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A dental dam or rubber dam (sometimes termed "Kofferdam"—from German), designed in the United States in 1864 by Sanford Christie Barnum,[1] is a thin, 6-inch (150 mm) square sheet, usually latex or nitrile, used in dentistry to isolate the operative site (one or more teeth) from the rest of the mouth. It is used mainly in endodontic, fixed prosthodontic (crowns, bridges) and general restorative treatments. Its purpose is both to prevent saliva interfering with the dental work (e.g. contamination of oral micro-organisms during root canal therapy, or to keep filling materials such as composite dry during placement and curing), and to prevent instruments and materials from being inhaled, swallowed or damaging the mouth. In dentistry, use of a rubber dam is sometimes referred to as isolation or moisture control.[2]

Dental dams may also be used as a safe sex technique to reduce the risk of sexually transmitted infections (STIs) during oral sex.

Contents

DentistryEdit

 
Dental dam in place during a dental procedure.

BackgroundEdit

 
Rubber dam isolation of upper left second premolar, held in place with a rubber dam clamp during endodontic therapy.

The dam is held over individual teeth or groups of teeth by appropriate rubber dam clamps over the anchor tooth. The tooth crown stands out from the rubber dam through individual holes made by a hole punch, isolating the tooth to be treated from the rest of the person's mouth which keeps the tooth dry and reduces risk of exposure to oral micro-organisms. An ink stamp is available to guide placement of the holes prior to application of the dam.[3]

ArmamentariumEdit

The set up of Rubber dam comprises of many elements and involves the use of specific tools and accessories that may be:

  • Rubber dam sheets
  • Clamps or hooks
  • Frame
  • Forceps
  • Dam Punch
  • Dental floss
  • Resin barriers
  • Wooden Wedges or Wedjets [4]


The dam sheets are generally made our of rubber materials like latex or nitrile and tend to be 15cm x 15cm in length and width. The thickness of each dam sheet is approximately between 0.14 and 0.38mm but the sizes, shapes, colours and material that the sheet can vary with different manufacturers. Most manufacturers will make rubber dam sheet alternatives that are suitable for patients with allergenic issues towards materials such as latex or versions that can be autoclaved.

The clamps are essentially metal clips that sit around the crown of the tooth to anchor and secure the rubber dam sheet around the tooth or teeth that are being worked on during the dental procedure. The clamps come in a variety of shapes and sizes which suit the anatomy of the different teeth in the mouth. Before placing the dam in the mouth dental professionals may choose to loop dental floss around the clamps, this acts as an anchor for the hook to prevent aspiration or swallowing of the clamp. [5]

The frame of the rubber dam is used to keep the dam sheet stretched out so that it can be placed over the tooth and a clinician can work effectively on the tooth without the dam sheet getting in the way. There are several types of dam frames, Stainless steel or polypropylene or other polymer plastics. No matter what material the frame is made out of, the frame will have small pins on the edges which act to anchor the dam sheet to the frame. The plastic dam frames are generally used in a case where dental radiography is planned and therefore the frame should be radiolucent to ensure that the frame isn’t superimposed in the radiograph.

The dam punch is a tool used to perforate holes of various sizes, generally corresponding to the size of the tooth that needs to be isolated in the rubber dam sheet. The rubber dam clamp is placed partially through the hole and applied to the tooth which then allows the tooth to pass through to be viewed clinically. [6]

AdvantagesEdit

  • Clean and dry operating field (saliva, blood). For dentistry procedures involving bonding with adhesives or cements it is to be encouraged as the operative field must avoid contamination in order to achieve maximum bond strength between restorative material, enamel and dentin. Poor bonding may compromise the success or longevity of the restorations. There is some evidence to suggest that the use of a rubber dam may increase the survival time of dental restorations compared to the use of cotton rolls as an isolation method.[7]
  • Decreased contamination of dental treatment with oral micro-organisms in saliva[8]
  • There is improved visibility of the operative site (retracts the lips and cheeks, reduced mirror fogging, enhanced visual contrast)[9]
  • Decreased (but not eliminated) chance of accidental swallowing or inhaling restorative instruments, tooth fragments or debris.[10] Should this occur, hospital admission might be necessary for a chest x-ray, and potentially an operation to remove it.
  • Corrosive endodontic irrigants such as sodium hypochlorite (bleach) are contained, which could damage the soft tissues of the mouth and be harmful if swallowed[11]
  • Reduction in the risk of cross-infection in the dental practice by decreasing the microbial content of splatters and air turbine aerosols produced during dental treatment[12]
  • When rubber dams are used in association with amalgam restorations, they may reduce the person's exposure to potentially harmful adverse effects of mercury ingestion[13][14]
  •  
    Sealing agent used on a patient to fill in some gaps between the rubber dam and gingiva, after a tear was caused in the rubber dam
    Protecting soft tissues of oral mucosa from sharp instruments or materials. A caulking adhesive is sometimes used to fill in the gaps between the rubber dam and gingiva. It can adhere to wet rubber dam, or mucosal tissues.[15]
  • Some patients find it more comfortable to have treatment with a dental dam since there is no water in the mouth and they feel safer and more dissociated from the noise of drilling etc.[16]
  • In some parts of the world, use of a dental dam is mandatory for procedures such as root canal therapy for reasons of safety and cross infection control, and if any injury that could have been prevented by its use occurs, it is medicolegally indefensible.
  • The dental dam significantly reduces the ability of the dental patient to communicate. This can be considered a disadvantage (see below), or an advantage, e.g. in over-talkative patients to facilitate faster treatment
  • A Cochrane review in 2016 suggested that on using rubber dam as an isolation method, there's a chance dental restorations last longer.[17]

