September 1, 2011
by Ellis Neiburger, DDS
Though repeatedly proclaimed as an indispensable element of quality operative dentistry, the rubber dam is seldom used in private practice. This is because of the numerous hazards and inconveniences for the patient and dentist, which have been rarely mentioned. These dangers and more effective alternatives to the dam’s use in modern dentistry are discussed.
Since Dr. Barnum’s popularization in the 1860s, the rubber dam has been used in most fields of dentistry.1 With the help of ligatures and clamps, the rubber dam is considered a boon to the dentist and the patient. Skill in its application is a required features of most dental schools and license examinations.2,3 Many authors have expressed its use as a symbol of high quality, meticulous dentistry and its non-use as an example of shoddy dental treatment bordering on malpractice.1,3
The rubber dam has been used for dozens of reasons: providing a clear field, saliva and muscle control, aspiration and infection prevention, gingival isolation from caustic agents and as a treatment time saver.1-9 Many clinicians and educators have insisted that the rubber dam should be routinely used in “quality” dentistry and medical-legal protection, even though good dental care (including successful malpractice defense) can be accomplished without it.9-12 Although actively promoted in dental schools and the literature, very few practitioners routinely use a rubber dam today.3,11
Most dental literature describes the rubber dam in positive terms, but little is mentioned of its many hazards to the patient and the staff and the many superior alternatives to its use, which are available to the modern dentist. Because MOST of this literature stresses only the benefits, this paper will emphasize the dangers related to its use in an effort to encourage a balanced perspective.
In the early days of dentistry, practitioners had few ways of controlling the oral environment during restorations. The primitive instruments and materials available to the dentist of the 1860s-1930s required lengthy procedures during which a completely dry and clearly visible field was needed. The rubber dam was developed for this purpose and numerous techniques were devised for its use in the many cases of less-than-ideal operative situations. These techniques, compromises of classical dam technique, included the split dam, mini dam, double dam and large hole techniques.4,13 In earlier times, use of the rubber dam was necessary to insure a quality restoration or course of treatment. Today, such necessities are very rare.
The use of the rubber dam presents hazards, which can be classified into three categories: material limitations, improper application and inadequate design situations.
OF THE RUBBER DAM
Most rubber dams are made from latex rubber and tend to tear, leak and disintegrate as they quickly age, a process accelerated by a few days of exposure to air and its pollutants (03, NO2) (Fig. 1).4,14 Latex tends to decompose or melt near flame and under high intensity lights (for example during bleaching). It is difficult to patch in the event of rips, sticks to numerous restorative materials (impression putty, adhesives) and can lose its integrity when exposed to certain solvents (e.g. alcohol, methacrylate).2,19
The latex dam is difficult to sterilize because it is damaged by heat and some disinfectant chemicals (most dentists use dams directly from the non-sterile box). Contrary to popular belief, the latex in the dam poorly insulates the staff and patient from infectious microbes such as hepatitis B or the Human Immunodeficiency Virus, distorts light through reflection and produces abnormal color contrasts.14,15 It often has a “sickly rubber” odor.
The rubber dam contacts the patient’s face and oral tissues (with or without a napkin) and can initiate moderate to severe allergic reactions in sensitized patients and staff.16-18
IMPROPER APPLICATION AND USE
With a limited number of clamp sizes fitting an unlimited variety of tooth shapes, rubber dam clamps often gouge the gingival, abrade the cementum and root surface; especially when inadequately seated and supported (Fig. 2).20 Clamps tend to crack porcelain crowns, break at the bow and pose an aspiration or ingestion danger.3 The clamps and dam can cause further damage when placed on teeth that are poorly shaped, partially erupted, decayed (gingivally) and in tight contact with each other. Gingiva can be lacerated with resultant periodontal damage and bateremia when seating clamps.5,19 The placement of the dam is time consuming for the dentist and prolongs treatment time for the patient, especially when dam weight, frame, hole location, sizing and dam placement is not precise. A TORN dam will compromise saliva control and may leave difficult-to-find rubber fragments in the gingival sulcus resulting in soft tissue inflammation, apical migration of the epithelial attachment and possible tooth loss (Fig. 2).
OF THE RUBBER DAM SYSTEM
Not all patients qualify for rubber dam application. Phobics and other psychologically limited patients may be further agitated by wearing the dam and the feelings of helplessness and personal invasion THAT its presence denotes. The dam restricts normal mouth movement which adds stress to the dental procedure. It is contraindicated in epileptics, some handicapped and patients who may experience aspiration of their vomit, psychogenic coughing or gagging.21 The presence of the dam can snag burs and rotary instruments, drawing them into the soft tissue. It can hide serious bleeding beneath the dam (e.g. hemophilia, BLOOD THINNERS) thus potentially delaying immediate treatment. The latex can fragment and be DRIVEN GINGIVALLY OR inhaled during oral placement and removal.5,7,21
The dam can also retard the full visualization of the oral cavity (e.g. lingual fold), obstructing the view of non-isolated teeth, blocking high speed suction and irritating the patient’s mucosa and skin.6,17,18 Removal of the dam can damage new restorations and increase the danger of aspirations.7,20
Dentistry has greatly changed since the days of the first rubber dam. Long periods of painful, intraoral treatment are no longer routine. Materials are easy to apply and relatively quick-setting.
Patients are generally well-educated and cooperative as compared to their Victorian-age relatives who require dam use. Many alternatives to the use of the rubber dam, which did not exist in the past, are now available to the practitioner and patient. These include high speed suction, custom retraction devices, disposable cotton rolls, gauze packs and throat screens, retraction cord systems, electrosurgery and relatively moisture tolerant restorative materials (e.g. low zinc amalgam vs. gold foils).5,22
I believe the rubber dam still has some practical uses in modern dentistry and should not be abandoned. Unfortunately, advocating unrestricted and arbitrary widespread use, often under the guise of “good dental practice” is abusive to the patient and dentist for, in most cases, more efficient and comfortable alternatives exist. This antiquated technology consumes too much valuable energy, materials and time of dental school faculty and licensing boards at the expense of more significant procedures (e.g. bonding). Today, very few dentists (approximately five percent) routinely use the dam. General application of the rubber dam is hazardous to the patient, costly in time, effort, money and, with few exceptions, is seldom necessary in today’s modern dental practice.
Like the tooth key, gold foil restoration and the 22K gold shell crown (which were once considered “good” dentistry), the rubber dam should take its place as a historical “old friend” and occasional adjunct to dental treatment. It should not be taught nor used as a constant (and over-utilized) companion to the modern practitioner
Dr. Ellis Neiburger is a general practitioner in Waukegan, IL. He is director of the Center for Dental AIDS Research and vice president/editor of the American Association of Forensic Dentists. Contact Dr. Neiburger at: ENEIBURGER@COMCAST.NET
Reprinted with permission, Ellis Neiburger, DDS, for Chairside magazine. Copyright ©2010 Ellis Neiburger. All rights reserved.
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14. Baker, R. Precautions when lightning strikes during monsoon: the effect of ozone on condoms. JAMA 1988:260:10:1404-5.
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21. US Dept. H.E. W. The dental implications of epilepsy 1977: p.2.
22. Van Dijken, J. W. et al Effect of the use of rubber dam versus cotton rolls. Acta Odontol Scand 1987:45(5): 303-8.