Rubber dam: an overviewDental Point
Fuss and bother
If you are very lucky the dentist that you work with will use rubber dam for root canal treatments and some restorative work, so this article won’t be a lot of use to you. However, if you work with one of the 85% of dentists who do not use rubber dam, consider it a waste of time and say that ‘patients don’t like it’, then read on. Furthermore leave this magazine open at this page on your dentist’s desk and wait for the above reaction – I guarantee it! When Dr Sanford Christie Barnum first described the use of rubber dam in the Dental Cosmos in 1864, I don’t think he had any idea of the fuss and bother he would be causing. To those of us who use rubber dam routinely for many procedures and certainly all root canal procedures, it seems a simple and natural thing to do. However, to the majority of UK dentists out there who do not use rubber dam, the procedure seems difficult, unnecessary and intrusive. The simple reply to this opinion is that it really isn’t! The main aim of this article is to try and persuade the non-believers that rubber dam is an easy, ordinary and necessary treatment modality. The secondary aim is to share a few rubber dam ‘tips’ for the experienced dam user. I realise this might place you in an undesirable position – but blame me. I am very used to dentists sounding off about the perils of rubber dam!
Have a go
There is no ‘wrong way’ of placing rubber dam; if it works for you and your dentist, your way is great! The following examples are clinical scenarios that work for me, bearing in mind I am an endodontist. When I was first working in my own general dental practice over 40 years ago, I was not using rubber dam, and my endo was probably rubbish. I attended a lecture by Chris Stock, now retired but then a new endodontic voice on the lecture circuit. He literally inspired me at that meeting and after a deeply embarrassing conversation with Chris at the coffee break, I drove home like Saul on the road to Damascus determined to ‘do better’. Interestingly ‘could do better’ was always the mantra of my school reports, and when you think about it, this is not a bad attitude to have for our patients. To those of you reading this article who are trying to do better, why not join me on the road to Damascus and ‘have a go’ with rubber dam, or even better, try and persuade your boss to use it.
Four handed support
Working as I do in full time endodontic referral practice, I rely heavily on my dental nurse for her four handed support. When we know the tooth and procedure we are going to carry out we will discuss the operative details. ‘Lower left 6, PW’ would refer to the tooth and the typical wingless lower molar clamp that I would employ. The nurse will then punch the relevant hole in the dam and present me with a clamp forcep with the PW clamp on. I simply place the clamp on the tooth, the nurse passes the dam and I place it over the clamped tooth, followed by the frame. The whole process usually takes about 20 seconds. As we continue the endodontic treatment, the nurse is heavily involved in the procedure. We both find this is a very significant part of our working environment. Indeed patients will often comment after an hour under rubber dam during an endodontic procedure ‘how well we work together’! I’ll let you guess my nurse’s reply.
The benefits of using rubber dam for the patient, the operator and the assistant are:
- Improved access and visibility
- Reduced operative time
- Containment of irrigants – bleach
- Reduced stress: operator-patient-assistant
- Secures airway and GI tract
- Improved cross infection control.
Reduced operative time
The problem here is that if you use rubber dam and you are good at placing it – simple! If you don’t like it and you are no good at placing it, it is difficult and time consuming, so get good at it – practise!
Containment of irrigant – bleach
If you are going to achieve good root canal results, then you need to use sodium hypochlorite. Bleach tastes awful; if you don’t believe me try some! You need to use rubber dam when using bleach in the mouth.
Ask any experienced dental nurse who works with rubber dam what they prefer when assisting with the removal of a large amalgam from an upper seven with or without rubber dam. You can guess the answer. So many of my patients remark on how ‘relaxing’ an hour long root canal session was under rubber dam. From the operator’s perspective, particularly carrying out root canal with magnification, your perspective and focus is enhanced hugely. The ability to find the eponymous second mesial buccal canal becomes a reality. From the nurse’s perspective it is mind bogglingly better.
Secures airway and GI tract
If while carrying out root canal your patient is clever enough to swallow or even worse inhale an endodontic file, they will very sensibly successfully sue your boss and the rest of us will pay for it. Well actually I don’t want to, so please use rubber dam!
Improved cross infection control
There are two separate, independent research papers published in the late 1980s that showed categorically a huge 90% reduction in aerosol-born cultivatable microorganisms when using rubber dam. This is real evidence-based dentistry: eat your heart out HTM 01-05. It is certainly your boss’s responsibility to provide you with an optimum working environment, and using rubber dam has to be part of that.
Set out below are some clinical examples of the way I use rubber dam. I have two overriding principles: I use a wingless dam clamp and place the dam over this and I hardly ever use clamps on anterior teeth, and significantly I would not contemplate carrying out root canal therapy without rubber dam. If the patient declines rubber dam following reasoned explanation, I would decline to carry out the endodontic procedure.