DisadvantagesEdit

Although there are many advantages of rubber dams during dental treatment there are also associated risks and disadvantages. The rubber dam can take extra time to apply; however with consistent practice and use by the dental practitioner this may not have an effect on the length of the appointment. Insufficient training and the inconvenience of application can also be a deterrent for its use and can also contribute to lost time.[18] The cost of dental dams is an expense to the dental practice and could also be a disincentive. Although the rubber dams are inexpensive to purchase, initial costs for the armamentarium can be high.

There is a risk of rubber dam clamps breaking during application due to the chemical effects of sodium hypochlorite, an antimicrobial solution used during root canal treatments, repeated stresses of clinical use,[19] or autoclaving,[20] all of which can potentially weaken the material. To avoid swallowing or aspiration of broken clamps, the dental practitioner should place floss around the clamp to allow its retrieval if it snaps or springs off during a procedure.

As the dental dam clamp is placed along the gum line, this can cause some discomfort or pain (especially in a patient who does not require local anaesthesia), bleeding from the gums, damage to the periodontal ligament or abrasion of the cementum on the root of the tooth, which may cause an uneven surface on the tooth root that can retain plaque.[21]

The dental dam is placed over the mouth, effectively blocking off the airway, which means the patient must be able to comfortably breathe through their nose. This is a problem for patients with nasal airway obstruction such as the common cold, a broken nose, adenoids, recurring sinus issues, or those who habitually breathe through their mouths. Patients can also find that communication is reduced between the dental practitioner and themselves, which may result in feelings of claustrophobia, vulnerability and anxiety. Those prone to dental phobia and individuals who have learning difficulties, disabilities or special needs may find the use of dental dams impossible.[22]

To an extent, the use of a dental dam may lead to visual distortion of tooth morphology since the other teeth and the rest of the mouth are hidden from view. This may lead to perforation if an access cavity is incorrectly angled during root canal therapy. For this reason, endodontists may routinely begin their access cavity before applying the dam, to ensure the correct orientation before the root canal system is opened up.

The rubber dam, which is usually brightly coloured (blue or green), may alter the apparent colour of the tooth, which can lead to incorrect choice of shade, e.g. during placement of a dental composite during a restorative procedure. For this reason, dental practitioners should select the appropriate shade of material prior to the application of rubber dam.

As the rubber dams are primarily made of latex, patients may experience reactions which range from uncomfortable (allergic contact dermatitis, allergic contact cheilitis, allergic contact stomatitis) to life-threatening (anaphylaxis). Nitrile versions are available for those with latex allergies and adverse reactions can be avoided by patients informing dental practitioners of latex allergies prior to treatment or adverse reactions after rubber dam application.

Safe sexEdit

For safer sex and to protect against sexually transmitted infections (STIs), dental dams are sometimes suggested for use as a physical barrier against the exchange of body fluids during cunnilingus and anilingus, especially for women who have sex with women.[23] However, they are rarely used for this purpose,[23][24][25] and there is no good evidence that their use reduces the risk of STI transmission, including the risk of infection with human immunodeficiency virus.[25]

After lubrication with a water-based lubricant, an unpunctured dental dam may be held over the vulva or anus, allowing oral stimulation of these areas without transmission of bodily fluids or direct physical contact. Plastic cling wrap, condoms or latex gloves (cut open longitudinally) can be used for STI protection in a similar manner as a dental dam, by providing a physical barrier to cover the vaginal or anal areas during oral sex, these alternative barrier methods are more affordable and readily available than dental dams.[23][26][27]

