Germany: The use of rubber dams during endodontic procedures is considered common practice and is recommended by international associations and organisations. However, dental practitioners seem to struggle with its use more than endodontists do.
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 statement 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, 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.
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.
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.
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 Castellucci 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.
Incidents around the world have shown time and time again what can happen when a dentist fails to put a rubber dam in place. 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. 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.