Endodontists importance dental dam

Monique Mehler, DTI

Wed. 11. December 2019

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LEIPZIG, Germany: The idea of using a sheet of rubber to create a dry work environment for dental professionals goes back to the nineteenth century and can be attributed to Dr Sanford Christie Barnum. In the spring of 1864, the dentist from New York had the idea of making a hole in his protective napkin and placing it around his patient’s tooth. And just like that, the rubber dam was born. Now, over 150 years later, the use of rubber dams during endodontic procedures is considered common practice and is recommended by international associations and organisations. However, for various reasons, not all dental professionals performing endodontic treatment adhere to these standards. General dental practitioners seem to struggle with its use more than endodontists do. But why is this the case and what can be done to promote rubber dam tooth isolation?

To understand the underlying issues, it is important to note that the use of rubber dams is not mandatory for dentists—it is simply recommended. A position statement from 2017 published by the American Association of Endodontists reads: “Tooth isolation using the dental dam is the standard of care; it is integral and essential for any nonsurgical endodontic treatment.” Although ethically the implications are clear, there is no law that punishes dentists for not using a rubber dam. However, as stated by Dr Patrick Wahl, any potential lawsuit will be lost if a patient is injured during a treatment where no protection was put in place. But more on that topic later.

In an interview with Dental Tribune International, Prof. Paul Dummer, CEO of the European Society of Endodontology (ESE), explained why making the use of a dental dam compulsory is difficult in a legal sense: “As a matter of general principle, it is impossible to regulate its use in any clinic and by any dentist, which is why a law would be meaningless and totally impractical. Secondly, the benefits of rubber dams have some, but not very strong, scientific evidence in terms of the outcomes of treatment. Although, of course, it is necessary to prevent inhalation or ingestion of instruments.”

According to Dummer, the problem that remains is the question of what happens when the dentist cannot place a rubber dam for a particular reason. Must the tooth then be extracted or a dentist punished? This would certainly be counter-productive.

No rubber dam, no endodontic treatment?

When asked about alternatives to the rubber dam, Dr David Jaramillo, associate professor of endodontics at the University of Texas Health Science Center at Houston and scientific chairman of ROOTS SUMMIT 2020, outlined the following options:

“In a gingivectomy procedure, one would use cyanoacrylate to glue the rubber dam directly on to the tooth structure to make it stable during the therapy or a so-called liquid dam. In summary, you cannot perform root canal treatment without isolation.”

In recent studies that investigate the use of rubber dams by general dentists compared with their use by endodontists, the figures make the situation clear. In the US, for example, a survey conducted in 2014 showed that only 60% of the surveyed general dentists who performed root canal therapy said that they always used a rubber dam and 11% said that they never used one. Those who had graduated more recently from dental school were more likely to use rubber dams compared with those who had been working in the profession for 20 years or longer. An association between clocked hours of continuing education and compliance with rubber dam use was not established. One year later, it was found that general dentists’ attitudes towards rubber dam use varied. It was commonly believed that they were “ineffective, inconvenient, time-consuming, hard to place or affected by patient factors” and these opinions were significantly associated with lower rubber dam use. In Saudi Arabia, a survey from 2016 revealed that almost 85% of endodontists who perform root canal therapy use a rubber dam, but only 22% of general practitioners who perform root canal therapy do so. Those who do not use a dental dam claim to accomplish isolation with a combination of cotton rolls, high-volume saliva ejectors and gauze. Interestingly, half of the participants reported that, in their opinion, better undergraduate promotion would increase rubber dam use.

Advantages of the use of a rubber dam

Earlier, Dummer mentioned that there is “some, but not very strong, scientific evidence in terms of the outcomes of treatment”. Clinical results from researchers from Taiwan confirmed this statement. The study aimed to investigate whether rubber dam use affects the survival rate of initial root canal therapy using a nationwide population-based database consisting of 517,234 teeth that had undergone root canal therapy. The survival probability of initial root canal therapy using rubber dams after 3.43 years (the mean observed time) was 90.3%, which was greater than the 88.8% observed without the use of rubber dams.

For Dr Arnaldo Castellucci, who is an endodontist and a long-time advocate of rubber dams, the advantages of the inventions are unquestionable. In an article he wrote, he listed the following points as some of the major benefits: barrier to the airway, a clean surgical field, retraction/protection of the soft tissue, improved visibility, reduced risk of cross-contamination and greater comfort for the patient. Another renowned practitioner, teacher and speaker in the field of endodontics, Dr Daniel Černý, agreed:

“I have been teaching about rubber dam advantages since 2000. Hundreds of students have had to use it to pass my clinical training at school. Nobody has seen a single workflow photograph in those 300+ lectures without a rubber dam,” he said.

Through his work, Černý actively promotes the use of rubber dams. But education at undergraduate level and courses for general dentists are not the only current measures for improvement. Dummer added: “ESE develops and publishes undergraduate curriculum guidelines. We hold workshops and symposia at our congresses and we hold regular meetings and congresses to inform dentists in general about endodontics, so this information is not limited to just rubber dam use.”

Better safe than sorry

Incidents around the world have shown time and time again what can happen when a dentist fails to put a rubber dam in place. In a 2016 case well covered by the media, a patient from Bristol in England was injured during root canal therapy when an endodontic file was inadvertently dropped and entered into her oesophagus. Because she was choking, the file moved down to her stomach where it reportedly pierced the stomach wall. The patient claimed that she had not been offered the option of rubber dam isolation.

Even though not all the benefits of rubber dams, like treatment outcome, weigh in equally heavily, the implications are clear. Whenever possible, rubber dams should be used, not just for reasons of comfort or for an easier workflow. Most importantly, patients and dentists need to be protected in the rare cases in which something really does go wrong. Research has shown that there is a discrepancy between prescribed standards and actual clinical practice, and societies like ESE work hard to close the dental dam gap. Experts agree that more educational work must be done on the early training of aspiring endodontists and general dental practitioners in order to emphasise the importance of using a rubber dam when performing root canal therapy. At the same time, continuous training should be offered for existing dentists.