Rubber Dam in Dental Procedures Part 3: Preparing Your Armamentarium

In our previous articles, we discussed the origins of the rubber dam, current objections to its use by dental professionals, and the advantages of its use in routine operative dentistry. In this article, we will outline the armamentarium required for rubber dam use in dental practice, essential for achieving precise isolation and improving procedural outcomes.

Armamentarium for Using Rubber Dam in Dental Procedures

Rubber dam placement in dental procedures necessitates a specialized set of tools designed to ensure effective isolation and patient comfort.

The main equipment required for rubber dam dental placement can be summarized as:

1. Rubber dam sheets,
2. Rubber dam napkins,
3. Hole punch,
4. Rubber dam forceps,
5. Rubber dam frame,
6. Rubber dam clamps,
7. Lubricant,
8. Wedges and wedgets (Duggal et al),
9. Floss,
10. Teflon tape, and
11. Ora-seal.

The armamentarium can be chosen and set up in many ways dependent on the operator’s education and preference.

Material Choices in Rubber Dam Sheets

Dental dam is classically supplied as a 150mm (6-inch) square sheet of latex or latex-free (usually nitrile) in various thicknesses and colors. The thickness is typically between 0.14mm and 0.38mm and is usually classified as thin, medium, or heavy.

Latex offers better adaptation of the dam to the tooth and improved seals and is easier to place; however, the risk of latex allergy should be considered. The author recommends latex-free products within a dental practice setting.

Natural latex comes from the tree Hevea brasiliensis which grows in the tropics.

The latex is then modified with chemicals to create the rubber dam sheet. Allergic reactions may be either immediate (IgE mediated) or delayed (T-Cell mediated): the severity and symptoms of the reaction vary from person to person.

 

Immediate Type I Reaction

Delayed Type IV Reaction

This type of reaction occurs very soon after latex exposure and is caused by the proteins in the latex: symptoms manifest within 30 minutes of exposure and typically resolve within 24 hours. It has the potential to cause anaphylaxis, a life-threatening medical emergency in the dental office, characterized by symptoms such as itching, urticaria, angioedema (swelling around the eyes and oral cavity), and breathing difficulties.

This results from the chemicals or powder added to the latex during the manufacturing process. Symptoms typically appear 48-72 hours following allergen exposure and may persist for a week. They include itching and allergic contact dermatitis, characterized by redness, swelling, weeping, and blistering. Anaphylaxis does not occur in this type of reaction.

 

It should be noted that rubber dam placement tends to cause more severe reactions than, for example, examination of a limb with latex gloves because greater amounts of the allergens can be absorbed via mucous membranes. Risk increases with existing allergic diseases (e.g., asthma, eczema, hay fever, or food allergy) or immediate family history of latex allergy. In summary, latex rubber dam should be avoided.

Nitrile rubber dam is manufactured from synthetic polyisoprene polymer, which can be made in thinner sections, has greater tear resistance (although it has lower memory), and, most importantly, reduces the risk of allergic reaction (Andre et al., 2022).

The author prefers heavy gauge rubber dam since it has superior adaptation and is less likely to tear during placement and throughout operative procedures. Operators should be aware that some lower quality (and less expensive) rubber dams may have significant inconsistencies in thickness within the same batch.

Color choice is left to the discretion of the operator; numerous colors are available, with blue (Image 1) and green being the most common, in addition to black, grey, beige, and pink. Black can be useful when photographing cases because it provides a neutral, yet high-contrast background (Image 2).

The Function of Rubber Dam Napkins

Rubber dam napkins (for example, Ora Shield, Coltene) are prefabricated non-woven rayon fabric slips that go between the rubber dam and the patient's skin. Their function is to protect the skin from saliva, water, and perspiration. In addition, they reduce post-operative skin soreness caused by the rubber dam abrading the skin.

Rubber Dam Punch Design Options

The rubber dam punch is used to place the appropriately sized hole in the rubber dam. There are many designs, although the Ainsworth (Image 3) is perhaps the most common. It allows the operator to choose between five different hole sizes.

