Operative Dentistry

Extending the use of rubber dam isolation: alternative procedures. Part IWilliam H. Liebenbcrg-'

Most dentists are well aware of the value of the rubber dam in allowing technicalexcellence: however, few recognize the potential for protecting the dentist and staffagainst the ever-growing number of carriers of the iiepatitis and human immunodefi-ciency viruses. The effectiveness ofthe rubber dam as an isolation barrier is dependenton Ihe consistency of its application. Sporadic rubber dam application is therefore aweak link in an infection control program. This paper describes additional modifiedutilizations of rubber dam, uses that are generally not attempted with restrictiveorthodox application methods, in addition, practical hints on other means of retentionare offered, with the emphasis on nuisance-free and easy application.(Quintessence lnt 1992,•23:657-665.)

Introduction

Rubber dam isolation has undeservedly acquired thereputation of being "dentistry's ugly duckling.""' As ameans of encotiraging the use of rubber dam. dentaleducators have emphasized its various advantages,which have tended to center around the quality of therestorative product.-"' Most dentists are therefore wellaware of [he vaiue and numerous benefits of the rub-ber dam in allowing technical excellence. Some papershave attempted to introduce methods and techniquesthat prevent accidents during dental treatment.**"'"Nevertheless, few clinicians appear to recognize thepotential for health and safety provided by the routineuse of rubber dam isolation. The role of the dam inprotecting the dentist and staff against the ever-grow-ing number of carriers of hepatitis and the human im-munodeficiency virus (HIV) must be reemphasizcd."This is not a new concept; others have reported on therole that rubber dam plays in preventing cross con-tamination and the spread of communicable dis-eases.'''

Privíite Practice. PO ßo\ I15Ö. 212S Rivunia, Johannesburg,South Africa.

The quality of infection control as it relates to a pa-tient's well being during a dental procedure has comeunder the media spotlight as a result of a case of ac-quired immunodeficiency syndrome reputedly causedby HIV transmission from dentist to patient."* Al-though the risk that a health care worker will transmitHIV is small-1 in 263,000 to 1 in 2.600,()00-the en-suing media coverage greatly alarmed the public. Thefact that 1.171 cases of acquired immunodeficieneysyndrome have been reported among dentists, dentalhygienists. and dental assistants throughout theUnited States since 1981 has also done little to instillconfidence among patients in their safety.'" The con-sensus is that any risk, no matter how small, of HIVtransmission from health care workers to patientsmust be taken seriously. '̂ Consequently, there hasbeen a shift in emphasis on the cross-contaminationpathway during dental procedures, as patients arequestioning the HIV status of health care workers.

The following statement, by Prime,'^ appears to beeven more appropriate some 54 years after it was readat the 78th annual session of the American Dental As-sociation: "The only thing that permits the man notusing the rubber dam to continue in practice is the factthat the public does not know what you and I knowabout the rubber dam. the role it plays in operativeprocedures."

It has been suggested that the routine use of rubber

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dam can contribute sif̂ itificanlly to the (ivcrall infec-tion control program in the dental office.'''̂ The rubberdam offers an adjunciive method of reducing thespread of infectious disease agents in ihe dental officeand. more importantly, provides barrier protection atthe source of microbial eoniaminatiun.'""-' Yel it is re-grettably true that, "no other technique, treatment, orinstrument used in denlistry is so universally acceptedand advocated by the recognized authorities and souniversally ignored by the practicing dentists.""

The leading yardstick of an infection control pro-gram hes in the consistency of its application. Sporadicrubber dam apphcation is a weak link in the "infectioncontrol checkiist." lt is indisputable that the disclosureof the HfV status of both patient and health care workercannot be relied upon, ft is for this reason that everyattempt should be made lo reintroduce rubber damisolation to its rightful place in the dental operatory.

The insistence of dental educators in promoting"textbook-perfect" rubber dam isolation and the de-mand of traditional application methods on utilizingretainers with rubber dam material are among thereasons that so few dentists use rubber dam routinely.

