CLINICAL ARTICLE  131

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Bhavin Bhuva, Bun San Chong, Shanon Patel tio
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Rubber dam in clinical practice

Bhavin Bhuva
Endodontic Postgraduate
Unit, Guy’s Hospital,
King’s College London
Dental Institute,
London SE1 9RT, UK
Email:
Key words asepsis, medico-legal, rubber dam bhavinb@hotmail.com

Bun San Chong

Endodontic Postgraduate
Unit, Guy’s Hospital,
Good practice guidelines recommend the use of rubber dam for all nonsurgical endodontic procedures; King’s College London
Dental Institute,
there are also safety and medico-legal implications. However, many unfounded reasons have been cited London, UK
for not using rubber dam. By explaining why it is essential when performing endodontic treatment, and
Shanon Patel
describing the various techniques of placement, the hope is that it will encourage the routine use of rubber Endodontic Postgraduate
dam in everyday clinical practice. Unit, Guy’s Hospital,
King’s College London
Dental Institute,
London, UK

 Introduction culty of use and patient comfort3. These misconcep-

Sanford Christie Barnum first advocated the use of
rubber dam almost 150 years ago1. Even in that era of
dentistry, the benefit of isolating a tooth to obtain a
dry working field, free of salivary contamination, was
appreciated.
The European Society of Endodontology guide-
lines2 recommend the routine use of rubber dam for all
nonsurgical endodontic procedures. However, despite
being considered an essential part of the endodontic
curriculum in undergraduate dental schools, the routine
use of rubber dam in general dental practice is far from
widespread3. The main reasons cited for not using
rubber dam by dental practitioners include cost, diffi-
tions have led to poor uptake of the technique in gen-
eral dental practice.
A survey in the United Kingdom found that only
20% of the dentists questioned used rubber dam reg-
ularly for endodontic procedures3, and that 60% of
the respondents never used rubber dam. Surveys car-
ried out in the United States and New Zealand found
that 59% and 57% of dental practitioners, respec-
tively, used rubber dam as a matter of routine4,5. Inter-
estingly, a study in Belgium found that only 3.4% of
dentists in the country used rubber dam routinely6. A
recent investigation into the attitudes and use of rubber
dam by Irish general dental practitioners reported that
it was not used by 39% of respondents when per-

