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Rubber dam use during root canal

treatment
Findings from The Dental Practice-Based Research Network
Mona F. Anabtawi, DDS, MS; Gregg H. Gilbert, DDS, MBA; Michael R. Bauer, DDS;
Gregg Reams, DMD; Sonia K. Makhija, DDS, MPH; Paul L. Benjamin, DMD;
O. Dale Williams, MPH, PhD; for The National Dental Practice-Based Research Network
Collaborative Group

T
he rubber dam has been
used in dental care for
AB STRACT A D
A
J
decades. It is considered the ✷ ✷
reference standard in root Background. The Dental Practice-Based
®

N
CON
canal treatment (RCT) because of

IO
Research Network (DPBRN) provided a means to

T
the advantages that it offers with

A
N
investigate whether certain procedures were per-

I
U C
U

regard to infection control, patient A 4

IN
G ED

formed routinely. The authors conducted a study to RT

I C LE
protection and treatment efficacy.1-4 quantify rubber dam use during root canal treatment
Nonetheless, its use during RCT is (RCT) among general dentists and to test the hypothesis that cer-
hardly ubiquitous; studies have tain dentist or practice characteristics were associated with rubber
observed wide ranges of usage.5-20 dam use.
The results of the small number of Methods. DPBRN practitioner-investigators (P-Is) answered a
studies of dentists in the United questionnaire that included items about rubber dam use and other
States have shown some low usage forms of isolation during RCT. DPBRN enrollment questionnaire
rates.7,13,20 The investigators of the data provided information regarding practitioner and practice
most recent study found that 11 per- characteristics.
cent of general dentists never used a Results. A total of 729 (74 percent) of 991 P-Is responded; 524
rubber dam during RCT and only 58 were general dentists who reported providing at least some RCTs
percent used one during every RCT.7 and reported the percentage of RCTs for which they used a rubber
The results of a study in England dam. Of these 524 P-Is, 44 percent used a rubber dam for all RCTs,
regarding whether dentists use 24 percent used it for 51 to 99 percent of RCTs, 17 percent used it for
other isolation methods during RCT 1 to 50 percent of RCTs, and 15 percent never used it during RCT.
showed that the use of cotton rolls Usage varied significantly by geographic region and practice type.
without a rubber dam also was The use of cotton rolls and other forms of isolation also was reported.
common.10 Conclusions. Similar to other reports in the literature, not all
The Dental Practice-Based Re- DPBRN general dentists used a rubber dam during RCT.
search Network (DPBRN) was a Clinical Implications. Because the clinical reference standard is
consortium of dental practices with to use a rubber dam during RCT, increasing its use may be important.
a broad representation of practice Key Words. Rubber dam; root canal treatment; practice-based
types, dentists and treatment phi- research; dentistry.
losophies that conducted research JADA 2013;144(2):179-186.
with the ultimate goal of improving
Dr. Anabtawi is a program manager, Department of Medicine, School of Medicine, University of Alabama at Birmingham. She was an instructor, Department
of General Dental Sciences, School of Dentistry, University of Alabama at Birmingham, when this article was written.
Dr. Gilbert is a professor and the chair, Department of Clinical and Community Dental Sciences, School of Dentistry, University of Alabama at Birmingham,
SDB Room 109, 1530 3rd Ave. South, Birmingham, Ala. 35294-0007, e-mail ghg@uab.edu. Address reprint requests to Dr. Gilbert.
Dr. Bauer is a general dentist, Health Partners Dental Group, Minneapolis.
Dr. Reams is an endodontist, Permanente Dental Associates, Portland, Ore.
Dr. Makhija is an associate professor, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham.
Dr. Benjamin is in private practice of general dentistry, Miami.
Dr. Williams is a professor and the chair, Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International
University, Miami.