Most practicing dentists consider rubber dam retain-ers to be an indispensable component of the rubberdam isolation armamentarium. Rubber dam retainersare used to hold the distal ends of the rubber aroundthe most posterior tooth, providing retention of rub-ber dam material, which is accepted as a fundamentalrequirement in the successful preparation of theoperating field during the rubber dam isolation proce-dure. The selection of these retainers is generally madeaccording to the recommendations of the manufac-turers or lists of preferred retainers used by individualclinicians."^ However, successful retainer application isultimately still based on an individual's practical experi-ence and. for this reason, presents the biggest hurdleto the routine use of rubber dam.

I have found that the application methods tradition-ally used are, in many cases, antiquated, because theywere designed to retain rubber dam material of agreater thickness than that currently available. Whenthinner rubber dam material is utilized, alternative re-tention methods make the isolation procedure fareasier and less time-consuming.

This three-part paper describes additional, modifieduses of rubber dam that are generally not attemptedwith restrictive orthodox application methods. In ad-dition, practical hints on alternative means of reten-tion are offered, with the emphasis on nuisance-freeand easy application.

Additional ases Tor rubber dam isolation

Attacltrnent of prnstheses to osscointegrated implants

A large number of potential accidents are associatedwith the delivery of health care, accidents that can andshould be avoided. The increasing number of malprac-tice suits is a reflection that the delivery of dental careis as prone to accidents as any otheT health service. Amajor hazard associated with Ihe delivery of routinedental care is aspiration or swallowing of dental intru-ments and materials.'" The use of rubber dam isolationas a barrier against the aspiration or swallowing of end-odontic instruments has long been advocated in dentalliterature.'*''"'" Nonetheless, little attention has beendirected toward the potential problem of aspirationduring restorative dentistry procedures.'"

Techniques that overcome the difficulty of rubberdam application to crownless and cone-shaped teethduring endodontic procedures have been accepted asstandard practice."'' Similarly, there should be no ex-ceptions to the value of patient protection during im-plant procedures. Further clinical studies are neededto ensure that the value of patient protection is ex-tended to include all restorative procedures. To dateno cases of litigation following the inhalation of an im-plant component have been recorded, yet it is inevita-ble that in the years to eome prosthodontie treatmentplanning will have to make allowance for isolation ofthe working field during the delivery of all restorativeoptions.

Although it is unlikely that rubber dam applicationwill ever routinely accompany the attachment phase ofthe implant-supported prosthesis, it is a valuable aidwhen treating a patient suffering from a disease inwhich muscular control is less than ideal. The transferand placement of screws intraoraliy in situations oflimited access should, where possible, be done withthe protection of rubber dam isolation. It is no lesshazardous for a patient to itihale an implant compo-nent than it is an endodontic reamer.

The two cases depicted in Fig 1 and 2 serve as indica-tions of further clinical applications open to cUniciansas they progress toward routine patient protection.

Placetnent of fixed orthodontic brackets

Although a survey of the literature shows universalagreement about the need to maintain a completelydry working field during bonding procedures in orth-odontics, there is not a single reference to the advan-tage of using rubber dam in attaining uncompromisedisolation.^^"'' The advantages of bonding under rubber

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Fig la Preoperative retainer selection for the placementof a four-unit implant and tooth-borne prosthesis. Theflanges ot a No. 00 retainer are smoothed and polished toprevent their nicking the surface of the titanium abutment.

Fig 1b A three-hoied rubber dam ¡previously punchedusing the cast as reference) is stretched over the abut-ments. Digital pressure, applied to the dam curtain, pro-vides complete marginal exposure.

Fig 1c The splinted tooth abutments are cemented into Fig Id An occlusal view immgdiately posioperatively,place and the implant-borne prosthesis is screwed downafter the precision attachment is engaged.

Fig 2a Lateral intraoral view of a mandibuiar arch with twoabutments isoiated with the aid of "anterior-sized" anchor-ings.

Fig 2b Infraoral view of the prosthesis. The isolation setuphas been designed to facilitate the concurrent placement ofthe freestanding fixed partial denture and the porcelainlaminate veneer

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Fig 3a The hands-free aspect aiiows the operator to takefull advantage of measuring devices, winich aiiows accuratebracket placement.

