Dr. Ellis Neiburger’s most recent Chairside^® article, “Rubber Dam Hazards,” received an abundance of feedback (Vol. 5, Issue 3; print only). Here is a sampling of the responses that flooded the Chairside magazine inbox.

Dear Dr. DiTolla,

What an interesting and controversial article on rubber dams. While I can appreciate two points Dr. Neiburger makes concerning rubber dams — the fact that clamps can cause soft tissue and restoration damage and can snag rotary instruments (so can cheeks, tongues, etc.) — his characterization of the rubber dam as obsolete is ludicrous and may indicate he has never mastered placement of a rubber dam. After more than 30 years of clinical dentistry, the dam is as important to me now as it’s ever been. And with there being several good, nonlatex alternatives, part of his argument goes down the suction. REALITY has evaluated numerous alternatives to the dam for the past 24 years, and I can tell you we have not found any contemporary device that gives the clinician the same virtually unrestricted access for rendering care. The dam, without a doubt, makes it much easier for a dentist to treat patients at a higher level of quality than when not used.

– Michael B. Miller, DDS
President, REALITY Publishing Company

Response from Dr. Ellis Neiburger:

Dear Dr. Miller,

While your points on the rubber dam are well-taken, they miss the importance of the message: The rubber dam is a 19th century vestige of dental technology that was needed for gold foil preparations. This is the 21st century. There are superior alternatives for isolation, moisture control, tissue retraction and drop hazard prevention during modern restorations and endodontics, too; but like using a horse-drawn wagon to move cargo, you can travel more easily, more efficiently and more comfortably using a modern-day air-conditioned van.

There are clinical situations in which the dam is helpful, but you must ask if alternative modern techniques are better for the patient’s well-being. Is a cotton roll less intrusive and atraumatic than a traditional rubber dam and clamps?

There are multiple ways to do restorations/endo, but dentists are honor bound to provide treatment in the least harmful and intrusive manner. Even though the dam makes it easier to treat patients (with what they perceive to be a higher level of quality), you must consider the patient’s comfort and convenience.

The dam, just like gold foil, is a legitimate technique and very helpful in some situations. The issue is whether dentists are skilled enough in other less-intrusive isolation techniques to make a wise choice as to how they treat their patients and less prone to snipe over ramparts of holy, definitional clinical purity. I hope you will test other alternatives and perhaps find some new techniques to replace the rubber dam.

– Ellis

To Whom It May Concern,

I read the article “Rubber Dam Hazards,” and I find it surprising you published this obvious justification for substandard dentistry. I am sorry, but if you cannot place and secure a rubber dam, then perhaps you should find a new profession. The risks of not using a rubber dam far outweigh the risks of using one. In my opinion, there are two types of dentists: Those who use a rubber dam and those who should. This article is a testimony to today’s lack of quality dentistry.

– Amy Kinney, DDS
Bozeman, Mont.

Response from Dr. Ellis Neiburger:

Dear Dr. Kinney,

Thanks for your feedback. Your points are well-taken and demonstrate why some dentists should overcome their I-was-told-in-dental-school-so-it-must-be-right mentality. The world is not black and white. Everything is gray. As clinicians interested in the welfare of our patients, we must recognize that every case is unique and the best tools and treatment for one patient may not be the best for another. The rubber dam technology of the 1800s has many hazards for the patient and the dentist. One must weigh the advantages and disadvantages of the technique on a situational level. Do you need to place a dam or will a simpler and less-invasive technique suffice? Are you placing a dam and traumatizing the patient only because Professor Looser in dental school told you to?

I believe that placing a dam on every patient and equating it with quality dentistry is simplistic and ill-advised. Most dentists do not routinely use the rubber dam, which, to a lay jury, indicates that dam use is substandard in today’s clinical world. I use the dam when it seems to be the best choice, which is rare considering the many alternatives modern dentists have for moisture, tongue control and drop hazards, not to mention the comfort of the patient and the ergonomic and financial realities of a successful practice.