JADA 144(2) http://jada.ada.org February 2013 179

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quality of care in dental practices.21-26 It com-
prised practitioner-investigators (P-Is) and staff
members in outpatient dental practices mainly
from five regions: Alabama/Mississippi (AL/MS);
Florida/Georgia; Minnesota, encompassing den-
tists employed by HealthPartners Dental Group
(HPDG), Minneapolis, or in private practice;
Permanente Dental Associates (PDA), in cooper-
ation with Kaiser Permanente’s Center for
Health Research, Portland, Ore.; and the Scan-
dinavian countries Denmark, Norway and
Sweden. Additional P-Is also were recruited in
other U.S. states. The DPBRN provided a
means to investigate whether certain dental
procedures were performed routinely in
everyday clinical practice. The results of a 2010
DPBRN study about restorative dentistry
showed that 63 percent of P-Is did not use a rub-
ber dam for any dental restorations.27 As part of
an overall effort to quantify the DPBRN’s infra-
structure capabilities, DPBRN had an opportu-
nity to include in a questionnaire items about
the use of a rubber dam during RCT.
We conducted this study to quantify—among
general dentists who reported providing at least
some RCT—the percentage of DPBRN P-Is who
indicated that they used a rubber dam during
RCT, to quantify the percentage who reported
using some other form of isolation during RCT
and to test the hypothesis that certain dentist
or practice characteristics were associated with
use of a rubber dam during RCT.
METHODS
DPBRN recruitment process. We recruited
P-Is into The DPBRN at continuing education
courses and through mass mailings to licensed
dentists from the participating regions. The
DPBRN completed a total of 22 studies, which
included a broad range of study designs, topic
areas and enrollment sizes.23,28 Although most
DPBRN studies involved data collection from
dental patients, some studies used only
questionnaires.
The data for this study were collected and the
original manuscript was prepared under the
auspices of The DPBRN. That organization
evolved into The National Dental Practice-
Based Research Network, under the aegis of
which we prepared the final version of this
article.
Study design. This was a cross-sectional
study, consisting of a single administration of
the Infrastructure Update Survey to all DPBRN
P-Is who had participated in one or more
DPBRN studies of any type and who were in
practice with an active practice address (that is,
180 JADA 144(2) http://jada.ada.org February 2013
Page 180
still practicing at that address). We collected
data from December 2010 through May 2011.
This study was approved by the human partici-
pants institutional review board at the Univer-
sity of Alabama at Birmingham and all of The
DPBRN’s regional institutional review boards.
All participants who participated in this study
provided informed consent after we fully
explained the nature of the procedures.
Main questionnaire content. Questions
about rubber dam use were included in a ques-
tionnaire designed to provide updated informa-
tion about certain infrastructure capabilities of
DPBRN. The questionnaire is publicly avail-
able.29 The main questions of interest for our
study were as follows: the first was “Do you per-
sonally do any root canal procedures?”; those
who responded in the affirmative were asked,
“On what percent of these root canals do you
estimate that you use a rubber dam?” and “Do
you use any other type of isolation?” and if yes,
“please specify.”
DPBRN enrollment questionnaire. Since
2005, as part of enrollment in DPBRN, P-Is
completed a 101-item enrollment questionnaire
about their practice characteristics and them-
selves. The distribution of these characteristics
for DPBRN dentists has been reported previ-
ously.24,25 Among other items, this questionnaire
included practice location, type of practice (solo
private practice; group private practice, not
HPDG or PDA; HPDG or PDA; public health
practice, community health center or publicly
funded clinic; or other type), whether the den-
tist was a generalist or specialist, year of gradu-
ation from dental school, and the dentist’s sex,
race and ethnicity.
Data collection process. Before full imple-
mentation of the survey, 34 practitioners and
DPBRN staff members pretested the question-
naire to assess the feasibility and comprehen-
sion of each questionnaire item, as well as its
online administration. The DPBRN central
office staff members sent by means of postal
mail preprinted invitation letters to eligible
practitioners, inviting them to participate and
to provide them with a unique identification
number and log-in code to complete the online
survey.
P-Is were asked to complete the question-
naire within three weeks. DPBRN staff mem-
ABBREVIATION KEY. AL/MS: Alabama/Mississippi.
DPBRN: Dental Practice-Based Research Network.
HPDG: HealthPartners Dental Group. PDA: Perma-
nente Dental Associates. P-Is: Practitioner-
investigators. RCT: Root canal treatment.
179_186_Gilbert.qxp:Layout 1 1/10/13 3:00 PM Page 181
bers sent a reminder letter after the fourth
week to P-Is who had not completed the ques-