Dental dams were initially promoted in the 1980s in some safer sex campaigns as a barrier to prevent transmission of STIs during oral sex.[23] They were introduced for use in some women's prisons in Canada and Australia (in NSW, ACT, WA and SA states) in the 1990s as a form of sexual barrier protection after the World Health Organization (WHO) recommended that female prisoners should have access to dental dams.[23][28] Inmates have reported numerous barriers for dental dam use, including the dam being too thick, lack of availability, poor taste, and reduced sensations when used for oral sex. Dental dams are often reappropriated for other uses by prison inmates, such as hair elastics, placemats or shoelaces.[29] They are relatively expensive and difficult to obtain outside of the prison system.[30] Rubber dams are not manufactured, marketed, registered, tested or evaluated for their effectiveness as an STI prevention aid, and no studies currently exist on their permeability to STI pathogens.[31]

ReferencesEdit

  1. ^ Elderton, R. J. (1971-02-01). "A modern approach to the use of rubber dam--1". The Dental Practitioner and Dental Record. 21 (6): 187–193. ISSN 0011-8729. PMID 5278933.
  2. ^ Luca Martinelli, The rubber dam technique, Academia.
  3. ^ Bun San Chong, Shanon Patel, Bhavin Bhuva, Rubber dam in clinical practice, ENDO (Lond Engl) 2008;2(2):131–141.
  4. ^ Duggal, Monty; Cameron, Angus; Toumba, Jack. Paediatric dentistry at a glance. Wiley-Blackwell. p. 22. ISBN 978-1-444-33676-4. Retrieved 8 May 2019.
  5. ^ Martinelli, Luca. "THE RUBBER DAM TECHNIQUE". Academia. Retrieved 8 May 2019.
  6. ^ Scheller-Sheridan, Carmen. Basic guide to dental instruments (2nd ed.). Wiley-Blackwell. ISBN 9781118713587. Retrieved 9 May 2019.
  7. ^ Wang, Yan; Li, Chunjie; Yuan, He; Wong, May CM; Zou, Jing; Shi, Zongdao; Zhou, Xuedong (2016-09-20). "Cochrane Database of Systematic Reviews". Cochrane Database of Systematic Reviews. 9: CD009858. doi:10.1002/14651858.cd009858.pub2. PMC 6457832. PMID 27648846.
  8. ^ Cochran, M. A.; Miller, C. H.; Sheldrake, M. A. (1989-07-01). "The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment". Journal of the American Dental Association. 119 (1): 141–144. doi:10.14219/jada.archive.1989.0131. ISSN 0002-8177. PMID 2760346.
  9. ^ Reid JS, Callis PD, Patterson CJ (1991). Rubber Dam in Clinical Practice (1st ed.). London: Quintessence Publishing.
  10. ^ Tiwana, Karen K.; Morton, Teresa; Tiwana, Paul S. (2004-09-01). "Aspiration and ingestion in dental practice: a 10-year institutional review". Journal of the American Dental Association. 135 (9): 1287–1291. doi:10.14219/jada.archive.2004.0404. ISSN 0002-8177. PMID 15493393.
  11. ^ Cohen, S.; Schwartz, S. (1987-04-01). "Endodontic complications and the law". Journal of Endodontics. 13 (4): 191–197. doi:10.1016/S0099-2399(87)80139-5. ISSN 0099-2399. PMID 3471843.
  12. ^ Harrel, Stephen K.; Molinari, John (2004-04-01). "Aerosols and splatter in dentistry: a brief review of the literature and infection control implications". Journal of the American Dental Association. 135 (4): 429–437. doi:10.14219/jada.archive.2004.0207. ISSN 0002-8177. PMID 15127864.
  13. ^ Kremers, L.; Halbach, S.; Willruth, H.; Mehl, A.; Welzl, G.; Wack, F. X.; Hickel, R.; Greim, H. (1999-06-01). "Effect of rubber dam on mercury exposure during amalgam removal". European Journal of Oral Sciences. 107 (3): 202–207. doi:10.1046/j.0909-8836.1999.eos1070307.x. ISSN 0909-8836. PMID 10424384.
  14. ^ Halbach, S.; Vogt, S.; Köhler, W.; Felgenhauer, N.; Welzl, G.; Kremers, L.; Zilker, T.; Melchart, D. (2008-05-01). "Blood and urine mercury levels in adult amalgam patients of a randomized controlled trial: interaction of Hg species in erythrocytes" (PDF). Environmental Research. 107 (1): 69–78. Bibcode:2008ER....107...69H. doi:10.1016/j.envres.2007.07.005. ISSN 0013-9351. PMID 17767927.
