Esthetic dentistry is arguably the most difficult type of dentistry we perform. Not only are expectations high (on both sides of the chair) but the techniques require an artful approach combined with a deep knowledge of material science, occlusion, phonetics, and pleasing smile characteristics. As clinicians, we will usually perform better when stress levels are lowered and expectations are realistic; however, the fact that esthetic dentistry is challenging remains.
One powerful method to reduce stress and improve outcomes is via rubber dam isolation. Unfortunately, most dentists have not had the practice-changing experience that comes with routine rubber dam use.1
While performing esthetic dentistry, our bonding materials must work as promised to achieve long-term success.2 When manufacturers report bond strengths in the clinical arena, studies are conducted with the rubber dam in place (figures 1 and 2). When etched surfaces are exposed to the oral environment, including expired air while using typical isolation devices, the surfaces are challenged by moisture from numerous sources, causing the adhesive chemistry to be altered. Hence, to achieve the best bond strengths, a well-sealed barrier will help our results, often dramatically.
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In addition to optimal bonding, the rubber dam may retract the tissues when placed properly, improving our visualization of finish lines, margins, and adhesive materials. One of dentistry’s rubber dam advocates, Dr. Hunter Brinker (the inventor of the B1-B6 clamps), often said “to see is to know” when referring to the benefits of the rubber dam to improve attention to detail through better visual access. It is interesting to note that when the rubber dam is properly placed, it will not only retract the tongue, lips, and cheeks, but it will also atraumatically retract the gingiva, typically 2–3 mm, and expose areas that could not be visualized by any other nonsurgical means (figures 3–5).
After removing a two-week-old provisional, it’s a rare day that we don’t experience some minor inflammation of the soft tissues. Even with the best prototypes/provisionals and meticulous oral hygiene, gingival tissues will bleed, exude fluids, and generally cause problems when isolating teeth for adhesive delivery. With a direct composite, the existing decay is an irritant, and the best isolation device will not address the bleeding tissue adjacent to an extensive class II cavity.
With an inverted rubber dam, however, bleeding becomes a nonissue and allows the clinician to focus on preparation design, pulpal protection, adhesive strategies, and restoration placement—all in a clean and well-sealed environment.3 “Beating the blood” need not be your approach when one of dentistry’s least-used gems is close at hand (figures 6 and 7).
Punching holes is dependent on the position of the desired isolation. The holes are generally about 6 mm (1/4") apart on center for both maxillary and mandibular isolations, except for the anterior mandible where the holes will be about 4 mm apart. When the holes are placed too far apart, the dam is difficult to place and tends to bunch up interproximally, leading to poor retraction and potential interference. When the holes are too close together, the dam may tear more easily during placement and the smaller septal area will not cover the tissue adequately, leading to leakage.
Clamps are small enough to be swallowed or aspirated. Clamps will fatigue after use and may break along the bow. Securing the initial clamp (no need for a secondary clamp as the patient is already protected by the dam) with dental floss through both holes and around the clamp is an effective and safe method (figures 17 and 18). Once the clamp is placed, the floss may be cut and removed if it impedes access.
Clamps without wings may be used with the simultaneous dam-clamp technique by simply placing the bow through the hole. Winged clamps may be secured along their lateral wings. The technique involves placing the dam and clamp together while securing the clamp on the retainer tooth.
This technique has the advantage of having the dam around the clamp from the onset, rather than trying to place the dam over a clamp that’s located distantly in the oral cavity. The disadvantage of the simultaneous technique is that securing the clamp with the clamp stability rule is more difficult. I’ve placed thousands of dams over nearly 40 years and have found that placing the clamp first leads to less tissue trauma and better compliance with the clamp stability rule.
Saliva is not a suitable lubricant. Local anesthetic is not a suitable lubricant. Vaseline isn’t either. It is highly recommended to use a mild soap in a small quantity on the underside of the dam. One of these products is Barbasol (brushless shaving cream), but other water-based lubricants and glycerin work reasonably well.
Resist the temptation to rely on the floss to pass the dam through the contacts. Instead, firmly stretch the dam thin and knife it through the teeth. Patience is key as the dam pushes gently on the teeth, and compression of the periodontal ligament allows for minor tooth movement and dam passage, often negating the use of floss on all but a few tough and tight contacts.
