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IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 16, Issue 4 Ver. I (April. 2017), PP 70-74 www.iosrjournals.org
DOI: 10.9790/0853-1604017074 www.iosrjournals.org 70 | Page
The Experience and Attitude of Saudi Patients towards Rubber Dam
Isolation during Dental Treatments
Basil Yousif Alamassi1, Mowaffq Shafi2, Ahmed Alenezi2,
Abdullah Alghamdi2, Mohammed Alerredi2,
Omar Alwazzan2
1Lecturer - Department Of Restorative Dentistry- Riyadh Colleges Of Dentistry And Pharmacy
2Riyadh Colleges Of Dentistry And Pharmacy
Abstract:
Objective: The aim of this cross-sectional questionnaire-based study is to determine dental patients’ attitudes
toward and experiences with rubber dam (RD) isolation during endodontic or operative procedures at Riyadh
Colleges of Dentistry and Pharmacy Teaching Hospital.
Materials and Methods: A questionnaire comprising 12 questions was distributed to 120 patients after they
were treated using rubber dam isolation by final year students in the clinics of the Riyadh Colleges of Dentistry
and Pharmacy. The respondents were asked to complete the questionnaire immediately after the completion of
the procedure. The questions were designed to evaluate their attitudes toward and experiences with RD
isolation.
Results: Out of 120 questionnaire distributed, 95 (73 male, 22 female) were completed and returned.
The majority of the patients (80%) had never been treated using RD outside the Riyadh Colleges. A total of
71.6% of the patients were comfortable during treatment with the RD and 75.8% indicated preference for
treatment with it in the future. Protection from inhaling or swallowing foreign objects was the most commonly
mentioned advantage for the patients (93.6%), while the inability to rinse was the aspect of RD they expressed
the most frequent dislike. The only factor that had a statistically significant influence on patients' preference for
future treatment with RD was the degree of discomfort they experienced during treatment (P<0.05).
Conclusion: Patients’ experiences with and attitudes toward RD isolation during dental treatment were
positive, and most of them indicated a preference for treatment with it during future visits. Dentists and dental
students should educate their patients briefly about the importance and advantages of RD to achieve high levels
of acceptance.
Keywords: Rubber dam, isolation, attitude, acceptance
Abbreviation:
RD: Rubber Dam
I. Introduction
The use of rubber dam (RD) in endodontics and restorative dentistry is the only available way to
guarantee high-quality, safe, efficient, and successful treatment. For a long time, it has been considered the ideal
isolation tool, and working with RD during root canal treatment has been considered the standard of care. The
RD offers the practitioner a wide variety of advantages. These include infection control; the prevention of the
aspiration of fine instruments; the provision of a dry, clean operating field from which saliva, hemorrhage, and
other tissue fluids are isolated; improved visibility and access; and the protection and retraction of soft tissue
(lips, cheeks, tongue) that can disrupt operative procedures3,4. Clinicians are protected from litigation that would
result from aspiration or a patient’s swallowing of an endodontic file. Christensen et al.5 demonstrated that the
use of the RD helped to keep the operating field free of saliva and other contaminants, improving the quality of
restorative work and making patients more comfortable. The RD minimized patient conversation and the need
for frequent rinsing during treatment, which improved the efficacy of the dental procedure 5.
Although there is agreement regarding the importance of using RD, their actual usage is low among
dental practitioners worldwide6,7,8,9,10. The frequently reported reasons for this limited usage of RD during
endodontic and operative procedures include patient discomfort, insufficient time and training, cost, prolonged
treatment time, and lack of compliance on the patients’ part6,7,8. Lynch et al stated that these arguments have
been mentioned most often by those dentists who themselves do not use RD9. However, according to several
studies, the attitudes of patients toward RD were positive, and they showed high levels of acceptance10,11,12,13,14.
Their positive attitudes toward RD application could be linked to the proper explanation of its benefits, proper
application techniques, and short treatment times12. In the studies that investigated patients' attitude toward RD,
the majority of patients demonstrated high levels of acceptance and preferences for its use during their
subsequent appointments and in most of the cases they had positive experience with this isolation tool12,13,14.
The Experience And Attitude Of Saudi Patients Towards Rubber Dam…
DOI: 10.9790/0853-1604017074 www.iosrjournals.org 71 | Page
Most previous studies were directed at determining dentists’ and dental students' attitudes toward RD
usage, and little data was available about patients' attitudes toward and experiences with this method of
isolation. Hence, our study was directed at investigating patients' attitudes toward and acceptance of RD usage
during endodontic and operative procedures by final year dental students at the Riyadh Colleges of Dentistry
and Pharmacy.
