The purpose of this study was to evaluate the general attitude of senior dental students towards rubber dam use, specifically focusing on endodontic practices prior to starting to serve community. Questionnaires were distributed to senior year students of a private school and a state school in Istanbul. Questions were asked about areas where the students used rubber dam, its advantages and difficulties, and whether they agreed or disagreed with some aspects of the rubber dam. The private school students rated isolation whereas those of the state school selected prevention of aspiration which the top advantage rubber dam provides. Students of the state school agreed with the opinion that isolation cannot be achieved without rubber dam and it extended the procedure with a significantly higher ratio compared to the private school. Within the limitations of the present study, it can be concluded that the perceptions of dental students on rubber dam needs to be improved and strategies should be developed so that this valuable adjunct will comprise one of the indispensable elements of dental care.
Rubber dam is universally acknowledged as a mandatory adjunct particularly during endodontic treatment. Many authorities advocate its usage and encourage practitioners to adopt it in routine practice, stressing that it is an indispensable element of contemporary health service [
Endodontic treatment and operative dentistry are two major areas where rubber dam is used. Specifically, endodontic textbooks and specialty organizations endorse rubber dam use during endodontic procedures, indicating it as a standard of care [
With all these advantages as well as legal aspects favoring rubber dam, there still seem to be reluctance and some resistance by practitioners to use it in routine care. This issue has been drawing attention by authors who determined a significant underuse in general practice [
Contemporary dental education’s primary mission is to produce dentists who fulfill all competencies expected from qualified healthcare personnel. This mission can be accomplished by creating a strong foundation by the delivery of information and implementing basic aspects of dental care related with safety and high quality treatment. Rubber dam usage definitely falls into this latter category and the dental student is expected to have acquired the skills of rubber dam placement and adopted the philosophy of safe and high quality service prior to working independently.
It is evident that dental schools put special emphasis on rubber dam application ever since the students’ first encounter with patients. On the other hand, what really matters is whether they will strongly adopt using rubber dam after graduation. Since surveys among dental students are helpful tools to draw the outline of future dental workforce, investigating dental students’ perceptions and attitudes towards rubber dam use will contribute to underlining the inherent problems related with implementation of this worldwide acknowledged methodology. Depending on the results, strategies can be developed to enhance the way 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 a group of Turkish senior dental students enrolled in 2 different schools towards rubber dam application, specifically focusing on endodontic treatment, evaluate the problems they encounter related with this tool, and gather information about their prospective presumptions about using it in the future.
Anonymous survey questionnaires were distributed to senior students enrolled in two prominent dental schools in Istanbul, one state (Istanbul University Faculty of Dentistry) school and one private (Yeditepe University, Faculty of Dentistry) school. During the preparation of the questionnaire, the study by Mala et al
Statistical analysis was performed using NCSS (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
All the respondents returned the forms with an overall response rate of 100%. Altogether, eighty-four (57.1%) were females whereas 63 (42.9%) were males. There were no significant differences between males and females in terms of rubber dam selection (
In general, 57.1% of the students did not ask patients about latex allergy. The majority did not use rubber dam for pedodontics (89.1%) and restorative procedures (82.3% and 81%, resp.). Most students (72.1%) applied rubber dam after determining root canal accesses during endodontic treatment. One hundred and nine (74.1%) of the students believed they received satisfactory education regarding rubber dam usage. Furthermore, a major proportion (75.5%) never used rubber dam while working on teeth with extensive tissue loss. The remaining students indicated that they perform a restoration and then apply the rubber dam in case they are dealing with severely damaged teeth.
In terms of the greatest advantage offered by rubber dam, provision of isolation and an aseptic field was the top ranked benefit. As for the most difficult stage of rubber dam application, clamp placement seemed to be the predominant answer (66.7%).
Most students agreed with the opinion that treatments performed using the rubber dam were more successful than those where it was not used (71.4%). Most students also shared the opinion that adequate isolation cannot be achieved without rubber dam (66%). On the other hand, students rather disagreed with the opinion that rubber dam use would ease access to root canals (60.50%). The majority of students thought rubber dam usage posed difficulty in taking radiographs (88.4%). Most students also shared the opinion that application of the dam was difficult and it consisted of too many components (79.6% and 76.9%, resp.). The majority also thought that rubber dam use would increase the duration of the procedure (87.8%). The mandible was ranked as the jaw where rubber dam placement was more necessary by most students (92.5%). The students generally thought that assistance was not required for the placement of the dam. A high proportion of the respondents agreed that patients disliked the rubber dam (87.8%). A higher proportion (62.6%) indicated that they use the rubber dam at the students clinic because they were obliged to, compared to the 37.4% who really believed in its usefulness. 25.2% of the students declared they would never use a rubber dam after graduation whereas 25.2% indicated that they would use it when necessary. The majority of the remaining students (49%) indicated that they would use the rubber dam only for endodontics. When the students who would not use rubber dam were questioned about the reasons, spending extra time for its placement, the belief that it is not necessary, difficulty in application, and patients’ dislike were declared as factors for such a decision.
