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L13 Rubber Damns for Endodontics_formatted_text

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Rubber Dam for Endodontics

Prof. Paul V. Abbott AO BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT

Specialist Endodontist Winthrop Professor of Clinical Dentistry UWA Dental School The University of Western Australia

NOTE

The rubber dam, now more accurately called a dental dam as most versions are latex-free, is an essential and mandatory tool for modern endodontics. Any practitioner not using a dental dam should not be performing root canal treatments.

Introduction and History1

A New Innovation?

  • Most patients think so!!!

  • First use was on 15th March 1864

    • Dr. Sanford C. Barnum - New York, USA

  • 154 years ago !!!

  • It was developed over 155 years ago.

Dr. S. C. Barnum2

At the time when the idea of rubber dam dawned on my mind, I was practising in Monticalls, Sullivan Co., New York. It was the result of much persecution from the inroads of saliva. I had spent many an hour, weary and distracted, battling against its incursions. Many a sleepless night had I over sad failures … with the one absorbing question ever before me unanswered. “How shall I keep the cavities dry?” The answer came … on the 15th day of March 1864, a case presented itself of a cavity in a lower molar standing alone, on the left side, in a mouth, as wet — well as water gushing from every duct could make it. In a sort of half desperate way, and partly to try the new idea, I cut a hole in my napkin protector and over the tooth it went. There was the rubber dam.

Sanford C. Barnum 1877⁴

**University of Illinois - 1900

NOTE

Historical photographs, such as one from the student clinic at the University of Illinois in 1900, clearly show patients being treated with rubber dams in place. This demonstrates that its use was standard practice in dental education over 120 years ago.

**

Historical Recommendation3456

  • First reported use in 1864
    • Dr. S.C. Barnum – USA
  • Recommended by ALL teaching authorities and professional societies since the 19 Century for ALL endodontic procedures
    • And for many other dental procedures!!

NOTE

While that number may be extensive, there are at least nine critically important reasons to use a rubber dam.

In 1937, Dr. James M. Prime outlined 58 valid reasons for using the rubber dam. Many lecturers and authors have referred to these reasons over the years. It is interesting to review this outline 48 years later, and see what reasons do and do not apply to dentistry in 1985.

Fifty-Eight Reasons for Using Rubber Dam by James Mark Prime, DDS

The use of the Rubber Dam is so tremendously important in operative procedures and because so many operators are failing to use it, it is considered advisable to enumerate some of the places where its use is strongly indicated. Habitual users will, no doubt, see other places than what are mentioned in the following fifty-eight reasons:

Reasons for Using Rubber Dam7

NOTE

The use of a rubber dam is critical for infection control, patient safety, and improving the quality and efficiency of dental treatment.

  1. Infection control
  2. Patient safety
  3. Patient comfort
  4. Moisture control
  5. Increased visibility
  6. Increased access
  7. Increased efficiency
  8. “Dento-legal” reasons
  9. Improved treatment outcome

1. Infection Control89

NOTE

Working in a patient’s mouth without a dam creates a significant aerosol of water and saliva, spreading microorganisms throughout the operatory.

  • ==Aerosol Contamination: An experiment using a clear screen placed over a patient who had rinsed with a plaque-disclosing solution showed extensive red spatter covering the screen, the dentist, and the assistant after a procedure without a dam.==
  • ==Conclusion: The rubber dam is a highly effective tool for cross-contamination control, protecting the dental team and the clinical environment.==

Recovery of Microorganisms With and Without Use of the Dental Dam During Cavity Preparations (Cochran et al, JADA 1989)

At Dental Light Unit

LocationWithout Dam (Mean CFU)With Dam (Mean CFU)% Reduction
Actual Cavity Preparation
Maxillary Anterior210100%
Mandibular Anterior10100%
Maxillary Posterior412150%
Mandibular Posterior10.487%
Simulated Study
Maxillary Anterior170100%
Mandibular Anterior30100%

At Patient’s Chest

LocationWithout Dam (Mean CFU)With Dam (Mean CFU)% Reduction
Actual Cavity Preparation
Maxillary Anterior2114280%
Mandibular Anterior1201588%
Maxillary Posterior3818478%
Mandibular Posterior5003670%
Simulated Study
Maxillary35611> 95%
Mandibular235> 99%

2. Patient Safety101112

NOTE

The rubber dam acts as a crucial barrier, preventing the accidental swallowing or inhalation of small instruments and materials.

  • Bur in the Lung

  • Temporary Crown swallowed

  • Pin and chuck swallowed

  • Gates-Glidden bur in an Appendix

  • Endodontic files

  • ==Soft Tissue Protection: The dam retracts the tongue, cheeks, and lips, protecting them from injury by high-speed or low-speed handpieces if the patient moves unexpectedly.==

  • ==Material Ingestion: It prevents small pieces of restorative material, such as amalgam, from being swallowed or inhaled during placement or carving.==

Rubber Dam in Clinical Practice

3. Patient Comfort1314151617

NOTE

Contrary to some dentists’ beliefs, most patients prefer the use of a rubber dam.