II. Materials and Methods
This descriptive questionnaire-based study was approved by ethical committee of the research Center at
Riyadh Colleges of Dentistry and Pharmacy. A closed-ended questionnaire comprising 12 questions was
prepared to determine what patients' experiences with RD isolation during dental treatment were. The patients
included had just undergone operative or endodontic treatment under RD isolation by final year dental students
at the Riyadh Colleges of Dentistry and Pharmacy Teaching Hospital. The questionnaires were distributed to
120 patients, who were asked to complete them immediately then return them to one of the investigators. Each
patient received an explanation of the aim of the study and was informed that the data collected would be used
confidentially and the completion of the questionnaire would be considered to be consent for participation. Data
was collected and descriptive analysis was performed using version 20 of the Statistical Package for the Social
Sciences (SPSS) to determine the patients’ levels of acceptance and future preference of RD and to correlate
these acceptance levels to different factors either associated with the patients (for instance, age or gender) or
with the clinical procedure performed (endodontic or operative, degree of discomfort experienced, first
experience with RD or having prior experience, and having received an explanation from the treating student or
not). The level of significance was selected 0.05.
III. Results
Out of 120 questionnaires distributed to the patients, only 95 (73 male and 22 female) were completed
and returned. The ages of the respondents ranged from 18 to 59 years, with a mean age of 36.4 years. The
majority of the patients (n = 76) had never been treated with RD outside the Riyadh Colleges (80%), and their
first experience with RD had occurred at the Riyadh Colleges Dental Clinics. Eighty-five patients (89.4%) stated
that they had already received a brief explanation of the benefits of using the RD during operative and
endodontic treatment from the treating student before the procedure began. When they were asked about their
comfort level during treatment with RD, sixty-eight of the respondents (71.6%) indicated that they were
comfortable during treatment with RD, while fourteen patients (14.7%) stated that they were uncomfortable
with it. Only nine patients (9.5%) indicated that it was painful for them (Table 1).
Table 1. Respondents' experiences and degree of comfort during treatment with RD
Frequency (n)
Percentage (%)
Pleasant
4
4.2
Comfortable
68
71.6
Uncomfortable
14
14.7
Painful
9
9.5
Regarding the question of who benefitted more from the use of RD, seventy-one (74.7%) of the
patients believed that both dentists and patients benefitted from its use, while12.7% of them (n= 12) considered
the of use RD to be beneficial for the dentist only. Moreover,5.2% (n= 5) said that the procedure had no benefits
for both (Table 2).
Table 2. Respondents’ feelings regarding who benefitted more from RD usage
Benefits from RD Usage
Frequency (n)
Percentage (%)
Dentist and Patient
71
74.7%
Dentist only
12
12.7%
Patient only
7
7.4%
No benefits for either
5
5.2%
For 43.3% of the patients (n=41), the inability to rinse during the procedure was the most frequent aspect of RD
isolation they did not like. The different aspects of RD usage they did not like are presented in table 3.
The Experience And Attitude Of Saudi Patients Towards Rubber Dam…
DOI: 10.9790/0853-1604017074 www.iosrjournals.org 72 | Page
Table 3. Aspects of RD isolation that the participants did not like
Aspects that participants did not
like
Frequency (n)
Percentage (%)
Pain
9
9.5
Inability to rinse
41
43.1
Difficulty breathing
12
12.6
Inability to communicate
17
17.8
Nausea
5
5.2
Length of time of application
28
29.5
Pain in the TMJ
3
3.2%
When questioned about the aspects of RD isolation they considered beneficial, a high percentage of
respondents (93.6%) indicated that it protects from inhaling or swallowing foreign objects such as the
instruments used during the procedure. The aspects of RD isolation toward which they felt positively are
summarized in table 4.
Table 4. The advantages and benefits that respondents associated with the use of RD
The benefits of RD
Frequency (n)
Percentage (%)
Reduced cross infection
54
56.8
Protection from inhalation or swallowing of
foreign objects
89
93.6
Protection from soft tissue injury
66
69.4
Prevention of accumulation of water in the
mouth
77
81
Protection of soft tissue from irritant
solutions and chemicals
73
76.8
Improved quality of restorations and
endodontic treatment
65
68.4
Regarding their preference for treatment under RD in future visits, seventy-two of the patients (75.8%)
indicated that they would prefer to be treated with it in the future, while twenty three patients (24.2%) did not
express this preference. Patients' preferences to future RD treatment in relation to age, gender and type of the
procedure is presented in table 5.
Table 5. Age, gender and procedure type in relation to patients preference to future treatment under RD.
N (%)
Prefer
N (%)
Don't
prefer
N (%)
Significance
"P value"
Gender
Male
73(76.85)
55 (75.34)
18 (24.66)
0.29
Female
22(23.15)
17(77.27)
5 (22.72)
Age groups
18-30
38(40)
30(78.94)
8(21.06)
0.09
31-44
41(43.15)
31(75.6)
10(24.4)
45>
16(16.85)
11 (68.75)
5(31.25)
Procedure
Operative
51(53.68)
38 (74.5)
13 (25.5)
0.86
Endodontic
44(64.32)
34 (77.3)
10(22.7)
Total
95 (100)
72 (75.8)
23(24.2)
Their recommendations to others, such as friends or relatives, regarding treatment with RD isolation
are presented in Table 6. Only five patients felt the use of RD is not necessary and they will not recommend its
use for others. The only factor that showed a statistically significant influence on patients' future preferences for
treatment with RD isolation was the degree of discomfort they experienced (P<0.05) during treatment with the
RD. Other factors, such as age, gender, type of procedure (endodontic or operative), first experience or having
prior experience, having received an explanation regarding RD, showed no statistically significant influence on
patients’ preference for RD usage in the future.
