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Bhavin Bhuva, Bun San Chong, Shanon Patel

Rubber dam in clinical practice

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Bhavin Bhuva
Endodontic Postgraduate Unit, Guy’s Hospital, King’s College London Dental Institute, London SE1 9RT, UK Email: bhavinb@hotmail.com

Key words

asepsis, medico-legal, rubber dam

Bun San Chong

Good practiceguidelines recommend the use of rubber dam for all nonsurgical endodontic procedures; there are also safety and medico-legal implications. However, many unfounded reasons have been cited for not using rubber dam. By explaining why it is essential when performing endodontic treatment, and describing the various techniques of placement, the hope is that it will encourage the routine use of rubberdam in everyday clinical practice.

Endodontic Postgraduate Unit, Guy’s Hospital, King’s College London Dental Institute, London, UK

Shanon Patel
Endodontic Postgraduate Unit, Guy’s Hospital, King’s College London Dental Institute, London, UK

Sanford Christie Barnum first advocated the use of rubber dam almost 150 years ago1. Even in that era of dentistry, the benefit ofisolating a tooth to obtain a dry working field, free of salivary contamination, was appreciated. The European Society of Endodontology guidelines2 recommend the routine use of rubber dam for all nonsurgical endodontic procedures. However, despite being considered an essential part of the endodontic curriculum in undergraduate dental schools, the routine use of rubber dam in general dental practice isfar from widespread3. The main reasons cited for not using rubber dam by dental practitioners include cost, diffi-

culty of use and patient comfort3. These misconceptions have led to poor uptake of the technique in general dental practice. A survey in the United Kingdom found that only 20% of the dentists questioned used rubber dam regularly for endodontic procedures3, and that 60% of therespondents never used rubber dam. Surveys carried out in the United States and New Zealand found that 59% and 57% of dental practitioners, respectively, used rubber dam as a matter of routine4,5. Interestingly, a study in Belgium found that only 3.4% of dentists in the country used rubber dam routinely6. A recent investigation into the attitudes and use of rubber dam by Irish general dentalpractitioners reported that it was not used by 39% of respondents when per-

ENDO (Lond Engl) 2008;2(2):131–141


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Bhuva et al

Rubber dam in clinical practice

Why use rubber dam?
There are several advantages to using rubber dam during endodontic treatment, as outlined below.

Safety and medico-legal considerations
Rubber dam protects the patient’s oropharynx,preventing the ingestion8,9 or aspiration9,10 of endodontic instruments/materials and associated dental debris. Performing endodontic treatment without using rubber dam risks harming the patient, and is considered legally indefensible11,12 and contrary to recommended guidelines5,13,14.

Aseptic working environment
The importance of microbes in the pathogenesis of apical periodontitis is wellestablished15,16. The objectives of endodontic treatment are to eliminate microbial infection, and to prevent re-infection of the root canal system. These can only be predictably achieved when endodontic treatment is carried out under rubber dam. Rubber dam acts like a surgical drape, isolating the operating field from microbial contamination. In an outcome study, 2459 roots were re-examined 2 to 7years after initial pulpectomy or following completion of root canal treatment17. No rubber dam was used, and the overall success rate was only 53%. Although no direct inference can be made, the lack of controlled asepsis may also explain the poor outcome also reported by others18. In another outcome study on root canal retreatment, teeth were treated with (51.1%) and without (48.9%) the use of...