1. 0.076”: used for the anchor tooth (the tooth which receives the clamp)
2. 0.064”: used for molars
3. 0.052”: used for premolars and canines
4. 0.041”: used for upper incisors
5. 0.029”: used for lower incisors

Care should be taken to ensure that the punch is sharp so that the holes are punched cleanly without tags, which can cause the rubber dam to tear during placement. During sterilization, the assistant should check that all waste dam is removed from the punch holes. Residual waste dam will result in sterilization issues and can make subsequent hole punching more challenging, potentially causing ragged holes, and tearing of the dam.

When isolating multiple teeth, the hole positions should follow the curve of the dental arch. A template can be used to ensure correct positioning of the hole punch (Image 4); these work well when the teeth are aligned. However, they are less successful when there is significant spacing or crowding of the teeth.

If spacing or crowding is present, the dam can be placed over a model of the teeth and tooth positions marked with a Sharpie marker.

If floss ties are planned for the case, care should be taken to make the holes further apart than normal (around 1-2 mm). This allows enough volume of the dam to invert into the sulcus on adjacent teeth. Failure to allow for this additional space usually results in the gingival papilla popping out of the dam, causing leakage of saliva, crevicular fluid, and blood.

How Lubricant Makes Rubber Dam Placement Easier

Prior to placing the rubber dam clamp, it is good practice to apply a lubricant on the mouth side of the dam. The lubricant enables the rubber dam to slide over the clamp and more easily into the interproximal during placement. Placement can be made more expedient if the operator flosses the teeth prior to dam placement (pre-flossing).

Several options have been proposed, including shaving cream, glycerine, and KY Jelly. The author favors the latter, which is available in various fruit flavors that make the experience of rubber dam placement more pleasant for the patient.

The Function of the Rubber Dam Frame

The function of the frame is to keep the sheet of rubber dam tight, ensuring the operator and assistant can work without the dam obstructing vision and becoming entangled in rotary and hand instruments. Taut rubber dam also improves suction efficiency and reduces the noise of suction during the procedure.

There are many dam frames on the market; all have small pins at the periphery that secure the dam to the frame and are sized as child (smaller) or adult (larger) (Image 5). The frames can be made of stainless steel, polypropylene, or another polymer plastic (Image 6). The plastic frames can be useful where radiography is anticipated during the procedure (e.g., endodontics) since they are not radio-opaque and reduce the risk of superimposition of the frame onto the radiograph. However, the plastic frames are less robust and more difficult to use since the pins are blunter.

The author prefers the metal Young's pattern frame (Image 7) because it is durable and easy to use, in addition to having a ball finish to the free ends, which reduces the risk of iatrogenic damage to the patient's face during placement and removal.

Selecting Rubber Dam Forceps

The forceps are used to open the dam clamp and position it accurately on the anchoring tooth (Image 8). There are numerous designs: Brewer (Image 9), Palmer (Image 10), and Lightweight (Image 11).

The main difference is in the shape of the tines at the tip: these are usually either ball-ended (Image 12) or non-ball-ended (Image 13). The author prefers the non-ball-ended type because they make the placement of the clamp simpler since the forceps disengage more easily.

Optimizing Rubber Dam Use in Dental Practice

The proper selection and use of rubber dam in dental armamentarium significantly enhance the efficiency and safety of dental procedures. From the choice of rubber dam sheets, whether latex or latex-free, to the precise use of punches, forceps, and frames, each element plays a crucial role in ensuring successful isolation and patient comfort.

It is essential to consider the material properties, potential allergic reactions, and procedural nuances to optimize the use of rubber dams in dental practice. In my next article, we will delve into rubber dam clamp options, floss ties, and the use of Teflon tape.

 

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

References

• Scheller-Sheridan, C. (2013). Basic guide to dental instruments (2nd ed.). Wiley-Blackwell.
• Duggal, M., Cameron, A., & Toumba, J. (2012). Paediatric dentistry at a glance (p. 22). Wiley-Blackwell.
• André, R., Alipour Tehrany, Y., Bugey, A., Edder, P., & Piletta, P. (2022). Hand dermatitis aggravated by contact allergy to methylisothiazolinone in protective nitrile gloves. Contact Dermatitis, 87(5), 383-384.