tionnaire. After an additional four weeks, a final
reminder was sent, and this time a printed ver-
sion of the questionnaire was included and prac-
titioners were offered the option of completing
the online or paper version of the questionnaire
(87 [12 percent] of 729 practitioners completed
the paper version instead of the online version).
Data collection was closed after a final three-
week waiting period. Practitioners or their busi-
ness entities received remuneration in the
amount of $50 for completing the questionnaire
at the end of the survey if they requested it.
Statistical methods. All analyses were done
using statistical software (SAS/STAT Version
9.2, SAS Publishing, Cary, N.C.). Statistical sig-
nificance was assumed for P < .05. In addition
to quantifying frequency distributions, we con-
ducted bivariate cross-tabulations to examine
the associations between rubber dam use and
certain dentist and practice characteristics,
using χ2 and Mantel-Haenszel χ2 trend tests for
statistical significance or Fisher exact test
extension for contingency tables in case of small
cell sizes. We conducted analyses by using mul-
tiple logistic regression to examine simultane-
ously the effect of explanatory variables (for
example, practice type, year of graduation) on
the outcome (use of a rubber dam during RCT)
after adjusting for the effect of other explana-
tory variables. Because data regarding use of a
rubber dam was coded by using a four-point
ordinal scale (none, 1-50 percent, 51-99 percent,
100 percent), we conducted a preliminary
ordinal logistic regression by using that scale.
However, the proportional odds assumption
required for ordinal logistic regression was vio-
lated, so we coded the outcome by using a three-
point scale (none, 1-99 percent, 100 percent). By
using this three-point ordinal outcome, the pro-
portional odds assumption was no longer vio-
lated. Because type of practice and DPBRN
region were redundant for some regions, we did
not include both variables in a single regression
owing to multicollinearity. There were five types
of practice in our study. The results of prelimi-
nary logistic regressions showed that one prac-
tice type (HPDG or PDA) had a substantially
different effect magnitude than did the other
practice types. Consequently, we thereafter
coded type of practice dichotomously as “HPDG/
PDA” or “not HPDG/PDA.” We adjusted prelimi-
nary regressions for the following variables:
dentist’s year of graduation, sex, race and eth-
nicity. We found that none of these variables
were statistically significant nor did they im-
RESEARCH
prove model fit, and we excluded them from
subsequent analyses. The multivariable regres-
sion became a regression with only one explana-
tory covariate (type of practice).
RESULTS
Characteristics of dentists who reported
providing RCTs. Of 1,007 P-Is invited to par-
ticipate, we determined that 16 were ineligible
(13 retired or sold their practice, two no longer
had an active practice address, and one was
deceased). Of the remaining 991 P-Is, 74 per-
cent (n = 729) completed the questionnaire or
almost all of it. Differences in characteristics
between respondents (n = 729) and nonrespon-
dents (n = 262) were not statistically significant
with regard to the dentist’s sex or year of gradu-
ation from dental school. P-Is in the AL/MS
region had a significantly lower response rate
(67 percent; P < .01, χ2 test) than did those in
the other regions combined (79 percent).
Of the 729 P-Is who completed the question-
naire, 554 (76 percent) responded “Yes” to the
question about whether they perform any RCTs,
and 553 also reported the percentage of RCT
procedures in which they use a rubber dam. Of
these 553 dentists, 14 were endodontists and 15
reported that they were another type of spe-
cialist. All of the endodontists reported that
they use a rubber dam for 100 percent of the
root canal procedures that they performed. Of
the 15 other specialists, one (7 percent) said
that a rubber dam was used none of the time,
three (20 percent) said a rubber dam was used 1
to 50 percent of the time, four (27 percent) said
a rubber dam was used 51 to 99 percent of the
time, and seven (47 percent) said a rubber dam
was used 100 percent of the time. The re-
maining 524 dentists, all of whom were general
dentists, were the focus of the remainder of our
study. Their characteristics are shown in Table 1.
Use of a rubber dam and dentist and
practice characteristics. A total of 229 P-Is
(44 percent) reported that they use a rubber
dam for all RCTs they provide (Table 2, page
183), and 80 (15 percent) reported that they do
not use a rubber dam for any of the RCTs that
they provide.
Table 2 also shows rubber dam according to
certain dentist and practice characteristics. We
found a statistically significant association
between the DPBRN region and rubber dam
use, with the highest use occurring in PDA or
other West region practices (“other West region
practices” are those in western states that are
not PDA practices), and the lowest use occurred
in the AL/MS region. We also observed signifi-
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TABLE 1 P < .001). The type-of-practice variable (HPDG/

