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RestorativeDentistry Enhanced CPD DO C

Louis Mackenzie

Mike Waplington and Steve Bonsor

Splendid Isolation: a Practical


Guide to the Use of Rubber Dam
Part 1
Abstract: Rubber dam isolation is generally considered to be the optimal method of moisture control in dentistry and is taught at the
majority of dental schools worldwide. Unfortunately, undergraduate training does not always translate into use in dental practice, with the
majority of clinicians never using a rubber dam, even for endodontic procedures, where its use is regarded as best practice in the United
Kingdom (UK) and elsewhere. The COVID-19 pandemic has increased interest in the use of rubber dam as a highly effective infection
control barrier. As professional and patient experience of rubber dam isolation is extremely limited, these two papers are designed to
support the practical training of clinical teams in the confident, skilful use of rubber dam, to outline its advantages and to help overcome
barriers to its routine use. Part one provides an update of the latest equipment and materials for rubber dam isolation and part two
provides a practical guide to rubber dam isolation techniques for endodontic and operative/restorative procedures.
CPD/Clinical Relevance: Mastering rubber dam isolation will enhance patient care and be professionally rewarding for clinical teams.
Dent Update 2020; 47: 548–558

Timing of the introduction of rubber dam practice of dental therapists and dental transmission of SARS-CoV-2 infection has
to dentistry is famously precise; the first nurses who have received appropriate renewed interest in research, advocating
reported use was by Dr Sanford C Barnum training. the use of rubber dam as an infection
on 15 March 1864.1 Since then, rubber Rubber dam is universally control barrier during aerosol and splatter
dam teaching has been progressively recognized as the optimal method generating procedures,4,5,6,7 and its routine
introduced at the vast majority of dental of moisture control, and its use is use has been strongly recommended
schools worldwide. In the UK, rubber dam considered to be best practice in the UK by the British Dental Association for this
placement is also within the scope of and internationally during endodontic purpose:
treatment.2 However, the majority of ‘Rubber dams are very effective
clinicians never use it or use it rarely.3 in reducing bioaerosols and so where
Louis Mackenzie, BDS, FDS
Explanations for the pervasive professional it is possible, it should be used when
RCPS(Glasg), General Dental Practitioner
reluctance to adopt the use of rubber dam carrying out AGPs’ (aerosol generating
(GDP), Birmingham, Clinical Lecturer,
are well established: procedures)8
University of Birmingham; School of
‘Probably no other technique, Rubber dam has long been
Dentistry and Head Dental Officer,
instrument or treatment in dentistry has been recognized as the optimal infection
Denplan, Winchester, Mike Waplington,
more universally accepted and advocated, control barrier during endodontic
BDS, MDentSc, GDP, Specialist in
and yet is so universally ignored by practising and restorative procedures, enabling
Endodontics; Past President, British
dentists. Many reasons can be given, but a reduction in microorganisms in the
Endodontic Society and Steve Bonsor,
in most cases the fundamental cause is operative field.5,6,7 Optimal rubber
BDS(Hons), MSc, FHEA FDS RCPS(Glasg),
inadequate explanation and training in the dam isolation in combination with
MDTFEd, GDP, The Dental Practice,
dental schools. If any operative technique is high-volume aspiration, high-quality
Aberdeen; Hon Senior Clinical Lecturer,
not clearly taught and seen to be efficiently four-handed techniques and effective
Institute of Dentistry, University of
executed by the teachers, the new members of use of appropriate personal protective
Aberdeen; Online Tutor/Clinical Lecturer,
the dental profession will not use it willingly.’4 equipment, should be capable of
University of Edinburgh, Edinburgh, UK.
Mitigation of the risk of reducing the risk of infectious disease
548 DentalUpdate July/August 2020
RestorativeDentistry

 Infection control, eg sterile operative field, during aerosol generating procedures