  15. ^ "OraSeal*". CLINICAL RESEARCH DENTAL. Retrieved 2018-05-27.
  16. ^ Stewardson, D. A.; McHugh, E. S. (2002-10-01). "Patients' attitudes to rubber dam". International Endodontic Journal. 35 (10): 812–819. doi:10.1046/j.1365-2591.2002.00571.x. ISSN 0143-2885. PMID 12406374.
  17. ^ Wang, Yan; Li, Chunjie; Yuan, He; Wong, May CM; Zou, Jing; Shi, Zongdao; Zhou, Xuedong (2016-09-20). "Rubber dam isolation for restorative treatment in dental patients". Cochrane Database of Systematic Reviews. 9: CD009858. doi:10.1002/14651858.CD009858.pub2. ISSN 1465-1858. PMID 27648846.
  18. ^ Hill, Edward E.; Rubel, Barry S. (2008-10-01). "Do dental educators need to improve their approach to teaching rubber dam use?". Journal of Dental Education. 72 (10): 1177–1181. ISSN 0022-0337. PMID 18923098.
  19. ^ Chhabra, Mudrika; Greenwell, Ann L (2018). "Effect of Repeated Sterilization on the Tensile Strength of Rubber Dam Clamps". Pediatric dentistry. 40(3): 1. PMID 29793571.
  20. ^ Sutton, J.; Saunders, W. P. (1996-09-01). "Effect of various irrigant and autoclaving regimes on the fracture resistance of rubber dam clamps". International Endodontic Journal. 29 (5): 335–343. doi:10.1111/j.1365-2591.1996.tb01394.x. ISSN 0143-2885. PMID 9206417.
  21. ^ Wakabayashi, Hajime; Ochi, Kouichi; Tachibana, Hitoshi; Matsumoto, Koukichi (1986). "A clinical technique for the retention of a rubber dam clamp". Journal of Endodontics. 12(9): 1. doi:10.1016/S0099-2399(86)80078-4.
  22. ^ Soldani, Francesca; Foley, Jennifer (Jan 2007). "An assessment of rubber dam usage amongst specialists in paediatric dentistry practising within the UK". International Journal of Paediatric Dentistry. 17(1).
  23. ^ a b c d e Richters, J; Prestage, G; Schneider, K; Clayton, S (Jun 2010). "Do women use dental dams? Safer sex practices of lesbians and other women who have sex with women". Sexual Health. 7 (2): 165–9. doi:10.1071/SH09072. PMID 20465981.
  24. ^ Yap, L; Richters, J; Butler, T; Schneider, K; Kirkwood, K; Donovan, B (Jun 2010). "Sexual practices and dental dam use among women prisoners--a mixed methods study". Sexual Health. 7 (2): 170–6. doi:10.1071/SH09138. PMID 20465982.
  25. ^ a b Jonathan Zenilman, Mohsen Shahmanesh (2012). Sexually transmitted infections : diagnosis, management, and treatment. Sudbury, Mass.: Jones & Bartlett Learning. p. 330. ISBN 9780763786755.
  26. ^ Yap, L; Richters, J; Butler, T; Schneider, K; Kirkwood, K; Donovan, B (June 2010). "Sexual practices and dental dam use among women prisoners - a mixed methods study". Sexual Health. 7 (2): 170–6. doi:10.1071/SH09138. PMID 20465982.
  27. ^ "Dental Dam Use". www.cdc.gov. Centers for Disease Control and Prevention. Retrieved 2018-09-18.
  28. ^ Yap, L; Richters, J; Butler, T; Schneider, K; Kirkwood, K; Donovan, B (June 2010). "Sexual practices and dental dam use among women prisoners - a mixed methods study". Sexual Health. 7 (2): 170–6. doi:10.1071/SH09138. PMID 20465982.
  29. ^ Yap, L; Richters, J; Butler, T; Schneider, K; Kirkwood, K; Donovan, B (June 2010). "Sexual practices and dental dam use among women prisoners - a mixed methods study". Sexual Health. 7 (2): 170–6. doi:10.1071/SH09138. PMID 20465982.
  30. ^ Stevens, P; Hall, J (July 2001). "Do women use dental dams? Safer sex practices of lesbians and other women who have sex with women". Journal of Obstetric, Gynecologic & Neonatal Nursing. 30 (4): 439–447. doi:10.1111/j.1552-6909.2001.tb01563.x.
  31. ^ Richters, J; Clayton, S (June 2010). "The practical and symbolic purpose of dental dams in lesbian safer sex promotion". Sexual Health. 7 (2): 103–106. doi:10.1071/SH09073.