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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 97-101

Rubber dam isolation in clinical adhesive dentistry: The prevalence and assessment of associated radiolucencies

1 Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, Abha, Saudi Arabia
2 Intern, College of Dentistry, King Khalid University, Abha, Saudi Arabia

Date of Submission16-Dec-2019
Date of Acceptance31-Dec-2019
Date of Web Publication12-Feb-2020

Correspondence Address:
Shafait Ullah Khateeb
Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_81_19

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Aim: This study aims to identify the prevalence of the use of rubber dam (RD) for isolation during resin composite restorations in a clinical scenario. It also aims to evaluate restorations done with and without RD for radiolucencies present postoperatively. Methods: A total of 50 voluntarily participating dentists were asked to do posterior composite restorations for primary caries lesions affecting the occluso-proximal surfaces. The isolation protocols followed were noted, and postoperative bitewing radiographs were evaluated independently by two investigators. The presence of radiolucencies between the tooth-restorative interface and in the body of the restoration was assessed and statistically evaluated using Chi-square test at a significance level of P≤ 0.05. Results: The results showed that 71.5% of the restorations were not done under RD isolation. There was a statistically significant difference in the number of radiolucent areas seen in restorations done with and without RD. Conclusion: This study shows a low percentage of clinicians use RD for isolation during composite restorations. It also indicates that radiolucent areas are more often associated with restorations done without RD isolation. This study stresses that there is a need to change the clinician's convictions about isolation protocols followed during composite restorations.

Keywords: Clinical study, composite restorations, radiolucent defects, rubber dam isolation

How to cite this article:
Alqarni MA, Mathew VB, A. Alsalhi IY, F. Alasmari AS, Almojathel Alqisi AY, H. Asiri RA, Khateeb SU. Rubber dam isolation in clinical adhesive dentistry: The prevalence and assessment of associated radiolucencies. J Dent Res Rev 2019;6:97-101

How to cite this URL:
Alqarni MA, Mathew VB, A. Alsalhi IY, F. Alasmari AS, Almojathel Alqisi AY, H. Asiri RA, Khateeb SU. Rubber dam isolation in clinical adhesive dentistry: The prevalence and assessment of associated radiolucencies. J Dent Res Rev [serial online] 2019 [cited 2023 Jan 30];6:97-101. Available from: https://www.jdrr.org/text.asp?2019/6/4/97/278223

  Introduction Top

The success of restorative procedures in adhesive dentistry is based in part on the isolation procedures that are followed by the dentist. The simplification of the steps required to bond resin composite restorations has improved technique sensitivity and quality of restorations. However, there are still no adhesive materials or methods that can be effective in conditions where isolation is compromised. The changes that have come to restorative dentistry make it seem that paradigm shifts in concepts of caries management are now the reality of clinical dental practice. The conventional era that emphasized the use of silver amalgam has steadily given way to a more esthetic and plastic phase of restorative practice. The developments in adhesive technologies are the key which helped realize this shift in management. Tooth preparation design and extension for prevention are now considered superfluous, and preservation of tooth structure and dependence on adhesion rather than mechanical interlocking for retention is widely accepted and practiced. Adhesion relies on two key factors to succeed clinically. Clean surface to bond and isolation from oral contaminants. Isolation is often the area that compromises the efficient completion of restorations.[1] It is never possible to achieve the ideal properties of restorative materials and proper bonding of restorative materials to the tooth structure in the presence of saliva. The effective control of moisture and microbes during a restorative dental procedure is a determining factor for the successful restoration.

There are several methods of isolation that are followed by routine restorative procedures. The ideal method recommended for effective isolation is the use of rubber dam (RD). It is globally stressed that isolation with the application of RD is necessary for a successful composite resin restoration.[2] The alternative isolation methods are categorically inferior in the amount of isolation provided. The concept of using RD to achieve this high level of isolation is stressed during the stages of dental education provided globally.[3] However, the use of RD in daily clinical practice seems to be a reluctant habit that clinicians need to develop. The general consensus among dental students is that RD use is an integral part of restorative and endodontic procedures. This is a key to the success of treatment. Few are the studies on the actual use and outcomes due to lack of isolation. Studies assessing the success of composite restorations emphasize the importance of RD to improve the longevity of the restoration.[4],[5] During endodontic treatment, RD is universally acknowledged as a mandatory adjunct, and many authors have advocated its usage in routine practice including the operative dentistry field.[2]

The past estimates on the use of RD by dental clinicians show a low prevalence of RD usage for restorative procedures. The frequency of the RD usage during endodontic treatment had been higher (71.11%) compared to dental restorations (35.55%).[6] Majority 71% use RD when doing root canal treatment, while 29% said they used it for any operative procedure.[7] While others have recognized that only 0.4% and 3.1% of the practitioners had used RD isolation during direct restorations and root canal therapies, respectively.[8]

This logically leads us to ask the question: what is the effect of RD isolation is on restorative procedures done with resin composites. This study attempts to tackle this clinical question. The objectives of the study are to estimate the prevalence of the use of RD during the restoration of occlusal and/or proximal caries in posterior teeth with resin composites and evaluate the presence of radiolucencies in tooth restorative interface and the body of the restoration in the two categories.

