|Year : 2012 | Volume
| Issue : 3 | Page : 142-146
Attitudes towards use of rubber dam in private practices in the United Arab Emirates
Sheela B Abraham, Betul Rahman, Ali Istarabadi, Abdul Wahab Hussain Ali Mahmoud, Quqa Danielle
Department of General and Specialist Dental Practice, College of Dentistry, University of Sharjah, Sharjah, United Arab Emirates
|Date of Web Publication||30-May-2013|
Sheela B Abraham
College of Dentistry, University of Sharjah, P.O. Box: 27272 Sharjah
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Introduction: The benefits of rubber dam in dental practice are well known and it is accepted worldwide as a standard of care. In spite of this, rubber dam use is disregarded by most practicing dentists. The purpose of this study was to assess the use of rubber dam by private practitioners in the United Arab Emirates (UAE) for operative and endodontic procedures and to assess dentists' attitude towards the use of rubber dam. Materials and Methods: Three senior dental students of the University of Sharjah distributed 200 "closed" surveys among private clinics in the UAE. A total of 151 questionnaires was filled and returned. Data was entered into an electronic database (Microsoft Excel 2003) and the results were statistically analyzed through SPSS Statistics version 18. Results: 64.5% of dentists agreed that the use of rubber dam provides clearer access during restorative treatment and there was a higher clinical standard achieved. However, the majority of these dentists did not use the rubber dam in actual practice. Furthermore, 57.2% disagreed that they were not taught or had forgotten the use of rubber dam. It was also evident that there is less frequent use of rubber dam in the treatment of anterior root canals or restorations when compared to posterior. Conclusions: Dentists practicing in the UAE were trained in the use of rubber dam but few of them use it in their dental practice. These findings suggest the need to re-enforce the rubber dam use in various clinical procedures for delivering a better standard of care and obtaining predictable outcomes.
Keywords: Attitudes of dentists, endodontics, rubber dam
|How to cite this article:|
Abraham SB, Rahman B, Istarabadi A, Ali Mahmoud AH, Danielle Q. Attitudes towards use of rubber dam in private practices in the United Arab Emirates. Saudi Endod J 2012;2:142-6
|How to cite this URL:|
Abraham SB, Rahman B, Istarabadi A, Ali Mahmoud AH, Danielle Q. Attitudes towards use of rubber dam in private practices in the United Arab Emirates. Saudi Endod J [serial online] 2012 [cited 2019 Dec 7];2:142-6. Available from: http://www.saudiendodj.com/text.asp?2012/2/3/142/112708
| Introduction|| |
Rubber dam has long been used in the dental field for its many helpful advantages during operative and endodontic procedures. , Rubber dam offers an excellent means of infection control during dental treatment by mainly reducing bacterial contamination of any dental preparations or root canal systems. , Furthermore, rubber dam prevents the transmission of any infectious agents between the patient and dentist. Rubber dam also protects any inhalation or swallowing of dental materials, fine instruments, and irrigants and/or tooth fragments into the patient's oropharynx by simply acting like a shield in the working area. , Retraction of the lips, cheeks and tongue are also facilitated by the use of rubber dam, which contributes to more successful treatments.  In spite of all its known advantages, application of the rubber dam is believed to be difficult and time consuming and patients are usually not compliant with its use.  Apart from these reasons, insufficient time and training for dentists, cost of treatment and patient discomfort are also cited as factors which support its limited use in dental private practices. ,, Jenkins et al. - in North America observed that rubber dam was not routinely used, even for root canal treatment.  In Great Britain, only 5% of dentists working with the National Health Service were reported to use rubber dam when compared with the colleagues in private practices.  Over the past decade, the United Arab Emirates (UAE) has developed into a very diverse multi- cultural country harnessing medical and dental practitioners from many cultural backgrounds and countries like Middle -Eastern Arab Countries, India, Europe and America. It is interesting to study the rubber dam use in the UAE and that would make this study very important. As a part of this study, private practicing dentists were inquired about their perception and attitude to the use of rubber dam in their dental practice. The study also assessed the use of rubber dam in routine restorative procedures and root canal procedures in the UAE.