ENDO (Lond Engl) 2008;2(2):131–141

132  Bhuva et al Rubber dam in clinical practice
forming root canal treatment on anterior teeth, 32%
when treating premolar teeth and 26% when treating
molar teeth7. Many respondents (57%) considered
rubber dam ‘cumbersome and difficult to apply’.
The aims of this article are, firstly, to explain why
rubber dam is essential when performing endodontic
treatment, and secondly, to describe the various tech-
niques of applying rubber dam.
 Why use rubber dam?
There are several advantages to using rubber dam
during endodontic treatment, as outlined below.
 Safety and medico-legal considerations
Rubber dam protects the patient’s oropharynx, pre-
venting the ingestion8,9 or aspiration9,10 of endodon-
tic instruments/materials and associated dental debris.
Performing endodontic treatment without using
rubber dam risks harming the patient, and is consid-
ered legally indefensible11,12 and contrary to recom-
mended guidelines5,13,14.
 Aseptic working environment
The importance of microbes in the pathogenesis of
apical periodontitis is well established15,16. The objec-
tives of endodontic treatment are to eliminate micro-
bial infection, and to prevent re-infection of the root
canal system. These can only be predictably achieved
when endodontic treatment is carried out under
rubber dam.
Rubber dam acts like a surgical drape, isolating the
operating field from microbial contamination. In an
outcome study, 2459 roots were re-examined 2 to 7
years after initial pulpectomy or following completion
of root canal treatment17. No rubber dam was used,
and the overall success rate was only 53%. Although
no direct inference can be made, the lack of con-
trolled asepsis may also explain the poor outcome also
reported by others18.
In another outcome study on root canal retreat-
ment, teeth were treated with (51.1%) and without
(48.9%) the use of rubber dam19. A total of 612 teeth
were retreated including cases with and without evi-
dence of periradicular pathosis. It was reported that
ENDO (Lond Engl) 2008;2(2):131–141
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A pulp capping study evaluated P ubresponse of
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healthy human pulps to calcium hydroxide and tbond-
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ing agent, carried out with andte
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without the
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rubber dam . Direct pulp capping was performed on
20
40 caries-free human premolars, which were sched-
uled for orthodontic extraction. After a period of 30
or 60 days, the teeth were extracted and serial histo-
logical sections of the teeth prepared. The study
found a more severe inflammatory response in the
pulps of teeth capped with the bonding system in the
absence of rubber dam. The authors concluded that
the only explanation for the poorer results with the
bonding agent group, where pulp capping was car-
ried out without rubber dam isolation, was likely to be
due to bacterial contamination during the operative
procedure.
There is evidence suggesting a relationship bet-
ween choice of irrigant and rubber dam usage3-5. In a
study of British general dental practitioners, 71% of
rubber dam users irrigated root canals with sodium
hypochlorite compared with only 38% who did not use
rubber dam3. A positive relationship between the use
of rubber dam, and irrigation with sodium hypochlo-
rite and/or EDTA was also observed in surveys carried
out on dentists in the United States and New
Zealand4,5.
 Access and visualisation
Rubber dam improves access to the operating field as
the soft tissues including the cheeks and tongue are
retracted and protected. In addition, visual contrast is
enhanced when a dark-coloured rubber dam, for
example green or blue, is used21.
 Improved efficiency
Rubber dam facilitates the efficient practice of four-
handed dentistry during endodontic treatment.
Instead of having to be careful about protecting the
patient’s airways, controlling and retracting the soft
tissues, both the operator and the dental nurse can
concentrate on the endodontic procedure. Treatment
is also not interrupted as rubber dam reduces the
patient’s need to spit or rinse out by reducing the
accumulation of fluids in the mouth.