  Methods Top

The study was registered and ethical approval received from the Human Research Ethics Committee of King Khalid University, Abha, Asser region of Saudi Arabia. It was carried out in accordance with the code of ethics in the Declaration of Helsinki. This study was a cross-sectional study done from September to December 2017 to analyze permanent resin composite restorations in posterior teeth done by clinicians practicing privately. The participants for the study were selected based on the criteria that they have had ≤5 years of clinical experience and represent a workforce that has recently finished their graduation and started independent clinical practice. Voluntary participants who gave informed consent were included in the study. The selection criteria for the participants are given in [Table 1].
Table 1: Selection criteria for participants in the study

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A total of 250 permanent posterior composite restorations done in 147 patients were assessed radiographically in the study. The patients included in the study were adult male patients between the ages of 20 and 50 years. They had primary caries lesions involving the dentin in the permanent posterior teeth on the occluso-proximal surfaces that were restored in a single appointment.

The patient requiring complex restorations, pulpally or periodontally involved teeth, with localized misalignments in the area needing the restoration, missing adjacent teeth, congenital defects or acquired noncarious defects were excluded. Patients with known allergies to rubber-based products, asthmatic patients or with any systemic conditions that contraindicate the use of RD were excluded from the study.

The operators were given a chart to fill which indicated the basic demographic and diagnostic characters of the patients, and they were unaware to the objective of the study which was to assess the use of RD for isolation. The reason for placing the restoration was primary caries. The operator noted the tooth number and assessed the carious lesion location, extension, and depth from preoperative radiographs.

They treated the patients as per their requirements, and postoperative digital bitewing radiographs were taken to assess the restorations. An additional parameter assessed by the investigators was the use of RD for isolation while doing the permanent resin composite restorations. The digital bitewing radiographs were assessed by two operators independently. The evaluators were to identify areas of radiolucency at the tooth-restoration interface and/or in the body of the restoration.

  Results Top

The number of each posterior tooth that was evaluated in the study and the percentage of them treated under RD [Table 2]. It shows that 28.4% (71) of the patients were treated with RD and that it was used more for restorations in molars than premolars. An observation which was statistically evaluated was that more often the teeth that required only occlusal restorations were treated without RD. Further, the radiolucencies seen between the tooth-restorative interface and in the body of the restoration were assessed and statistically evaluated with Chi-square test [Table 3]. It showed a significant difference between the group using RD and not at a P≤ 0.05. There were about 70% restorations done with RD without any noticeable radiolucency as compared to 53.5% of teeth that were restored without the use of RD. The major radiolucencies noticed were within the restoration rather than at the tooth-restoration interface in both groups.
Table 2: Frequency distribution and percentages of patients who were treated with and without rubber dam

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Table 3: Chi-square test comparing the presence of radiolucency in tooth restorative interface and restoration in teeth restored with and without rubber dam

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  Discussion Top

There have been many studies that have assessed the knowledge and attitude of the dentist at different levels of their career to evaluate if this step is considered as vital as it is suggested to be.[9],[10],[11]

The conclusion of studies conducted concurs that there exists an adequately high level of knowledge and a positive attitude toward the need of using RD for isolation.[2],[8],[9],[12]

A study conducted in 2017 concluded that students of dental colleges agreed with the opinions that proper isolation cannot be achieved for the restoration of operative procedures without using RD.[2] Studies have also shown that restoration placed under RD has a greater longevity than those placed without.[13] Even though it is considered to be vital in endodontic procedures, the need for RD isolation in restorative dentistry is equally stressed globally in teaching. Studies have focused on the effect of RD isolation in affecting the success of treatments such as vital pulp therapy.[14] The focus has been the decrease in bacterial contamination that is afforded by the isolation and its eventual effect on the success of the treatment. They have concluded that a better prognosis can be expected when better isolation is maintained.[9]

