More on rubber dam use

More on rubber dam use

COMMENTARIES RUBBER DAM USE In Table 1 of the January JADA article titled, “Techniques and Materials Used by General Dentists During Endodontic Trea...

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COMMENTARIES

RUBBER DAM USE

In Table 1 of the January JADA article titled, “Techniques and Materials Used by General Dentists During Endodontic Treatment Procedures: Findings From the National Dental Practice-Based Research Network” (Eleazer PD, Gregg GH, Funkhouser E, et al. JADA. 2016;147 [1]:19-27), the statistics on rubber dam use clearly show that 53% of general dentists do not always use rubber dams. Yet, this was not really discussed in the Discussion section. I graduated from the University of Florida in 1985. Dr. Frank Vertucci, the endodontics director at the time, clearly stated that performing root canal therapy without a rubber dam was malpractice. You cannot disinfect a canal with saliva in it. You cannot prevent sodium hypochlorite from entering the patient’s mouth, nor can you protect the patient from dropped files. After I graduated, I went to Parris Island Marine Recruit Depot. We had over 40 dentists and saw over 25,000 recruits per year. With these patients going all over the world after training (many areas and embassies without ready access to dental care), their Class I dental health was our primary duty. If a tooth could not be isolated by a rubber dam (unable to flap, crown lengthen, and so forth), it was deemed nonrestorable and extracted. Why? Because teeth treated without a rubber dam are doomed to failure sooner than those treated using a rubber dam. This policy persisted throughout my naval career, both as a general dentist for 7 years and then as a board-certified periodontist and assistant clinical director. In private practice, when I discussed this issue with endodontists, they all agreed. Rarely did they perform anything but the most urgent treatment without a rubber dam. Most endodontists referred patients for crown lengthening or performed flaps for access if deemed appropriate. Some would even clamp

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the gingiva to isolate as much as possible (not the desired periodontal procedure, however). My colleagues were appalled at the lack of regular usage of rubber dams by general dentists. The number of retreat cases was much higher from referrers who did not use rubber dams routinely. Whenever I did a combined procedure involving root canal therapy, I would perform the flap and crown lengthening first, achieve hemostasis, isolate with a rubber dam, complete the root canal treatment, and then finish closing the surgical site. Rubber dams are not hard to master. Please isolate whenever possible. Although it is not always possible during most surgical procedures, throat packs and other techniques protect as much as possible. The same should be true for the inside of a tooth. All of your restorative work will be better when isolation is possible. David K. Oyster, DMD, MS, CDR, DC, USN (ret) Diplomate American Board of Periodontology and Past Fellow Academy of General Dentistry Mount Pleasant, SC

http://dx.doi.org/10.1016/j.adaj.2016.03.009 Copyright ª 2016 American Dental Association. All rights reserved.

MORE ON RUBBER DAM USE

In their January JADA article, “Techniques and Materials Used by General Dentists During Endodontic Treatment Procedures: Findings From The National Dental Practice-Based Research Network” (Eleazer PD, Gregg GH, Funkhouser E, et al. JADA. 2016;147 [1]:19-27), Dr. Eleazer and colleagues reviewed data reported by general dentists (GDs) to The National Dental Practice-Based Research Network. Based on their analysis of the data, the authors concluded that, “Most GDs are using appropriate techniques and have adopted newer technologies. We found that only a small

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percentage of GDs are not using appropriate techniques.” As a former dental educator, I was pleased by their suggestion that endodontic education, either in dental school or through continuing education, is associated with a decreased use of the inappropriate techniques listed. However, as an endodontist, I was dismayed by the data shown in Table 1 that only 47% of responding GDs routinely used a dental dam during endodontic procedures. From a safety standpoint, a dental dam reduces the risk of ingestion or aspiration of endodontic instruments during treatment,1,2 and just as importantly, from a biological standpoint, it provides a more aseptic working environment that helps prevent contamination of the canal spaces with oral bacteria. In a 2014 issue of Endodontics: Colleagues for Excellence, the American Association of Endodontists reiterated its position that “tooth isolation using the dental dam is . integral and essential for any nonsurgical endodontic treatment,” and practicing dentists who do not use a dental dam for all endodontic treatments are not practicing to the standard of care.3 Although it may be gratifying to know that most GDs are using “appropriate techniques” for instrumentation, irrigation, and obturation of root canals, we endodontic educators should refrain from patting ourselves on the back until the dental dam is recognized as an essential “appropriate technique” by all dentists performing nonsurgical endodontic procedures. Thomas M. Buttke, DDS, PhD, FICD Endodontist Private Practice Nags Head, NC and Adjunct Associate Professor School of Dentistry University of North Carolina Chapel Hill, NC

http://dx.doi.org/10.1016/j.adaj.2016.03.010 Copyright ª 2016 American Dental Association. All rights reserved.

