Rubber dam use in dentistry – Is it better?

Wheaton family dental practice

Rubber dam use in dentistry.  Is it better?

Mid mesial root canal with rubber dam
Mid mesial root canal with rubber dam

It is generally accepted that use of the rubber dam (and perhaps the Isolite or something similar) is both safer and clinically more efficient and effective for root canal therapy.  There is also a general belief that this holds for composite dentistry as well.  However, whether this is true for composite dentistry or not is debatable.  The main arguments for use is that it creates a cleaner field to work in, lowers the humidity, and creates a more predictable working environment.  All of these may be true, but are somewhat subjective and tough to measure.  Rubber dams do lower both the patient’s exposure level to minute levels of toxins that are commonly used in dentistry.  Rubber dams also lower the exposure level of infective agents to the doctor and the assistant.  The most important question that remains unclear is; Does using a rubber dam improve the quality of dental composite dentistry in a clinically relevant manner?  The answer seems to be NO!

How can this be?  It seems other factors outweigh any effects that could be gained from a rubber dam.  I think the general belief that rubber dams are better come from the fact that the skill level of dentists doing composite dentistry is so variable.  Composite dentistry is a technique sensitive procedure and attention to detail is critical to long term success.  Those dentists that do use a rubber dam for their composite dentistry are likely producing better composites due to their meticulous and some might say obsessive attention to detail rather than the use of the rubber dam itself.  Thus it appears to many that the rubber dam is superior when in all likelihood it is the operator.

I think Jones sums up the advantages of a rubber dam nicely.  Jones 1988  “The increasing reliance of modern dentistry on adhesive materials, has acted as a renewed incentive for the use of rubber dam. A safe, dry field in a comfortable patient, with the teeth and colored rubber dam contrasting, are the major advantages to the operator. Few articles have assessed the reactions of either the patient or the operator; in this study, it is accepted well.”

Studies on rubber dam use with bonding and longevity

Systemic Review – Cajazeira 2014 Am J Dent Effects of the isolation method of the operative field (rd or cotton rolls) did not impact longevity.

Lit Review – Brunthaler 2003  Effects of the isolation method of the operative field (rd or cotton rolls) and the professional status of operators (university or general dentist) on composite failure rates were not found to be significant.

Van Dijken 1987 using SEM showed that the use of rubber dam had no effect on marginal adaptation for anterior composites.  They did show that time and type of composite used DID have a big effect on marginal adaption.

Eidelman 1983 compared sealant retention with and without rd.  This is likely a good study to look at but I don’t have access to it 🙁
Lygidakis 1994 also compared sealant retention rates and shows little difference between cotton rolls or rubber dams.
Smales 1993 BDJ There were no clinically-significant differences present in the survival rates of amalgams or composites which could be directly related to the use of a rubber dam.
Smales 1992 The low mean deterioration scores for most of the clinical factors assessed were also fairly similar, irrespective of the isolation method used.
Barghi 1991 showed a difference in bond strength.  I can only assume that the rubber dam was higher???
Wood 1989 showed no difference in retention rates of sealants with cotton roll or VacEjector

Studies of rubber dam use for root canals

Lin Nov 2014 JOE states survival rate of teeth with rd was 90.3% and 88.8% without.  In my mind that means not using might be more successful as they just looked at outcomes of doctors that use and don’t use and most that use are probably better clinicians.

Rubber dam effects on Exposure levels

Berglund 1997 showed that mercury levels immediately after removal of amalgams were raised in patients without a rubber dam in comparison to those using a rubber dam.  However, these are merely short-term changes.  One year later the differences were indistinguishable.

Kremers 1999    The use of rd during amalgam removal shortens the interval to reach new reduced steady-state levels. Yet, this effect is of minor toxicological relevance in light of the low concentration levels in both rd and no rd individuals 3 months after removal.

Exposure to airborne pathogens

Samaranayake 1989  and  Cochran 1989  and  The University of Chicago Press 2003  Rubber dams create less bacterial exposure to those in the vicinity of a dental patient.