 Reduction of aerosol contamination
The air turbine is an effective atomiser of saliva, blood,
crevicular fluid and exhaled products from the alimen-
tary and respiratory tracts. Without rubber dam the
aerosol created may result in contamination of the
working environment; this has cross-infection implica-
tions for both dental team members and patients. The
use of rubber dam results in a reduction of 70 to
98.8% in the microbial content of air turbine aerosols
produced during operative procedures, thereby reduc-
ing the risk of cross-infection22-24.
 Patient comfort
Contrary to belief, most patients do not find the use
of rubber dam an unpleasant experience. Like any-
thing new, if it is the patient’s first experience of rubber
dam, the concept may be daunting. However, rubber
dam is well accepted by patients25 and the argument
against its use because of patient comfort is an
unfounded myth.
 How to use rubber dam
The basic parts of the rubber dam kit are described
below.
 Rubber dam
Rubber dam is available in pre-cut, commonly 150 mm
squares (Fig 1). In addition, and less common, rubber
dam is also available in a roll that can be cut to size.
Scented rubber dam is manufactured by some com-
panies and this variety may be useful when treating
children, as they may dislike the smell of rubber.
Rubber dam comes in a variety of thicknesses –
light, medium, heavy and extra heavy. Medium thick-
ness rubber dam is more suitable for endodontic treat-
ment; it is thin enough to be stretched easily over the
rubber dam clamp and tooth, yet thick enough not to
tear easily.
Rubber dam is available in a variety of different
colours; the darker colours, for example, green, black
and purple, give better colour contrast and therefore
may help reduce eye strain. The choice of rubber dam
thickness and colour is usually down to personal pref-
Bhuva et al Rubber dam in clinical practice  133
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erence. Rubber dam is usually shiny on one side and
matt on the other side; when placed, the matt side
should, preferably, face the operator as it reduces glare
and eye strain.
The performance and quality of rubber dam is best
where the stock is not too old and has been stored in
a cool, dry environment, preferably refrigerated. Old
stocks of rubber dam that has not been stored prop-
erly may lose its elasticity and become more suscepti-
ble to tearing.
 Rubber dam clamps
The rubber dam is usually anchored to the tooth with
a rubber dam clamp. There are over 50 different
designs of rubber dam clamps (Fig 2) available, from
a variety of different manufacturers. Some are labelled
numerically and others alphabetically; there are even
colour-coded systems (Hygenic Fiesta, Coltène/
Whaledent, Cuyahoga Falls, OH, USA). Each clamp
consists of a set of jaws connected by a bow. There are
also clamps with asymmetric and serrated jaws to pro-
vide better anchorage to the tooth (Fig 3). The
selected rubber dam clamp should achieve four-point
jaw contact at the cervical region of the tooth.
The clamp that is chosen will be dependent on
the tooth to be isolated, the application technique
employed and the operator’s preference. Rubber dam
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134  Bhuva et al Rubber dam in clinical practice
Fig 2 An assortment of rubber dam clamps.
clamps may be classified as winged or wingless (Fig 4).
Winged clamps allow rubber dam to be applied in one
step and also result in more tissue retraction. Wingless
clamps are used with the two-step technique (see later).
Most rubber dam clamps are made of stainless
steel but some are made from plated steel. There are
also non-metallic clamps made of plastic (SoftClamp,
KerrHawe, Bioggio, Switzerland) on the market.
Rubber dam clamps made of plated steel are more sus-
ceptible to corrosion; they are affected by, for exam-
ple, sodium hypochlorite. More importantly, all clamps
are at risk of fracture during use. Although rubber dam
clamps are very durable when appropriately handled
and treated, they do not last forever. Fracture of the
rubber dam clamp in the mouth is probably the only
serious risk associated with rubber dam usage. The risk
of inhaling or swallowing the fractured or dislodged
clamp may be minimised if it can be retrieved. A gen-
erous length of dental floss or tape may be tied
through one of the clamp holes, wound around the
bow of the clamp and then passed through and tied
to the opposite clamp hole (Fig 5) for this purpose.
Rubber dam clamps can also be classified as reten-
tive or bland (Fig 6). Retentive clamps provide four-
point contact on the tooth. They engage the tooth at
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a point below its greatest convexity.
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beyond, the level of the gingival margin. uBland
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tion with a more passive engagement. ss e n c e
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impingement is less likely with bland clamps but these
clamps are more susceptible to dislodgement.
 Clamp forceps
The rubber dam clamp forceps are used to transfer,
place, adjust and remove the clamp. Rubber dam
clamp forceps come in a variety of designs, and in
some cases, may be specific to a particular clamp
system. Popular forceps designs include the University
of Washington/Stoke, Brewer (Ash, Dentsply, Wey-
bridge, Surrey, UK) (Fig 7) and Ivory (Heraeus Kulzer,
South Bend, IN, USA) patterns. With some patterns, if
the jaws are too retentive, it is difficult to disengage
the forceps from the clamp. The jaws may be modi-
fied to make them less retentive to allow for easier
clamp disengagement.
 Rubber dam punch
A punch is used to make the necessary number of
holes in the rubber dam, corresponding to the
number of teeth to be isolated. In the case of
endodontic treatment, usually single tooth isolation
is used. There are two main types of rubber dam
punches. A single-hole punch (Ash, Dentsply) (Fig 8)
will cut a standardised hole of 1.63 or 1.93 mm.
Punches with a rotating table (e.g. Ainsworth, Ivory)
are for cutting different sized holes. The Ainsworth is
a five-hole punch (Fig 9), which will make holes of
diameters ranging from 0.5 to 2.5 mm. Rubber dam
punches capable of producing multiple sized holes
are meant to allow the operator to vary the size of
the hole according to the tooth to be isolated or the
clamp to be used. Larger holes may be chosen for
molar teeth or winged clamps. However, one of the
disadvantages is that unless the punch table is prop-
erly aligned, the result will not be a cleanly produced
hole and the rubber dam will tear.
For single tooth isolation, a hole is punched
approximately 2 cm from the centre of the rubber
dam, in a position corresponding to the position of
the tooth in the quadrant. If several teeth are to be
 Bhuva et al Rubber dam in clinical practice  135