 Moisture control (saliva, blood, gingival crevicular fluid)
 Increased patient comfort during operative/restorative treatments, eg no debris
 Dry field enhances diagnosis
 Increases success of endodontic procedures9
 Optimization of adhesive procedures10
 Protection of the orpharynx (ingestion/inhalation), eg medicaments, debris, instruments, tooth fragments
 Soft tissue retraction and protection, eg rotary instruments, phosphoric acid-etching gel, sodium hypochlorite solution
 Improved visual access, enhanced contrast, reduced mirror fogging
 Significant time saving
 Reduction in treatment interruption, eg reduced need for rinsing
 Possible increased restoration longevity (compared to cotton wool roll isolation)10
 Reduced exposure to mercury during dental amalgam placement and removal
 Reduced clinician stress/anxiety, significant reduction in pain perception by patients11
 Reduced risk of successful dento-legal clinical negligence claims
Table 1. Advantages of rubber dam isolation.

Reasons Cited for not Using Rubber Counterargument/Notes


Dam
Concerns over patient acceptance The overwhelming majority of patients prefer treatment under rubber dam12
Patient resistance Once used, patients commonly request rubber dam for subsequent treatments12
Time required for application <90 seconds for most clinical situations
Rubber dam may be prepared in advance of patient attendance
Application difficulties Rubber dam use becomes easy and routine after dedicated training and with experience
Financial considerations ~ £0.60 per case
Latex allergy Use of non-latex products predominates
Loss of orientation May be managed with multi-tooth isolation
Psychological reasons Very occasional claustrophobia/gagging may preclude use for restorative procedures
NB: Use is considered best practice for endodontic procedures and patients should be advised
accordingly1
Mucosal, hard tissue or restorative Plastic retainer alternatives are available (Figure 1)
damage from retainers Sharp points on metal retainers may be rounded using suitable rotary instruments (coarse/
medium composite shaping discs are recommended)
Occlusal restorative assessment cannot Careful pre-operative occlusal analysis (supplemented by clinical photography) and accurate
be carried out with rubber dam in place restorative shaping mitigate the need for major occlusal adjustments (Figure 1)
Rubber dam and retainers complicate Specialized endodontic sensor/film holders optimize radiographic quality
endodontic radiography Specialized plastic universal retainers are partially radio-opaque (Figure 1)
Effective use of apex locators may eliminate the need for some radiographic exposures
Lack of proper training Educational quality, time and dedication to mastering rubber dam techniques all have a
significant impact on rubber dam use as do the curricula of individual dental schools13
Technique sensitivity Operator/team experience improves patient compliance13 and optimizes all future endodontic
and restorative procedures
System of remuneration The majority of UK Health Service dentists never use rubber dam isolation in endodontic
treatment13
Choice of endodontic irrigant13 Sodium hypochlorite is universally recognized as the solution of choice for endodontic
irrigation and its use without rubber dam isolation is indefensible. The use of alternative
irrigants, eg chlorhexidine, local anaesthetic is not recommended
Table 2. Barriers to the routine use of rubber dam, alongside well-recognized counterarguments from experienced users.

July/August 2020 DentalUpdate 549


RestorativeDentistry

a d 2. To outline the other advantages of


rubber dam isolation and help clinical
teams overcome barriers to its routine
use;
3. To provide an update on the latest
equipment, materials and clinical
techniques for optimizing rubber
dam isolation during endodontic and
operative/restorative procedures.

Advantages of rubber dam


b e isolation
While rubber dam isolation has gained
increased focus during the worldwide
COVID-19 pandemic, a wide range of
other advantages have been cited,
and include those listed in Table 1.
Barriers to the routine use of rubber
dam are also well documented and
are listed, alongside well-recognized
counterarguments from experienced
users in Table 2.

