In our previous article, we traced the origins of rubber dam application in dental practice, sometimes called the cofferdam, setting the stage for a deeper exploration of its contemporary relevance. Despite its historical precedence, the widespread adoption of the rubber dam remains an ongoing challenge in modern dentistry. In this follow-up, we delve into the persisting objections to its use and advocate for a renewed commitment to cofferdam.

Widespread adoption of the rubber dam remains an ongoing challenge
Widespread adoption of the rubber dam remains an ongoing challenge.

Objections to Rubber Dam Usage

Rubber dam is accepted to be the optimal method of moisture control and is a best practice during endodontic therapy1. Carrying out endodontic procedures in the absence of rubber dam is now considered to be malpractice2.However, rubber dam is seldom used in operative dentistry: 39% of US dentists do not routinely use rubber dam for posterior direct composite3.

Several surveys of dental students indicate that rubber dam usage for operative procedures in dental school is commonplace. However, the same students surveyed did not expect to use rubber dam for the same procedures when they progress to private practice3,4.

The reasons for not using rubber dam listed by dentists are:

  1. Inconvenience,

  2. It is unnecessary5,

  3. Time,

  4. Cost,

  5. Low patient acceptance,

  6. Cannot scan teeth for chairside indirect restorations with rubber dam in situ.

However, it is noted the time spent applying rubber dam is compensated by the time gained operating in a clean field with good visibility.

Why Cofferdam is Worth Considering

With adequate training, rubber dam can be placed in less than 90 seconds for most clinical scenarios. Most of the rubber dam set up can be prepared in advance and in many states an Expanded Function Dental Assistant can place the dam.

The cost of rubber dam consumables is less than a dollar.

Further, several studies have shown that patient acceptance is high6.

Routine use of the rubber dam positions you as being safety and quality oriented
Routine use of the rubber dam positions you as being safety and quality oriented.

As an aside, the author has been using rubber dam routinely since 1992. He notes that patient acceptance is dramatically improved by a brief conversation with the patient which includes:

  • Showing the rubber dam (care should be taken to avoid showing the clamp which can alarm nervous patients), the term “retainer” should be used rather than “clamp” because it is more patient friendly.

  • Explaining the rationale for use (patient safety, control of infection and improved restoration quality),

  • Emphasizing that the patient will be able to breathe via the nose and the open sides of the dam,

  • Demonstrating a swallowing strategy whereby the patient places the tongue to the palate prior to swallowing. This is easier for the patient and is less likely to induce panic.

Using this approach allays the patients fear of the unknown and increases acceptance rates to close to 100%. Indeed, it is the author’s experience that most patients request rubber dam for subsequent treatments.

The routine use of the rubber dam is a very strong subliminal sales strategy for your practice because it positions you above your competitors as being safety and quality orientated.

Advantages of Routine Rubber Dam Usage
  1. Infection control

Rubber dam usage results in a significant reduction of microorganisms within the operative field7,8. Ideal rubber dam isolation in combination with high volume aspiration, efficient four-handed techniques, and effective use of personal protective equipment (PPE) should reduce the risk of transmission of infectious diseases to close to zero. In recent times, rubber dam has been proposed as a method of risk mitigation of SARS-CoV-2 infection transmission9.

  1. Reduction in swallowed/aspirated dental instruments10

  2. Reduction in peak plasma mercury levels when removing silver amalgam restorations11

  3. Increased quality of procedures and reduced operator stress

A clear focus on one task at a time, such as tooth preparation followed by restoration placement, creates an environment where a higher quality restoration can be produced in less time and with reduced stress compared to multitasking, which involves controlling blood, saliva, cheeks, and tongue. This is the concept of deep work12.

  1. Digital scanning

Scanning under rubber dam offers a final impression in a stress-free environment minus blood and saliva. This results in time saving and improved visualization of the finish line13.

  1. Improved bond strengths

A recent study demonstrated that rubber dam has a significant positive effect on bond strengths to enamel, independent of the adhesive system14. In this study, mesial, distal, lingual, and buccal surfaces of extracted human molars were prepared and embedded in a palatal acrylic splint. Composite cylinders were bonded to the teeth intra-orally with and without rubber dam. Two bonding agents were used: Optibond FL and Prime and Bond Active. The outcome was that bond strengths were higher under rubber dam irrespective of the bonding agent used. The rationale is that rubber dam reduces contamination and humidity in the oral cavity.

Supporting Strong Dental Fundamentals

Advocating for rubber dam or cofferdam use continues to be crucial. Despite its historical significance and proven benefits, challenges persist in its widespread adoption. However, through a thorough examination of objections and a compelling presentation of its advantages, the case for cofferdam integration becomes indisputable. Our upcoming article will delve into the practical aspects of ideal rubber dam placement, equipping dental professionals with the necessary tools to seamlessly integrate this invaluable technique into their everyday practice.

 

Jason Smithson, BDS (Lond), DipRestDentRCS (Eng), is a member of Spear Resident Faculty.

References:

  1. Consensus Report of the European Society of Endodontology. Quality Guidelines for Endodontic Treatment. Int Endod J. 2006; 39:921-30.

  2. Alrahabi M, Zafar MS, Adanir N. Aspects of Clinical Malpractice in Endodontics. Eur J Dent. 2019 Jul;13(3):450-458.

  3. Hill EE, Rubel BS. Do dental educators need to improve their approach to teaching rubber dam use? Journal of Dental Education. 2008;72(10):1177–1181.

  4. Mala S, Lynch CD, Burke FM, Dummer PM. Attitudes of final year dental students to the use of rubber dam. International Endodontic Journal 2009;42(7):632–638.

  5. Clark DM, Oyen OJ, Feil P. The use of specific dental school-taught restorative techniques by practicing clinicians. Journal of Dental Education 2001;65(8):760–765.

  6. Stewardson DA, McHugh ES. Patients’ attitudes to rubber dam. International Endodontic Journal 2002;35(10):812–819.

  7. Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc. 1989; 119:141-144

  8. Harrel SK. Airborne spread of disease – the implications for dentistry. J Calif Dent Assoc. 2004; 32:901-906

  9. Ather A, Patel B, Ruparel N, Diogenes A, Hargreaves K. Coronavirus Disease 19 (COVID-19): implications for clinical dental care. J Endod. 2020; 46:584-595.

  10. Hill EE, Rubel B. A practical review of prevention and management of ingested/aspirated dental items. General Dentistry. 2008;56(7):691–694.

  11. Berglund A, Molin M. Mercury levels in plasma and urine after removal of all amalgam restorations: the effect of using rubber dams. Dental Materials. 1997;13(5):297–304.

  12. Newport C. Deep Work: Rules for Focused Success in a Distracted World. Piatkus 2016.

  13. Henarejos-Domingo V, Clavijo V, Blasi Á, Madeira S, Roig M. Digital scanning under rubber dam: An innovative method for making definitive impressions in fixed prosthodontics. J Esthet Restor Dent. 2021 Oct;33(7):976-981.

  14. Falacho RI, Melo EA, Marques JA, Ramos JC, Guerra F, Blatz MB. Clinical in-situ evaluation of the effect of rubber dam isolation on bond strength to enamel. J Esthet Restor Dent. 2023; 35(1): 48-55.

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