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Fig 3 Rubber dam clamps with serrated, asymmetric jaws: Fig 4 Winged (Ash A & K) and wingless (Ash PW) rubber
Hygenic 12A (left) and 13A (right). dam clamps.

Fig 5 Floss tied onto the rubber dam clamp to aid retrieval in Fig 6 Bland (left) and retentive (right) rubber dam clamps.
case of fracture or dislodgement.

Fig 7 University of Washington/Stoke (left) and Brewer Fig 8 The Ash single hole rubber dam punch.
(right) rubber dam clamp forceps.

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136  Bhuva et al Rubber dam in clinical practice
Fig 9 The Ainsworth rubber dam punch.
isolated, it may be helpful, but not essential, to use a
rubber dam stamp (e.g. Hygenic Dental Dam Stamp,
Coltène/Whaledent), to facilitate correct positioning
of the holes. Irrespective of the type of rubber dam
punch used, it is important to ensure that the cutting
part of the punch is sufficiently sharp so that clean
holes are obtained consistently.
 Rubber dam frame
The final component is the rubber dam frame; this is
used to retract the edges of the rubber dam. The
rubber dam is pulled over the frame and secured in
place by the retaining spikes. Metal (Fig 10) and non-
metal rubber dam frames are available. Plastic rubber
dam frames (Fig 11), some with rounded retaining
spikes, are lighter and more comfortable for the
patient. A further advantage of a plastic frame is that
some are not radiopaque, so may be left in place when
taking radiographs. Foldable rubber dam frames (e.g.
Ash, Dentsply) with an articulated joint are also avail-
able to facilitate radiography.
 Techniques for rubber dam
placement
There are a variety of techniques for rubber dam
placement. Irrespective of the technique used, certain
preparatory steps must be taken to ensure safe and
effective rubber dam placement:
• Flossing the interproximal space between the teeth
beforehand makes rubber dam placement easier.
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Fig 10 Metal (Young’s style) rubber dam frame.
The contact points of the tooth/teeth isolated
should also be flossed again following placement
of rubber dam to ensure that the entire circumfer-
ence of the tooth is sealed.
• As mentioned previously, a length of floss may be
tied around the clamp as a safely measure, to aid
retrieval, in the event the rubber dam clamp is dis-
lodged or fractures26.
• The rubber dam clamp should be placed on the
tooth to check that the jaws are in contact with the
tooth and the clamp is stable. The stability of the
clamp may be confirmed by applying gentle pres-
sure with a forefinger to the bow of the clamp to
check if the clamp moves.
• A clean hole should be punched in the rubber dam;
there should be no irregular edges or tears, which
may increase the probability of the rubber dam
tearing.
 One-step technique
A winged rubber dam clamp is selected and placed on
the tooth to check for suitability; the clamp should be
stable with good contact between the jaws and the
tooth. The clamp is then removed from the tooth. A
correctly positioned hole is punched through the
rubber dam, and the bow of the clamp is pushed
through the hole, leaving just the wings of the clamp
under the rubber dam (Fig 12). The forceps are then
used to engage and spread open the jaws of the
clamp. The whole assembly is transferred and posi-
tioned on the tooth. The clamp is then released from
the forceps and the stability of the clamp rechecked.
 Bhuva et al Rubber dam in clinical practice  137

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tissue may be placed below the rubber dam to absorb ss e n c e
fo r
any saliva and improve patient comfort before placing
the rubber dam frame. Finally, the frame is used to sta-
bilise and retract the edges of the rubber dam.
A modification of this technique involves the
rubber dam, clamp and frame being all applied in one
action27. This ‘all-in-one’ technique involves attaching
the punched rubber dam to the frame, with the hole Fig 11 Two types of plastic rubber dam frames: Starlight Visi-
positioned roughly in the centre. The clamp is then Frame (left) and Nygaard-Ostby (right)

placed through the rubber dam as described above.