Information obtained when the two schools were analyzed individually is summarized in Tables
Answers given by students to questions regarding utilization of rubber dam.
School A | School B | Significance | |||
---|---|---|---|---|---|
Gender | |||||
Male | 55 | 55.00% | 29 | 61.70% |
|
Female | 45 | 45.00% | 18 | 38.30% |
|
Do you ask your patients whether they have latex allergy prior to rubber dam use? | |||||
Yes | 56 | 56.00% | 7 | 14.90% |
|
No | 44 | 44.00% | 40 | 85.10% |
|
Do you use rubber dam in paediatric patients? | |||||
Yes | 16 | 16.00% | 0 | 0.00% |
|
No | 84 | 84.00% | 47 | 100.00% |
|
Do you use rubber dam during amalgam restorations? | |||||
Never | 79 | 79.00% | 42 | 89.40% | |
Rarely | 16 | 16.00% | 4 | 8.50% | |
Sometimes | 4 | 4.00% | 1 | 2.10% |
|
Always | 1 | 1.00% | 0 | 0.00% |
|
Do you use rubber dam during composite restorations? | |||||
Never | 75 | 75.00% | 44 | 93.60% | |
Rarely | 18 | 18.00% | 2 | 4.30% |
|
Sometimes | 7 | 7.00% | 1 | 2.10% |
|
During which stage of endodontic treatment do you use rubber dam? | |||||
Following anesthesia | 4 | 4.00% | 2 | 4.30% | |
During access cavity preparation | 1 | 1.00% | 7 | 14.90% | |
Following identification of root canal orifices | 72 | 72.00% | 34 | 72.30% | |
During root canal shaping | 22 | 22.00% | 3 | 6.40% |
|
During root canal filling | 1 | 1.00% | 1 | 2.10% |
|
Do you think you have been given adequate and satisfactory education regarding rubber dam? | |||||
Yes | 68 | 68.00% | 41 | 87.20% |
|
No | 32 | 32.00% | 6 | 12.80% |
|
During endodontic treatment of teeth with extensive tissue loss | |||||
I don’t use rubber dam | 74 | 74.00% | 37 | 78.70% |
|
I perform a restoration so that I can place the rubber dam | 26 | 26.00% | 10 | 21.30% |
|
Opinions of students about the usage of rubber dam.
What in your opinion is the greatest advantage offered by the rubber dam? | School A | School B | Significance | ||
---|---|---|---|---|---|
Provision of isolation and an aseptic working area | 44 | 44.00% | 32 | 68.10% | |
Prevention of swallowing or aspirating instruments | 51 | 51.00% | 13 | 27.70% |
|
Prevention of ingestion of irrigants | 5 | 5.00% | 2 | 4.30% |
|
Opinions of students about the most difficult aspect regarding rubber dam usage.
What is the major factor that makes rubber dam application a difficult procedure? | School A | School B | Significance | ||
---|---|---|---|---|---|
Selection of the clamp and its adaptation | 73 | 73.00% | 25 | 53.20% | |
Placement of the rubber dam | 25 | 25.00% | 22 | 46.80% |
|
Placement of the frame | 2 | 2.00% | 0 | 0.00% |
|
Agreement or disagreement of students regarding various aspects of rubber dam.
School A | School B | Significance | |||
---|---|---|---|---|---|
Rubber dam eases the restoration stage | |||||
I agree | 57 | 57.00% | 27 | 57.40% |
|
I disagree | 43 | 43.00% | 20 | 42.60% |
|
Treatments performed using the rubber dam are more successful than those performed without using it | |||||
I agree | 71 | 71.00% | 34 | 72.30% |
|
I disagree | 29 | 29.00% | 13 | 27.70% |
|
An adequate isolation cannot be achieved in case rubber dam is not used | |||||
I agree | 73 | 73.00% | 24 | 51.10% |
|
I disagree | 27 | 27.00% | 23 | 48.90% |
|
Rubber dam eases access to root canals | |||||
I agree | 41 | 41.00% | 17 | 36.20% |
|
I disagree | 59 | 59.00% | 30 | 63.80% |
|
Rubber dam makes radiograph taking procedure difficult | |||||
I agree | 87 | 87.00% | 43 | 91.50% |
|
I disagree | 13 | 13.00% | 4 | 8.50% |
|
Rubber dam is difficult to apply | |||||
I agree | 81 | 81.00% | 36 | 76.60% |
|
I disagree | 19 | 19.00% | 11 | 23.40% |
|
Rubber dam consists of too many components | |||||
I agree | 86 | 86.00% | 27 | 57.40% |
|
I disagree | 14 | 14.00% | 20 | 42.60% |
|
Rubber dam shortens/extends treatment period | |||||
Extends | 92 | 92.00% | 37 | 78.70% |
|
Shortens | 8 | 8.00% | 10 | 21.30% |
|
Rubber dam is more necessary while working in the | |||||
Mandible | 90 | 90.00% | 46 | 97.90% |
|
Maxilla | 10 | 10.00% | 1 | 2.10% |
|
Assistance is necessary during rubber dam application | |||||
I agree | 33 | 33.00% | 20 | 42.60% |
|
I disagree | 67 | 67.00% | 27 | 57.40% |
|
Patients do not like the rubber dam | |||||
I agree | 87 | 87.00% | 42 | 89.40% |
|
I disagree | 13 | 13.00% | 5 | 10.60% |
|
Opinion of students about the present and future usage of rubber dam.