The use of regular unwaxed floss is recommended. Prefloss the isolation area to remove debris and identify problem areas. Occasionally, an overcontoured or irregular restoration that’s planned for replacement should be disassembled before attempting rubber dam isolation.
Think about flossing the surface of the contact and not the dam. Pass the floss between the dam and the tooth, and then floss again with the tail of the floss before removing it. The tightest and most stubborn contacts can be successfully negotiated with this technique (figures 19 and 20).
After the contacts have been navigated, the dam might have excess lubricant, saliva, and even blood present. Thoroughly rinse with water and follow with air spray. Even though we use a mild soap to lubricate the dam, patients don’t find this objectionable. In any case, a quick saliva ejector pass under the dam will eliminate any residual taste.
The most important step to ensure a moisture-free dam that is well sealed and can retract the tissue is inverting the rubber dam. This step is performed after the dam has been flossed through the contacts and rinsed and dried. An explorer with air spray usually inverts most areas. When checking for inversion, floss the interproximals and hug the tooth while doing so; this will usually flip the dam over without inverting the explorer further.
When an apically extensive lesion is present, a second clamp may provide significant additional retraction of the dam while exposing the lesion. Secondary clamps may be piggybacked with retainer clamps (figure 21). Often secondary clamps must be secured with compound or composite to maintain their position.
A small scissor like a Castroviejo is used to snip through the septal areas of the dam, which are stretched either facially or lingually before cutting. Care must be taken not to damage the tissues during this step; always visualize the entire scissor blade before cutting. The clamp is then removed with the dam, and the dam may then be spread out on a flat surface and inspected for missing segments. Missing pieces may be easily removed with a knot tied in dental floss. Patients will usually express relief that the dam is removed, but they wouldn’t want it any other way once they’re educated!
After placing thousands of rubber dam isolations, some situations arise that make rubber dam isolation impractical or contraindicated. Severe gaggers, mentally and emotionally challenged patients, and certain tooth shapes and clinical crowns (delayed passive eruption and certain rare dental conditions) may make rubber dam application too arduous. However, it must be emphasized that lack of experience, low confidence, or poorly organized/equipped armamentaria are not reasonable contraindications.
The excuse that patients don’t want the dam simply hasn’t shown to be true; it’s been demonstrated that most patients prefer using the rubber dam for restorative procedures.4 We all learned how to use a rubber dam to some degree in dental school. It was the gold standard, yet in practice many discard the dam except perhaps for endodontics.
With practice and dedication, the application of the dam should take less than 60 seconds. It will become a second-nature procedure and one that will not only benefit patients but lower our stress levels, improve proficiency (efficiency plus excellence), and build a practice with satisfied patients.5 Esthetic dentistry is hard, but it may be less difficult when we realize the virtues of the rubber dam. We may think of the rubber dam as the “second assistant” in the operatory—one that is a lifetime dedicated employee of the dental practice (figures 23–28).
A dental dam or rubber dam is a thin, 6-inch (150 mm) square sheet, usually latex or nitrile, used in dentistry to isolate the operative site (one or more teeth) from the rest of the mouth. Sometimes termed "Kofferdam" (from German), it was designed in the United States in by Sanford Christie Barnum [de].[1] It is used mainly in endodontic, fixed prosthodontic (crowns, bridges) and general restorative treatments. Its purpose is both to prevent saliva interfering with the dental work (e.g. contamination of oral micro-organisms during root canal therapy, or to keep filling materials such as composite dry during placement and curing), and to prevent instruments and materials from being inhaled, swallowed or damaging the mouth. In dentistry, use of a rubber dam is sometimes referred to as isolation or moisture control.[2]
Dental dams are also used for safer oral sex.[3][4][5]
The technique used to apply the dental dam is selected according to the tooth requiring treatment. Several techniques can be used including single tooth isolation, multiple tooth isolation or split dam technique. The dental dam is prepared by punching one or more holes in the dental dam sheet to enable isolation of the appropriate number of teeth required for the dental procedure. The dental dam is then applied to the tooth, anchored into place using a metal or flexible plastic clamp (chosen according to the tooth and area it will be applied to). The clamp will ideally fit snugly around the tooth along the margin of the gingiva, stabilising the dental dam and preventing contamination of the working area due to saliva ingress.[citation needed] Individuals may experience subjective discomfort due to the tight sensation of the dam clamp, therefore topical anaesthetic (liquid or gel) may be applied to the gingiva at the operator's discretion prior to applying the dental dam.[6]
Prior to the use of the rubber dam isolation method, many dental procedures had a high risk of contamination from saliva and bacteria infiltrating the tooth during a procedure. This can lead to the failure of the treatment being undertaken which can result in further interventions or the loss of a tooth. Dr Sanford C. Barnum was the original designer of the dental dam as a way to keep the operation site clear from saliva. It was in that Dr S. S. White improved the design further by adjusting the hole punched into the sheet. In spite of these changes, it was found to be difficult to stabilise the dam around the tooth until Dr. Delous Palmer developed the metal clamps which anchors the dam around the selected tooth. These clamps are available in various shapes and sizes which are designed to fit different tooth structures and morphology.[2]
There are several treatments where dental dam can be applied; dental restorations, endodontic treatments including root canal therapy, fissure sealants, preparation of dental crown, dental implant and some veneer placements.