In contrast, when studies have been done to assess the basic use of RD for isolation in standard operative procedures without any emphasis on the type of treatment, there was a very low percentage of compliance seen by the clinicians during routine restorative cases.[15] This lack of commitment by clinicians to ensure adequate isolation is seen to increase as time lapses after graduation. In one of the earliest studies to quantify the use of RD in general clinical practice done by a practice-based research network which assessed 229 dentists found that 63% did not use RD for restorations. Of the dentist using RD, only 12% were used for restorations.[16] This shows a definite low application of RD for operative isolation. Another practice-based study done on the use of RD for isolation during the endodontic treatment found that only 15% of dentists did not use it at all. This is certainly high adherence with the expected standard protocols to follow during endodontic treatment.[4]

These contrasting findings from the contemporary literature on the changes in attitude and application of knowledge about the need of RD for successful restorative procedures can be due to a few factors. Studies have shown that the decrease in RD usage is more pronounced after 5–10 years of clinical practice.[8],[17] The increase in the clinician's ability to prepare and restore the tooth seems to have a negative impact on their commitment to follow ideal isolation protocols. We intended to study a facet of this conundrum. The aim of this study was to focus on the clinician early in his/her career. This is the reason for selecting the group of clinicians who have been practicing for ≤5 years. All the participants were equal in their level of knowledge about the use of composite resins for restorations. All the participants were independently working on patients and catering to all the treatment needs of the patient. The patient treatment plan proceeded without any intervention by the researchers and any indication that any steps were to be evaluated. The treatment provided in all cases has to be thus considered unbiased. All restorations were routinely radiographed after completion and these standardized bitewing radiographs were used for evaluation postoperatively. The success of a composite restoration is assessed both clinically and radiographically especially in proximal surfaces. While clinical form and function as well as shade and surface texture can be observed there are some features in the restoration that can be seen only by imaging.

The presence of radiolucencies in composite generally denotes areas where gaps occur. These can occur between the composite restoration-tooth interfaces when the bonding has been compromised. The common reason for a compromise in the adhesion of composite is lack of isolation and resulting contamination by oral fluids. This does adversely affect the success of the restoration and is the basis of why isolation is considered vital to a successful restoration.[18],[19] The other common radiolucency noticed postoperatively is that which occurs within the body of the restoration. The use of multiple increments introduces the possibility that contamination can occur between the increments as easily as it can occur during the stages of bonding. Contaminants can cause a lack of cohesion between succeeding increments and can also persist as radiolucent artifacts in the restoration. These defects, if present, can be noticed postoperatively and so are used to evaluate if there were any deficiencies in establishing good isolation that could have contributed to contamination of the restoring surfaces. Even though their influence on the success of the restoration is not positive, it was not within the scope of this study to evaluate it.

The results of this study unequivocally showed that the use of RD during resin composite restorations was only 28.4%. This is a poor percentage considering the lesser amount of time elapsed since the graduation of the clinicians. However, it is more than other similar studies done and this is certainly reason for praise. Historically, there seems to be an increasing trend toward more use of RD in operative procedures as the percentage of use has increased from a meager 5% in 1989[20] to about 12% in 2010.[16]

This change may reflect the changes in patient attitudes, restorative materials used in clinical practice, and also the increased emphasis on teaching in dental schools.[3],[21]

The presence of radiolucent areas associated with the restoration showed a statistically significant difference between the groups using RD and not. The presence of radiolucent areas could not be totally avoided by the use of RD as nearly 31% of the teeth restored with RD had a radiolucent area. The other factors that influence the thickness of the bonding agent and patterns of incremental build-up could have contributed to these findings. In 46.4% of the teeth radiolucencies were seen when no RD was used. This is a logical outcome as the lack of adequate isolation will result in more defects in the restoration. However, the majority of the restorations done with other methods of isolation did successfully show restorations devoid of any radiolucent areas (53.6%). This finding suggests that it may be possible to successfully do a resin composite restoration without RD. However, variables that were not segregated like the extent, location and depth of caries and the alternates used for isolation cannot be evaluated to prove the point.

Hence, within the parameters of this study and considering the limitations, it can be concluded that the use of RD in restorative procedures by practicing dentist is low. There are radiolucent areas that are present in the tooth-restorative interface and the body of the restoration when the procedure is done with and without RD for isolation. However, a significantly higher number of defects are observed in the absence of RD isolation. This stresses on the need to increase clinician's conviction for ensuring adequate isolation to improve the quality of the composite resin restoration. The study also suggests that increased focus has to be given in dental schools to convince the students on the need of isolation not only for endodontics but also for adhesive restorations. Advances in materials and technology can only take us so far; changes in restorative dentistry require a concerted effort by the dentist to practice better isolation protocols in clinical practice.