Clinical case example


Figures 1 (a−f ) illustrate the advantages
of rubber dam equipment used during
the endodontic and restorative treatment
of a mandibular right first permanent
premolar, including the following:
 The universal plastic SoftClamp™ (Kerr,
Bioggio, Switzerland) is suitable for all
c f molar and premolar teeth;
 Isolation optimizes safety and infection
control (patient/clinical team) and
improves visual and operative access;
 The partially radio-opaque SoftClamp™
still allows diagnostic radiographic
information and still facilitates probity
checks relating to dam use. (Plastic
rubber dam frames also prevent
radiographic ‘masking’);
 Completing all endodontic and direct
restorative stages in one procedure
maximizes efficiency for both patient and
clinical team;
Figure 1. (a) Rubber dam isolation for an endodontic/restorative procedure. (b) Radiolucent  Adhesion and access for resin
SoftClamp™ retainer. (c) All adhesive and direct restorative stages completed using rubber dam. (d) composite placement are optimized
Accurate shaping under dam minimizes/eliminates the need for occlusal adjustment. (e) Rubber dam by moisture control and soft tissue
isolation optimizes endodontic and adhesive/restorative outcomes. (f) Restoration at four years post- retraction;
operatively.  Access for shaping, finishing and
polishing procedures is more convenient
and more comfortable for patients;
transmission in dental surgeries close to clinical teams in the confident, skilful  Accurate shaping minimizes or
zero. Accordingly, this paper has three main use of rubber dam isolation as a reliable eliminates the need for adjustment with
aims: method of infection control during dental rotary instruments once the rubber dam
1. To support the practical training of procedures; is removed;
550 DentalUpdate July/August 2020
RestorativeDentistry

a can breathe and swallow normally, that


they will get no debris in their mouth,
and that a saliva ejector can be placed
under the rubber dam, if necessary;
 Informing patients that the rubber
dam retainer (avoid use of the word
clamp) will prevent full closure and
reminding them not to bite down firmly;
 Asking patients to raise a hand if they
have any concerns (usually unnecessary
as patients are generally more relaxed
once the rubber dam is in place);
 Demonstrating the rubber dam to
the patient and explaining the isolation
b process.

Operative site preparation


Rubber dam isolation should be planned
in advance of the patient’s attendance
Figure 2. Two-person teamwork is essential for and preparation involves a number of
training and mastery of rubber dam isolation considerations:
techniques.  Tooth position, arch, crowding,
spacing;
 Tooth morphology, eg type, bulbosity,
crown height;
 Significantly increased long-term success  Number of teeth to be isolated and
may be expected from endodontic and choice of retainer tooth/teeth;
restorative procedures carried out using  Tooth state, eg caries, fracture,
rubber dam isolation.7,8 Figure 3. Unsatisfactory simulation (a) and restoration(s), partial eruption;
clinical (b) rubber dam isolation outcomes, after
 Contact tightness (routinely test
training, demonstrate suboptimal knowledge,
Rubber dam training understanding and clinical technique.
contacts using dental floss prior to
Rubber dam training is optimized by using rubber dam placement/pre-wedging may
a two-person team approach with an be carried out to open tight contacts);
 Tooth preparation requirements, eg
unrestricted time limit to develop confidence
clinical teams and the refinement smooth sharp edges, debride teeth,
and enable mastery of materials, equipment
of equipment, materials and remove restorations;
and clinical techniques (Figure 2). Negative
clinical techniques for clinicians  Occlusal contacts should be assessed,
reports of insufficient training may be
who routinely employ rubber marked (and ideally photographed) prior
ascribed to:
dam isolation for endodontic and to isolation;
 Poor initial learning experiences (in
restorative procedures.  Complex cavities may require a
simulation and clinical settings),14 eg
temporary foundation restoration to
working alone, time limitations, lack of close
enable retainer placement;
supervision; Patient preparation  Artificial undercuts may be created by
 Practice limitations, eg equipment As most patients have never temporary placement of flowable resin
availability, time restrictions, financial experienced dentistry carried out composite;
limitations; under a rubber dam, it is important  Anaesthetic (confirm that local or
 Negative word of mouth, eg rubber dam topical anaesthesia has been achieved
to explain why it is being used and
use is difficult and clinically unnecessary; prior to isolation).
what to expect. The advantages listed
 Lack of perseverance following initially
in Table 1 may be summarized to
discouraging outcomes (Figure 3).
help inform patients of the benefits Equipment selection
of rubber dam and additional advice A wide array of rubber dam materials and
may include: equipment is available, from a range of
Practical guidelines for rubber  Reassuring patients that rubber different manufacturers. The purchase
dam isolation dam helps enhance their safety and and mastery of a small selection of high-
The following practical guidelines aim to comfort during dental procedures; quality equipment will bring long-lasting
support both the training of inexperienced  Reminding the patient that they rewards at minimal expense (Figure 4).
552 DentalUpdate July/August 2020
RestorativeDentistry

selection and placement include:


