Key words:
Isolation - operative dentistry - rubber dam
INTRODUCTION
Rubber dam is universally acknowledged as a mandatory adjunct, particularly during
endodontic treatment. Many authors advocate its usage and encourage practitioners
to adopt it in routine practice including operative dentistry field.[1] Rubber dam offers the practitioners with a wide variety of advantages such as isolation
of the operative area, provision of aseptic field, improving infection control, preventing
ingestion or aspiration of burs or instruments, as well as protection and retraction
of soft tissue.[2]
[3]
[4]
[5] Other advantage is increased patient comfort with a positive opinion about rubber
dam application.[6]
Operative dentistry field is a major area where rubber dam is used.[7] Moreover, rubber dam use should be reevaluated from a medicolegal point of view,
considering an increase in malpractices, directed against general practitioners. Failure
to use rubber dam has been described as a serious departure from the standard of care.[8]
With all these advantages as well as the legal aspects favoring rubber dam, but many
practitioners still resist its use in routine care. They claim that it is time consuming
and uncomfortable for the patients.[9]
[10]
[11]
[12]
[13]
[14] Training on rubber dam application has been considered as an integral part of the
contemporary dental education. Many dental schools advocate the use of rubber dam
by their students from the first meeting with the patient.[2]
Since surveys among dental students are helpful tools to draw the outline of the future
dental workforce, so investigating dental students’ perceptions and attitudes toward
rubber dam use will contribute to underlining the inherent problems related with the
implementation of this worldwide acknowledged methodology. Depending on the results,
strategies can be developed to enhance the way of contemporary, and high-quality aspects
of clinical dentistry are delivered and instilled.
The purpose of the present study was to determine the general attitude of Saudi dental
students’ groups enrolled in two different private colleges toward rubber dam application,
specifically focusing on operative field treatment and evaluates the problems they
encounter related with this tool.
METHODS
Anonymous survey questionnaires were distributed to undergraduate clinical students
enrolled in two private dental colleges in Saudi Arabia; (a) Al-Farabi Private College,
Riyadh, KSA and (b) Buraidah Private Colleges, Qassim, KSA. Before the study, anonymity
of the respondents was confirmed. A total of 294 survey forms were printed and delivered
to the students. Two hundred copies were directed to the undergraduate clinical years’
students (A) and 94 copies (B). The students were not held obliged to return the forms.
In the questionnaire, students were asked about areas of dental practice in operative
field where they used rubber dam. The survey continued with questions regarding students’
opinion about rubber dam’s advantages as well as difficulties. They were asked if
they agreed or disagreed with certain aspects of rubber dam and whether they use it
because they believe that the restorations placed under rubber dam have a greater
longevity or not. They were also asked whether they frequently use the rubber dam
for isolation in maxillary anterior Class V restoration or just they isolate using
the cotton roll. They were asked if they integrate rubber dam as a mandatory tool
in both adults and children and during which procedures or cavity type, they will
plan to use it. The printed questionnaires were delivered to the students at the beginning
of the practical session and collected back at the end of the session with respond
rate of 100%.
Statistical analysis was performed using Number Cruncher Statistical System 2007 Statistical
Software (Utah, USA) pocket program. In addition to descriptive statistical methods,
Chi-square test was used for the comparison of qualitative data. Results were evaluated
at a significance level of P < 0.05.
RESULTS
The final results were summarized in [Tables] 1 and [2] and illustrated in [Figures 1] and [2]. The majority of the students of both colleges responded negatively to use rubber
dam for children (96.59%). On the other hand, most of them confirmed the use of rubber
dam with adult patients in restorative procedures (97.61). Application of rubber dam
in posterior esthetic restoration was highly recommended by the students of both colleges,
while this is not true regarding amalgam. Regarding anterior restorations, the students
of both colleges advocate the use of rubber dam, with a higher percentage for resin
composite comparing with glass ionomer cement.
Regarding preclinical training, most of the school A students believed they received
satisfactory education regarding rubber dam usage, whereas only two-thirds of school
B students agreed with that opinion. This difference in response was statistically
significant (P < 0.05), also there is a significant difference regarding the use of rubber dam in
maxillary anterior Class V with a higher percentage for school A compared to school
B students.
Most students agreed with the opinion that operative procedures and treatments performed
using the rubber dam were more successful in both cavity preparation and restorative
material properties than those where it was not used. Not only the students shared
the opinion that proper isolation cannot be achieved for the operative field without
using rubber dam, but also they shared the opinion that restorations placed under
rubber dam have a greater longevity than those placed without. On the other hand,
more than one-half of school B disagreed with the opinion that rubber dam use would
give good visibility and enables clearer access during both cavity preparation and
placing restoration, whereas only one-quarter of school A students adopt this opinion.
