Rubber dam application in endodontic practice: an update on critical educational and ethical dilemmas HMA Ahmed,* S Cohen,† GL evy,‡ L Steier,§ F Bukiet¶ *School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia. †Arthur A Dugoni School of Dentistry, University of the Pacific, San Francisco, California, USA. ‡EA 3412 Universit e Paris Nord, Facult e de Chirurgie Dentaire, Universit e Paris Descartes, Sorbonne Paris Cit e Paris, France. §Warwick Medical School, The University of Warwick, United Kingdom. ¶UFR Odontologie de Marseille, Aix Marseille Universit e, Assistance Publique des H^ opitaux de Marseille, France; Laboratoire Biologie Sant e et Nanosciences EA 42-03, UFR Odontologie de Montpellier 1, France. ABSTRACT Proper isolation is an essential prerequisite for successful endodontic treatment. This article aims to provide an update on the prevalence of rubber dam (RD) use, and the role of education along with attitudes of general dental practitioners (GDPs) and patients towards the application of RD in endodontics. Critical ethical issues are also highlighted. Using cer- tain keywords, an electronic search was conducted spanning the period from January 1983 to April 2013 to identify the available related investigations, and the pooled data were then analysed. The results show that although RD is the Stan- dard of Care in endodontic practice, there is a clear discrepancy in what GDPs are taught in dental school and what they practice after graduation. There is little scientific evidence to support the application of RD; however, patient safety and clinical practice guidelines indicate that it is unnecessary and unethical to consider a cohort study to prove what is already universally agreed upon. A few clinical situations may require special management which should be highlighted in the current guidelines. This would pave the way for clear and straightforward universal guidelines. Keywords: Attitude, dental practitioners, education, endodontics, ethics, rubber dam. Abbreviations and acronyms: GDPs = general dental practitioners; RD = rubber dam. (Accepted for publication 7 January 2014.) INTRODUCTION ‘Endodontic procedures must never be performed without the rubber dam’ is the title of a paper by Hel- ing and Heling 1 that clearly emphasizes the essential role of the rubber dam (RD) for every endodontic procedure. For more than 150 years, it has been known that RD use reduces microbial contamination and the potential for patients swallowing or inhaling irrigants, hand-files, infected tooth debris, etc. Fur- thermore, every dental student is taught early in instruction that in clinical practice the RD enhances visibility, improves visual access to the canal(s), opti- mizes moisture control and retraction of the soft tis- sue, thus enhancing the efficiency of every endodontic treatment procedure. 2–5 Therefore, it is clear that the RD represents the indispensable Gold Standard of Care in endodontic practice. 6 Despite this, a recent clinical survey by Anabtawi et al. 5 has shown that only 44% of general dental practitioners (GDPs) use RD for every tooth scheduled for endodontic treatment. This surprising finding indicates a clear discrepancy between the expected learning outcomes in higher dental education and attitude of GDPs before and after graduation. This article aims to discuss the prevalence of RD use amongst different countries. The role of education and attitude of GDPs and patients towards the application of RD is also analysed. Finally, critical ethical issues and considerations are discussed. LITERATURE SEARCH METHODOLOGY A PubMed electronic search was conducted spanning the period from January 1983 to April 2013 to iden- tify the available investigations written in the English language and published on the application of the RD in endodontic practice using the following keywords: ‘rubber dam’ AND ‘endodontic treatment’ OR ‘end- odontic therapy’ OR ‘root canal therapy’ OR ‘root canal treatment’ AND ‘prevalence’ OR ‘education’ OR ‘attitude’ OR ‘ethics’. After deleting duplicated © 2014 Australian Dental Association 457 Australian Dental Journal 2014; 59: 457–463 doi: 10.1111/adj.12210 Australian Dental Journal The official journal of the Australian Dental Association