Rubber Dam

We are celebrating the 150th anniversary

On the 15th of March, 1864, Dr. Sanford Christie Barnum from New York wrote:

“At the time, when the concept of a rubber dam was forming in my mind, I was practicing in Monticallis, Sullivan Co., New York. It was the result of my torment caused by saliva. I had passed hours, tired and distracted by my incessant struggle against unending saliva contamination. I had passed many sleepless nights obsessed over my sad failure….asking myself the same old question, that had yet to be answered: “How can I keep a cavity dry ?” The answer revealed itself on the 15th of March, 1864, while I was working on a lower left molar, in a mouth in which saliva was flowing everywhere. Desperate and eager to try a new idea, I made a hole in my protective napkin and placed it around the tooth. And that is how the rubber dam came to be.”

At the time, trying to keep the rubber around the tooth was quite problematic, but things would soon improve a few years later, when in 1882 S.S White introduced a rubber dam punch which is similar to the one that is still in use now and when, in the same year, Dr. Delous Palmer and later on Dr. Stokes and Dr. Elliot introduced a set of metal clamps for different teeth.

A good 150 years have passed since that distant day and if Dr. Barnum could see us now, he would definitely tear his hair out…!!! Its quite incredible that after such a long period of time we are still discussing if the rubber dam is or is not necessary in Endodontics. There is no doubt that placing the rubber dam, 150 years ago, was quite challenging, but today it requires only a few seconds and a minimum amount of instruments.

It seems incredible that even today, two centuries later and now living in the third millennium, that there are still some colleagues who aren’t convinced of the usefulness, or rather, the necessity of this simple sheet of rubber and that the Scientific Associations that are in charge of laying down the “Guide Lines” haven’t included the rubber dam as a mandatory requisite during the practice of Endodontics ! The Quality Assurance Guidelines proposed by the American Association of Endodontists [1] establishes that “cleaning, shaping, disinfection and obturation of all canals are accomplished using an aseptic technique with rubber dam isolation whenever possible”. According to the author’s opinion, whenever isolation with rubber dam isn’t possible, the clinician has two options: one is to make it possible, the other is to extract the tooth ! There are no other choices.

Some dentists justify not using rubber dam by declaring that since the tooth is ravaged by caries or by trauma it is impossible to place a clamp around the crown. Very well, if the tooth is in such dire conditions, a dentist will have three options: clinical crown lengthening, that will expose healthy tissue on which to anchor the clamp, orthodontic extrusion, that will yield the same results, and lastly tooth extraction. Where we place the clamp today, is where the future margins of the restoration will be. If the tooth cannot be isolated, it cannot be restored and the aforementioned options will have to be considered. The only tooth that should be treated without the rubber dam is a tooth that is so destroyed, that the only necessary instrument for its therapy that can be used without the rubber dam is the extraction forceps.

There cannot be any excuses for not using the rubber dam in Endodontics and the law should severely punish the dentist who causes serious injury, including death, to a patient because he did not use one [2-6]. Patrick Wahl correctly reminds us that in the United States any law suit is lost if the rubber dam has not been used during an endodontic treatment [7].

A contraindication for the use of the rubber dam is a patient’s allergy to the chemical constituents of rubber [8,9]. Today, however, it is possible to buy latex free rubber dam sheets [10] with which allergy problems are completely resolved. This “no-latex” dam has the same elasticity as the latex dam and it is even more resistant to corrosion due to endodontic solutions, such as sodium hypochlorite or solvents such as chloroform.

There are odd rumors about the use of the rubber dam; for example, it is claimed that it takes to much time to position. On this topic, Cragg [11] correctly states that “the most time consuming thing about the rubber dam is trying to convince the dentist to use it”. It is worth spending a few seconds to position the rubber dam for use in endodontic procedures and thus improve the entire treatment.

Rubber Dam advantages in Endodontics

Use of the rubber dam in Endodontics offers the following advantages:

1. Patients are protected from ingestion or, worse, inhalation of small instruments, dental fragments, irrigating solutions, or irritant substances, etc.
2. The opportunity to operate in a clean surgical field.
3. Retraction (very important for working in the posterior areas) and protection of the soft tissues (gums, tongue, lips, and cheeks), which are sheltered from the cutting action of the bur.
4. Better visibility in the working area. The advertisement of a famous manufacturer of instruments for the positioning of the rubber dam correctly reads: “Do better what you see and see better what you do”.
5. Reduction of wasted time: the patients, fortunately with a few rare exceptions, cannot converse except with great difficulty; besides, they will certainly not have to rinse their mouth every five minutes.
6. The dentists and dental assistants are protected against infections which can be transmitted by the patient’s saliva [12].
7. The dentists are more comfortable, as they may work at a more leisurely pace and may be free to answer an important telephone call, leaving the patients well protected with the rubber dam and the dental assistant close to them.
8. Better tactile sensitivity during the cleaning and shaping procedure. Without the rubber dam, the dentists, aware of the risk of causing the patients to ingest or inhale an instrument, holds the files in such a way that they will not slip from their fingers. The pressure they apply to the grip of these instruments reduces the sensitivity of their fingers and precludes using the instruments to perform delicate procedures. With the rubber dam in place, on the other hand, they may hold the instruments delicately, without fearing that they may slip from their hand [13].
9. Patients are more comfortable, as they do not feel that their mouth is invaded by hands, instruments, and liquids.
   Patients increasingly appreciate the use of the rubber dam. On occasion, they may ask whether it is a new invention [14], and once they have tried it, they do not want to have future treatment without it.

These are the advantages gained from using a rubber dam. I would like to invite anyone who still has any doubts and doesn’t use it, to point out even just one reason that justifies not using it and that is keeping them from using this fundamental device…

Thank you Dr. Barnum !!!

[Published on Dental Tribune Italian Edition – March 2014]

For your safety, expect from your dentist the use of the rubber dam !!!

Root canal instrument into the trachea. The patient underwent an emergency tracheotomy.

Root canal instrument in the intestinal loops. The patient died of internal bleeding.

Bibliography