CLINICAL ARTICLE  131

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Bhavin Bhuva, Bun San Chong, Shanon Patel i N

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t t r f e o ssence Rubber dam in clinical practice

Bhavin Bhuva Endodontic Postgraduate Unit, Guy’s Hospital, King’s College London Dental Institute, London SE1 9RT, UK Email: Key words asepsis, medico-legal, rubber dam [email protected] Bun San Chong Endodontic Postgraduate Unit, Guy’s Hospital, Good practice guidelines recommend the use of rubber dam for all nonsurgical endodontic procedures; King’s College London Dental Institute, there are also safety and medico-legal implications. However, many unfounded reasons have been cited London, UK for not using rubber dam. By explaining why it is essential when performing endodontic treatment, and Shanon Patel describing the various techniques of placement, the hope is that it will encourage the routine use of rubber Endodontic Postgraduate dam in everyday clinical practice. Unit, Guy’s Hospital, King’s College London Dental Institute, London, UK

 Introduction culty of use and patient comfort3. These misconcep- tions have led to poor uptake of the technique in gen- Sanford Christie Barnum first advocated the use of eral dental practice. rubber dam almost 150 years ago1. Even in that era of A survey in the United Kingdom found that only , the benefit of isolating a tooth to obtain a 20% of the dentists questioned used rubber dam reg- dry working field, free of salivary contamination, was ularly for endodontic procedures3, and that 60% of appreciated. the respondents never used rubber dam. Surveys car- The European Society of Endodontology guide- ried out in the United States and New Zealand found lines2 recommend the routine use of rubber dam for all that 59% and 57% of dental practitioners, respec- nonsurgical endodontic procedures. However, despite tively, used rubber dam as a matter of routine4,5. Inter- being considered an essential part of the endodontic estingly, a study in Belgium found that only 3.4% of curriculum in undergraduate dental schools, the routine dentists in the country used rubber dam routinely6. A use of rubber dam in general dental practice is far from recent investigation into the attitudes and use of rubber widespread3. The main reasons cited for not using dam by Irish general dental practitioners reported that rubber dam by dental practitioners include cost, diffi- it was not used by 39% of respondents when per-

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when treating premolar teeth and 26% when treating influence on the results of the retreatment. b y molar teeth7. Many respondents (57%) considered A study evaluatedQ the response of

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rubber dam ‘cumbersome and difficult to apply’. healthy human pulps to calciumi hydroxide and bond-N