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There is an ongoing controversy with the use and efficacy of rubber dam among dental practitioners.[7] Some practitioners may routinely employ its use, for others it may only be applied during selective treatments whereas many others will avoid its application altogether. Although the use of rubber dam is considered a standard of care, studies showed that a large number of dental practitioners do not utilise it during procedures. The standard is defined by reasonable standard supported by evidence.[clarify][8]
The set up of a rubber dam has many elements and involves the use of specific tools and accessories which usually consist of:
Other materials that may be used to assist with the setting up of rubber dam are:
The dental dam sheets are predominantly made from rubber materials such as latex or nitrile and tend to be 15 cm by 15 cm in length and width. The thickness of each dam sheet is approximately between 0.14 mm and 0.38 mm but the size, shape, colour and material that the dam sheet is made from can vary with differing manufacturers. Most manufacturers will also make dental dam sheet alternatives that are suitable for patients with allergies to materials such as latex and some may even make alternatives that can be autoclaved.
The dental dam is anchored around the crown of the tooth using a metal clamp to seal and secure the rubber dam sheet to the tooth or teeth that are receiving treatment during the dental procedure. The clamps come in a variety of shapes and sizes which suit the anatomy of the different teeth in the mouth. Before placing the dam in the mouth dental professionals may choose to secure dental floss around the clamps; this acts as an anchor to prevent aspiration or swallowing. It can also provide a point of reference for the clinician to be able to visualise and retrieve the clamp if it dislodges from the tooth or the dam forceps.[2]
The purpose of the rubber dam frame is to keep the dam sheet taut around target areas; this will ensure that a clinician can work effectively on the tooth without the dam sheet obstructing vision and becoming entangled in dental instruments during the procedure. There are several types of dental dam frames which have an array of purposes. The frames are made from stainless steel, polypropylene or other polymer plastics. Irrespective of the material the dam frame is made from, the frame will always have small pins on the outer edges which act to secure the dam sheet to the frame. The plastic dam frames are predominantly used in the case where dental radiography is planned as they are less radiodense, ensuring the frame appears radiolucent to avoid superimposition of the frame in the radiograph.
The dam punch is a tool used to perforate holes of various sizes into the dental dam sheet. When punching holes in the rubber dam prior to a procedure the size and spacing of the teeth to be isolated should be taken into consideration. In multi-tooth isolation, the holes should correspond to the curve of the dental arch. The rubber dam armamentarium can be set up in a variety of ways; this usually depends on clinician preference and education.[11]
In difficult clinical cases, the standard dental clamp needs to be adapted. One efficient method is using the carved gypsum cast as described by NCE Cazacu.[12]
Using a rubber dam for dental procedures can provide multiple advantages. A rubber dam can provide a clean and dry operating field away from substances such as saliva and blood. This is important for dental procedures as the bonding ability of adhesives and cements is heightened in a clean and dry field away from possible contamination, in order for maximum adhesive strength between the restorative materials, dentin and enamel. If the environment is contaminated leading to poor bonding of the materials, the success and longevity of the restoration is shortened.[13][needs update]
When using the rubber dam, it is possible to isolate one or more teeth. By doing this, the clinicians visibility of the tooth is greatly improved, due to the increase in contrast with the rubber dam around the tooth or teeth, whilst at the same time it retracts the soft tissues such as the lips, tongue, and cheeks, and reduces mirror fogging:allowing the clinician to focus solely on the restorative site, which can lead to the procedure also being more time-efficient.[14][15] Even though it is commonly said that the rubber dam takes too much time to apply, in many ways it can reduce the time needed for the procedure, as not only does it isolate the tooth, it reduces the ability for the patient to communicate with the clinician. This is most beneficial for the over talkative patients which can sometimes hinder the efficiency of treatment and can instead allow more time for the clinician to focus on the task at hand in order for the procedure to take less time.[citation needed]
