Reducing Exposure to COVID-19- A Rubber Dam Guide

Written by Dr. Sunny Virdi

We all know the importance of isolation during dental treatment. Dentists may opt for different methods including cotton rolls, systems like iso-lite, prayer, or using a rubber dam. We aren’t here to start a debate, or judge which method you use. However, using a rubber dam is not only for posting cases on social media, it can have an impact in our offices by reducing the aerosolization of infectious agents.

With the outbreak of COVID-19, most offices are currently only providing emergency treatment as recommended by various regulatory boards to reduce community spread. This outbreak has made many of us rethink our personal protective equipment’s (PPE) ability to protect our patients, staff and ourselves. One of the measures the ADA has recommended is to use a rubber dam to “decrease possible exposure to infectious agents”.

It has been reported that the use of a rubber dam could significantly reduce airborne particles in an approximate 3 foot diameter of the operational field by 70%.

That’s why we have created this basic Rubber Dam Guide to show you the equipment you need and provide a refresher on how to place one.

Equipment

Here is what you’ll need:

The Rubber

There are different gauges of rubber dams and the thickness does change depending on the company. I typically use a medium dam for routine procedures that do not require more advanced, subgingival isolation. I have included the common types I typically use, however, in no way is this an advertisement and I am not sponsored by rubber dam manufacturers.

This list is not in order of quality or preference, all the brands listed here will give you success in isolation.

1. ISODAM by 4D Rubber (Medium or Heavy Gauge) – Latex free*
2. Polyisopreme Rubber Dam by Hedy (Medium or Heavy Gauge) – Latex free*
3. Dental Dam by Nic Tone (Medium or Heavy Gauge) – Latex Rubber Dam

The Frame

Plastic frames work well if you will be taking a radiograph mid-procedure. I typically find, however, that metal ones are easier to use and maintain over time.

Clamps

There are many clamps to choose from, and oftentimes the right clamp is simply the one that fits the situation and gets the job done. I have included a list of the common ones used that you may not be familiar with. 

• Soft Clamp – May serve as a workhorse posterior molar clamp. It is especially useful for cases where you are placing a clamp on a tooth with a large restoration that you are worried about damaging. The clamp is plastic and does not have teeth, so you can rest assured the restorative margins will be safe.
• W3 – This is the true workhorse clamp for all Maxillary and Mandibular molars. It is a wingless clamp that fits on most posterior teeth and is extremely easy to place. Oftentimes clinicians find difficulty placing clamps on second molars due to the location of the ramus and general lack of space. The W3 has a tight profile that helps overcome this issue and will provide clinicians with the freedom to place the clamp wherever they need
• 13A/12A – The traditional clamp for molars. These clamps have an active component (the teeth) that help retain them on shorter teeth. In the photo attached you can see how we have modified the clamp to recreate the profile of a W3 for ease of placement
• W2 – Carries the benefits of the W3, but is to be used primarily on premolars or smaller molars.
• B4 – A small and delicate clamp that can provide extra retraction around anterior teeth. It is extremely easy to place, however it does not have the greatest retention so the clinicians must be careful not to dislodge the clamp while working.
• 12 – A commonly used clamp for anterior endodontics however it can also be used for other procedures. We can modify the clamp to remove one of the wings to provide ample working space. 

While there are many clamps available, the clamps you currently have in your office should suffice.

Rubber Dam Hole Punch

Just your basic one will do however hole spacing and size selection is important.

• The Clamp – teeth that will have the clamp placed should use the largest holepunch 
• Molars – All molars not receiving a clamp should use the second largest
• Premolars/Canines – 3rd biggest
• Maxillary Incisors – 2nd smallest
• Mandibular Incisors – Smallest

There are a variety of templates that exist, such as PacDam, but many practitioners do not rely on them.

The biggest takeaway to hole spacing is to give yourself enough room between the teeth to retract the soft tissue. When you punch the holes to close together, you will notice the papillae pinching through the rubber dam.

This can create issues when completing class II restorations from an isolation standpoint.

Placement

There are a variety of ways to place the rubber dam 

1. Placing the clamp first, then stretching the dam overtop
   • This gives you the greatest control over placement and ensuring a secure fit of the clamp
2. Placing the clamp with the dam overtop the clamp bow
   • This method provides a lot of control over placement, without the need to stretch the rubber dam overtop the bow
3. Placing the clamp and dam simultaneously
   • This method may provide to be the “fastest” in terms of placement, but only exists for “winged” clamps. The difficulty with winged clamps is the lack of space posteriorly. Nonetheless, the option exists.

Floss is used to push the dam through the contacts, and from there you are ready to proceed with treatment! There are many “advanced” techniques on isolation such as floss ties, blind clamps, and further modification of clamps for more retraction. The take home message is that some form of isolation will help keep you and your patients safe as we continue to face new and upcoming infectious diseases.

Dr. Sunny Virdi
Born and raised in Winnipeg Manitoba and graduated from the University of Manitoba in 2016. He maintains a full-time ownership role in a group private practice in Winnipeg, Manitoba. Dr. Virdi has received postgraduate training in the latest techniques regarding isolation, adhesion, materials science and esthetic dentistry. Dr. Virdi strives for excellence through continuing education and life-long learning. He has received extensive training in the latest restorative techniques with world renowned leaders in restorative and esthetic dentistry. Dr. Virdi is a fan of collective learning and always keen to share his experience by participating in multiple study clubs. Dr. Virdi is a member of the Canadian Dental Association and the Manitoba Dental Association. Dr. Virdi can be reached by email at sunnyvirdi.dr@gmail.com or through Instagram @dmdsunny