Characteristics of general dentist PDA or not HPDG/PDA) was statistically signif-
icant, with a large effect (odds ratio = 10.1; 95
practitioner-investigators percent confidence interval = 5.1-19.8). We in-
included in the analysis cluded no other variables because they were not
statistically significant and did not improve
of rubber dam use (n = 524). model fit.
CHARACTERISTIC (N) PERCENTAGE* Other types of isolation used during
Dental Practice-Based Research RCTs. In addition to using a rubber dam, P-Is
Network Region reported using other forms of isolation. Of the
Alabama/Mississippi (196) 37 524 general dentists who performed RCT and
Florida/Georgia (117) 22
reported the percentage of time in which they
Other Southeast (39) 7
use a rubber dam, 204 (39 percent) dentists
Midwest or Northeast (69) 13
reported using at least one other type of isola-
PDA† or other West (47) 9
Scandinavia (56) 11
tion in addition to reporting whether or not they
Missing (0) —‡
used a rubber dam. We recoded these open-
ended responses into three categories: cotton
Type of Practice
Solo private practice (263) 50
rolls or gauze, a dry-field illuminator (Isolite,
Group private practice, not HPDG§ 30
Isolite Systems, Santa Barbara, Calif.) and all
or PDA (156) others. We evaluated responses from the 204
HPDG or PDA (72) 14 dentists who reported using at least one other
Public health practice, community health 5 type of isolation by dividing the dentists into
center or publicly funded clinic (26) three groups: practitioners who reported never
Other type (7) 1 using a rubber dam (n = 53), practitioners who
Missing (0) — reported using a rubber dam but in less than
Year of Graduation From Dental 100 percent of RCTs (n = 126) and practitioners
School who reported using a rubber dam during all
Before 1970 (14) 3
RCTs (n = 25).
1970-1979 (132) 25
Among the 53 practitioners who reported
1980-1989 (176) 34
never using a rubber dam, 44 reported using
1990-1999 (111) 21
2000 or later (91) 17
cotton rolls or gauze, eight reported using Iso-
Missing (0) —
lite, and one reported using another type of iso-
lation. Among the 126 practitioners who re-
Sex of Dentist
Male (408) 78
ported using a rubber dam but in less than 100
Female (116) 22
percent of RCTs, 95 reported using cotton rolls
Missing (0) — or gauze, 13 reported using Isolite, and 18 re-
ported using some other method of isolation.
Race of Dentist
White (435) 89
Among the 25 practitioners who reported using a
Nonwhite (54) 11
rubber dam during all RCTs, seven reported also
Missing (35) — using cotton rolls or gauze, four reported also
Hispanic/Latino Ethnicity of Dentist
using Isolite, and 14 reported using some other
Non-Hispanic (413) 96
isolation method in addition to a rubber dam.
Hispanic (15) 4
DISCUSSION
Missing (96) —
* The percentages in each section may not add up to 100 percent
Use of a rubber dam overall. Rubber dam
owing to rounding. isolation is considered the standard of care for
† PDA: Permanente Dental Associates. RCT by the American Association of Endodon-
‡ Dash indicates not applicable.
§ HPDG: HealthPartners Dental Group. tists.4 However, only 44 percent of general den-
tists in our study reported that they always used
cant associations between rubber dam use and a rubber dam during RCT, with another 24 per-
practice type, as well as between rubber dam cent indicating that they used it more than one-
use and year of graduation from dental school. half of the time. Investigators in previous
The results of the ordinal logistic regression studies have reported a broad range of rates of
using the three-point outcome scale (none, 1-99 rubber dam usage,5-20 and the finding in our
percent, 100 percent) exhibited a modest model study is within this range. For example, the
fit (area under a receiver operating character- results of a study of RCT among practitioners in
istic curve = 0.59; likelihood ratio χ2 = 67.4; the United Kingdom showed that less than 19

