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Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 39-43

A cross-sectional study on frequency of rubber dam usage among dentists practicing in Maharashtra, India

Private Practice, Mumbai, Maharashtra, India

Date of Web Publication10-Jan-2018

Correspondence Address:
Apeksha Mahendra Sanghvi
405, Sumer Tower No: 1, Sheth Motisha Road, Mazgaon, Mumbai - 400 010, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_92_16

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Introduction: Rubber dam was introduced more than 150 years ago. It has been the standard of care, especially in endodontics. In spite of its advantages, dentists still refrain from using it. Hence, the objective of this study was to investigate the frequency of rubber dam usage among dental practitioners in Maharashtra, India.
Materials and Methods: It was a cross-sectional study. The questions were regarding the usage of rubber dam in their practices which was answered by the dentists. A sample size of the study was 400. Questionnaire included eight questions and the last question was open-ended.
Results: Dentists using the rubber dam in their daily practice were only 23.8%. Out of which, only 4.2% dentists use it in 100% of the cases. When the reason for not using the rubber dam was asked, 40% dentists said they do not use rubber dam because its time consuming, 37% do not use it due to patient compliance, 14% responded that it is expensive, and 9% were unsure of the technique.
Conclusions: The low percentage of rubber dam usage in Maharashtra is not acceptable, and dentists should follow recommended standard of care. Dental schools should make it mandatory for students to use rubber dam in root canal treatments.

Keywords: Bleaching, endodontics, isolation, rubber dam

How to cite this article:
Sanghvi AM, Nagda RJ, Raju PJ. A cross-sectional study on frequency of rubber dam usage among dentists practicing in Maharashtra, India. Saudi Endod J 2018;8:39-43

How to cite this URL:
Sanghvi AM, Nagda RJ, Raju PJ. A cross-sectional study on frequency of rubber dam usage among dentists practicing in Maharashtra, India. Saudi Endod J [serial online] 2018 [cited 2023 Jan 31];8:39-43. Available from: https://www.saudiendodj.com/text.asp?2018/8/1/39/222765

  Introduction Top

Rubber dam was introduced in 1864 by Dr. Sanford Barnum.[1] He described his delight in finding such a simple means of saliva control at a time when saliva control was very rudimentary. Since then, the technique has been perfected, taught, used, and rejected by many in the profession.[2] Isolation of the operative field during dental interventions is imperative or even obligatory in some cases such as root canal treatment. Absolute isolation of the area can be obtained only using the rubber dam.[3] However, many dentists still refrain from using rubber dam. A recent survey showed that only 44% of general dentists used rubber dam during endodontic treatment.[4] As Cragg said, “It takes more time to convince the doctor to use it, then eventually using it.”[5]

Rubber dam is a low-cost and high-efficiency appliance. It improves treatment results by retracting soft tissues to provide better access to the operating field, provides a dry field for improved visibility, reduces fogging of mirror and enhances visual contrast, protects patients from aspiration and ingestion of small instruments used during procedures and irrigating solutions, minimizes patient conversations, and encourages them to keep their mouth open during treatment.[6]

Saliva plays an important role in the oral microflora. It contains microorganisms and antigens from the food ingested. Rubber dam provides an aseptic operating field, isolating the tooth from oral and salivary contamination. It cannot be stressed enough that contamination of the root canal with saliva introduces new microorganisms to the root canal which may prolong treatment and reduce prognosis.[7]

The dissemination of knowledge in the field of dentistry is immense and readily accessible. The rationale of the study was that in spite of proven evidence regarding advantages of rubber dam, dentists did not use it routinely in their practices. Hence, we decided to (a) investigate the rubber dam usage frequency among dental practitioners in Maharashtra, India, (b) to determine the dental procedures, in which the rubber dam is frequently used, and (c) the reasons why the rubber dam is not preferred.