The discussion is academic sniping over arbitrary walls of definitional purity. I know of not one good 21st century scientific study that proves the rubber dam is superior to any other isolation technique. Perhaps it was in the 19th century, but that was also a time of primitive, traumatic dentistry. The only one who counts is the patient, who, when hurt or injured or inconvenienced, will leave your practice and give his or her money to another dentist. It’s not unusual for the patient to mention the damn rubber dam — this is a serious message. I suggest asking your patients what they would like; if you don’t offer less traumatic options, learn them. Patient rejection is emotionally and financially hazardous. Patient acceptance is rewarding beyond measure. Don’t delude yourself. Patients hate the damn dam for good reasons and prefer its modern and kinder alternatives.

– Ellis

Dear Dr. DiTolla,

I read with interest, and a little shock, the Chairside^® article “Rubber Dam Hazards.” As a practicing dentist who has routinely used rubber dams for 38 years, I was quite surprised to see this article in your magazine, which has always shown such forward thinking.

Neiburger mentions the possibility of deterioration of and/or sensitivity to latex. These arguments would be the same for the use of latex gloves, yet conscientious dentists all over the world use them. Nitrile or plastic can be substituted for latex-sensitive operators or patients.

He also mentions the difficulty of placing rubber dam clamps, and that this procedure can be time consuming. While this is sometimes true, it is not the rule. And the time saved in doing multiple restorations under a rubber dam can easily make up for the time of placements, which can be accomplished by an experienced clinician or staff member.

The author showed a radiograph of an ingested clamp, but did not show the much more likely radiograph of an aspirated endo file.

Lastly, Dr. Neiburger implied that modern materials, such as spherical alloy, are not as sensitive. This comment verged on ludicrous, as the use of amalgam is on the decline, and the bonded composite being used in its place is much more sensitive to moisture contamination.

I would argue that use of rubber dams is quick and easy for anyone who uses them routinely. It is still the best method of preventing moisture contamination, and modern dentists should routinely use it … though I can understand why a forensic dentist might not appreciate its benefits.

– Richard R. Pence, DDS, MAGD, FICD
Lincolnton, N.C.

Dear Dr. Neiburger,

I was quite unimpressed by your article “Rubber Dam Hazards” and question why you would even present a narrative opposing its use. You said you wished to provide a balanced perspective. Balance is a poor word choice; negligence is more accurate.

For many of the same reasons that condoms are indispensable in the fight to prevent the spread of HIV and examination gloves are worn when following Universal Precaution protocols, the rubber dam is the benchmark product when barrier protection or isolation requiring treatments are rendered in dentistry.

Not one single “hazard” or “limitation” you’ve discussed even comes close to precluding the use of the rubber dam or could legitimately even be characterized as a hazard or limitation, for that matter.

I’ve read many dental abstracts, articles, research papers and editorials in the 18 years I’ve been an endodontist. Yours is probably the worst article I’ve ever read. I could kick myself for picking up this magazine and will likely never do it again!

– Reid El Attrache, DMD
Washington, Pa.

Dear Dr. DiTolla,

The article “Rubber Dam Hazards” by Dr. Neiburger has me concerned. I guess I have to speak for the “approximately 5 percent of dentists who routinely use a rubber dam” and say that he is one of the 95 percent of dentists looking for any excuse or reason not to use this technique. I doubt the hazards of the rubber dam are any more prevalent than the use of a scalpel, handpiece, bur or anything else if used improperly. I’ve been using the rubber dam since 1967 and have found it to increase efficiency, patient comfort and profitability. The rubber dam allows quadrant dentistry to be accomplished more comfortably for me and my patient. I have many patients who absolutely love it!

Most let me put it on and then nap during the procedure.