This difference was statistically significant (P < 0.05). There was an agreement between the two dental colleges’ student for the
opinion that application of the dam was difficult and patients dislike it.
Figure 1: Bar chart showing the percentage of answers given by students to questions regarding utilization of rubber dam
Table 1:
Answers given by students to questions regarding utilization of rubber dam
|
Questions
|
School A, n (%)
|
School B, n (%)
|
|
Q1. Do you use rubber dam on adult?
|
|
Always
|
180 (90)
|
80 (84.10)
|
|
Sometimes
|
14 (7)
|
13 (14)
|
|
Rarely
|
6 (3)
|
1 (1.20)
|
|
Never
|
0
|
0
|
|
Q2. Do you use rubber dam on child?
|
|
Always
|
0
|
0
|
|
Sometimes
|
8 (5)
|
2 (2.40)
|
|
Rarely
|
12 (7.8)
|
11 (13.55)
|
|
Never
|
180 (96.2)
|
81 (83.15)
|
|
Q3. Do you use the rubber dam during operative procedures for anterior composite?
|
|
Always
|
142 (71)
|
69 (73.55)
|
|
Sometimes
|
50 (25)
|
20 (21.25)
|
|
Rarely
|
8 (4)
|
5 (5.20)
|
|
Never
|
0
|
0
|
|
Q4. Do you use the rubber dam during operative procedures for anterior glass ionomer?
|
|
Always
|
102 (51)
|
53 (56.38)
|
|
Sometimes
|
44 (22)
|
26 (27.65)
|
|
Rarely
|
34 (17)
|
11 (11.70)
|
|
Never
|
20 (10)
|
4 (4.20)
|
|
Q5. Do you use the rubber dam during operative procedures for posterior composite?
|
|
Always
|
194 (97)
|
88 (93.61)
|
|
Sometimes
|
4 (2)
|
3 (3.19)
|
|
Rarely
|
2 (1)
|
3 (3.19)
|
|
Never
|
0
|
0
|
|
Q6. Do you use the rubber dam during operative procedures for posterior glass ionomer?
|
|
Always
|
133 (66.50)
|
57 (60.63)
|
|
Sometimes
|
49 (24.5)
|
17 (18.08)
|
|
Rarely
|
11 (5.5)
|
13 (82)
|
|
Never
|
7 (3.5)
|
7 (7.44)
|
|
Q7. Do you use the rubber dam during operative procedures for posterior compomer?
|
|
Always
|
149 (74.5)
|
75 (79.78)
|
|
Sometimes
|
40 (20)
|
16 (17.02)
|
|
Rarely
|
11 (5.5)
|
3 (3.19)
|
|
Never
|
0
|
0
|
|
Q8. Do you use the rubber dam during operative procedures for posterior amalgam?
|
|
Always
|
11 (5.50)
|
1 (1.06)
|
|
Sometimes
|
59 (29.50)
|
12 (12.76)
|
|
Rarely
|
99 (45)
|
33 (35.10)
|
|
Never
|
31 (15.50)
|
48 (51.06)
|
Figure 2: Bar chart showing the percentage of answers given by students to questions regarding attitude of students to the use of rubber dam
Table 2:
Answers given by students to questions regarding attitude of students to the use of
rubber dam
|
Questions
|
School A, n (%)
|
School B, n (%)
|
|
Q9: Did you receive training in rubber dam placement during your preclinical studies?
|
|
Yes
|
168 (84)
|
62 (65.95)
|
|
No
|
32 (16)
|
32 (34.05)
|
|
Q10. Do you frequently use the rubber dam for isolation in maxillary anterior class
V restoration or just isolate using the cotton roll?
|
|
Yes
|
148 (74)
|
50 (53.19)
|
|
No
|
52 (26)
|
44 (46.81)
|
|
Q11. Did operative procedures in posterior teeth and treatment perform using the rubber
dam was more successful in both cavity preparation and restorative material properties
than those where it was not used?
|
|
Yes
|
150 (75)
|
68 (72.34)
|
|
No
|
50 (25)
|
26 (27.65)
|
|
Q12. Do you agree that proper isolation cannot be achieved for restoration of operative
procedures without rubber dam
|
|
Yes
|
196 (98)
|
90 (95.74)
|
|
No
|
4 (2)
|
4 (4.26)
|
|
Q13. Do you agree that patient do not like rubber dam
|
|
Yes
|
190 (95)
|
85 (90.42)
|
|
No
|
10 (5)
|
9 (9.57)
|
|
Q14. Do you agree that restorations placed under rubber dam have a greater longevity
than those placed without
|
|
Yes
|
198 (99)
|
92 (97.87)
|
|
No
|
2 (1)
|
2 (2.13)
|
|
Q15. Do you agree that rubber dam use would give good visibility and enables clearer
access during both cavity preparation and placing restoration
|
|
Yes
|
148 (74)
|
40 (42.55)
|
|
No
|
52 (26)
|
54 (57.45)
|
|
Q16. Do you agree that rubber dam is difficult to apply
|
|
Yes
|
180 (90)
|
77 (81.91)
|
|
No
|
20 (10)
|
17 (18.09)
|
In spite of the agreement of the students of both colleges that adequate isolation
cannot be achieved without rubber dam, there was a significant difference (P < 0.05) between the two colleges with a higher percentage to Al-Farabi College compared
to Buraidah College. On the other hand, more than one-half of the students of Buraidah
College disagreed with the opinion that rubber dam use would give good visibility
and enables clearer access during both cavity preparation and placing restoration
contrary to the student of Al-Farabi College who believe in this opinion. This difference
between the two colleges was statistically significant (P < 0.05). No statistically significant differences were determined between the two
colleges in terms of the other evaluated parameters (P > 0.05).