School A | School B | Significance | |||
---|---|---|---|---|---|
I use the rubber dam in the clinic, because | |||||
I strongly believe that it is a helpful tool | 38 | 38.00% | 17 | 36.20% |
|
I only use it because I am obliged to | 62 | 62.00% | 30 | 63.80% |
|
Following graduation | |||||
I intend to use the rubber dam during all procedures indicated | 25 | 25.00% | 12 | 25.50% | |
I intend to use it only during restorative procedures | 1 | 1.00% | 0 | 0.00% | |
I intend to use it only during root canal treatment | 45 | 45.00% | 27 | 57.40% |
|
I will never use it | 29 | 29.00% | 8 | 17.00% |
|
Major reasons for not planning to use the rubber dam in future practice.
School A | School B | Significance | |||
---|---|---|---|---|---|
I do not believe that it is a helpful adjunct | 6 | 19.40% | 7 | 50.00% | |
I experience difficulty during application | 8 | 25.80% | 4 | 28.60% | |
I believe that it consumes time | 14 | 45.20% | 3 | 21.40% |
|
I believe that patients do not like it | 3 | 9.70% | 0 | 0.00% |
|
The selection of advantage rating of rubber dam yielded differences when the two schools were compared. The state school students rated isolating effect as the top advantage lower than the private school with a statistical difference. On the other hand, the students of the state school selected the prevention of ingestion and aspiration as the top advantage with a significantly higher ratio (
The students of the state school agreed with the suggestion that adequate isolation cannot be achieved without rubber dam with a higher ratio and the difference was statistically significant (
The students of the state school agreed that rubber dam consisted of too many components with a higher ratio compared to the private school and the difference was statistically significant (
The students of the state school agreed that usage of rubber dam extends the treatment period with a higher ratio compared to the private school, with a statistically significant difference (
No statistically significant differences were determined between the two schools in terms of the other evaluated parameters, including the intention of rubber dam usage in the future and reasons in case the question was responded negatively (
The students surveyed in the present study were not asked whether they use rubber dam during endodontic treatment, because it is already known that rubber dam use for endodontics is mandatory in both schools. Hill and Rubel [
The majority of dental schools teach their students that the use of rubber dam is mandatory for procedures such as endodontic therapy and adhesive dentistry [
Selection of the clamp and adaptation were regarded as the most difficult steps of rubber dam application by most students. This may be in part due to the fact that students may not have supplied their armamentarium with adequate numbers and types of clamps, suitable for each specific case. Furthermore, extensive loss of tooth structure may pose difficulty in adapting a regular clamp. It was interesting that the majority of students did not prefer to use the dam in severely damaged teeth. This brings into mind the reality that clinic instructors are more flexible in rubber dam application in case students are confronted with teeth with extensive tissue loss.
Another disadvantage of rubber dam has been reported as the difficulty of mounting radiographs in the proper position with the dam in place. On the other hand, removal of the dam during radiography cannot be accepted as this step is specifically performed with an instrument within the root canal to determine the working length. During this step, the patient is generally left alone at the radiography site and there is no possibility of intervention in case hazards occur. Therefore, radiographs should definitely be taken with the rubber dam placed in position.
Whitworth et al
There is a general belief supported by dental practitioners that patients dislike rubber dam usage. However, this statement has been contradicted by studies concluding that rubber dam is an accepted element of dental care by patients [
It is also noteworthy to mention that dental students may display more idealistic views about contemporary methodologies upon graduation. With the progression of years of dental service, there might be some alterations in their views. This was further emphasized with anticipation by Mala et al
Hill and Rubel [
In general, presence of latex allergy was not asked to the patients by almost half of the students, higher than the ratio reported by Mala et al. [
It was rather disappointing to determine that a proportion of students are not planning to use the rubber dam in the future. Percentages of students with this opinion were higher than those reported by Mala et al
Within the limitations of this study, it can be concluded that although students at the final year of education cannot be criticized in terms of awareness of rubber dam’s advantages, there is some doubt about future integration of this tool in routine practice. This result is in line with other studies which indicate a general reluctance of using rubber dam amongst dental practitioners and can be regarded as a universal issue that requires further attention.
The authors declare that there is no conflict of interests regarding the publication of this paper.