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t t r f e o The aims of this article are, firstly, to explain why ing agent, carried out with and withoutssen cthee use of rubber dam is essential when performing endodontic rubber dam20. Direct pulp capping was performed on treatment, and secondly, to describe the various tech- 40 caries-free human premolars, which were sched- niques of applying rubber dam. uled for orthodontic extraction. After a period of 30 or 60 days, the teeth were extracted and serial histo- logical sections of the teeth prepared. The study  Why use rubber dam? found a more severe inflammatory response in the pulps of teeth capped with the bonding system in the There are several advantages to using rubber dam absence of rubber dam. The authors concluded that during endodontic treatment, as outlined below. the only explanation for the poorer results with the bonding agent group, where pulp capping was car-  ried out without rubber dam isolation, was likely to be Safety and medico-legal considerations due to bacterial contamination during the operative Rubber dam protects the patient’s oropharynx, pre- procedure. venting the ingestion8,9 or aspiration9,10 of endodon- There is evidence suggesting a relationship bet- tic instruments/materials and associated dental debris. ween choice of irrigant and rubber dam usage3-5. In a Performing endodontic treatment without using study of British general dental practitioners, 71% of rubber dam risks harming the patient, and is consid- rubber dam users irrigated root canals with sodium ered legally indefensible11,12 and contrary to recom- hypochlorite compared with only 38% who did not use mended guidelines5,13,14. rubber dam3. A positive relationship between the use of rubber dam, and irrigation with sodium hypochlo-  rite and/or EDTA was also observed in surveys carried Aseptic working environment out on dentists in the United States and New The importance of microbes in the pathogenesis of Zealand4,5. apical periodontitis is well established15,16. The objec- tives of endodontic treatment are to eliminate micro-  bial infection, and to prevent re-infection of the root Access and visualisation canal system. These can only be predictably achieved Rubber dam improves access to the operating field as when endodontic treatment is carried out under the soft tissues including the cheeks and tongue are rubber dam. retracted and protected. In addition, visual contrast is Rubber dam acts like a surgical drape, isolating the enhanced when a dark-coloured rubber dam, for operating field from microbial contamination. In an example green or blue, is used21. outcome study, 2459 roots were re-examined 2 to 7 years after initial pulpectomy or following completion  of root canal treatment17. No rubber dam was used, Improved efficiency and the overall success rate was only 53%. Although Rubber dam facilitates the efficient practice of four- no direct inference can be made, the lack of con- handed dentistry during endodontic treatment. trolled asepsis may also explain the poor outcome also Instead of having to be careful about protecting the reported by others18. patient’s airways, controlling and retracting the soft In another outcome study on root canal retreat- tissues, both the operator and the dental nurse can ment, teeth were treated with (51.1%) and without concentrate on the endodontic procedure. Treatment (48.9%) the use of rubber dam19. A total of 612 teeth is also not interrupted as rubber dam reduces the were retreated including cases with and without evi- patient’s need to spit or rinse out by reducing the dence of periradicular pathosis. It was reported that accumulation of fluids in the mouth.

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opyrig  Reduction of aerosol contamination Not for PublicationC Fig 1 hPre-cut squares of rubbert dam.

b y The air turbine is an effective atomiser of saliva, blood, Q

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crevicular fluid and exhaled products from the alimen- i N

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t t r f e o tary and respiratory tracts. Without rubber dam the ssence aerosol created may result in contamination of the working environment; this has cross-infection implica- tions for both dental team members and patients. The use of rubber dam results in a reduction of 70 to 98.8% in the microbial content of air turbine aerosols produced during operative procedures, thereby reduc- ing the risk of cross-infection22-24.

 Patient comfort Contrary to belief, most patients do not find the use of rubber dam an unpleasant experience. Like any- thing new, if it is the patient’s first experience of rubber dam, the concept may be daunting. However, rubber dam is well accepted by patients25 and the argument against its use because of patient comfort is an erence. Rubber dam is usually shiny on one side and unfounded myth. matt on the other side; when placed, the matt side should, preferably, face the operator as it reduces glare and eye strain.  How to use rubber dam The performance and quality of rubber dam is best where the stock is not too old and has been stored in The basic parts of the rubber dam kit are described a cool, dry environment, preferably refrigerated. Old below. stocks of rubber dam that has not been stored prop- erly may lose its elasticity and become more suscepti- ble to tearing.  Rubber dam Rubber dam is available in pre-cut, commonly 150 mm  squares (Fig 1). In addition, and less common, rubber Rubber dam clamps dam is also available in a roll that can be cut to size. The rubber dam is usually anchored to the tooth with Scented rubber dam is manufactured by some com- a rubber dam clamp. There are over 50 different panies and this variety may be useful when treating designs of rubber dam clamps (Fig 2) available, from children, as they may dislike the smell of rubber. a variety of different manufacturers. Some are labelled Rubber dam comes in a variety of thicknesses – numerically and others alphabetically; there are even light, medium, heavy and extra heavy. Medium thick- colour-coded systems (Hygenic Fiesta, Coltène/ ness rubber dam is more suitable for endodontic treat- Whaledent, Cuyahoga Falls, OH, USA). Each clamp ment; it is thin enough to be stretched easily over the consists of a set of jaws connected by a bow. There are rubber dam clamp and tooth, yet thick enough not to also clamps with asymmetric and serrated jaws to pro- tear easily. vide better anchorage to the tooth (Fig 3). The Rubber dam is available in a variety of different selected rubber dam clamp should achieve four-point colours; the darker colours, for example, green, black jaw contact at the cervical region of the tooth. and purple, give better colour contrast and therefore The clamp that is chosen will be dependent on may help reduce eye strain. The choice of rubber dam the tooth to be isolated, the application technique thickness and colour is usually down to personal pref- employed and the operator’s preference. Rubber dam

