to bring down the sheet from the wings. It's one of the best tools I have ever used while using the rubber dam isolation. What's the actual name of the tool? It's a composite applicator, but it's non-coated. So it's cheap. Don't worry about scratching it or damaging it. It's like a... Like an angulated spatula. Right. Angulated thin spatula. And I think you had a last tip on Teflon. Actually, when applying Teflon in deep cases, you always have to remember two things. We need to have dry field and wet instrument. Teflon is a hydrophobic. If I use a wet instrument, and I usually wet my instrument with alcohol, it will not stick. to the instrument i'm using and i will be actually having a really easy time inserting into the sulks as an endodontist uh and as someone who teaches isolation i think you've really uh no pun intended isolated on a topic that is so really so important um very very good stuff thank you very much for your time and uh i appreciate you getting on the call after such a long day thank you so so much I was very happy to be here today and thank you for giving me this opportunity I hope I give the audience some new tips and tricks