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Dental India Dental India Update dated  1st October 2008
All dental related Google/Yahoo searches landing in

British Dental Journal 205, 295 - 296 (2008)
Published online: 27 September 2008 | doi:10.1038/sj.bdj.2008.811

Rubber dam purpose
R. Mackay from Chalfont St. Peter


In a science-based profession such as dentistry new discoveries can provide valuable insight into
how and why treatments work, and therefore enable techniques to be improved. However, this only happens
if the deductions that follow the discovery are intelligent and the conclusions reached are true.

The discovery that the bacterium Enterococcus faecalis is often found in teeth where endodontic treatment
has failed has led some in the dental profession to conclude that the use of rubber dam should be mandatory.
They assume the bacteria are transferred to open root canals by saliva. I believe this conclusion is
illogical and probably not true.

   1. Enterococcus faecalis is often found in teeth that have been treated with rubber dam applied
   2. Many root fillings done without rubber dam are permanently successful. No study has shown that
      rubber dam has any effect on the success of endodontic treatment
   3. Teeth can be reasonably well isolated with cotton wool rolls, and the presence of sodium
      hypochloride in the canal must surely act as a barrier to saliva.

Is it absolutely certain that saliva is a contaminant? Oral surgeons do not think so. Nature has programmed
animals to lick wounds and we advise that an avulsed tooth be placed in the patient's mouth to ensure that
it is bathed in saliva. Unless Enterococcus faecalis is also present in the blood, surely it cannot be
present in the saliva at the point it emerges from a healthy salivary gland. Given the frequency with
which we swallow, it would seem unlikely that saliva is in the mouth long enough to become colonised.

Surely a more likely explanation for Enterococcus faecalis being associated with failed root fillings is
that the endodontic treatment achieved only partial eradication of microbes. This means that the bugs
remaining will be the stronger more virulent varieties, which then proliferate and colonise the habitat
left vacant by the removal of less hardy types.

If we accept that some feature of modern endodontic technique is resulting in inadequate disinfection of
the canals, a possible candidate must surely be the practice of completing both preparation and obturation
at the same appointment. This technique is popular with specialists, who favour it purely for
administrative convenience.

I am a GDP yet in endodontics I achieve a near perfect success rate. I attribute this to never completing
the treatment in one appointment. After the canals are prepared they are soaked in a solution of
parachlorophenol, which is left in situ for several days before the obturation appointment. If I exclude
special circumstances such as root fracture and cases treated during a brief period some six years ago
(when I had been persuaded to use calcium hydroxide in place of parachlorophenol), in the last ten years
I have not had to extract any tooth that I had previously root filled. This involves some 2,000 treatments,
mostly on molar teeth. Whilst this is not an audited survey I do have a stable patient base and review
most of my patients at least once a year. There may be failures I do not know about, but surely it would
be churlish not to allow that my endodontic treatments are, generally, a worthwhile exercise.

In spite of this, a specialist endodontist would describe what I do as 'clinically negligent' simply
because, in common with many non-specialist practitioners, I do not use rubber dam. Why do so many senior
members of the dental profession accept and support this unproven view? Why is the contrary view put
forward by the moderate majority simply swept aside?

No dentist wishes to be charged with clinical negligence, therefore many may decide not to provide endodontic
treatment. Their patients who require this treatment will then be faced with a stark choice. Either pay a
higher fee to a specialist (often hundreds of pounds more than would have been charged by their own dentist),
or have the tooth extracted. Many people will not be able to afford the higher charge and will therefore be
forced to have their tooth extracted. Or worst, have no treatment at all and risk developing a potentially
life threatening abscess.

It used to be said that for endodontics, rubber dam was essential to prevent instruments being dropped down
the patient's throat. I understand it has now been agreed that by taking a number of simple measures, a root
filling done without rubber dam can actually pose less risk in this respect than many other dental procedures.
Unless a robust case is made to show that it is essential to achieve absolute isolation of the tooth,
what purpose is served by the claims made for rubber dam?

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Some nice curves in the mesial canals, and I troughed away a lot of tissue between DB and Pal.- Bill Seddon

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Lower third molar. Extremely curved distal root....I hate x-rays because it shows you nothing at times. Used nothing but hand files in the apical region.... and then , had to carefully pre-bend it just right to stick it out of POE - Ahmad Tehrani

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