Fig 3b The proximity of the wings of the rubber dam re-tainer to the buccal tube during the band cementationphase inhibits placement of the molar bands.

dam arc the same irrespective of tlie application; how-ever, in no procedure is the "hands-free" aspect of rub-ber dam isolation as welcome as in placement oforthodontic brackets. Tight cervical adaptation and li-gation of rubber dam material around each tooth areneces5ary if the operator is to capitalize on this isola-tion technique. The entire arch is cleaned, con-ditiotied, sealed, atid bonded as one utiit.

The hands-free aspect allows the operator to takefull advantage of measuring devices, which allow accu-rate bracket placement (Fig 3a), The operator canwork in a relaxed manner and obtain optimal bondstrength for each bracket. There is no need to hurry,since there is no chance of moisture contamination.The transfer, positioning, fitting, and removal of ex-cess adhesive is thus enhanced. An etching time of 15seconds is adequate. Localized enamel tearouts duringdebonding are not a complication following bondingunder rubber dam isolation, because the minimumamount of adhesive is used.'"'̂ ^

The apparent difficulty in cementing the band withthe retainer in situ during "traditional" rubber dam iso-lation is likely the reason that this isolation techniquehas not been encouraged for orthodontic bonding. Theproximity of the wings of the rubber dam retainer tothe buccal tube during the band cementation phaseinhibits placement of the molar bands (Fig 3b). Thesolution is to ease the retainers off the molars, whilemaintaining bidigital pressure on the dam curtains,thus maintaining molar isolation during band cementa-tion {Fig 3c). Traditional retention is terminated, whilerubber dam stability is maintained by the newly

cemented bands (Fig 3d). The initial "isolatioti hassles"pay dividends as the operator is able to work throughthe strictly mechanical ligating phase with speed andaccuracy and without fear of traumatizing the tissues(Fig 3e), The floss slip knots are released with a gentletug, the interdental strips are cut, and the rubber damis removed.

Removed of cast restorations

Removal of cast restorations under rubber dam protec-tion is far more comfortable for the patient, who doesnot have to contend with the residual "filings." Thereis no ehance that a patient will aspirate a sectioned res-toration, and the occasional unexpected pulpal expo-sures are immediately well isolated. The fact that theremoval of east restorations is almost always an elec-tive procedure allows a certain degree of foresight inthe isolation planning. This foresight provides patientcomfort and protection as well as operator ease (Figs 4to 7).

Mampulcttion of the interdental latex strip

There is a direct relationship between the need to iso-late an operative area and the degree of difficulty ex-perienced in attaining adequate isolation; ie, the areasthat require ardous rubber dam applieation skills arethe very areas where the application is of benefit. Theapparent difficulty in satisfying the requirement of suf-ficient interproximal access during the restorative pro-cedure is often the criterion that sways the clinician infavor of the less-than-adequate option of eotton rollisolation. The benefit of the rubber dam is lost in

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Fig 3c Bidigital pressure on the dam curtain maintains Fig 3d Retainerless, the patient is allowed a weicome in-molar isoiation dunng band cementation, teriude whiie the cement sets.

Fig 3e The initial "isoiation fiassies" pay dividends as theoperator is able to work through the strictly mechanicaiiigating phase with speed and accuracy witiiout fear oftraumatizing tfie tissues.

Fig 4a Cast cores have been piaced on the premolars.The defective crown on the canine is to be sectioned underthe same isolation procedure.

Fig 4b The ligature retention negates the need for a re-tainer anterior to the operatory fieid, Digitai pressure isappiied to the buccai curtain, exposing the coronai marginduring sectioning. The fioss stabilizes the dam dunng thismanipulation.

Fig 5 Contraiateral isoiation is secured with iigature reten-tion anteriorly. Once tfie crowns have been removed, thedam is replaced with a new dam, which is prepunched ac-cording to ffie requirements of the restorative procedures.

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F¡g 6 A retainer that does not provide close buccal adap-tation has been selected, because the bur must have ac-cess to the sulcular area during the sectioning of the cir-cumference of this subgingivally piaced crown.