  Materials and Methods Top

It was a cross-sectional, question-based survey carried out among practicing dentists in Maharashtra, who were registered with the Dental Council of India at that moment. The sample size was 400. Participants were selected randomly with no age or gender bias. This study was conducted in the months of July and August 2015. Prior approval from the Ethical Committee and written consent of the participants were obtained. The mode of delivery of questionnaire was hand delivered with two rounds of follow-up from their areas of practice.

The method for measurement of the prevalence of use of rubber dam among this population was a self-designed, pretested questionnaire consisting of section 1 and 2. Section 1 gathered information about age, area, gender, and specialty. Section 2 consisted of eight questions, of which six questions were closed-ended, where the participants were instructed to tick the most relevant option for each question. Question 7 consisted of five options, and the last option was left open for the participants to write about other procedures where they use the rubber dam. Question 8 was an open-ended question for which the participants were asked to write their views. The answers for the open-ended questions were limited, hence were coded and statistically analyzed [Appendix 1] [Additional file 1].

Statistical analysis

Data were subjected to statistical analysis using Statistical Package for the Social Sciences (SPSS version 22.0 IBM, Armonk, NY: IBM Corp, USA). Results are presented as percentage and frequency of responses to each question. P≤ 0.05 was considered statistically significant.

  Results Top

Four hundred questionnaires were distributed to the private dental offices in Maharashtra. Mean age of the dentists was 38.5 years. There were 217 males and 183 females. There were 315 general practitioners and 85 specialists.

Ninety-five dentists (23.8%) said yes that they used a rubber dam in their routine practice and 305 (76.2%) did not use a rubber dam. Nearly 21.26% of general dentists and 32.94% specialists used rubber dam during their routine procedures. Statistically significant difference was found (P < 0.05).

Among the 95 dentists who responded yes, 4.2% dentists said that they used it in all cases, 28.1% dentists used in 50%–99% cases, and 67.7% dentists used in <50% cases.

When the reason for not using the rubber dam was asked, 40% dentists said they did not use rubber dam because it is time consuming, 37% did not use it due to patient compliance, 14% responded that it is expensive, and 9% were unsure of the technique.

Three hundred and fifty-one (87.8%) dentists thought that they cannot achieve 100% accuracy in their cases without the rubber dam.

Three hundred and eighty-seven (96.8%) dentists agreed that the dental educators needed to improvise their technique toward teaching the usage of rubber dam in dental practice.

Among the dentists that used a rubber dam, 20.5% of dentists used rubber dam with frames, 1.3% used frameless rubber dams, and 1.8% used both frame and frameless rubber dams. From the dental procedures, 91.57% dentists used rubber dam in endodontic procedures, 64.21% used in restorative procedures, and 17.89% used during bleaching.

Nearly 85.3% practicing dentists said that there were no alternatives for rubber dam. The remaining 14.7% dentists believed that things such as cotton rolls, suction tips, and Svedopter were the alternatives for rubber dam.

  Discussion Top

Application and advantages of the rubber dam are taught in undergraduate education. Rubber dam represents the gold standard of care in endodontic practice.[8] Various studies have been conducted to check the frequency of rubber dam usage worldwide [Table 1].[6],[9]
Table 1: Frequency of rubber dam use in endodontic treatment

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There is a need to encourage the use of rubber dam and to make it mandatory in routine procedures. In a survey conducted by Koshy and Chandler, 72% of general practitioners with <10 years of experience were using the rubber dam.[2]

A study conducted by the Dental Practice-Based Research Network (DPBRN); 44% dentists used rubber dam for root canal treatments in 100% cases, 24% used in 51%–99% cases, 17% dentists used in 1%–50% cases, and 15% dentists did not use it at all.[4] In a study of Belgium, 65% reported never or seldom using a rubber dam and only 7% used rubber dam in all cases.[16] Ninety-eight percent of senior year students in two schools learning dentistry in Wales and Ireland reported that they would continue to place rubber dam in their practices as well as during performing root canal treatments.[17] Whereas rubber dam use tends to decrease dramatically following graduation, and root canal treatment is usually performed without it in general dental practice.[6]

