Rubber Dam It

Summer 2004 Lifeline

Although patient safety is every dentist’s main concern, it can be easy to take short cuts when performing routine procedures numerous times in a day. This can also be true when using uncomfortable or awkward devices such as rubber dams. Rubber dams are generally uncomfortable for patients because they force their mouths open and cause their jaws to ache. Patients often complain that rubber dams smell, taste bad and irritate their skin. While it may be tempting to concede to these complaints and not use rubber dams, the goal of patient safety should win out.

Dentists are taught in school that rubber dams isolate selected teeth and safeguard the rest of the patient’s mouth during treatment. Quite often new graduates falsely assume that rubber dams are only training devices used in dental school. The standard of care dictates the use of a rubber dam for endodontic procedures. Additionally, many dentists regularly use rubber dams for many different types of restoration procedures.

Rubber dams prevent contamination, promote infection control, serve as barriers, and limit bacterial splash and splatter of saliva and blood. Rubber dams prevent patients from swallowing or aspirating debris or dental instruments. They also improve visibility and tooth access, and provide moisture control to help with the placement of restorative materials. Rubber dams also protect the patient’s soft tissue by keeping the tongue, lips and cheeks out of the way. In 2003, 9 percent of TDIC’s professional liability claims involved patients swallowing or aspiring objects such as crowns or burs. Many of these claims could have been avoided had the doctors used rubber dams.

Generally, rubber dams are made of latex; however, latex free rubber dams are also available. Ask patients about latex allergies on their health history forms. Make sure that the patient marks either “yes” or “no” and does not leave the question blank. To minimize the amount of possible exposure to latex, schedule all latex sensitive patients first thing in the morning. Review the label on rubber dams to ensure they are truly latex-free. To prevent future incidents, document in the chart whether the patient had a reaction.

Include the use and application of a rubber dam in the informed consent discussion. Explain how the device works and why it is needed. If a patient does not agree with the use of a rubber dam, explain its importance and the risks associated with not using the rubber dam, such as contaminating the area with bacteria, swallowing or aspiring debris, and not isolating or controlling moisture around the tooth. Document the conversation and the patient’s response in the patient’s chart. If the patient still refuses the use of a rubber dam, an informed refusal form may prompt a patient to change his or her mind. When patients see in print the possible negative consequences of their decision, it might cause them to reverse it. However, a patient’s refusal of treatment does not allow a dentist to practice below the standard of care. Patients have limited opportunity to influence treatment decisions, but this does not include consenting to substandard treatment.

The next time you consider whether to use a rubber dam, remember that they:

• Serve as an important infection control barrier.
• Improve access to and visibility of the tooth.
• Protect the patient from accidentally inhaling or swallowing dental instruments, materials or equipment.
• Provide moisture control that is essential for the placement of restorative materials.
• Protect the tooth from contamination by saliva, debris or other dental materials.
• Are the standard of care for endodontic procedures.
• Are widely used for many restoration procedures.
  

You can download an informed refusal form from the Risk Management section of our Web site.

Case Study

A 53-year-old female patient presents to her general dentist complaining that tooth #30 aches and is sensitive to heat. The dentist tests the tooth with ice and determines that a root canal is needed. The dentist has room in his schedule so he begins to prep the tooth for the root canal. The dentist believes that because the patient is already a patient of record and has had previous root canals, an informed consent discussion is not necessary. The dentist anesthetizes the area. He does not like to use rubber dams, as he feels they are cumbersome and annoy patients. This patient in particular expressed her dislike of the dam during her last root canal. The dentist does tie dental floss to the instruments in case the patient inhales or swallows them.

After preparing the tooth, the dentist places gauze in the back of the patient’s mouth. The dentist takes six radiographs of the tooth. He asks the dental assistant to prepare a diluted Clorox solution to irrigate the canals. The assistant hands the syringe to the dentist who then irrigates the canals. The patient ingests some of the solution, begins to cough and gag, and eventually vomits. She complains of a strong odor of bleach. The dentist tells the patient that he used a Clorox solution. She continues to cough and gag for 10 minutes and then complains of burning in her throat. The dentist and staff wait for her to stop gagging and then finish the procedure. They send the patient home without instructions for treating the burning in her throat but do schedule the second appointment to complete the root canal.

The dentist calls the patient that night to check on her. She tells the dentist that her throat is still burning. He assures her that the irritation should go away soon. During the next several days the patient suffers from increasingly painful burning symptoms in her throat and is unable to speak properly. Four days later, she makes an appointment to see her physician, who diagnoses her with a chemical burn and edema.

The patient initiates a lawsuit against the dentist alleging the Clorox solution caused permanent vocal chord injury. Since she is a vocal music instructor and professional singer, she claims the injury has caused her to miss work and poses a threat to her future income as a professional singer. The dentist contacts his professional liability carrier when he gets the notice of the lawsuit. Since the dentist admits he did not use a rubber dam, the case settles for an undisclosed amount.

What Went Wrong?
The dentist did not use a rubber dam for a procedure that typically requires one. Using a rubber dam would have contained the irrigating solution and prevented the patient from swallowing it. In the eyes of a jury, the dentist should have taken all precautions necessary to safeguard the patient.

The dentist had the responsibility to conduct an informed consent discussion with the patient to discuss the treatment options, risks and benefits as well as allowing enough time for the patient to ask questions concerning the treatment. Even though the patient previously had endodontic treatment, the dentist was still obligated to have an informed consent discussion with her, including the use of a rubber dam. Had the patient refused to use the dam, the doctor had the same obligation to discuss the risks and benefits and the possible negative consequences of that decision. Even the use of an informed refusal form would not allow the dentist to practice below the standard of care.

After the patient ingested the solution, the dentist should have continued to follow up with the patient to monitor her progress. The dentist should have paid attention to her symptoms, and referred the patient to her treating physician for evaluation and treatment. After referring any patient to another practitioner, especially after an injury, follow up with the patient as well as the treating practitioner. Patients are less likely to get upset after an untoward result when they believe the dentist is compassionate and shows an interest in their well-being.