COMMENTARIES

1. Bondarde P, Naik A, Patil S, Shah PH. Accidental ingestion and uneventful retrieval of an endodontic file in a 4 year old child: a case report. J Int Oral Health. 2015;7(suppl 2):74-76. 2. Jain V, Dubey A, Kumar J, Srivastava S, Tripathy M. Accidental ingestion of a hypodermic needle during root canal treatment: a case report. Gen Dent. 2015;63(5):30-32. 3. American Association of Endodontists and the AAE Foundation. Dental dam. Endodontics: Colleagues for Excellence. Available at: http:// www.aae.org/uploadedfiles/publications_and_ research/newsletters/endodontics_colleagues_ for_excellence_newsletter/ecfefall2014 standardofpractice.pdf. Published Fall 2013. Accessed March 9, 2016.

Authors’ response: We appreciate the comments made by Drs. Oyster and Buttke. We refer them to 2 articles from The National Dental Practice-Based Research Network published in 2015.1,2 Reasons for rubber dam use include compliance to the standard of care, patient safety issues such as avoiding aspiration of instruments and introduction of disinfectants into the oral cavity, as well as operator safety issues such as reducing potentially infected aerosols. In addition, there is the issue of efficacy of treatment. A 2013 article by Goldfein and colleagues3 reported on significantly poorer outcomes with post placement without rubber dams. One of the major principles of endodontic therapy is to reduce intracanal bacteria. Rubber dam

isolation facilitates this better than alternative methods. Allowing salivary contamination when placing a post seems inappropriate. The American Association of Endodontists’ position statement notes that the dental dam is the standard of care, and that it is the only method to preclude ingress of oral bacteria, provide a clean operating field, and prevent canal instruments, irrigants, and other dental materials from harming patients.4 We thank these writers for their interest and encourage all JADA readers to use rubber dams for all orthograde endodontic procedures as well as for post placement. Paul D. Eleazer, DDS, MS Professor and Chair Department of Endodontics Gregg H. Gilbert, DDS, MBA Professor and Chair Department of Clinical and Community Sciences Ellen Funkhouser, DrPH Associate Professor Division of Preventive Medicine Department of Medicine School of Dentistry University of Alabama at Birmingham Birmingham, AL Gregg J. Reams, DMD Endodontist Permanente Dental Associates Portland, OR

Alan S. Law, DDS, PhD Private Practitioner Lake Elmo, MN Paul L. Benjamin, DMD Clinical Associate Professor Department of Community Dentistry and Behavioral Science University of Florida Gainesville, FL

http://dx.doi.org/10.1016/j.adaj.2016.03.011 Copyright ª 2016 American Dental Association. All rights reserved.

1. Lawson NC, Gilbert GH, Funkhouser E, Eleazer PD, Benjamin PL, Worley DC; National Dental PBRN Collaborative Group. General dentists’ use of isolation techniques during root canal treatment: from the National Dental Practice-based Research Network. National Dental PBRN Collaborative Group. J Endod. 2015;41(8):1219-1225. 2. Gilbert GH, Riley JL, Eleazer PD, Benjamin PL, Funkhouser E; National Dental PBRN Collaborative Group. Discordance between presumed standard of care and actual clinical practice: the example of rubber dam use during root canal treatment in the National Dental Practice-Based Research Network. BMJ Open. 2015;5(12): e009779. 3. Goldfein J, Speirs C, Finkelman M, Amato R. Rubber dam use during post placement influences the success of root canaltreated teeth. J Endod. 2013;39(12):1481-1484. 4. AAE Position Statement. Dental dams. Chicago, IL: American Association of Endodontics, 2010. Available at: https://www.aae. org/uploadedfiles/publications_and_research/ guidelines_and_position_statements/ dentaldamstatement.pdf. Accessed March 15, 2016.

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