Fig 7 Gênerai fiöid isolation of this cantiievered abutmentprovides all the advantages of traditional retention in a frac-tion of the placement time.̂ -̂̂ ^

Fig 8a Premoiar previousiy prepared to receive a castpost and core. The rubber dam covers the root surfacemargin, providing cumbersome and inadequate isolation.

Fig 8b With the help of a beaver-tail burnisher, the rubberdam is stretched over the buccal flange, creating thenecessary access for post cementation.

Fig 8c Once the post is in position, the dam is returned toits circumferential position and the adjacent tooth is pre-pared. The interdentai latex strips are then cut to change togeneral field isolation for the core preparation.

Fig 9a With insufficient preplanning, the wings of the re-tainer prevent adaptation of the floss to the interproximalarea.

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Figs 9b and 9c Floss has been threaded through the holes ¡n the retainer, ensunng maximal adaptation to the gingival wallon withdrawal and optimizing interproximal finishing.

Fig 10a A provisional occiusal stop is needed on tooth 37while the patient undergoes the periodontal phase oftherapy. The rubber dam is moved mesially, temporarilyfacilitating the required embrasure access for matrix mani-pulation. The proximal corners of the tooth are closely en-gaged by the buccal and lingual flanges, providingadequate retention, but preventing compiete matrix adapta-tion aiong the gingival box.

Fig 10b The pressure of the retainer is momentarily re-leased, allowing the strip matrix to be gently eased intoposition. The retainer is then allowed to spnng back intocontact with the tooth so that the matrix is adapted evenmore tightly,^'

Rq 10c The dam is tlicked back into position and awedge is driven interdentally. Floss is passed info the em-brasure at this stage, anticipating interproximal burnishingonce the matrix has been removed.

Fig lOd The restoration is placed. The final occiusal ad-justment is made after rubber dam removal.

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Figs 11 a and 11 b A radiograph has indicated Ihe presence of a subgingivai carious lesion mesiai to the first molar The cavitypreparation will of necessity extend below the interdentai latex strip.

Fig 11 c Flicking the interdentai strip into the next embra-sure creates the required access for caries excavation andrefinement of the gingival floor.

Fig l i d Cavity preparation is complete. The matrix isadapted. The rubber dam is returned to its interproximalposition. A wedge is placed above the dam and the cavitycleansing is completed.

those instances where the rubber dam is rejected onthe basis of the priority of interproximai access.

General field isolation is a solution, because it per-mits complete interproximal access.-'''-̂ ^ However, gen-eral field isolation nullifies the protective, retractive,and compressive features of traditional rubber dam ap-plication and is best avoided when possible. The prac-tical solution of interdental latex strip manipulationpermits all proximal restorations to be completedunder rubber dam isolation. Figures S to 11 provideexamples of this technique.

A case has been reported in which a post and corewas dropped into a patient's pharynx during thecementation stage. '''The supine position of the patient

increases the risk of this event. It is easily avoidedwith routine rubber dam application (Fig 8),

Interproximal access is of primary considerationwhen retainers are chosen for rubber dam stabilityduring bonding procedures. The interproximal finish-ing strategy must be planned well in advance of theadhesive bonding phase, because special attentionmust be paid to the prevention of periodontal irrita-tion caused by excess composite resin (Fig 9).

When the rubber dam interferes with matrix adapta-tion, the ruliber dam can be displaced temporarily tofacilitate the required embrasure access {Fig 10). Theretainer is momentarily released, allowing the matrixto be moved into position. The dam is flicked

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back into position and a wedge is driven interdcn-tally.

The presence of a subgingival carious lesion willnecessitate a eavity preparation that extends below theinterdental latex strip of the rubber dam. Flicking theinterdetital strip into the next embrasure will createthe required access (Fig 11).

Acknowledgments

1 would like to acknowledge my chairsicte assistant, Ms KerryLeslie, for her assistance in the operatory procedures depicted inthis article, and Mrs Daptine Roberts for typing and editorialassistance.

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