| Materials and Methods|| |
A pre-piloted questionnaire  with "closed questions" (questions with answers to choose from) was, distributed by three senior dental students of the University of Sharjah door-to-door among private clinics throughout the different emirates of the UAE, (Fujairah, Ras Al-Khaimah, Umm Al-Quwain, Ajman, Sharjah, Dubai, Abu Dhabi). Information related to year of graduation, practice type and gender of the respondents, information related to use of rubber dam in operative and endodontic procedures, information related to the dentist's attitude to the use of rubber dam and information related to dentist's reasons for using or not using rubber dam were sought in the questionnaire. Informed consent was obtained from all participants. The surveys were dropped off and collected a week later. Data from the completed questionnaires were entered onto an electronic database (Microsoft Excel 2003).The results were then statistically analyzed through SPSS Statistics version 18 after simple frequencies were calculated and cross-tabulations were performed.
| Results|| |
200 questionnaires were distributed door to door among private clinics in the different emirates of the UAE and 151 (75.5%) were filled and returned. The questionnaires were only sent to private practitioners in the non-government sector. The majority of the participants were in the 30-49 age groups [Table 1]. About 11.7% of male dentists and 6.8% of female dentists always used the rubber dam for anterior composite restorations. 3.9% of male dentists and 5.1% of female dentists always used it for posterior composites and only one female dentist used a rubber dam always while placing posterior amalgam restorations. In regard to root canal treatment, 12.5% of male dentists and 11.3% of female dentists always used rubber dam for anterior root canal procedures [Table 2]. 17.9% of males and 21.3% of female dentists always used rubber dam for root canal treatment of premolars [Table 3] and 20.3% of male dentists and 21.7% of female dentists always used rubber dam while performing molar endodontics [Table 4]. Participants of the survey were given ten statements to which they were asked to agree or disagree [Table 5]. Almost 50% of dentists believed that a root canal treatment performed without a rubber dam is just as successful as one performed with it and 64.5% of dentists agreed that the rubber dam enables clearer access to the operating site when restoring teeth. The most common reasons private dentists in the UAE cited for not using rubber dam were patient discomfort and insufficient time [Figure 1].
| Discussion|| |
This is the first study conducted evaluating the use of rubber dam among private practitioners in the UAE. Interestingly, we have found similar results with other international studies. ,,, In spite of the known benefits of rubber dam in infection control, patient safety and medicolegal concerns, the use of rubber dam by private practitioners in the UAE in operative and endodontic procedures was quite low.
Although more than half of the respondents to the survey agreed that posterior composites can be placed more easily with the rubber dam and 57% have been trained in applying the rubber dam, they still didn't routinely use it as they felt that they could achieve proper isolation to place a composite restoration even without it. 49% of the respondents were confident that root canal fillings placed in the absence of rubber dam were just as successful. Unlike the reasons cited by Marshall and Page (1990) in their study,  for not using rubber dam, the main reasons mentioned in our survey by the private practitioners in the UAE were patient discomfort and insufficient time. Patient discomfort may not be a valid reason as the survey was conducted among dentists rather than patients, and therefore could be the dentist's view. The best way to improve patient acceptance is for the operator to use the rubber dam frequently and thus become proficient.  The ability to place a rubber dam successfully and efficiently comes with experience, which in turn comes with regular use. Therefore the limited utilization may be due to lack of proficiency rather than lack of knowledge or insufficient training.  The study by Stewardson and McHugh (2002)  revealed that patients actually preferred to have the rubber dam placed. We recommend a similar survey for patient's preferences in the UAE population be conducted to get a clearer picture.
Another obstacle cited for the use of rubber dam was the additional time taken in placing the rubber dam. However, the literature suggests that even an inexperienced operator can apply rubber dam in a few minutes.  In addition, the extra time spent in placing the dam is more than compensated with better working conditions offered by the dam including controlling the saliva contamination and eliminating the need to frequently change cotton rolls as well as limiting the movements of the patient's tongue and lips. As it is already evident that rubber dam may reduce the incidence of post-treatment disease during root canal treatment,  it may be necessary to increase the awareness of private practitioners to the benefits of rubber dam use by means of continuing education and stressing its importance in undergraduate studies.