A Cochrane review in suggests that the use of rubber dam as an isolation method provides a chance for dental restorations to last longer. Disregarding the fact that it is low-quality evidence, there is still proof that over a two-year period, comparing restorations done using rubber dams versus cotton roll isolation, the rubber dam group had a lower risk of failure with a risk ratio of 0.80 compared to cotton roll isolation at 1.19, however, further research is needed on varying restorative treatments.[16]
Additionally, a rubber dam can act as an infection control barrier and reduce the risk of cross-contamination and infection. In case the patient may have a contagious disease the rubber dam decreases the chance of the splatter of microbial content if the patient were to cough or the spread of microbes being caused by the pressure from the triplex, which is a tube or syringe used to deliver air or water under pressure.[17]
A rubber dam can also protect patients' airways. It does not eliminate the chance, but decreases the possibility of the patient accidentally swallowing or inhaling restorative instruments, tooth fragments or debris. [10] That has happened in the past, and should this occur, the patient must always be admitted into hospital as a chest X-ray is necessary in order to discover where the inhalant may be and whether it may potentially need to be removed on the operating table or not. As it has potential to be life-threatening if ignored.[18]
Not only instruments or debris, but also chemical materials used in dental procedures (such as acid etch, seals, and amalgam) can have harmful effects. In endodontic procedures, corrosive irrigants are contained such as sodium hypochlorite (bleach).[19] Without the protection of a rubber dam, there is an increased risk of this chemical damaging the soft tissues of the mouth and being more harmful if swallowed. Another example is during amalgam restorations, as amalgam contains the element mercury, and if ingested during the placing of amalgam can cause potentially harmful side effects if not treated. However, after amalgam is placed safely, evidence does suggest the exposure to mercury is at a level which is non-harmful and safe for the human body.[20][21]
The rubber dam can also offer additional protection of the soft tissues of oral mucosa from sharp instruments, acting as a barrier between the instrument and the soft tissue. Additionally, associated with rubber dam is a caulking adhesive, caulking in definition is a material used to seal joints, in this can be used to fill in gaps between the rubber dam and gingiva as it adheres to the wet rubber dam or mucosal tissues, acting as another mode of protection.[22]
A big issue surrounding the rubber dam is its use as part of a legal obligation. In some parts of the world, the use of a rubber dam is obligatory for procedures such as endodontic treatment. The reason for this is that if an injury was to occur or possible cross-contamination and the result could have been prevented by rubber dam, this situation is regarded as medico-legally indefensible, meaning the clinician will not be able to defend themselves in court due to the duty of care falling under negligence of the patient.
Lastly, some patients, in fact, prefer using the rubber dam, as having been told and understanding the risks instead feel more comfortable knowing they are safer with it than without it, as well as feeling dissociated from the noises happening around them such as the drilling. Additionally, some patients tend to be more comfortable as they may prefer the feeling of not having water and suction running within their mouths.[23]
Although there are many advantages of rubber dams during dental treatment there are also associated risks and disadvantages. The rubber dam can take extra time to apply; however, with consistent practice and use by the dental practitioner, this may not have an effect on the length of the appointment. Insufficient training and the inconvenience of application can also be a deterrent for its use and can also contribute to lost time.[24] The cost of dental dams is an expense to the dental practice and could also be a disincentive. Although the rubber dams are inexpensive to purchase, initial costs for the armamentarium can be high.
There is a risk of rubber dam clamps breaking during application due to the chemical effects of sodium hypochlorite, an antimicrobial solution used during root canal treatments, repeated stresses of clinical use,[25] or autoclaving,[26] all of which can potentially weaken the material. To avoid swallowing or aspiration of broken clamps, the dental practitioner should place floss around the clamp to allow its retrieval if it snaps or springs off during a procedure.