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pyri Co gh a point below its greatest convexity.Not for Publication Retentive tclamps

retract the gingival tissues if the jaws engage bat, or y beyond, the level of the gingivalQ margin. Bland clamps

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t t r f e o tion with a more passive engagement.ssenc eGingival impingement is less likely with bland clamps but these clamps are more susceptible to dislodgement.

 Clamp forceps The rubber dam clamp forceps are used to transfer, place, adjust and remove the clamp. Rubber dam clamp forceps come in a variety of designs, and in some cases, may be specific to a particular clamp system. Popular forceps designs include the University of Washington/Stoke, Brewer (Ash, Dentsply, Wey- , Surrey, UK) (Fig 7) and Ivory (Heraeus Kulzer, South Bend, IN, USA) patterns. With some patterns, if the jaws are too retentive, it is difficult to disengage the forceps from the clamp. The jaws may be modi- fied to make them less retentive to allow for easier Fig 2 An assortment of rubber dam clamps. clamp disengagement.

clamps may be classified as winged or wingless (Fig 4).  Winged clamps allow rubber dam to be applied in one Rubber dam punch step and also result in more tissue retraction. Wingless A punch is used to make the necessary number of clamps are used with the two-step technique (see later). holes in the rubber dam, corresponding to the Most rubber dam clamps are made of stainless number of teeth to be isolated. In the case of steel but some are made from plated steel. There are endodontic treatment, usually single tooth isolation also non-metallic clamps made of plastic (SoftClamp, is used. There are two main types of rubber dam KerrHawe, Bioggio, Switzerland) on the market. punches. A single-hole punch (Ash, Dentsply) (Fig 8) Rubber dam clamps made of plated steel are more sus- will cut a standardised hole of 1.63 or 1.93 mm. ceptible to corrosion; they are affected by, for exam- Punches with a rotating table (e.g. Ainsworth, Ivory) ple, . More importantly, all clamps are for cutting different sized holes. The Ainsworth is are at risk of fracture during use. Although rubber dam a five-hole punch (Fig 9), which will make holes of clamps are very durable when appropriately handled diameters ranging from 0.5 to 2.5 mm. Rubber dam and treated, they do not last forever. Fracture of the punches capable of producing multiple sized holes rubber dam clamp in the mouth is probably the only are meant to allow the operator to vary the size of serious risk associated with rubber dam usage. The risk the hole according to the tooth to be isolated or the of inhaling or swallowing the fractured or dislodged clamp to be used. Larger holes may be chosen for clamp may be minimised if it can be retrieved. A gen- molar teeth or winged clamps. However, one of the erous length of or tape may be tied disadvantages is that unless the punch table is prop- through one of the clamp holes, wound around the erly aligned, the result will not be a cleanly produced bow of the clamp and then passed through and tied hole and the rubber dam will tear. to the opposite clamp hole (Fig 5) for this purpose. For single tooth isolation, a hole is punched Rubber dam clamps can also be classified as reten- approximately 2 cm from the centre of the rubber tive or bland (Fig 6). Retentive clamps provide four- dam, in a position corresponding to the position of point contact on the tooth. They engage the tooth at the tooth in the quadrant. If several teeth are to be

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Fig 3 Rubber dam clamps with serrated, asymmetric jaws: Fig 4 Winged (Ash A & K) and wingless (Ash PW) rubber Hygenic 12A (left) and 13A (right). dam clamps.

Fig 5 Floss tied onto the rubber dam clamp to aid retrieval in Fig 6 Bland (left) and retentive (right) rubber dam clamps. case of fracture or dislodgement.