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percent of practi- TABLE 2

tioners ever used a RCTs* in which a rubber dam is used, according to
rubber dam during
RCT; 45 percent re- characteristic (n = 524).
ported that they CHARACTERISTIC (n) RCTs IN WHICH A RUBBER DAM
never used a rubber WAS USED, NO. (%)
dam.9 The investiga- None 1-50 51-99 100
tors of a study in Overall 80 (15) 90 (17) 125 (24) 229 (44)
England found that
Dental Practice-Based Research Network Region †
63 percent of respon-
Alabama/Mississippi (196) 50 (26) 48 (25) 52 (27) 46 (23)
dents never used a Florida/Georgia (117) 13 (11) 18 (15) 29 (25) 57 (49)
rubber dam during Midwest or Northeast (69) 4 (6) 6 (9) 18 (26) 41 (59)
RCT.10 In a study of Other Southeast (39) 3 (8) 5 (13) 9 (23) 22 (56)
Belgian dentists, 65 PDA‡ or other West (47) 0 (0) 0 (0) 2 (4) 45 (96)
percent reported Scandinavia (56) 10 (18) 13 (23) 15 (27) 18 (32)
never or seldom using Type of Practice †
a rubber dam, and Solo private practice (263) 42 (16) 58 (22) 69 (26) 94 (36)
only 7 percent used a Group private practice, not HPDG§ or PDA (156) 34 (22) 25 (16) 37 (24) 60 (38)
rubber dam in all RCT HPDG or PDA (72) 0 (0) 1 (1) 10 (14) 61 (85)
cases.11 In a national Public health practice, community health center or 2 (8) 5 (19) 8 (31) 11 (42)
survey of general den- publicly funded clinic (26)
tists in New Zealand, Other type (7) 2 (29) 1 (14) 1 (14) 3 (43)
a rubber dam was Year of Dental School Graduation †
used routinely during Before 1970 (14) 7 (50) 4 (29) 0 (0) 3 (21)
RCT by 57 percent of 1970-1979 (132) 22 (17) 19 (14) 35 (27) 56 (42)
practitioners.15 1980-1989 (176) 25 (14) 34 (19) 44 (25) 73 (41)
Association 1990-1999 (111) 15 (14) 24 (22) 24 (22) 48 (43)
between rubber 2000 or later (91) 11 (12) 9 (10) 22 (24) 49 (54)
dam use and cer- Sex of Dentist¶
tain dentist or Male (408) 63 (15) 72 (18) 97 (24) 176 (43)
practice character- Female (116) 17 (15) 18 (16) 28 (24) 53 (46)
istics. We observed Race of Dentist ¶

significant variation Nonwhite (54) 7 (13) 6 (11) 14 (26) 27 (50)

in rubber dam use White (435) 70 (16) 77 (18) 107 (25) 181 (42)
across our DPBRN Missing (35) 3 (9) 7 (20) 4 (11) 21 (60)
regions, although Hispanic/Latino Ethnicity of Dentist ¶

region was con- Hispanic (15) 1 (7) 2 (13) 6 (40) 6 (40)

founded with practice White (413) 63 (15) 73 (18) 98 (24) 179 (43)
type because in two Missing (96) 16 (17) 15 (16) 21 (22) 44 (46)

DPBRN regions * RCTs: Root canal treatments.