  Conclusion Top

This study shows a low percentage of clinicians use RD for isolation during composite restorations. It also indicates that radiolucent areas are more often associated with restorations done without RD isolation. This study stresses that there is a need to change the clinician's convictions about isolation protocols followed during composite restorations.


The authors would like to thank the Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, Abha, Saudi Arabia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Terry DA. An essential component to adhesive dentistry: The rubber dam. Pract Proced Aesthet Dent 2005;17:106, 108.  Back to cited text no. 1
Al-Sabri FA, Elmarakby AM, Hassan AM. Attitude and knowledge of isolation in operative field among undergraduate dental students. Eur J Dent 2017;11:83-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Hill EE, Rubel BS. Do dental educators need to improve their approach to teaching rubber dam use? J Dent Educ 2008;72:1177-81.  Back to cited text no. 3
Anabtawi MF, Gilbert GH, Bauer MR, Reams G, Makhija SK, Benjamin PL, et al. Rubber dam use during root canal treatment: Findings from The Dental Practice-Based Research Network. J Am Dent Assoc 2013;144:179-86.  Back to cited text no. 4
Barros de Campos PR, Maia RR, Rodrigues de Menezes L, Barbosa IF, Carneiro da Cunha A, da Silveira Pereira GD. Rubber dam isolation – Key to success in diastema closure technique with direct composite resin. Int J Esthet Dent 2015;10:564-74.  Back to cited text no. 5
Csinszka K, Ivácson A, Monica M, Mihai P, Aurita AS, Angela B. Prevalence of rubber dam usage among dental practitioners and final year students in Tirgu Mures: A questionnaire survey. Act Med Marisiensis 2015;61:188-91.  Back to cited text no. 6
Awooda E, Alwan M. Knowledge, attitudes and practice of rubber dam use among dentists working in private clinics in Khartoum city. Saudi J Oral Dent Res 2016;1:19-23.  Back to cited text no. 7
Zou H, Li Y, Lian X, Yan Y, Dai X, Wang G. Frequency and influencing factors of rubber dam usage in Tianjin: A questionnaire survey. Int J Dent 2016;2016:7383212.  Back to cited text no. 8
Abdulrab S, Al-Maweri S, Doumani M, Mourshed B, Alaizari N. RD: Attitudes and practices of senior dental students in Saudi Arabia. IOSR J Dent Med Sci 2016;15:79-83.  Back to cited text no. 9
Al-Abdulwahhab B, Al-Thabit H, Al-Harthi A, Shamina R, Al-Taher R, Al-Ashgai A, et al. The attitudes of dental interns to the use of the RD and obstacles to its use. Indian J Dent 2013;4:179.  Back to cited text no. 10
Kapitán M, Sustová Z. The use of rubber dam among Czech dental practitioners. Acta Medica (Hradec Kralove) 2011;54:144-8.  Back to cited text no. 11
Prasad AL, Cumberbatch M, Mohammadnezhad M. Experience and practicality of rubber dam use among undergraduate dental students in Fiji. J Oral Hyg Health 2018;6:2332-0702.  Back to cited text no. 12
Marshall K, Page J. The use of rubber dam in the UK. A survey. Br Dent J 1990;169:286-91.  Back to cited text no. 13
Udoye CI, Jafarzadeh H. Rubber dam use among a subpopulation of Nigerian dentists. J Oral Sci 2010;52:245-9.  Back to cited text no. 14
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:e009779.  Back to cited text no. 15
Gilbert GH, Litaker MS, Pihlstrom DJ, Amundson CW, Gordan VV. RD use during routine operative dentistry procedures: Findings from the dental PBRN. Oper Dent 2010;35:491-9.  Back to cited text no. 16
Wan Noorina WA, Abdullah D, Goo CL, Rahman MM. Practice of infection control amongst clinical dental students of three public universities in Malaysia. Eur J Dent Med 2016;8:6-11.  Back to cited text no. 17
Varughese RE, Andrews P, Sigal MJ, Azarpazhooh A. An assessment of direct restorative material use in posterior teeth by American and Canadian pediatric dentists: II. Rubber dam isolation. Pediatr Dent 2016;38:497-501.  Back to cited text no. 18
Whitworth JM, Seccombe GV, Shoker K, Steele JG. Use of rubber dam and irrigant selection in UK general dental practice. Int Endod J 2000;33:435-41.  Back to cited text no. 19
Gergely EJ. Desmond Greer Walker Award. Rubber dam acceptance. Br Dent J 1989;167:249-52.  Back to cited text no. 20
Stewardson DA, McHugh ES. Patients' attitudes to rubber dam. Int Endod J 2002;35:812-9.  Back to cited text no. 21


  [Table 1], [Table 2], [Table 3]

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