Fig 7 University of Washington/Stoke (left) and Brewer Fig 8 The Ash single hole rubber dam punch. (right) rubber dam clamp forceps.

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Fig 9 The Ainsworth rubber dam punch. Fig 10 Metal (Young’s style) rubber dam frame.

isolated, it may be helpful, but not essential, to use a The contact points of the tooth/teeth isolated rubber dam stamp (e.g. Hygenic Dental Dam Stamp, should also be flossed again following placement Coltène/Whaledent), to facilitate correct positioning of rubber dam to ensure that the entire circumfer- of the holes. Irrespective of the type of rubber dam ence of the tooth is sealed. punch used, it is important to ensure that the cutting • As mentioned previously, a length of floss may be part of the punch is sufficiently sharp so that clean tied around the clamp as a safely measure, to aid holes are obtained consistently. retrieval, in the event the rubber dam clamp is dis- lodged or fractures26.  • The rubber dam clamp should be placed on the Rubber dam frame tooth to check that the jaws are in contact with the The final component is the rubber dam frame; this is tooth and the clamp is stable. The stability of the used to retract the edges of the rubber dam. The clamp may be confirmed by applying gentle pres- rubber dam is pulled over the frame and secured in sure with a forefinger to the bow of the clamp to place by the retaining spikes. Metal (Fig 10) and non- check if the clamp moves. metal rubber dam frames are available. Plastic rubber • A clean hole should be punched in the rubber dam; dam frames (Fig 11), some with rounded retaining there should be no irregular edges or tears, which spikes, are lighter and more comfortable for the may increase the probability of the rubber dam patient. A further advantage of a plastic frame is that tearing. some are not radiopaque, so may be left in place when taking radiographs. Foldable rubber dam frames (e.g.  Ash, Dentsply) with an articulated joint are also avail- One-step technique able to facilitate . A winged rubber dam clamp is selected and placed on the tooth to check for suitability; the clamp should be stable with good contact between the jaws and the  Techniques for rubber dam tooth. The clamp is then removed from the tooth. A placement correctly positioned hole is punched through the rubber dam, and the bow of the clamp is pushed There are a variety of techniques for rubber dam through the hole, leaving just the wings of the clamp placement. Irrespective of the technique used, certain under the rubber dam (Fig 12). The forceps are then preparatory steps must be taken to ensure safe and used to engage and spread open the jaws of the effective rubber dam placement: clamp. The whole assembly is transferred and posi- • Flossing the interproximal space between the teeth tioned on the tooth. The clamp is then released from beforehand makes rubber dam placement easier. the forceps and the stability of the clamp rechecked.

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pyri Co gh The rubber dam is then eased off the wings of the Not for Publicationt

clamp with a flat plastic instrument or excavator. A b y napkin (e.g. Hygenic Ora-Shield Dental Dam Napkins, Q

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t t r f e o tissue may be placed below the rubber dam to absorb ssence any saliva and improve patient comfort before placing the rubber dam frame. Finally, the frame is used to sta- bilise and retract the edges of the rubber dam. A modification of this technique involves the rubber dam, clamp and frame being all applied in one action27. This ‘all-in-one’ technique involves attaching the punched rubber dam to the frame, with the hole Fig 11 Two types of plastic rubber dam frames: Starlight Visi- positioned roughly in the centre. The clamp is then Frame (left) and Nygaard-Ostby (right) placed through the rubber dam as described above. Having engaged the forceps to the rubber dam clamp, the whole assembly (Fig 13) is positioned on the tooth. The rubber dam is then eased off the wings and, if nec- essary, the frame can be adjusted to ensure there is not too much tension on the rubber dam. Where appro- priate this technique is extremely expedient as it is truly a one-stage technique. However, this technique is not easy to use, particularly when isolating posterior teeth because of reduced access.