Having engaged the forceps to the rubber dam clamp,
the whole assembly (Fig 13) is positioned on the tooth.
The rubber dam is then eased off the wings and, if nec-
essary, the frame can be adjusted to ensure there is not
too much tension on the rubber dam. Where appro-
priate this technique is extremely expedient as it is truly
a one-stage technique. However, this technique is not
easy to use, particularly when isolating posterior teeth
because of reduced access.

 Two-step technique
Rubber dam clamp first method

A winged or wingless rubber dam clamp is selected

Fig 12 A winged clamp in the rubber dam ready for place-
and placed on the tooth to be isolated (Fig 14). The ment in the one-step technique.
rubber dam is the stretched over the clamp (Fig 15)
and dental floss is passed through the interproximal
space (Fig 16). The frame is then used to hold the
rubber dam.

Rubber dam first method

A modification of the two-step technique is where the
rubber dam is applied first and then secured with a
clamp. This technique may be useful for isolating ante-
rior teeth where a butterfly-shaped rubber dam clamp
or a wedging device, for example, a strand of stabilis-
ing cord (Wedjets, Hygenic, Coltène/Whaledent) (Fig
17) is used. When isolating anterior teeth without the
use of a clamp, the rubber dam is applied to the teeth
to be isolated; each contact point is flossed to ensure
that the rubber dam has passed below the contact Fig 13 The assembled rubber dam, clamp and frame for the
point. The interproximal contact points may then be ‘all-in-one’ technique.

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138  Bhuva et al Rubber dam in clinical practice

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Fig 14 The selected winged rubber dam clamp is placed on Fig 15 The rubber dam is the stretched over the clamp.
the tooth.

Fig 16 Dental floss is passed through the interproximal

space.

Fig 17 Wedjets stabilising cord.

secured with a strip of rubber dam or stabilising cord
(Fig 18). Multiple teeth may be isolated with either of
the two techniques described above. A hole should be
punched for each tooth to be isolated, and these holes
should be approximately 6 mm apart and roughly
follow the curve of the dental arch to be isolated.
 Difficult to isolate cases
Split dam technique
If a tooth is broken down, there may not be sufficient
sound tooth structure to retain a rubber dam clamp.
Alternatively, the clamps available may not permit a
stable four-point contact around the tooth. In these
situations, one or both neighbouring teeth may be
used to help anchor the rubber dam. In the split dam
technique, a rubber dam clamp is placed on a neigh-
bouring tooth. Two holes approximately 5 mm apart
are punched through the rubber dam and linked up by
removing the rubber between the holes using scissors
or by punching a third hole to connect the first two
holes. The rubber dam is stretched over the rubber
dam clamp/s and teeth; the rubber dam frame is then
placed. When isolating anterior teeth, clamps may not
be necessary with the split dam technique (Fig 19).

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Fig 18 Rubber dam secured only with Wedjets stabilising Fig 19a A split rubber dam.
cord.

Fig 19b Oraseal used to seal deficiencies around the edges. Fig 20 Oraseal caulking agent.