 Purchase only high-quality rubber
dam retainers to minimize the risk of
fracture;
 Retainers should have at least four-
point contact to maximize stability and
resist rotation;
 Metal retainers are generally
considered to be the most effective
and long-lasting;
 The authors recommend winged
retainers (confusingly wingless
retainers are marked with a W);
 For endodontic treatment and for
restorative procedures not involving
proximal surfaces, the retainer is
usually placed on the subject tooth;
 For multiple tooth isolation,
retainers are placed on a tooth that is
distal to the subject tooth, to maximize
visual, operative and restorative access;
 Rubber dam retainers are orientated
with their bow distally to optimize
Figure 4. Basic rubber dam kit. Main components (Hygienic System 9, Coltène-Whaledent) 20 years old. visual and operative access;
 Molar retainer designs 12A and
13A may be used for most posterior
Rubber dam Retainer selection isolation procedures (Figure 7).
A wide variety of rubber dams are While the range of rubber dam retainers  When treating premolars, it is
available and may be selected based on is vast, mastery of a limited selection will recommended to place the retainer
operator preference using selection criteria enable excellent isolation in most clinical on an adjacent molar, as premolar
described in Table 3. situations. General guidelines for retainer morphology and premolar retainer

Size Rubber dams are generally available in two sizes, 13 x 13 cm and 15 x 15 cm


Larger sizes afford more coverage and may be easier to use in most operative procedures
Material Latex (good handling properties/hypersensitivity risk)15
Polyolefin (similar properties to latex)15
Elastic silicone plastomer (increased flexibility/tear resistance/small dam holes reduce risk of
displacement)15
Thickness Range includes thin (0.15 mm), medium (0.2 mm), heavy (0.25 mm), extra heavy (0.3 mm)
and special heavy (0.35 mm)
Medium thickness is recommended as thin dam is more fragile and likely to tear and thick
dam, although offering enhanced retraction, may be difficult to place through interdental
contact areas
Surface Where a rubber dam has a dull and a shiny side, it should be orientated so that the dull side
faces the occlusal surfaces
Flexibility Flexibility of the dam affects tension on retainers and patient comfort
Colour Contrasting and light-reflecting colours improve visual access
Light blue dam is recommended for clinical photography backgrounds
Flavoured Designed to enhance patient acceptance
Specialized design User friendly rubber dam systems may be useful when learning isolation techniques (Figures
5 and 6)
Table 3. Rubber dam selection criteria.

July/August 2020 DentalUpdate 553


RestorativeDentistry

a b

Figure 8. Dental floss placed around a molar


retainer for safe retrieval if retainer fracture or
displacement occurs during retainer fit test
without rubber dam.

Bioggio, Switzerland) promote user-friendly


isolation of broken down, terminal molar
c
teeth and partially erupted teeth and are
useful when not using anaesthesia, eg
fissure sealants and minimally invasive
preventive resin restorations (Figure 9).
 Double bow (‘butterfly’) retainers may
be used for anterior teeth; they are usually
orientated with the concave bow placed
palatally, but may be reversed if that
improves stability (Figure 10).
As double bow retainers may
obstruct anterior restorative procedures,
retainers may be placed distally and/or
specialized retainers employed (Figure 11).
Figure 5. OptiDam™ (Kerr, Bioggio, Switzerland) 3-dimensional shaped dam: (a) unique nipple design;
(b) contoured anatomical frame; (c) ease of use/rapid application/patient comfort.
Rubber dam punch, forceps
and frame
The cutting of holes is usually carried
out with a rubber dam punch, often
with a rotating metal table that allows
different-sized holes to be punched. This
is a precision instrument that must be
well maintained as clean cuts are required
to reduce the risk of tearing when the
dam is stretched over teeth/rubber dam
Figure 6. Drydam® (Directa, Upplands Väsby,
Figure 7. Versatile molar retainers 12A (mandibu- retainers. The accurate positioning of
Sweden) integral face mask and ear loops. Latex
lar right/maxillary left) and 13A (mandibular left/ rubber dam holes presents challenges
with an absorbent lining (patient comfort and
maxillary right) (Hygienic, Coltène-Whaledent).
reduced allergy). (Image courtesy of Jansie Van for the inexperienced user, which may be
Rensburg). overcome by using an inked rubber dam
stamp or template or by cutting, rather than
punching, a specialized dam (OptiDamTM
be secured with dental floss to allow safe Kerr, Bioggio, Switzerland) (Figure 5). Tips
design may limit stability; retrieval in the event of retainer fracture for the use of rubber dam punches, forceps
 Retainers may be tried in to test their (Figure 8). and frames are as follows:
fit. During fit testing, the retainer should  Versatile plastic SoftClamps™ (Kerr,  Traditionally the rubber dam may be
554 DentalUpdate July/August 2020
RestorativeDentistry