 Two-step technique Rubber dam clamp first method

A winged or wingless rubber dam clamp is selected Fig 12 A winged clamp in the rubber dam ready for place- and placed on the tooth to be isolated (Fig 14). The ment in the one-step technique. rubber dam is the stretched over the clamp (Fig 15) and dental floss is passed through the interproximal space (Fig 16). The frame is then used to hold the rubber dam.

Rubber dam first method

A modification of the two-step technique is where the rubber dam is applied first and then secured with a clamp. This technique may be useful for isolating ante- rior teeth where a butterfly-shaped rubber dam clamp or a wedging device, for example, a strand of stabilis- ing cord (Wedjets, Hygenic, Coltène/Whaledent) (Fig 17) is used. When isolating anterior teeth without the use of a clamp, the rubber dam is applied to the teeth to be isolated; each contact point is flossed to ensure that the rubber dam has passed below the contact Fig 13 The assembled rubber dam, clamp and frame for the point. The interproximal contact points may then be ‘all-in-one’ technique.

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Fig 14 The selected winged rubber dam clamp is placed on Fig 15 The rubber dam is the stretched over the clamp. the tooth.

Fig 16 Dental floss is passed through the interproximal space.

Fig 17 Wedjets stabilising cord.

secured with a strip of rubber dam or stabilising cord Alternatively, the clamps available may not permit a (Fig 18). Multiple teeth may be isolated with either of stable four-point contact around the tooth. In these the two techniques described above. A hole should be situations, one or both neighbouring teeth may be punched for each tooth to be isolated, and these holes used to help anchor the rubber dam. In the split dam should be approximately 6 mm apart and roughly technique, a rubber dam clamp is placed on a neigh- follow the curve of the dental arch to be isolated. bouring tooth. Two holes approximately 5 mm apart are punched through the rubber dam and linked up by  removing the rubber between the holes using scissors Difficult to isolate cases or by punching a third hole to connect the first two Split dam technique holes. The rubber dam is stretched over the rubber dam clamp/s and teeth; the rubber dam frame is then If a tooth is broken down, there may not be sufficient placed. When isolating anterior teeth, clamps may not sound tooth structure to retain a rubber dam clamp. be necessary with the split dam technique (Fig 19).

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Fig 18 Rubber dam secured only with Wedjets stabilising Fig 19a A split rubber dam. cord.

Fig 19b Oraseal used to seal deficiencies around the edges. Fig 20 Oraseal caulking agent.

If there are signs of leakage once the rubber dam Preparatory treatment is on the tooth, more likely with the split dam of a broken down tooth method, then caulking material (e.g. Oraseal, Ultra- dent, South Jordan, UT, USA) (Fig 20) or temporary Another option, if the tooth is too badly broken down filling materials (e.g. Cavit, 3M Espe, St. Paul, MN, and it is not possible to use rubber dam, is to consider USA) may be used to improve the seal. Oraseal is building a provisional restoration or placing a copper made from hectorite clay and is an easy to handle or orthodontic band on the tooth first. This is particu- caulking putty, which can be syringed directly around larly relevant if lack of structural integrity means the the tooth to seal any deficiencies (Fig 19b). However, tooth does not allow retention of an inter-appoint- an excessive amount should be avoided as the mate- ment temporary dressing without compromising the rial may contaminate the working field. Alternatively, coronal seal. light-cured materials (e.g. Kool-Dam, Pulpdent, A provisional restoration may be built using adhe- Watertown, MA, USA) are available. Cyanoacrylate sive materials such as composite resin or glass ionomer adhesive has also been suggested for sealing voids in cement. Alternatively, a customised and trimmed rubber dam28. copper or orthodontic band may be cemented on the tooth; this will then allow the effective placement of rubber dam.

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Fig 21 EndoRay II beam-aiming device for taking radi- ographs.

Fig 22 Non-latex, silicone rubber dam.