† P < .05; the association between the characteristic and percentage of RCTs in which the dentist uses a
(Minnesota and the rubber dam is statistically significant. Missing data were excluded before the statistical test was done.
PDA or other West The following variables had no missing data: Dental Practice-Based Research Network region, type of
region) most of the practice, type of dentist, year of dental school graduation and sex of dentist. The data in this table are
limited to the 524 general dentists who reported providing at least some RCTs and who reported the
P-Is were in a large percentage of RCTs in which they used a rubber dam.
group practice (more ‡ PDA: Permanente Dental Associates.
than three dentists in §¶ HPDG: HealthPartners Dental Group.
Not statistically significant.
a practice). We ob-
served substantially
higher rubber dam use among HPDG and PDA own practice organization, which reinforced the
dentists (as shown in Table 2 and in the logistic reference standard. In addition, because
regression results), even though P-Is in other training and emphasis may be different between
group practices in The DPBRN reported rubber U.S. and Scandinavian dentists in The DPBRN,
dam use at rates similar to those in solo private we considered limiting this report to U.S. den-
practice or public health clinics. One reason for tists only. However, the results with or without
higher use among dentists in HPDG and PDA the Scandinavian dentists were substantively
may be that these groups had a high level of the same, leading to the same conclusions from
peer review that occurred within the dentist’s the results. For example, when we excluded the