a c a

b d

Figure 11. Specialized rubber dam retainers for


direct (a) and indirect (b) restorative procedures.
(Images courtesy of Dipesh Parmar).

Figure 9. (a–d) Easy isolation of a partially erupted, malpositioned, third permanent molar enables
accurate diagnosis and minimally invasive management of an early Class I carious lesion.

arches or quadrants, for maximum


moisture and infection control it is Figure 12. Hole diagram and frame positioning
recommended to use the minimum to maximize respiratory isolation.
number of dam holes;
 Although punching smaller dam
holes will optimize the seal, usually
the largest hole may be selected for  Make sure that remnants from previous
convenience; punching are removed from the hole
 Once a rubber dam punch becomes punch wheel prior to use;
Figure 10. Double bow anterior retainers simplify  Lightweight rubber dam forceps are
worn, extended clinical use may be
anterior endodontic isolation but may obstruct recommended;
gained by using second or smaller holes
anterior restorative procedures.
to maintain cutting accuracy;  Although the retentive points on
 While templates are available, metal rubber dam frames are more
freehand hole punching is robust, the authors recommend plastic
folded and creased or marked to frames, eg Starlite visi-frame (QED endo,
recommended to suit individual tooth
identify the centre and approximate Peterborough, UK) (Figure 12);
positions;
position of the central incisal area  Once the first hole is punched, any  Rubber dam frames may be placed on
(~2.0 cm from the top of the dam to further holes are placed approximately top of, or beneath, the rubber dam or the
avoid covering the patient’s nose); 3.0−4.0 mm apart, leaving spaces for dam may be folded over the dam frame to
 However, to maximize respiratory missing teeth; create a well, designed to prevent water
infection control, holes may be  The easiest way to create the holes flowing off the dam edges (Figure 13);
repositioned to facilitate nose without ripping the dam is to punch  The rubber dam tension should be
covering4 (Figure 12).6 and push the punching tip through the minimized to allow flexibility during
 While it is possible to isolate full hole; placement and use.
556 DentalUpdate July/August 2020
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Accessory Function Example Brand/


Manufacturer
Dam stabilizing cord To prevent dam lifting Wedgets® (Latex) (Coltène-
between contacts Whaledent)
Dental floss ligatures To optimize dam inversion/ eg Oral B Pro-Expert (PTFE)
cervical seal
Rubber dam napkin To protect patient’s skin, eg Ora-Shield® (Coltène-
hypersensitivity Whaledent)

Caulking agent Optimize dam seal Oraseal™ (Optident, Ilkley,


(especially for endodontic Yorkshire) (Figure 14)
Figure 13. A rubber dam folded over the frame to procedures)
create a fluid-retentive well.
Rubber dam stamp/ Aids accurate positioning of Various
template rubber dam holes
Water soluble lubricant Facilitation of dam Various
placement through contacts
Table 4. Rubber dam accessories.

a b

Figure 14. Caulking agent15 Oraseal™ (Optident,


Ilkley, Yorkshire). Expanding hectorite clay
material prevents saliva leaking into the operative
field and blocks passage of chemicals to the
mouth, eg endodontic irrigants and phosphoric
acid etchant gel.
c d e

Accessory equipment
A wide range of accessories are available
to optimize rubber dam isolation, and
include the equipment listed in Table 4.