As the dental dam clamp is placed along the gum line, this can cause some discomfort or pain (especially in a patient who does not require local anaesthesia), bleeding from the gums, damage to the periodontal ligament or abrasion of the cementum on the root of the tooth, which may cause an uneven surface on the tooth root that can retain plaque.[27]
The dental dam is placed over the mouth, effectively blocking off the airway, which means the patient must be able to comfortably breathe through their nose. This is a problem for patients with nasal airway obstruction such as the common cold, a broken nose, adenoids, recurring sinus issues, or those who habitually breathe through their mouths. Patients can also find that communication is reduced between the dental practitioner and themselves, which may result in feelings of claustrophobia, vulnerability, and anxiety. Those prone to dental phobia and individuals who have learning difficulties, disabilities or special needs may find the use of dental dams impossible and intolerable.[28]
To an extent, the use of a dental dam may lead to visual distortion of tooth morphology since the other teeth and the rest of the mouth are hidden from view. This may lead to perforation if an access cavity is incorrectly angled during root canal therapy. For this reason, endodontists may routinely begin their access cavity before applying the dam. This will ensure the correct orientation prior to commencing removal of the blood vessels, nerve tissue and other cellular entities from the tooth.
The rubber dam, which is usually brightly coloured (blue or green), may alter the apparent colour of the tooth, which can lead to incorrect choice of shade, e.g. during placement of a dental composite during a restorative procedure. For this reason, dental practitioners should select the appropriate shade of material prior to the application of rubber dam.
As the rubber dams are primarily made of latex, patients may experience reactions which range from uncomfortable (allergic contact dermatitis, allergic contact cheilitis, allergic contact stomatitis) to life-threatening (anaphylaxis). Nitrile versions are available for those with latex allergies and adverse reactions can be avoided by patients informing dental practitioners of latex allergies prior to treatment or adverse reactions after rubber dam application.
Dental dams are sometimes suggested for use as a physical barrier against the exchange of body fluids during cunnilingus and anilingus, especially for women who have sex with women to protect against sexually transmitted infections (STIs).[29] However, they are rarely used for this purpose,[29][30][31] and as of , there is no evidence that their use reduces the risk of STI transmission, including the risk of HIV infection.[31]
After lubrication with a water-based lubricant, an unpunctured dental dam may be held over the vulva or anus, allowing oral stimulation of these areas without transmission of bodily fluids or direct physical contact. Plastic cling wrap, condoms (repurposed by cutting off the tip and ring and cutting them lengthwise) or latex gloves (cut open longitudinally) can be used for STI protection in a similar manner as a dental dam, by providing a physical barrier to cover the vulvar or anal areas during oral sex and these alternative barrier methods are more affordable and readily available than dental dams.[29][32][33] Dental dams were initially promoted in the s in some safer sex campaigns as a barrier to prevent transmission of STIs during oral sex.[29] They were introduced for use in some women's prisons in Canada and Australia (in the jurisdictions of New South Wales, the Australian Capital Territory, Western Australia, and South Australia) in the s as a form of sexual barrier protection after the World Health Organization (WHO) recommended that female prisoners should have access to dental dams.[29][32] Inmates have reported numerous problems with dental dam use, including the dam being too thick, lack of availability, poor taste, and reduced sensations when used for oral sex. Dental dams are often reappropriated by prison inmates for other uses, such as hair elastics, placemats or shoelaces.[32] They are relatively expensive and difficult to obtain outside of the prison system.[34] Rubber dams are not manufactured, marketed, registered, tested, or evaluated for their effectiveness as an STI prevention aid, and no studies exist (as of ) on their permeability to STI pathogens.[35]
A NIH study found that "[d]ental dams can be an invaluable tool for safe oral sex, and it is important for patients to know how to use them properly[...]Although dental dams have been associated with a reduction in STIs, the lack of statistical significance may thus be explained in part by small sample sizes[...]From experience with patients in the STI clinic, the authors advise purchasing dental dams made specifically for oral sex because these are thinner than even the thinnest dental dams available for oral surgery[...]At this time, it is unclear if dental dams play a statistically significant role in decreasing incidence and transmission of STIs based on the current literature; this may be accounted for by factors, such as a paucity of data, infrequent use due to sparse patient education, perceived barriers to procurement and accessibility, and unfamiliarity on the part of providers. Condoms have repeatedly been shown to decrease STI risk; it is likely that dental dams will decrease risk as well when extrapolating the aforementioned data on condoms. Yet, there is a clear need for more provisional research on dental dams to ascertain their usage, perceived barriers, and efficacy in STI prevention."[36]
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