I don’t know what the point of the article was, if none other than to continue to find support for its nonuse. The sequelae of use that Dr. Neiburger shows can happen to anyone not paying attention, but conscientious users of the rubber dam will rarely see these problems. Yes, I have had clamps break and encountered rubber dam tears that can be left in the sulcus if not checked and clamps that have popped completely out of the mouth, but I’ve never had a porcelain crown crack while it was being used. These events do not deter me from using the rubber dam; I still use it 97 percent of the time. Now, with ultra technique-sensitive composite restorations, I feel the need for the rubber dam has increased, not lessened.

Dr. Neiburger’s comment that the rubber dam should go the way of gold foil and not be taught in dental school conflicts with his prior statement that the “rubber dam still affords practical uses in modern dentistry and should not be abandoned.” In my experience, the rubber dam is not hazardous to the patient; not costly in time, effort and money; and even more necessary in contemporary practice, due to the sensitivity of modern materials to moisture. It has allowed me to provide a better quality of dentistry for my patients.

– Dennis J. Nowak, DDS
Orland Park, Ill.

Dear Dr. DiTolla,

Having used the rubber dam for operative dentistry for 40 years, I feel Dr. Neiburger’s concerns about the potential hazards of using the rubber dam are exaggerated and should be addressed.

Clearly many clinicians can deliver a quality service without the use of the rubber dam. However, the benefits of its use far outweigh any hazards mentioned.

A new RD will not tear when handled properly and applied with a water-soluble lubricant. Patching a RD seems awkward and not a likely solution to a torn dam. Preparing and placing a new dam is a quick and effective solution. A new RD is free of pathogens and should not need sterilization that may deteriorate the dam.

Infectious microbes that a patient may carry are numerous and range from hepatitis to common cold organisms. What a great barrier the dam becomes, protecting the operators from excessive pathogenic organisms found in aerosol mist generated by dental instruments.

Nonlatex dams are available for allergy concerns.

Careful application of a double-ligated clamp does not permanently injure tissue or restorations. A ligated clamp prevents aspiration or ingestion of a clamp or fragments of clamps.

The placement of the dam shortens treatment time and eliminates frenzy from the dental experience for patients and operators. Frenzy exists with choking, swallowing, gagging, spitting and rinsing, all of which are eliminated in the presence of the dam.

If instruments get snagged in the rubber, we can be thankful that the tongue and other soft tissues are protected. Just replace the damaged dam with a new one.

By isolating many teeth beyond the treatment sight, visualization is greatly increased and evacuation of water becomes much easier for assistants.

When removing the dam, it should be sectioned from hole to hole with scissors to prevent the disturbance of fresh restorations.

The application of the dam consumes very little time and should not be considered antiquated, especially when considering the technically sensitive nature of bonding procedures.

Indeed, the practice of operative dentistry becomes a pleasure when working under the ideal environment afforded by the use of rubber dam.

– James P. Whitman, DMD
Pittsfield, Mass.

Dear Dr. DiTolla,

The article posted on Rubber Dam Hazards is one of the most ridiculous articles I’ve ever encountered. How can you say that the rubber dam is obsolete when almost every dentist uses it and couldn’t live without it?

– Anonymous

Dear Dr. DiTolla,

I have read your magazine for many issues and have learned much from it. However, I have a serious issue with the article “Rubber Dam Hazards” by Ellis Neiburger (Vol. 5, Issue 3). Shame on you for publishing an article challenging decades of evidence a dry field is essential for composite bonding success. You are only serving the lazy dentist, who is looking for more excuses to shortcut the steps necessary in ensuring long-term predictability of composite restorations, especially in the posterior teeth.

The hazards listed are bogus and easily avoided with minimal attention to them. The alternatives are perhaps viable for “relatively moisture-tolerant restorative materials,” like amalgam. You can put amalgam in under water! Composite bonding demands an absolutely dry field. No cotton roll will serve that requirement.

Please tell the young dentists out there not to cut corners in order to save a minute and some hassle. Rubber dams are essential in posterior bonding. I have seen hundreds of failures in restorations placed without them, and I firmly believe they are the standard of care. Anything less is a disservice to the patient.

– Charles Anderson, DMD
Mt. Pleasant, S.C.