Our results show that almost 50% of the respondents were confident that root canal fillings placed in the absence of rubber dam were just as successful as those placed with a rubber dam. The role of microorganisms in endodontic pathology is well established  and several outcome studies have been conducted on this topic. In a retrospective clinical study by Van Nieuwenhysen et al.  the influence of various factors on the outcome of retreatment cases was evaluated and results showed that retreatment outcomes were significantly better in those cases isolated with a rubber dam. Another study done by Abbot (1994)  where he evaluated 100 referred patients who complained of continuing pain after commencement of root canal treatment. Of all the factors considered responsible for pain, lack of use of rubber dam ranked first and was observed in 87% of the patients. The presence of infection in the root canal at the time of root filling also affects the outcome of endodontic treatment.  The findings of the study by Nair et al.  also suggests that in a majority of root filled human teeth with therapy resistant periapical lesions, microorganisms may persist and play a significant role in endodontic treatment failures. Effective infection control can eliminate the existing infection and prevent re-infection of the root canal system. Sodium hypochlorite (NaOCl), considered one of the best irrigants of choice on account of its broad antimicrobial spectrum and unique capacity to destroy necrotic tissue remnants  is an irritant and should be used only with a rubber dam in place. There is also evidence suggesting a relationship between the rubber dam use and choice of NaOCl and ethylene diamine tetra-acetic acid (EDTA) as an irrigant.  Frequent rubber dam users were more likely to use NaOCl in higher concentrations than others who used more bland solutions like saline and local anesthetics.  The study by Kobayashi et al.  showed that caries free teeth with advanced periodontitis diagnosed as clinically dead were examined using culture and interference microscopy and it showed microorganisms present common to both sites i.e., the periodontium and the pulp suggesting that the periodontal pocket may be a source of the root canal infections.
It may be necessary to increase the awareness of private practitioners to the benefits of rubber dam use by means of continuing education and stressing its importance in undergraduate studies. The use of rubber dam in root canal procedures is considered the minimum safety standard of care. , The importance of the safety of the rubber dam is highlighted by the list of endodontic instruments that have been ingested or inhaled.  Susini et al.  examined the records of two insurance companies representing 24,651 French general dentists over a 11 yrs period and found that the incidence of aspiration or ingestion of endodontic instruments was quite low (0.001 per 100,000 and 0.12 per 100,000) root canal treatments respectively. Despite this, performing endodontic treatment without the rubber dam risks harming the patient and is considered legally indefensible. , The study by Cochran et al.  evaluated the rubber dam as an infection control barrier during standard restorative procedures. Microbial collection was performed during preparation and placement of amalgam and composites with and without rubber dam and during hand piece and air water syringe spraying with and without rubber dam. The rubber dam acts as a surgical drape and isolates the operating field from microbial contamination as the primary source and thereby protects the patient as well as the treating dentist.
Although the rubber dam has been researched extensively and is a universally advocated technique and majority of practicing dentists have been trained in the placement and use of rubber dam in their undergraduate courses, yet do not employ it when they begin to professionally practice. This indicates that the use of rubber dam within and outside the dental school is not because of insufficient training but as a result of less emphasis on the rationale of using the rubber dam and its relevance to the practice of modern dentistry. , Following graduation, courses especially those with a hands-on component is invaluable to improve and update the practitioners' knowledge and clinical skills.
| Conclusions|| |
Although most of the dentists who participated in the survey agreed that the use of rubber dam provides a clearer access during restorative treatment and believed that there was a higher clinical standard achieved, the majority of the private practicing dentists in the UAE did not use the rubber dam in actual practice. Furthermore, in our study, more than half of the participants agreed that they have been trained in the placement and use of rubber dam in their undergraduate courses. It was also evident that there is a less frequent use of rubber dam in anterior root canal treatments and restorations compared to posterior root canal treatments and restorations. The results of our survey show that there is a need to increase awareness among private practitioners in the UAE regarding the use of rubber dam to improve the quality of treatment delivered, infection control and patient safety and to avoid medico-legal issues.