Table 6. Patients’ advice to their friends or relatives on the use of RD during dental treatment
Advice
Frequency (n)
Percentage (%)
Highly recommended/ highly
necessary
4
4.2
Recommended / necessary
69
72.6
Optional
17
17.9
Not recommended / not necessary
5
5.2
The Experience And Attitude Of Saudi Patients Towards Rubber Dam…
DOI: 10.9790/0853-1604017074 www.iosrjournals.org 73 | Page
IV. Discussion
The aim of this study was to investigate patients’ attitudes toward and acceptance of RD isolation
during operative and endodontic treatment. The bulk of the available data in the literature focuses on dentists'
and dental students' attitudes regarding the use of RD, but little data is available about patients’ acceptance of
and attitudes toward this method of isolation.
The patients included in this study were those treated by the final year dental student in Riyadh
Colleges of Dentistry and Pharmacy with either endodontics or operative dental procedure where the use of RD
is mandatory is such treatments. Typically, dentists who use RDs do not explain their benefits to their patients.
In rare cases, some patients refuse treatment with it due to misconceptions or bad experiences. Currently, dental
institutions worldwide teach the use of the RD as an important method of tooth isolation for most dental
procedures in adult and child patients. Ideally, dental study should explain to the patient the importance and
advantages of RD use before starting the procedure. About ninety percents of the patients in this study said they
have received this explanation. The majority of the patients in this study had never experienced treatment under
RD outside the Riyadh Colleges Dental Clinics. The results were similar to those of the studies of Kapitan11 and
Stewardson13. This may highlight a general point of low levels of RD usage in Riyadh city. One of the reported
barriers to the use of RD by dentists worldwide is patients’ discomfort and incompliance4,5 . The results of our
study and many other studies11,12,13 showed high levels of acceptance and positive attitudes towards treatment
with the RD isolation, especially when they were educated about its importance and benefits during treatment.
Based on these findings, we could say that lack of patient compliance is not an acceptable reason for not using
this tool of isolation during operative or endodontic procedures.
Patients in this study expressed high levels of acceptance and preference for future treatment under RD.
Similar results were evident in other studies that investigated patient attitudes toward RD isolation 10,11,12,13,14. In
our study, final year students undertook the application of RD. Given their experience level, it is expected that
they would require longer application times than expert practitioners. Furthermore, in most of the cases, the time
students spent completing a procedure usually longer than that which dentists would spend completing the same
procedure. This may lead us to expect higher levels of acceptance and preference regarding future treatment
with RD when more expert dentists perform the procedure. In Stewardson’s study13, patient preference for
future RD usage was lower when students treated the patients, and the author concluded that operator experience
improved patient compliance. In Kapitan’s study [11], the application time did not influence patients’
acceptance. The only factor that was found in this investigation to influence patients’ preference for treatment
under RD in the future was the level of discomfort they experienced. Those who experienced discomfort or pain
during treatment expressed lower preferences for future treatment with RD. Same finding was reported by
Kapitan et al. Kapitan et al.11.
In our study, gender difference was found to have no statistically significant influence on patients'
acceptance of RD. These findings were in agreement with those of Kapitan’s study11, but in contrast to the
finding of Stewardson’s13 and Vadavathi’s12 studies, where females had higher levels of acceptance of RD. Age
was also found to have no influence on the level of acceptance; this was similar to the findings of Kapitan’s11
and Vadavathi’s12 studies but in contrast to the findings of Stewardson’s13. study where the preference for the
RD increased with the age of the patients. One of the limitations of this study is that it includes only patients
whom treated by students. Consequently, it did not evaluate the relation between operator experience and patient
acceptance of RD. Hence, it is recommended that investigations be undertaken to determine patients' attitudes
toward RD when general dentists or specialists with more clinical skills perform the treatment where the
application time and duration of the procedure are expected to be shorter than those associated with students’
work.
V. Conclusion
Within the limitations of this study, patients generally demonstrated good acceptance levels and
positive attitudes toward the use of RD during operative or endodontic procedures done by final year students.
The majority of the patients preferred treatment with dental dams in the future and recommended it to their
friends or relatives. A short explanation of the importance and benefits of this isolation tool is very important for
the improvement of patient acceptance. Hence, any practitioner should carry it out routinely before RD
application. The degree of discomfort during treatment with RD isolation was found to have a statistically
significant influence on patients' preferences for future treatment with RD.
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