Dammed if you do, dammed if you don’t

A dental or rubber dam, also known as a Kofferdam, is a thin, six-inch, latex or nitrile square sheet that is used in dentistry as a shield to isolate one or more teeth from the remainder of the mouth during a dental procedure. The rubber dam is used in dentistry mainly for endodontic, fixed prosthodontic (crowns and bridges), and restorative procedures. Aside from isolating the treatment or operative site, “the purpose of the rubber dam is to prevent saliva from interfering with the dental work, such as contamination of oral microorganisms during root canal therapy, or to keep fillingmaterials such as compositedry during placement and curing, and to prevent instruments and materials from being aspirated, swallowed, or damaging the mouth.”1 Consider this analogy: A doctor uses surgical drapes to isolate the area of the body being operated on to prevent bacterial contamination from occurring; this is the equivalent of a dentist using a rubber dam for a dental procedure where isolation is necessary.

The dental dam

The dental dam is detained over a single tooth or multiple teeth by the appropriate rubber dam clamps over the anchor tooth. The tooth crowns protrude out from the rubber dam through the individual holes made by a hole punch, isolating the tooth to be treated from the rest of the patient’s mouth. This keeps the tooth dry and reduces the risk of exposure to microorganisms. Listed below are several advantages and disadvantages of using a rubber dam during a dental procedure.2

The advantages of using a rubber dam:

• enhances visibility of the treatment site since the dam retracts the cheeks and lips



• reduces the risk of the patient swallowing instruments or debris



• reduces the risk of contamination of oral microorganisms in the blood and/or saliva



• provides a clean and dry operating field that is free of saliva, blood, and debris from the procedure, as well as achieves maximum bond strength when using restorative materials and cements



• reduces mercury exposure when using amalgam materials in the mouth;



• reduces aerosol splatters in the oral cavity from dental procedures;



• protects dentists, hygienists, and patients from possible exposure to HIV, hepatitis, and other infectious diseases or blood-borne pathogens during procedures



• The disadvantages of using a rubber dam:



• additional application time, which can be difficult and time-consuming



• additional cost of materials: stamp, dental clamps, rubber dam, frame



• rubber dam could break in the patient’s mouth, thus floss is placed around the clamp as a precaution for retrieval



• could cause damage to the oral mucosa during placement and removal of the dam



• patient may have discomfort or difficulty breathing due to blockage of the airway



• if the rubber dam is latex, it could cause a latex allergy or episode to occur



• may decrease communication between patient and operator



• may increase patient anxiety



• many patients refuse the rubber dam

When using a rubber dam in any dental procedure, not only does it isolate the tooth or teeth and offer better visibility for the dentist to focus, but most importantly, the rubber dam also keeps bacteria and saliva far from the treatment area to prevent infection and contamination.

There are more significant advantages in using a rubber dam during dental treatment than not. A rubber dam essentially limits the spread of bacteria to the isolated tooth during a procedure, as well as prevents that same bacteria from being swallowed or absorbed internally. In fact, the rubber dam is mandatory for certain endodontic procedures in the United States, and according to the American Association of Endodontists, it should be the required standard of care. It is a recommended universal precaution in Centers for Disease Control and Prevention statements on infection control in dental care practice. Additionally, the rubber dam adds protection for dentists by decreasing liability should a patient swallow or choke on something during treatment.1

How to prompt patients to dam it!

Generally, use of the rubber dam during dental procedures is not a problem for patients. However, persuading some patients to have a rubber dam placed before their procedures can be a daunting task. For patients who simply cannot breathe through their noses, having a rubber sheet over the face that blocks their airway can be extremely uncomfortable and claustrophobic. This can lead to difficulty breathing and may cause gagging. It is imperative that safety measures also be taken for patients with latex allergies. Latex-free options are available in all products today. A positive approach about rubber dam use by dentists and team members—along with their consistent use on patients—are major components that can work together to generate greater patient acceptance of them in the dental practice.

“Although some studies suggest that many dentists are foregoing the use of dental dams, most professional associations, including the American Dental Association, advocate their use and make a point of including them in training dental professionals.”3 When using a rubber dam in any dental procedure, not only does it isolate the tooth or teeth and offer better visibility for the dentist to focus, but most importantly, the rubber dam also keeps bacteria and saliva far from the treatment area to prevent infection and contamination.

Using a rubber dam for dental procedures should be mandated, but until then, when choosing to use a rubber dam, it is best to explain to the patient that the rubber dam will improve the completed treatment and the quality of care for the patient.

STACI VIOLANTE, RDH, BSDH, MSDH, graduated from the New York University College of Dentistry Dental Hygiene Program in 1997. She went on to complete her master’s degree at the Fones School of Dental Hygiene at the University of Bridgeport. She has been a practicing clinical dental hygienist for the past 20 years, as well as serving as clinical professor in the dental hygiene department at New York University College of Dentistry. She is currently pursuing her doctorate of health science in education.

References

1. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings—2003. MMWR. 2003;52(No. RR-17):1-76. https://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf

2. Gilbert GH, Litaker MS, Pihlstrom DJ, Amundson CW, Gordan VV, DPBRN Collaborative Group. Rubber dam use during routine operative dentistry procedures: findings from the Dental PBRN. Oper Dent. 2010;35(5):491-499. doi: 10.2341/09-287C.

3. Glossary of dental clinical and administrative terms: rubber dam. Code on dental procedures and nomenclature. American Dental Association website. Accessed 2017. http://www.ada.org/en/publications/cdt/glossary-of-dental-clinical-and-administrative-ter#r.

4. Perrine GA. A simplified rubber-dam technique for preparing teeth for indirect restorations. J Am Dent Assoc. 2005;136(11):1560-1561.

5. Reuter JE. The isolation of teeth and the protection of the patient during endodontic treatment. Int Endod J. 1983;16(4):173-181.