The main reasons for low frequency of rubber dam usage in our study were excessive time consumption and patient compliance. A literature suggests that even an inexperienced operator can apply a rubber dam in a few minutes.[18] In a study conducted on dental interns, the time taken to apply the rubber dam was mostly <5 min for both male and female interns.[19] In addition, the rubber dam offers better working conditions including maintaining a dry field, retracting the tissues, limiting tongue and lips movement by the patient, reducing the time of changing cotton rolls, and also preventing posttreatment diseases which compensates for the extra time used while placing it.[18] A study revealed that 45% of undergraduate respondents reported that patients did not prefer rubber dam,[17] whereas a study by Koshy and Chandler said that 23% practitioners considered patient intolerance as a disincentive.[2] Patient intolerance is a perception that is related to the dentist's attitude than the patients. Several studies indicate that almost all patients accept it satisfactorily.[2],[20],[21] A study by Stewardson and McHugh revealed that the patients actually preferred to have the rubber dam placed.[22] According to a US study by Hill EE, the most common reasons for not using the rubber dam for a particular procedure were inconvenience and belief that its use is unnecessary (time and cost were not of much importance).[21] The best way to improve patient acceptance for rubber dam is for the operator to use it frequently and thus become proficient.[22] Experience is the key to successfully and efficiently placing the rubber dam, which comes with regular use. Therefore, the limited utilization may be due to the lack of proficiency.[23]

In our study, 87.8% dentists agreed that they do not achieve 100% accuracy in their cases without the rubber dam. In spite of that, the usage of rubber dam is so very low. This reflects the need to motivate the dentist regarding its advantages. Maximum dentists agreed that the dental educators need to improvise their technique toward teaching rubber dam usage. Very few reported that they were unsure of the technique. In a study, 48.1% of participants believed that better implementation of rubber dam usage can be done by better undergraduate education followed by 22.8% believing in strict governmental regulations.[24]

There are potential ways to manage the negative attitude of practitioners toward rubber dam application. By continuing education programs and training, the time required for its usage can be reduced. Patient compliance can be increased by educating them about its advantages. Cost factor can be managed using surgical latex gloves as rubber dam or using rubber wedges to support rubber dam in anterior teeth. If the dentist has a fear that the patient might aspirate or ingest the clamp, then they can tie a dental floss through the holes of the clamp to prevent this occurrence. To prevent deterioration of breathing pattern, they can minimize the duration of application or create vents in the rubber dam in a place where leakage cannot occur.[9]

Other applications of rubber dam

Apart from endodontics, rubber dam can also be used in restorative procedures and during bleaching of teeth for isolation of oral cavity. In our study, maximum dentists used rubber dam in endodontics, followed by restorative procedures and bleaching. It also protects patients from accidental ingestion and aspiration of small instruments and irrigating solutions such as sodium hypochlorite.[6]

Contrasting findings have been found to check if rubber dam gives long-lasting, high-quality restorations. Barghi et al. observed reduced microleakage and significantly greater shear bond strength of resin bonded to enamel when rubber dam isolation was used, and the bond strength of some dentin bonding systems can be affected by moisture contamination.[24] Goldfein et al. found that using a rubber dam in prefabricated postplacement in root canal-treated teeth provides a significantly higher success rate.[25] In another survey conducted by Cochran et al., the results indicated that using a rubber dam significantly reduces microorganisms from 90% to 98%. Hence, the rubber dam provides an excellent barrier to the potential spread of infectious diseases in the dental office.[3] Lin et al. observed that the survival probability of root canal-treated teeth after 3.43 years was 90.3%, which was >88.8% observed without the use of rubber dam.[26] According to Rau et al., the proximal contact strength of the posterior composite restoration significantly increased from 2.26 ± 1.45 N before to 3.83 ± 2.34 N after rubber dam application.[27] Boon observed that the survival rate of the restorations was higher when using rubber dam irrespective of the operator or the glass ionomer cement material.[28]

