Continuing his ‘how to’ articles focusing on endodontics, Charlie Nicholas explores why rubber dam is a must and reveals the secrets to success, offering practical guidance as to its use.
History tells us that rubber dam has been in use since around 1864, to isolate a tooth that a dentist needs to treat. Why does something that is more than 150 years old and essential for endodontics still strike fear in even the very the best of dentists?
In truth, I was one of those dentists. When I graduated from university, I thought I would never have to place rubber dam again, and I was thrilled. Reality hit in practice, of course. I realised that for some treatments, including endodontics, rubber dam is not a choice – it is a must.
Does the following sound familiar? You can’t see the tooth you want to isolate with rubber dam because you’re in your own way.
You’ve got this thing that doesn’t have a lot of stretch to it, and it’s really difficult, because getting the correct clamp is quite tricky without experience, and then you’ve got to get that clamp on a very specific area of that tooth, and you’re trying to do that through a little hole on a sheet of rubber that’s taut… forget it!
Over time, however, I learned a great protocol for placing rubber dam and that is the secret to success. Bar a few ‘special’ cases, with the right guidance you can, in fact, place rubber dam in about 10 seconds.
I have also heard it said many times that patients don’t like rubber dam (not from patients I might add). I would suggest that actually they don’t like the idea of it – after all, the name itself just sounds horrible. But those who have experienced it are pleased to have it in place once they get over that first few seconds of oddness, and realise they simply need to breathe through their nose.
As for those who are new to rubber dam, if you explain its use properly, patients actively want it.
Why rubber dam?
First of all, rubber dam protects the airway. The mouth is a slippery place; we even use a lubricant in endodontic treatment, and we are using small files.
There is a catalogue of cases of patients who have needed a file rescued from halfway down their throat or even lung resections. This is not apocryphal, and you don’t want to be the one who becomes a byword for file retrieval!
Plus, you are using bleach in the oral cavity, and we simply cannot allow that to go down their throat. When you’ve got rubber dam on, and you’ve got good suction, the bleach will never have the chance to go beyond where you place it.
Rubber dam also stops saliva from getting into the tooth you are treating.
Tools and protocols
Obviously, you need rubber dam, plus rubber dam forceps, clamps, punch, and frame.
I would like to stress that rubber dam should be latex-free. Once upon a time, to go latex-free you had to use something about the thickness of a bicycle tyre. Thankfully, materials science has caught up with our need and there are some great products out there, my favourite being Isodam (see bit.ly/3A0MYbo for further information). So, go latex-free and you don’t have to worry about the possibility of a latex allergy ever again.
Clamps
In terms of clamps, I tend to keep things really simple. You can buy rubber dam kits and they will have nine or 10 different clamps, and personally I will only ever use one or two of them.
I have a premolar clamp, I have two molar clamps, one for each side, because they’re mirror images of each other, and I don’t use a clamp for anteriors, as they tend to be unwieldy, uncomfortable and can damage the gums.
Instead, I have a technique whereby we floss the rubber dam in place. Therefore, I am not clamping what are normally quite precious gingival margins, crowns, veneers, and so on.
Rubber dam forceps are the tool you use to place your clamp. There are lots on the market, so when choosing yours, make sure they have a groove in them. The rubber dam clamp sits in that groove, and you place it on the tooth. If the groove is very deep or very undercut when you’ve got quite a wide tooth that you put the clamp on, you can’t get the forceps off the clamp. So, it’s all about the groove.
Then you’ve got your rubber dam clamp punch. They tend to go rusty and wear down, so obviously they must be rust-free. You need to make sure that, when on the biggest setting, your punch cuts the complete circle. If it doesn’t cut a complete circle, you’ll pull at the uncut bit and the rubber dam will tear.
Frame
Lastly, the frame is a very personal preference. I tell everyone not to use a plastic frame because they go underneath the rubber dam. They are much fiddlier than metal frames, which go on top.
So, I use metal frames, but I acknowledge that lots of people like the plastic frames. I just think if you’re struggling, it’s important to know that there are metal frames that go on top, and then you can position that where you want. Anyone struggling with the plastic frames might find that much easier.
Clearly, there is only so much information that can be imparted via the written word. Seeing it done is so much better. With that in mind, I invite you to access Endoperfection’s Youtube channel at endoperfection.com/pages/movies, which demonstrates how to place dental rubber dam easily and quickly.
This article first appeared in Dentistry magazine. You can read the latest issue here.