 Endodontic radiography remove the rubber dam frame. Sometimes, only a corner needs to be freed from the frame to enable Radiographs are needed at various junctures during placement of the film packet/sensor. A radiolucent , for example, working length plastic or foldable rubber dam frame may be used if determination. The presence of rubber dam may this technique is chosen. hinder the use of beam-aiming devices when taking radiographs using the paralleling technique. There are specially designed devices available on the market that  Latex allergy permit the taking of radiographs without having to remove the whole rubber dam assembly. The EndoRay Allergy to latex in rubber gloves and rubber dam II (Dentsply Rinn, Elgin, IL, USA) (Fig 21), for exam- appears to be an increasing problem in dentistry. The ple, is a film packet holder with a basket to accommo- prevalence of latex allergy in the general population date the bow of the rubber dam clamp and root canal may be as low as 1%29. However, the prevalence may instruments. be higher in certain groups, including atopic individu- The rubber dam should not be removed during als and health workers30. Studies have suggested that treatment but, if necessary, the frame may be the prevalence of latex allergy may be as high as 6% removed when taking radiographs. The rubber dam in dental staff31 and 9.7% in dental patients32. There- is then gathered to one side of the mouth. It is imper- fore, the possibility of allergic or delayed-type sensitiv- ative to prevent the ingress of saliva into the work- ity reactions to latex rubber dam must not be under- ing field by ensuring that the edges of the rubber estimated. Careful identification of patients who are dam remain outside the mouth during the taking of known or suspected to be allergic to latex or natural radiographs. In order to facilitate correct orientation rubber is imperative. The patient’s medical history of the rubber dam frame when it is put back, a hole should be checked to ensure the use of latex rubber may be punched in a chosen corner of the rubber dam is avoided. Non-latex rubber dam, for example dam. Flexi Dam (Roeko, Coltène-Whaledent) (Fig 22), may In some cases, it may be possible to take peri-oper- be of use for allergic or high-risk cases patients such as ative radiographs without the need to completely atopic individuals.

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opyrig The increased awareness of latex allergy has led to 11. Peters OA, Peters FC. Ethical principles and considerationsNot for PublicationC h in endodontic treatment. ENDO (Lond Engl) 2007;1: t

some institutions, like dental schools, phasing out the 101-108. b y use of latex-containing products. However, there is still 12. Cohen SC. and litigation: an AmericanQ per-

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spective. Int Dent J 1989;39:13-16. N

