The idea of using a rubber sheet for isolating a tooth dates back exactly 156 years! This notion was first introduced by a young American dentist from New York, Sanford, named Dr Christie S Barnum. Dr Christie, in 1864 demonstrated the advantages of isolating a tooth with a rubber sheet.
According to Dr Christie, at the time when the idea of rubber dam dawned upon him, he was practicing in Monticallis, New York. He had spent many hours, drained and distracted, battling against saliva incursions. The case failures gave him sleepless nights and he always was on a lookout for an answer. “How to keep the cavities dry?”
The answer came on 15th March 1864, he got a case of a cavity in a lower molar standing alone, on the left side. Saliva gushing from every duct was making the
cavity impossible to keep dry. In a sort of half desperate way, and also partly
to try the new idea, he cut a hole in the protective napkin and put it over the
tooth. That is how rubber dam came to be.
However, having a rubber around a tooth was problematic and was difficult to work with. At the same time, keeping the rubber in place was a challenge, but things changed when in the year 1882, S. S. White introduced a rubber dam punch similar to that used even today.
Ever since, rubber dam has become a friend to every Dentist for procedures such as restorations and root canal treatments. Apart from easing the task of maintaining a dry cavity, a rubber dam also affects the prognosis/outcome of a treatment.
Various studies have been performed to find the co-relation between usage of rubber dam and outcome of an RCT, and it has been established that the use of a rubber dam during RCT could provide a significantly higher survival rate after initial RCT.
The results support that rubber dam usage improves the outcomes of endodontic treatments. However, even with a great friend that a rubber dam is to a dentist, the usage is very limited.
Interesting fact to note is that, even in medico-legal aspects, using a rubber dam has been advised as a standard practice.
According to a survey conducted among 500 dentists across India, including undergraduates, interns, postgraduates and private practitioners showed that only 40.7% of the study population used rubber dams. Information was sought about age, gender, educational qualification. The found that the use of rubber-dam was highest among the post graduates. Age, gender and educational qualification also showed statistically significant influence on the usage of rubber dam.
Another study with 737 participants showed that only 30% use rubber dam for some RCT procedure, while only 23% use it for all RCT procedures.
According to an article published in the journal of the American Dental Association (JADA), 53% of general dentists (mainly private practitioners) in USA do not always use rubber dams. Another study carried out in 2017 reports that 40 to 45% general dentists in USA do not use rubber dams.
Here is what a study conducted in Saudi Arabia states-
The percentage of endodontists who used rubber dam (84.8 %) was significantly greater than that of general practitioners (21.6 %). Large proportion of those who used rubber dam were working in the government sector (54.3 %).
Among rubber dam users, the greatest proportion were graduates from Saudi Arabia (57.8 %) compared to those from Egypt (34.3 %) and Syria (22.4 %). There was a significant correlation between the pattern of rubber dam use during
undergraduate education and its usage after graduation. A high proportion of participants (48.1 %) reported better undergraduate education as the most important factor that would increase rubber dam use in dental practice.
A study in Nigeria also reported underutilization of rubber dams in private dental practitioners.
Various other studies also reported similar results. There was statistically significant difference between rubber dam usage in general dentists and endodontists. Also, the institute of training had a pattern of rubber usage or non-usage.
All of these studies suggest that the degree of training is the biggest factor affecting the adoption and usage of rubber dams. The anxiety and fear of unknown seems to be the biggest hurdle especially in India. A country where hardly any institute trains undergraduates to use a rubber dams. By training, I mean the usage of it for every single patient that they perform a procedure on, and not just a demonstration of a rubber dam kit placement.
It is a well established fact that even a single droplet of saliva contains millions of organisms, enough to contaminate and infect your root canal treatment. No wonder we see so many terribly failed RCTs. Even in general patients, the perception of an RCT is becoming negative because of its failure rates, directly related to non-usage of a rubber dam.
It is thus imperative that the usage of rubber dam needs to be promoted by allowing sufficient practice. For those who give cost of a rubber dam as a reason to not use it, forget, that the cost of a repeat RCT or a tender tooth post RCT is much higher, in form of a bad customer experience, loss of patients and loss of goodwill. Moreover, the cost of rubber dam can be passed on to patients, if not adjustable in the price margin.
Please share your thoughts on ways and means to promote use of rubber dams for all endo procedures in India and other countries.
P.S.-The data obtained for all the studies mentioned here have been referred from articles published in various journals. Please write back for a reference, if need be.