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Scandinavian dentists, 70 (15 percent) P-Is
reported never using a rubber dam, 77 (16 per-
cent) P-Is used it from 1 to 50 percent of the
time, 110 (24 percent) P-Is used it from 51 to 99
percent of the time, and 211 (45 percent) P-Is
used it all the time. These findings are similar
to the overall percentage distribution shown in
Table 2.
The literature provides little guidance about
the possible role of practice type on rubber dam
use. The results of a National Health Insurance
System study conducted in Taiwan indicated
that rubber dam usage was significantly higher
in hospital settings than in private dental
clinics.17 Practitioners in group practices used a
rubber dam more than did those in solo prac-
tices.15,30 However, a higher use of rubber dams
in private practices was reported when com-
pared with that in mixed practices (mix of pri-
vate and public patients) and National Health
Services practices (68 percent, 55 percent, 45
percent), respectively.5
We observed that rubber dam use was uni-
versal among the 14 endodontists in The
DPBRN, which was much higher than that
among general dentists and other specialists.
Although investigators in few studies have
studied this topic, the investigators of a U.S.
national study conducted in 1994 observed that
92 percent of endodontists always used a rubber
dam compared with 59 percent of general den-
tists.13 We did not have information from our
respondents regarding whether they had
advanced training, such as that from a general
practice residency or advanced education in gen-
eral dentistry program, and, therefore, we could
not determine if advanced training among the
general dentists was associated with higher
rates of rubber dam use. Attendance at contin-
uing education courses about this topic also
could influence rubber dam use, but we did not
measure that. It also is possible that rubber
dam use is higher among general dentists who
have their dental assistants place the rubber
dam for RCT and other procedures.
Dentists in The DPBRN who graduated since
2000 were significantly more likely to have
reported rubber dam use than were those who
graduated earlier, although its use among den-
tists who graduated in 2000 or later still was
only 54 percent. Graduation year was not statis-
tically significant in multivariable regressions
that included the type-of-practice variable.
Other investigators observed higher use of
rubber dams among recent graduates in studies
published in 20008 and 2002.15 Investigators in a
U.K.5 and an Irish19 study found similar findings
184 JADA 144(2) http://jada.ada.org February 2013
Page 184
within the groups of practitioners who were
younger than 40 years. These findings are in
contrast with those of another study that
showed a trend of older practitioners’ using
rubber dams more than did their younger
counterparts.9
It is possible that many of the general den-
tists in our study performed RCTs only on ante-
rior teeth and referred patients to endodontists
for all RCTs in posterior teeth. Perhaps these
general dentists would have used rubber dams
on posterior teeth if they provided that type of
treatment. Another possible explanation for low
rubber dam use is that the general dentists in
this sample used rotary endodontic instruments
when providing RCTs. With rotary instrumenta-
tion, files are attached to a handpiece. Although
this circumstance would decrease the likelihood
of a patient’s aspirating or ingesting a file, the
other reasons for using a rubber dam—namely,
infection control and treatment effectiveness—
are not obviated. In addition, rotary instrumen-
tation is supplemented with hand files.
Other forms of isolation. In our study,
other than using a rubber dam, the most
common method used for isolation was cotton
rolls or gauze squares. This finding is consistent
with that of a study conducted in 2009 that indi-
cated that 37 percent of respondents used a
rubber dam in some patients, 29 percent used
cotton rolls alone or with some other form of iso-
lation, and 3 percent did not use any form of
isolation.10
A total of 25 general dentist practitioners
reported using Isolite, a device that simultane-
ously provides light, suction, retraction and
aspiration prevention. We are not aware of any
studies in which investigators compared the
safety, comfort and effectiveness of this device
with those of a rubber dam, although one
opinion piece has been published.31
Our study had certain limitations, and con-
clusions made from it should take them into
account. The main limitation is that the study
design relied on information from the question-
naire rather than information based on direct
observation of procedures. In addition, although
the response rate was good, it is possible that
nonrespondents would have reported different
behavior. Furthermore, although DPBRN P-Is
have much in common with dentists at large,24,25
it is possible that their RCT procedures might
not be representative of dentists at large.
Although we measured rubber dam use by using
a four-point ordinal scale (none, 1-50 percent,
51-99 percent, 100 percent), we had to conduct a
multivariable regression analyses by means of a
179_186_Gilbert.qxp:Layout 1 1/10/13 3:02 PM Page 185
three-point scale (none, 1-99 percent, 100 per-
cent), which could have affected these results.
Rubber dam use reduces the potential for
patients’ swallowing or inhaling materials or
objects used during RCT, as well as pieces of
tooth structure, restorative material or necrotic
tissue dislodged during access preparation.32-36
In addition to patient safety and occupational
safety benefits, better infection control and
treatment effectiveness have been reported.1-3
For these reasons, use of a rubber dam during
RCT is considered the reference standard.
CONCLUSION
Although they have much in common with den-
tists at large, DPBRN P-Is may be more attuned
to the role scientific evidence plays in everyday
clinical practice and be more open to incorpo-
rating it.21,23,37,38 However, even among these
practitioners, the use of a rubber dam during
RCT is not universal. Our finding of high levels
of rubber dam use among certain subgroups was
encouraging. The results of previous research
from DPBRN suggest that dentists who are per-
forming procedures in a manner consistent with
the latest scientific evidence can act as change
agents to encourage adoption by their col-
leagues38; this circumstance may provide guid-
ance as to how to improve rubber dam usage
among the group at large. ■
Disclosure. None of the authors reported any disclosures.
This investigation was supported by grants U01-DE-16746,
U01-DE-16747 and U19-DE-22516 from the National Institute of
Dental and Craniofacial Research, National Institutes of Health,
Bethesda, Md.
The authors are grateful for the data analysis by Dr. Abu Faisal
Hasme and for input from Dr. Paul Eleazer at the University of Ala-
bama at Birmingham.
Opinions and assertions contained herein are those of the authors
and are not to be construed as necessarily representing the views of
the respective organizations or the National Institutes of Health.
The National Dental Practice-Based Research Network Collabora-
tive Group comprises practitioner-investigators and faculty and staff
investigators who contributed to this DPBRN activity. Lists of these
people are available at http://nationaldentalpbrn.org/tyfoon/site/
fckeditor/file/Infrastructure%20Update%20Survey.pdf and http://
nationaldentalpbrn.org/tyfoon/site/fckeditor/file/IUS-faculty%
20and%20staff(1).pdf, respectively.
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