If there are signs of leakage once the rubber dam
is on the tooth, more likely with the split dam
method, then caulking material (e.g. Oraseal, Ultra-
dent, South Jordan, UT, USA) (Fig 20) or temporary
filling materials (e.g. Cavit, 3M Espe, St. Paul, MN,
USA) may be used to improve the seal. Oraseal is
made from hectorite clay and is an easy to handle
caulking putty, which can be syringed directly around
the tooth to seal any deficiencies (Fig 19b). However,
an excessive amount should be avoided as the mate-
rial may contaminate the working field. Alternatively,
light-cured materials (e.g. Kool-Dam, Pulpdent,
Watertown, MA, USA) are available. Cyanoacrylate
adhesive has also been suggested for sealing voids in
rubber dam28.
Preparatory treatment
of a broken down tooth
Another option, if the tooth is too badly broken down
and it is not possible to use rubber dam, is to consider
building a provisional restoration or placing a copper
or orthodontic band on the tooth first. This is particu-
larly relevant if lack of structural integrity means the
tooth does not allow retention of an inter-appoint-
ment temporary dressing without compromising the
coronal seal.
A provisional restoration may be built using adhe-
sive materials such as composite resin or glass ionomer
cement. Alternatively, a customised and trimmed
copper or orthodontic band may be cemented on the
tooth; this will then allow the effective placement of
rubber dam.

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140  Bhuva et al Rubber dam in clinical practice
Fig 21 EndoRay II beam-aiming device for taking radi-
ographs.
 Endodontic radiography
Radiographs are needed at various junctures during
root canal treatment, for example, working length
determination. The presence of rubber dam may
hinder the use of beam-aiming devices when taking
radiographs using the paralleling technique. There are
specially designed devices available on the market that
permit the taking of radiographs without having to
remove the whole rubber dam assembly. The EndoRay
II (Dentsply Rinn, Elgin, IL, USA) (Fig 21), for exam-
ple, is a film packet holder with a basket to accommo-
date the bow of the rubber dam clamp and root canal
instruments.
The rubber dam should not be removed during
treatment but, if necessary, the frame may be
removed when taking radiographs. The rubber dam
is then gathered to one side of the mouth. It is imper-
ative to prevent the ingress of saliva into the work-
ing field by ensuring that the edges of the rubber
dam remain outside the mouth during the taking of
radiographs. In order to facilitate correct orientation
of the rubber dam frame when it is put back, a hole
may be punched in a chosen corner of the rubber
dam.
In some cases, it may be possible to take peri-oper-
ative radiographs without the need to completely
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Fig 22 Non-latex, silicone rubber dam.
remove the rubber dam frame. Sometimes, only a
corner needs to be freed from the frame to enable
placement of the film packet/sensor. A radiolucent
plastic or foldable rubber dam frame may be used if
this technique is chosen.
 Latex allergy
Allergy to latex in rubber gloves and rubber dam
appears to be an increasing problem in dentistry. The
prevalence of latex allergy in the general population
may be as low as 1%29. However, the prevalence may
be higher in certain groups, including atopic individu-
als and health workers30. Studies have suggested that
the prevalence of latex allergy may be as high as 6%
in dental staff31 and 9.7% in dental patients32. There-
fore, the possibility of allergic or delayed-type sensitiv-
ity reactions to latex rubber dam must not be under-
estimated. Careful identification of patients who are
known or suspected to be allergic to latex or natural
rubber is imperative. The patient’s medical history
should be checked to ensure the use of latex rubber
dam is avoided. Non-latex rubber dam, for example
Flexi Dam (Roeko, Coltène-Whaledent) (Fig 22), may
be of use for allergic or high-risk cases patients such as
atopic individuals.

The increased awareness of latex allergy has led to
some institutions, like dental schools, phasing out the
use of latex-containing products. However, there is still
the danger that sensitisation to these alternative mate-
rials may occur. This was highlighted in a recent case
report, where a delayed Type IV allergic reaction
occurred during endodontic treatment, with the use of
latex-free gloves and a silicone rubber dam33.
 Conclusion
The use of rubber dam is mandatory during endodon-
tic treatment. Current guidelines have re-emphasised
that rubber dam should be universally employed for all
endodontic treatment. Endodontic treatment carried
out without the use of rubber dam has implications
both from a safety and medico-legal standpoint.
 Acknowledgment
Keith Marshall, Consultant in Restorative Dentistry,
Limpsfield, Surrey, for initial advice during the prepa-
ration of this manuscript.
 References
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