DISCUSSION
There is no doubt that rubber dam is generally preferred during endodontics, but its
usefulness during restorative treatment cannot be overlooked. The present study basically
directed toward the use of rubber dam in operative procedures as the use of rubber
dam in operative procedures is still questionable.
This survey was conducted on undergraduate students as they seem to give more honest
answers compared to the general practitioners who subjected to the stress of challenging
environment. This is in accordance with Hill and Rubel.[15] Most of the dental schools emphasize the importance of rubber dam application, especially
during endodontic and adhesive procedures.[16] In spite of the undoubted advantages of rubber dam, it is still believed to be controversy
issue among general practitioners.[17] The results obtained from this study support this hypothesis. Moreover, the trend
of these two dental colleges to stress on the usage of rubber dam in endodontic field
rather than operative field may positively affect this finding. In addition, extended
treatment period, patients dislike, and decreased clear access during both cavity
preparation and placing restoration also considered as disadvantages that may decrease
the use of rubber dam. This strongly supported by Whitworth et al. who found the majority of UK dentists never used the rubber dam for both endodontics
and operative procedures.[12]
In our study, the percentage of routine uses of rubber dam for adult patient was 90%
and 84% for the students of Al-Farabi and Buraidah, respectively. This result is in
disagreement with Unal et al.[18] who found only 5.1% of Turkish general practitioners use rubber dam. Furthermore,
Peciuliene et al. and Slaus and Bottenberg found that two-thirds of the general practitioner do not
use rubber dam.[19]
[20] Hill and Rubel related the low percentage of general practitioners using rubber
dam to the inconvenience and their belief it is unnecessary.[15] To overcome this opinion, the role of rubber dam plays in safety measures during
dental care can be further emphasized by showing complications arising from lack of
usage.
On the other hand, another study supported our result as he found the high percentage
of American general practitioners use rubber dam.[21] They refer this result to the strict malpractice regulations executed in the USA.
In our study, the reason of the high percentage of students using rubber dam may be
attributed to the close supervision of well-trained staff members in the different
clinical sessions as well as the rules and regulation implemented by the colleges
for the work in the undergraduate clinics.
In this study, a general belief among dental practitioners that patients dislike rubber
dam usage was observed. However, this result is contradicted by studies concluding
that rubber dam is an accepted element of dental care by patients.[6]
[22]
[23] This result may be related to insufficient experience of the surveyed undergraduate
student in dealing with the patients. This is supported by Whitworth et al. who found a great correlation between the negative practitioner attitude and patient
behavior toward rubber dam.[12] Furthermore, Stewardson and McHugh found that the experience of the dentist influences
the patient’s opinion.[6]
The percentage of students who did not use rubber dam for child patients in both schools
was 88.77% this exceeded the 68% reported by Mala et al.[2] This issue, however, needs to be considered from a pedodontic standpoint, probably
in a future study focusing on this group of patients.
Most of the surveyed students in both colleges respond positively to the use of rubber
dam for esthetic restoration either anterior or posterior. Terry explained the importance
of rubber dam on the basis of technique sensitivity of resin composite.[24] He stated that isolation of the operative field is very important before the placement
of esthetic restoration as contamination with saliva, blood, or crevicular fluid may
adversely affect the material property or the bond strength.
The use of rubber dam for maxillary anterior Class V was the least percentage among
the surveyed students. The students of Al-Farabi College use it more frequently than
Buraidah, and the difference was statistically significant. This may be explained
by sufficient isolation with cotton rolls due to the absence of major salivary glands
at this area.
It is also noteworthy to mention that dental students may display more idealistic
views about contemporary methodologies before graduation. With the progression of
years of dental service, there might be some alterations in their views.
CONCLUSIONS
Under the limitation of this study, we can conclude that rubber dam application has
a wide acceptance among underground students. However, we cannot depend completely
on the result of the survey, but it is acceptable tool to give an indication of what
will be the clinical practice in the near future.
Financial support and sponsorship
Nil.