the danger that sensitisation to these alternative mate- i

13. Faculty of General Dental Practitioners (UK). Clinicaln o

t t r f rials may occur. This was highlighted in a recent case Standards in General Dental Practice: Self-Assessmentess o ce Manual and Standards. London: Faculty of General Dental en report, where a delayed Type IV allergic reaction Practitioners, Royal College of Surgeons of England 1991. occurred during endodontic treatment, with the use of 14. Nehammer C, Chong BS, Rattan R. Endodontics. Clinical latex-free gloves and a silicone rubber dam33. Risk 2004;10:45-48. 15. Möller AJ. Microbiological examination of root canals and periapical tissues of human teeth. Methodological studies. Odontol Tidskr 1966;74:1-380. 16. Fabricius L, Dahlén G, Ohman AE, Möller AJ. Predominant  Conclusion indigenous oral bacteria isolated from infected root canals after varied times of closure. Scand J Dent Res 1982;90: 134-144. The use of rubber dam is mandatory during endodon- 17. Jokinen MA, Kotilainen R, Poikkeus P, Poikkeus R, Sarkki L. tic treatment. Current guidelines have re-emphasised Clinical and radiographic study of pulpectomy and root canal therapy. Scand J Dent Res 1978;86:366-373. that rubber dam should be universally employed for all 18. Kerekes K, Tronstad L. Long-term results of endodontic endodontic treatment. Endodontic treatment carried treatment performed with a standardised technique. J Endod 1979;5:83-90. out without the use of rubber dam has implications 19. van Niewenhuysen JP, Aouar M, D’Hoore W. Retreatment both from a safety and medico-legal standpoint. or radiographic monitoring in endodontics. Int Endod J 1994;27:75-81. 20. de Lourdes Rodrigues Accorinte M, Reis A, Dourado Loguercio A, Cavalcanti de Araújo V, Muench A. Influence of rubber dam isolation on human pulp responses after cap-  Acknowledgment ping with calcium hydroxide and an adhesive system. Quintessence Int 2006;37:205-212. Keith Marshall, Consultant in , 21. Kim S, Baek S. The microscope and endodontics. Dent Clin North Am 2004;48:11-18. Limpsfield, Surrey, for initial advice during the prepa- 22. Cochran MA, Miller CH, Sheldrake MA. The efficacy of the ration of this manuscript. rubber dam as a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119: 141-144. 23. Samaranayake LP, Reid J, Evans D. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamina-  References tion. ASDC J Dent Child 1989;56:442-444. 24. El-Din AZM, El-Hady Ghoname NA. Efficacy of rubber dam 1. Winkler R. Sanford Christie Barnum - inventor of the rub- isolation as an infection control procedure in paediatric den- ber dam. Quintessenz 1991;42:483-486. tistry. East Mediterr Health J 1997;3:530-539. 2. European Society of Endodontology. Quality guidelines for 25. Stewardson DA, McHugh ES. Patients’ attitudes to rubber endodontic treatment. Int Endod J 2006;39:921-930. dam. Int Endod J 2002;35:812-819. 3. Whitworth JM, Seccombe GV, Shoker K, Steele JG. Use of 26. Zinelis S, Margelos J. In vivo fracture of a new rubber-dam rubber dam and irrigant selection in UK general dental clamp. Int Endod J 2002;35:720-723. practice. Int Endod J 2000;33:435-441. 27. Reuter JE. The isolation of teeth and the protection of the 4. Whitten BH, Gardiner DL, Jeansonne BG, Lemon RR. patient during endodontic treatment. Int Endod J 1983; Current trends in endodontic treatment: report of a nation- 16:173-181. al survey. J Am Dent Assoc 1996;127:1333-1341. 28. Roahen JO, Lento CA. Using cyanoacrylate to facilitate rub- 5. Koshy S, Chandler NP. Use of rubber dam and its associa- ber dam isolation of teeth. J Endod 1992;18:517-519. tion with other endodontic procedures in New Zealand. N 29. Sussman GL, Beezhold DH. Allergy to latex rubber. Ann Z Dent J 2002;98:12-16. Intern Med 1995;122:43-46. 6. Slaus G, Bottenberg P. A survey of endodontic practice 30. Hamann CP, Turjanmaa K, Rietschel R, Siew C, Owensby D, amongst Flemish dentists. Int Endod J 2002;35:759-767. Gruninger SE, Sullivan KM. Natural rubber latex hypersen- 7. Lynch CD, McConnell RJ. Attitudes and use of rubber dam sitivity: incidence and prevalence of type 1 allergy in the by Irish general dental practitioners. Int Endod J dental professional. J Am Dent Assoc 1998;129:43-54. 2007;40:427-432. 31. Spina AM, Levine HJ. Latex allergy: a review for the dental 8. Kaufman AY. Accidental ingestion of an endodontic instru- professional. Oral Surg Oral Med Oral Pathol Oral Radiol ment. Quintessence Int Dent Dig 1978;9:83-84. Endod 1999;87:5-11. 9. Susini G, Pommel L, Camps J. Accidental ingestion and 32. Burke FJT. Wilson MA, McCord JF. Allergy to latex gloves in aspiration of root canal instruments and other dental for- clinical practice: case reports. Quintessence Int 1995;26: eign bodies in a French population. Int Endod J 2007;40: 859-863. 585-589. 33. Sunay H, Tanalp J, Güler N, Bayirli G. Delayed type allergic 10. Israel HA, Leban SG. Aspiration of an endodontic instru- reaction following the use of non-latex rubber dam during ment. J Endod 1984;10:452-454. endodontic treatment. Int Endod J 2006;39:576-580.

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