In our study, 14.7% of dentists used alternatives such as cotton rolls, suction tip, and Svedopter for rubber dam. In a 2009 study by Palmer et al., 29% used cotton rolls alone or with some other forms of isolation and 3% did not use any form of isolation.[15] In the study conducted by DPBRN, 25 general practitioners out of 524 reported using Isolite, a device that simultaneously provides light, suction, retraction, and aspiration prevention.[4]

  Conclusions Top

The low percentage of rubber dam usage in Maharashtra is not acceptable, and dentists should follow recommended standard of care. Dental schools should make it mandatory for students to use the rubber dam in root canal treatments. This in turn will increase its usage in dental practice. Dentists are aware of the advantages of rubber dam. Continuing education courses can play a vital role in increasing its usage by regular training and emphasizing its merits.


We would like to thank Dr. Dheeraj Kalra for helping and guiding us through the survey procedures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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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.  Back to cited text no. 2
Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119:141-4.  Back to cited text no. 3
Anabtawi MF, Gilbert GH, Bauer MR, Reams G, Makhija SK, Benjamin PL, et al. Rubber dam use during root canal treatment: Findings from The Dental Practice-Based Research Network. J Am Dent Assoc 2013;144:179-86.  Back to cited text no. 4
Cragg TK. The use of rubber dam in endodontics. J Can Dent Assoc (Tor) 1972;38:376-7.  Back to cited text no. 5
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Ahmed MF, Elseed AI, Ibrahim YE. Root canal treatment in general practice in Sudan. Int Endod J 2000;33:316-9.  Back to cited text no. 10
Stewardson DA. Endodontics and new graduates: Part I, practice vs. training. Eur J Prosthodont Restor Dent 2002;10:131-7.  Back to cited text no. 11
Slaus G, Bottenberg P. A survey of endodontic practice amongst Flemish dentists. Int Endod J 2002;35:759-67.  Back to cited text no. 12
Al-Omari WM. Survey of attitudes, materials and methods employed in endodontic treatment by general dental practitioners in North Jordan. BMC Oral Health 2004;4:1.  Back to cited text no. 13
Koch M, Eriksson HG, Axelsson S, Tegelberg A. Effect of educational intervention on adoption of new endodontic technology by general dental practitioners: A questionnaire survey. Int Endod J 2009;42:313-21.  Back to cited text no. 14
Palmer NO, Ahmed M, Grieveson B. An investigation of current endodontic practice and training needs in primary care in the north west of England. Br Dent J 2009;206:E22.  Back to cited text no. 15
Hommez GM, Braem M, De Moor RJ. Root canal treatment performed by Flemish dentists. Part 1. Cleaning and shaping. Int Endod J 2003;36:166-73.  Back to cited text no. 16
Mala S, Lynch CD, Burke FM, Dummer PM. Attitudes of final year dental students to the use of rubber dam. Int Endod J 2009;42:632-8.  Back to cited text no. 17
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.  Back to cited text no. 18
  [Full text]  
Al-Abdulwahhab BM, Al-Thabit H, Al-Harthi A, Shamina R, Al-Ashgai A, Al-Qabbani F, et al. The attitudes of dental interns to the use of the rubber dam at Riyadh dental colleges. Saudi Endod J 2012;2:75-9.  Back to cited text no. 19
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Stewardson DA, McHugh ES. Patients' attitudes to rubber dam. Int Endod J 2002;35:812-9.  Back to cited text no. 22
Madarati AA. Why dentists don't use rubber dam during endodontics and how to promote its usage? BMC Oral Health 2016;16:24.  Back to cited text no. 23
Barghi N, Knight GT, Berry TG. Comparing two methods of moisture control in bonding to enamel: A clinical study. Oper Dent 1991;16:130-5.  Back to cited text no. 24
Goldfein J, Speirs C, Finkelman M, Amato R. Rubber dam use during post placement influences the success of root canal-treated teeth. J Endod 2013;39:1481-4.  Back to cited text no. 25
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