(Gergely, BDJ 1989)

  • 99% of patients accepted the use of RD

    • 72% preferred RD
    • 20% had no preference
    • 8% preferred no RD

  • When appointment was 45-60 minutes:

    • 76% preferred RD
    • 24% had no preference
    • 0% preferred no RD

  • Favourable comments - 82% of patients:

    • Absence of things in the mouth
    • Secure, comfortable, safe, relaxed, detached
    • Tongue out of way, protected
    • No dribbling, no bad tastes
    • Can swallow any time & without fear of swallowing bits of filling, etc

  • Unfavourable comments - 18% of patients:

    • Disliked clamp placement
    • Breathing difficulties
    • Smell, colour
    • Rubber irritated
    • Apprehensive, claustrophobic

  • ==Managing Unfavorable Comments:==

    • ==Clamp Discomfort: This is a clinician issue, often due to poor clamp selection or placement.==
    • ==Breathing Difficulties: Educate the patient to breathe through their nose. For true mouth-breathers, a portion of the dam can be left off the frame to create an opening over the mouth.==
    • ==Smell/Color: Different colors and scented/flavored dams are available.==
    • ==Facial Irritation: Proper placement and frame choice (e.g., an Ospy frame) can hold the dam away from the face.==
    • ==Apprehension/Claustrophobia: Calmly explain the necessity of the dam and talk the patient through the placement process. For true claustrophobia, sedation or general anesthesia may be required, but the rubber dam must still be used.==

4. Moisture Control18

NOTE

The rubber dam provides total moisture control, which is a two-way benefit.

  1. Protecting the Patient: It prevents caustic and unpleasant-tasting irrigants used in endodontics (e.g., sodium hypochlorite, EDTA) from entering the patient’s mouth.
  2. Protecting the Tooth: It prevents saliva from contaminating the operating field, which is critical for disinfection and bonding procedures.

Saliva that pools under the dam can be managed by having the patient swallow or by lifting a corner of the dam to use an evacuator.

5. Increased Access & 6. Increased Visibility19

NOTE

The rubber dam transforms the operating field by retracting the lips, cheeks, and tongue.

  • ==Access: It creates a clear, unobstructed path to the tooth, eliminating the need for constant retraction with mirrors or other instruments.==
  • ==Visibility: The color contrast between the dam and the tooth structure enhances visibility, allowing for more precise and higher-quality work.==

“You can do it better when you can see it better!”

7. Increased Efficiency2021

  • Saves significant operating time

  • Quick to apply - mean: 1.9 minutes

    • Gergely BDJ 1989
    • BUT - they were general dentists
      • Only used RD 5% of the time
    • Regular users likely to be much faster

  • ==An experienced user can place a dam in 20-30 seconds.==

  • NB: Local Anaesthesia needs 3-5 minutes to be effective

NOTE

The time spent waiting for local anesthesia to become effective can be used to place the rubber dam, allowing treatment to begin immediately once the patient is numb.

NOTE

Failure to use a rubber dam for endodontic treatment is a significant departure from the accepted standard of care and poses a major legal risk.

  • ==Standard of Care: Its use has been recommended by all major authorities since the 19th century.==
  • ==Liability: In the event of an accident, such as an inhaled file, a case against a dentist who did not use a rubber dam would be virtually indefensible. An article in the Journal of Endodontics stated that in such a case, there would be

Premolar teeth23

Rubber Dam Sheets

  • ==Material: While latex is still available, non-latex dam is now the standard to prevent allergic reactions. It typically comes in single-use vacuum packs.==
  • ==Thickness: Medium body is the preferred thickness.==
    • ==Light body is prone to tearing.==
    • ==Heavy body is difficult to stretch over teeth.==
  • ==Color: Various colors are available (green, blue, pink). Green provides excellent color contrast with the tooth and is visually pleasant for the operator.==

Rubber Dam Punch

NOTE

A good punch is critical for creating clean, round holes that will not tear when stretched.

  • ==Punch Style: The turntable style is preferred over the slot style, as it is easier to use.==
  • ==Hole Size: Using the largest hole on the punch is sufficient for all teeth, including small lower incisors. There is no need to switch between different hole sizes.==
  • ==Technique: To ensure a clean cut without tags, use a **

Molar teeth24

  • ==2T: A versatile single-bowed clamp suitable for premolars, anterior teeth, and even some small molars. Its single bow provides better visual and physical access than the 9T.==
  • ==#0: A smaller clamp suitable for very small premolars or lower anterior teeth.==

Four rubber dam clamps are shown:

  • 4
  • 12A
  • 13A
  • 2A

NOTE

Lower Molars: The #4 clamp is the go-to clamp for virtually all lower molars. It is flat and provides a stable fit. Upper Molars:

  • ==12A and 13A: These are serrated, mirror-image clamps designed for upper molars. The longer beak goes to the buccal side.==

    • ==13A: For the upper right (Quadrant 1 - odd number).==
    • ==12A: For the upper left (Quadrant 2 - even number).==

  • ==2A: This clamp is slightly larger than the 2T and works well on smaller upper molars (e.g., second or third molars).==

  • Keep the choices simple!!