Matrix systems Figure 15. (a) Rubber dam isolation for a bonded amalgam restoration, dam holes spaced to
accommodate a missing tooth. (b) Retainer-less AutoMatrix® system assists isolation and does not
The use of rubber dam isolation
interfere with the rubber dam. (c) Rubber dam isolation protects patients from uncomfortable excess
optimizes adhesive procedures and,
amalgam particles during placement (and carving). (d) Anatomical carving is completed with rubber
with experience, may be confidently dam in place. (e) Minimal adjustment is necessary after rubber dam removal.
used for the vast majority of restorative
treatments. In conjunction with
rubber dam isolation, retainer-less,
circumferential matrix systems are
recommended, eg SuperMat (Kerr, restorative contacts. They also help to Summary
Bioggio, Switzerland) and AutoMatrix® retain the rubber dam and the absence of The use of rubber dam isolation optimizes
(DentsplySirona, York, Pennsylvania) a retainer reduces the risk of interference. endodontic and restorative procedures
(Figure 15 a−e). These versatile matrices may also be placed and provides a very high level of infection
These matrices are easy to use, on top of a suitable rubber dam retainer, eg control. The time taken to master rubber
promote better access and result in better when restoring the last tooth in an arch. dam materials, equipment and clinical
July/August 2020 DentalUpdate 557
RestorativeDentistry

techniques will enhance confidence, Dent Assoc 1989; 119: 141−144. 12. Stewardson D, McHugh E. Patients’ attitudes to

improve outcomes and be rewarding for 6. Ather A, Patel B, Ruparel N, Diogenes A, rubber dam. Int Endod J 2002; 35: 812−819.

patients and clinicians alike. Hargreaves K. Coronavirus Disease 19 (COVID-19): 13. Whitworth J, Seccombe G, Shoker K, Steele J. Use
implications for clinical dental care. J Endod 2020; of rubber dam and irrigant selection in UK general
46: 584−595. dental practice. Int Endod J 2000; 33: 435−441.
Compliance with Ethical Standards
7. Harrel SK. Airborne spread of disease − the 14. Hill E, Rubel B. Do dental educators need to
Conflict of Interest: The authors declare that
implications for dentistry. J Calif Dent Assoc 2004; improve their approach to teaching rubber dam
they have no conflict of interest. use? J Dent Educ 2008; 72: 1177−1181.
32: 901−906.
Informed Consent: Informed consent was 15. Bonsor S, Pearson G. A Clinical Guide to Applied
8. British Dental Association. Returning to work
obtained from all individual participants Dental Materials. London: Elsevier, 2013. ISBN 978-
toolkit. www.bda.com June 2020.
included in the article. 0-7020-3158-8.
9. Lin P-Y, Huang S-H, Chang H-J, Chi L-Y. The effect
of rubber dam usage on the survival rate of teeth
References receiving initial root canal treatment: a nationwide
1. Latimer O. Barnum's Rubber Dam. Dental Cosmos population-based study. J Endod 2014; 40:
August 1864; Vol VI. 1733−1737. CPD ANSWERS
2. Consensus Report of the European Society of 10. Wang Y, Li C, Yuan H, Wong CM et al. Rubber May 2020
Endodontology. Quality guidelines for endodontic dam isolation for restorative treatment in dental
treatment. Int Endod J 2006; 39: 921–930. patients. Cochrane Database Syst Rev 2016; 9(9):
3. Ahmad I. Rubber dam usage for endodontic CD009858.
1. A 6. C
treatment: a review. Int Endod J 2009; 42: 963−972. 11. Ammann P, Kolb A, Lussi A, Seemann R. Influence 2. C 7. B
4. Ireland L. The rubber dam – its advantages and of rubber dam on objective and subjective
application. Tex Dent J 1962; 80: 6–15. parameters of stress during dental treatment
3. C 8. A
5. Cochran MA, Miller CH, Sheldrake MA. The efficacy of children and adolescents − a randomized 4. B 9. C
of the rubber dam as a barrier to the spread of controlled clinical pilot study. Int J Paediatr Dent
microorganisms during dental treatment. J Am 2013; 23: 110−115.
5. B 10. B

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