| References|| |
|1.||Ahmad IA. Rubber dam usage for endodontic treatment: A review. Int Endod J 2009;42:963-72. |
|2.||Lynch CD, McConnell RJ. Attitudes and use of rubber dam by Irish general dental practitioners. Int Endod J 2007;40:427-32. |
|3.||Samaranayake LP, Reid J, Evans D. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. ASDC J Dent Child 1989;56:442-4. |
|4.||Sjogren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int Endod J 1997;30:297-306. |
|5.||Kuo SC, Chen YL. Accidental swallowing of an endodontic file. Int Endod J 2008,41;7:617-22. |
|6.||Susini G, Pommel L, Camps J. Accidental ingestion and aspiration of root canal instruments and other dental foreign bodies in a French population. Int Endod J 2007;40;8:585-9. |
|7.||Koshy S, Chandler NP. Use of rubber dam and its association with other endodontic procedures in New Zealand. N Z Dent J 2002;98:12-6. |
|8.||Jinks GM. Rubber dam technique in pedodontics. Dent Clin North Am 1966;4:327-40. |
|9.||Marshall K, Page J. Use of rubber dam in the UK. A survey. Br Dent J 1990;169:286-91. |
|10.||Gergely EJ. Desmond Greer Walker Award. Rubber dam Acceptance. Br Dent J 1989;167:249-52. |
|11.||Udoye CI, Jafarzadeh H. Rubber dam use among a subpopulation of Nigerian dentists. J Oral Sci 2010;52:245-9. |
|12.||Jenkins SM, Hayes SJ, Dummer PM. A study of endodontic treatment carried out in dental practice within the UK. Int Endod J 2001;34:16-22. |
|13.||Joynt RB, Davis El, Schreier PH. Rubber dam usage among practicing dentists. Oper Dent 1989;14:176-81. |
|14.||Stewartson DA, McHugh ES. Patient attitudes to rubber dam. Int Endod J 2002;35:812-9. |
|15.||Ryan W, O'Connell A. Attitudes of undergraduate dental students to the use of rubber dam. J Ir Dent Assoc 2007;53:87-91. |
|16.||Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long term results of endodontic treatment. J Endod 1990;16:498-503. |
|17.||Kakehashi S, Stanley HR, Fitzgerald R. The effect of surgically exposed dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340-9. |
|18.||Van Nieuwenhysen JP, Aouar M, Dhoore W. Retreatment or radiographic monitoring in endodontics. Int Endod J 1994;27:75-81. |
|19.||Abbott PV. Factors associated with continuing pain in endodontics. Aust Dent J 1994;39:157-61. |
|20.||Nair PN, Sjögren U, Krey G, Kahnberg KE, Sundqvist G. Intraradicular bacteria and fungi in root filled, asymptomatic root filled teet h with therapy resistant periapical lesions: A long term light and electron microscopic follow up study. J Endod 1990;16:580-8. |
|21.||Zender M. Root canal irrigants. J Endod 2006;32:389-98. |
|22.||Stewardson DA. Endodontics and the new graduates: Part I, practice vs training. Eur J Prosthodont Restor Dent 2002;10:131-7. |
|23.||Kobayashi T, Hayashi A, Yoshikawa R, Okuda K, Hara K. The microbial flora from root canals and periodontal pockets of non-vital teeth associated with advanced periodontitis. Int Endod J 1990;23:100-6. |
|24.||Cohen S, Schwartz S. Endodontic complications and the law. J Endod 1987;13:191-7. |
|25.||Peters OA, Peters FC, Fokke C. Ethical principles and considerations in endodontic treatment. ENDO-Endodontic Practice Today 2007;1:101-8. |
|26.||Cochran MA, Miller CH, Sheldrake MA. The efficacy of rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119:141-4. |
|27.||Swallow JN. Dental Practice in Northern Ireland, UK. Community Dent Oral epidemiol 1983;11:169-73. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]