General Principles and Clamp Selection25

  • ==Winged vs. Wingless: Winged clamps are highly recommended. They allow the dam to be stretched over the wings before placement, enabling the clamp and dam to be seated on the tooth in a single, efficient step.==
  • ==**Serrated (

Clamp Selection Guide26

NOTE

The lecturer recommends a minimal set of clamps for most procedures, primarily used with the

Isolation TypeTooth TypeClamp Selection
Single Tooth IsolationUpper IncisorsClamp # 9T
Upper CaninesClamp # 9T or # 2T
Upper PremolarsClamp # 2T
Upper MolarsTeeth 16, 17: Clamp # 13A
Teeth 26, 27: Clamp # 12A
Teeth 18, 28: Clamp # 2A
Lower IncisorsClamp # 9T
Lower CaninesClamp # 9T or # 2T
Lower PremolarsClamp # 2T
Lower MolarsClamp # 4
RD Cuff TechniqueUpper IncisorsClamp # 2T on the 1st Premolar tooth on the same side of the mouth.
Upper CaninesClamp # 2T on the 1st or 2nd Premolar tooth on the same side of the mouth.
Upper PremolarsTeeth 14, 15: Clamp # 13A on tooth 16.
Teeth 24, 25: Clamp # 12A on tooth 26.
Upper MolarsTooth 16: Clamp # 13A on tooth 17.
Tooth 26: Clamp # 12A on tooth 27.
Teeth 17, 27: Clamp # 2A on tooth 18 or 28 respectively, if present.
Lower IncisorsClamp # 2T on the 1st Premolar tooth on the same side of the mouth.
Alternatively for Teeth 31, 41 - Clamp # 00 on the 32 or 42 respectively.
Lower CaninesClamp # 2T on the 1st or 2nd Premolar tooth on the same side of the mouth.
Lower PremolarsClamp # 4 on the 1st Molar on the same side of the mouth.
Lower Molars1st Molars: Clamp # 4 on the 2nd Molar on the same side of the mouth.
2nd Molars: Clamp # 4 on the 3rd Molar on the same side of the mouth, if present.

Frames2728293031

  • Young’s frame (metal)

NOTE

Not recommended for endodontics as it is radiopaque and must be removed for radiographs.

  • **Star

NOTE

Can be uncomfortable, pressing on the upper lip and nose, potentially causing breathing difficulty for the patient.

“Visi” frame**

  • Nygaard-Östby frame

NOTE

The Ospy Frame is recommended instead. It is a four-sided, plastic, contoured frame.

  • ==It is designed to fit the contours of the face, with the top portion arching over the patient’s nose rather than blocking it.==
  • ==The frame is placed underneath the rubber dam, which holds the dam away from the patient’s face for increased comfort.==

Extra Items32333435363738

  • OraSeal

NOTE

A non-medicated, putty-like caulking material or

  • Wedjets

NOTE

A solid, non-latex rubber cord that comes in various sizes.

  • ==Use: Used to secure the rubber dam interproximally in situations where a clamp cannot be used.==

  • ==Application: The cord is stretched to become thin, passed through the contact point, and then released, where it

  • Wedjets + OraSeal

EXAMPLE

In a case with severely crowded and lingually-inclined lower incisors where a clamp could not be placed, Wedjets were used to secure a dam cuff, and Oraseal was used to seal the remaining gaps.

Endodontic “Working” Radiography394041

NOTE

The Ospy frame is ideal for endodontics because it greatly simplifies taking working radiographs without removing the rubber dam assembly.

  • ==Technique: Because the frame sits under the dam, a corner of the dam can simply be unhooked from the frame to create an opening.==
  • ==Sensor/Film Placement: This opening allows for easy placement of a digital sensor or film into the mouth using either a holder (e.g., artery forceps for lower posteriors) or the finger technique (for anteriors and upper posteriors).==
  • ==Stability: The rest of the dam and clamp remain securely in place, ensuring isolation is maintained throughout the radiographic procedure.==

Lower Posterior Teeth4243

Upper Posterior Teeth4445

Upper Anterior Teeth46

Lower Anterior Teeth

Rubber Dam Equipment

NOTE

Using high-quality, appropriate equipment is essential for easy and effective rubber dam placement.

Extra Items374138394041

  • OraSeal
  • Wedjets

Footnotes

  1. Original PDF page 2: L13 Rubber Damns for Endodontics, p.2 ↩

  2. Original PDF page 3: L13 Rubber Damns for Endodontics, p.3 ↩

  3. Original PDF page 4: L13 Rubber Damns for Endodontics, p.4 ↩

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  37. Original PDF page 65: L13 Rubber Damns for Endodontics, p.65 ↩ ↩2

  38. Original PDF page 66: L13 Rubber Damns for Endodontics, p.66 ↩ ↩2

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  42. Original PDF page 60: L13 Rubber Damns for Endodontics, p.60 ↩

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  44. Original PDF page 62: L13 Rubber Damns for Endodontics, p.62 ↩

  45. Original PDF page 63: L13 Rubber Damns for Endodontics, p.63 ↩

  46. Original PDF page 64: L13 Rubber Damns for Endodontics, p.64 ↩

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