An article by our Community member Dr. Vincenzo Vitale.
Rubber dam Isolation is a must to perfome a state of art adhesive dentistry.
Christie Barnum gave birth to this rubber sheet well over 150 years ago, exactly in 1864.
However, the rubberdam intended as we know it today came later on in 1882 when the S.S. White, Dr. Palmer, Stokes e Elliot introduced the punch hole piler, clamp forceps and metal clamps very similar to what we use nowdays [1].
Since then its use has always been controversial among practitioners even if the major scientific societies have expressed themselves,overall in endodontics, positively about it .
The AAE Position Statement from 2010 says “Only dental dam isolation minimizes the risk of contamination of the root canal system by indigenous oral bacteria. The dental dam also
offers other benefits, such as aiding in visualization by providing a clean operating field and preventing ingestion or aspiration of dental materials,
irrigants and instruments“[2].
The European Society of Endodontology from 2006 states: “Root canal treatment procedures should be carried out only when the tooth is isolated by rubber dam to: prevent salivary and bacterial contamination, prevent inhalation and ingestion of instruments and prevent irrigating solutions escaping into the oral cavity” [3].
A scientific paper from 1938 found 57 reasons to use rubberdam! [4].
Unfortunately, for various reasons, it is still little used today by most operators worldwide, considering all the benefits it allows too [5].
One of these reasons is its “difficulty” in being used correctly.
A perfect rubberdam isolation can often be very challenging and stressfull, overall at the beginning, when it is so frustrating and time consuming that leads to give up.
However with some practical advices can become a consolidated daily practice and which, contrary to any expectation, becomes a pure stressFREE procedure.
Yes, because working in a field full of cotton rolls, saliva, tongue, suction, cheeks and continuous rinsing by the patient (in addition to not having an optimal adhesion that can guarantee a very high success over time for your restorations) is much more stressful, you know yet!
Surely, if you are already a rubber dam lover, these tricks are well know to you. Although it’s always good to refresh them.
Countrary, for beginners, these can save a lot of frustrating experiences!
So let’s not loose time, move on with these 6 TIPS AND TRICKS !
1. Vaseline.
First of all, always remember to isolate more teeth than the only one you have to work on. I usually suggest 7, but 5 are enough too.
Why? Becouse in this way you can better stretch the rubber dam, having more space for an effective finger rest and a more desirable access and visibility for you and your assistant; moreover to get a view of the morphology of adjacent teeth which is going to help you for your fillings and preps!
Than, Immediately after you’ve punched your rubber dam, place just a drop of vaselline underneath and spread it between the holes. It will help the dam passing between teeth and thigh interproximal contacts.
2. Controlateral Clamp.
A problem often encountered for the isolation of a hemi arch, especially at the beginning, when the distance between the holes is not well managed, is the dam that tightens the working field from the inside.
Being elastic and under the pressure of the tongue it tends to stay bent on one side, leaving little room for the operator to maneuvers. In this case you can use a contralateral clamp without even having to make a hole for that tooth. This way the dam will be tight and you will have more space to work.
3. Cut and place a piece of Rubber dam to fix the end.
In the case of multiple teeth isolation, if the contact points are tight, the dam will remain in place without need to be blocked with the second clamp (like in anterior isolation from second left premolar to right second premolar.).
Often, however, this does not happen and we need to block the dam with a second clamp.
The latter, occasionally, can be annoying and painfull for the patient.
To overcome this problem, a piece of dam can be used between the last isolated tooth and the dam. In this way the patient will not feel any discomfort and your dam will stay still!
Sometimes it works with floss too. Try by your self and choose which one suits for you!
4. Holy Teflon.
PTFE or commonly called Teflon is what I consider the most versatile and easy to use dental material. Besides being cheap of course, which is always so good!
The two most used ways are:
– To protect adjacent teeth from etching and bonding. In fact, residues of the latter can often cause annoyance by creating roughness or thickness. having the patient felling the so loved phrase “it’s high or rough”.
-Used as a retraction cord. Packed into the sulcus, it will form a barrier along with the dam that will help keep everything dry!
5. Modified clamp, from “212” to “106”
The isolation of the V classes is the toughest. Even colleagues who use the dam almost routinely often give up and adopt the “retractor cord” solution.
With the modified clamp 212, (aka 106, due to the fact that now is half clamp) it is possible to isolate in a very simple way even the most cervical lesions thanks to its downward pointing beacks.
To modify it you have to cut the second braket of the 212 (which will allow you more space to work) and slightly fold the two jaws downwards with a plier (which will better engage cervically).
You will see that once you discover its potential you will use it more often than you think!
6. Stabilization with liquid rubber dam.
Ok now you are using clamp “106” and the first thing you’ve notice is that it seems unstable at times. Well it can be caused due to some unstable undercut (like in class 5) or especially after several uses (having only one jaw it becomes loose quite soon). But don’t panic, the liquid dam runs to your aid.
Without etching and bonding, apply some liquid dam (or even a flowable composite if you are a spendthrift) between the arch and the tooth, polymerize and you will see that the hook will remain there as you have chosen! At the end of the procedure just remove it with a probe. Easy, isn’t?
And now I’ll reveal another one too! the most important a seventh!.
7. Practice with the dam(n)!
Only practice makes perfect. At the beginning, it will take you 10 minutes, maybe 15 and even a good sweat for you and the patient.
But day by day you’ll become better, gentler and faster.
Once worked more times in a good isolation you’ll realize soon that you won’t be anymore able to work without it. Material, strategy and techniques will lead you to a successful rubberdam isolation[6].
Five minutes invested in a good isolation and so much stress relieved, raising the standard of your works by a lot!
I recommend persevering. This is the real key secret!
[1] – ANDRIEU, E.: Traité de Dentisterie Operatorie. Octave Doin, Editeur, Paris, 1889
[2] – AMERICAN ASSOCIATION OF ENDODONTISTS: AAE Position Statement, 2010.
[3] – EUROPEAN SOCIETY OF ENDODONTOLOGY: Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int. Endod. J. 39:921-30, 2006.
[4] – Prime JM. Fifty-seven reasons for using the rubber dam. Illinois Dent J 1938;7:197–198.
[5] – G S, Jena A, Maity AB, Panda PK. Prevalence of rubber dam usage during endodontic
procedure: A questionnaire survey. J Clin Diagn Res 2014;8(6):ZC01–ZC03.
[6] – Browet S, Gerdolle D. Precision and security in restorative dentistry: the synergy of isolation and magnification. Int J Esthet Dent. 2017;12(2):172-185. PMID: 28653049.
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