As a dental student, especially here in the UK, there is a great emphasis on placing a rubber (dental) dam when carrying out restorative procedures. So this post is a brief run-through of some of the basics of a rubber dam.

What is it?

Rubber dam refers to a sheet of material that is placed in order to isolate teeth/a tooth. Rubber dams are very useful when carrying out restorative dentistry and, especially, for endodontic treatment.

Advantages

  • Moisture isolation – when using materials like composite, which is hydrophobic, moisture isolation is crucial.
  • Improved vision – by isolating the teeth, it is easier to see the tooth you are working on and to carry out the treatment
  • Prevents movement of bacteria
    • Prevents bacteria from going from the decay to the rest of the mouth
    • Prevents any bacteria accessing the pulp if the pulp is accidentally exposed, therefore hopefully improving the prognosis of the tooth
  • Airway protection
  • Reduce contamination via saliva, blood and other debris
  • Reduce exposure to harmful substances

Disadvantages

  • Reduces patient communication – with the frame and rubber dam on, the patient is not able to communicate easily
  • Patient discomfort – patients often find it uncomfortable to wear a rubber dam
  • Placement – placement can sometimes be difficult (however with practice it is often easier to place)
  • With single tooth isolation, it may be difficult to match the morphology and long axis of surrounding teeth

How to place a Rubber Dam *

The first thing to note is the equipment and instruments you need:

  • Rubber dam (typically LATEX FREE)
  • Rubber dam frame
  • Rubber dam punch
  • Clamp – molar/premolar/anterior and winged/wingless
  • Forceps
  • Floss
  • Wedjets
  • Lubricant
  • Scissors
  • Gauze
  • Flat plastic (or alternative dental instrument)

Placement with a winged and wingless clamp varies slightly. I will go through placement of a wingless clamp first and later highlight differences from a winged clamp. This is the procedure I use to place a rubber dam.

  1. Stretch the rubber dam on to its frame, ensuring it is relatively taut. A useful tip is to stretch on to the corners first and secure these before attaching the other points.
  2. With the patient in the chair, roughly place the rubber dam over where it is to be located and then push down on to the teeth you wish to isolate. This will create saliva marks on the dam and will give a good indication of where to punch the holes.
  3. Use the punch to punch the holes at the marked locations. The holes should be at least 5mm apart and ensure the punch goes all the way through (otherwise there is a high probability the dam will tear).
  4. Use floss between the teeth before you place the dam, so that it will be easier to place it
  5. Ligate the clamp with the floss – this will protect the patient in case the clamp breaks.
  6. Use the forceps to pick up the clamp and keep this to one side (at hands reach) ready for placement.
  7. Use lubricant on the rubber dam around the holes – this is something that I tend not to do now, but initially, it was quite useful.
  8. Now it’s time to place the dam. Have the patient open wide and ensure the rubber dam is pushed and seated around the most distal tooth you want to isolate.
  9. While holding the dam in place, get the forceps with the loaded clamp and secure it around the tooth. The clamp should have even 4 point contact and should not be trapping the rubber dam (the dam should be below the clamp). The bridge of the clamp should be distally placed. It is often easiest to place the clamp buccally and then bring it over lingually/palatally.
  10. You can now let go of the dam and it should be pinned down by the clamp
  11. Gently manipulate the dam through the contact points. This may involve twisting the dam to push the edge through first or by using floss to gently coax the dam through.
  12. Once all the contacts are through, use a wedjet or a wedge to secure the dam and the more anterior location.
  13. Using the flat plastic, EVERT the dam so the there are no open edges around the teeth – allowing proper isolation.
  14. Ensure the patient is comfortable with the dam placement. If need be, use scissors to cut the dam so that they can breathe properly and use gauze on any corners of the frame that may be irritating the patient.
Demonstration on how to evert rubber dam

Demonstration on how to evert rubber dam

The below picture demonstrates rubber dam placement. There is a molar clamp placed on the most distal tooth and it is ligated with floss, with the bridge placed distally. The dam has been passed through each contact point and secured anteriorly using a wedjet. The rubber dam has also been everted at the gingival margin of each tooth.

Rubber Dam Placement

Rubber Dam Placement

When placing a winged clamp, the clamp is pushed through the dam hole before actual placement in the mouth (a). Forceps are then attached to the clamp and this, along with the not attached dam, is placed directly on to the most distal tooth to be isolated (b). A flat plastic must then be used to free the wing of the clamp, so that as before the rubber dam lies below the clamp.

Placement of a winged clamp

Placement of a winged clamp

Removal of the dam

  1. Remove any wedges or wedjets that have been placed
  2. Use forceps to gently remove any clamp
  3. Gently pull the rubber dam out of each contact and remove from the patients face.

As I have mentioned, there are many variations that may exist.

  • Sometimes it is not appropriate to place a clamp and so isolation must be carried out using wedjets to hold down the dam
  • For endodontic treatment, single tooth isolation is best to carry out
  • Quadrant isolation is best when carrying out restorations as you are able to see the tooth in relation to other teeth.
  • Sometimes a rubber dam isn’t appropriate to place at all!

*There are various ways to place a rubber dam. These are the ways that I have learnt – I encourage you to research alternative methods.

References and Recommended Reading

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About the author

Prateek Biyani

BDS (Hons.) MFDS RCPS (Glasg.)
Currently working as a Dental Core Trainee in OMFS

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