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1 Rubber dam use during root canal treatment Findings from The Dental Practice-Based Research Network Mona F. Anabtawi, DDS, MS; Gregg H. Gilbert, DDS, MBA; Michael R. Bauer, DDS; Gregg Reams, DMD; Sonia K. Makhija, DDS, MPH; Paul L. Benjamin, DMD; O. Dale Williams, MPH, PhD; for The National Dental Practice-Based Research Network Collaborative Group The rubber dam has been used in dental care for decades. It is considered the reference standard in root canal treatment (RCT) because of the advantages that it offers with regard to infection control, patient protection and treatment efficacy. 1-4 Nonetheless, its use during RCT is hardly ubiquitous; studies have observed wide ranges of usage The results of the small number of studies of dentists in the United States have shown some low usage rates. 7,13,20 The investigators of the most recent study found that 11 percent of general dentists never used a rubber dam during RCT and only 58 percent used one during every RCT. 7 The results of a study in England regarding whether dentists use other isolation methods during RCT showed that the use of cotton rolls without a rubber dam also was common. 10 The Dental Practice-Based Research Network (DPBRN) was a consortium of dental practices with a broad representation of practice types, dentists and treatment philosophies that conducted research with the ultimate goal of improving A B S T R A C T Background. The Dental Practice-Based Research Network (DPBRN) provided a means to investigate whether certain procedures were performed routinely. The authors conducted a study to quantify rubber dam use during root canal treatment (RCT) among general dentists and to test the hypothesis that certain dentist or practice characteristics were associated with rubber dam use. Methods. DPBRN practitioner-investigators (P-Is) answered a questionnaire that included items about rubber dam use and other forms of isolation during RCT. DPBRN enrollment questionnaire data provided information regarding practitioner and practice characteristics. Results. A total of 729 (74 percent) of 991 P-Is responded; 524 were general dentists who reported providing at least some RCTs and reported the percentage of RCTs for which they used a rubber dam. Of these 524 P-Is, 44 percent used a rubber dam for all RCTs, 24 percent used it for 51 to 99 percent of RCTs, 17 percent used it for 1 to 50 percent of RCTs, and 15 percent never used it during RCT. Usage varied significantly by geographic region and practice type. The use of cotton rolls and other forms of isolation also was reported. Conclusions. Similar to other reports in the literature, not all DPBRN general dentists used a rubber dam during RCT. Clinical Implications. Because the clinical reference standard is to use a rubber dam during RCT, increasing its use may be important. Key Words. Rubber dam; root canal treatment; practice-based research; dentistry. JADA 2013;144(2): C O N T J I N U A I N G D A ARTIC LE 4 I O N E D U C A T Dr. Anabtawi is a program manager, Department of Medicine, School of Medicine, University of Alabama at Birmingham. She was an instructor, Department of General Dental Sciences, School of Dentistry, University of Alabama at Birmingham, when this article was written. Dr. Gilbert is a professor and the chair, Department of Clinical and Community Dental Sciences, School of Dentistry, University of Alabama at Birmingham, SDB Room 109, rd Ave. South, Birmingham, Ala , ghg@uab.edu. Address reprint requests to Dr. Gilbert. Dr. Bauer is a general dentist, Health Partners Dental Group, Minneapolis. Dr. Reams is an endodontist, Permanente Dental Associates, Portland, Ore. Dr. Makhija is an associate professor, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham. Dr. Benjamin is in private practice of general dentistry, Miami. Dr. Williams is a professor and the chair, Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami. JADA 144(2) February

2 quality of care in dental practices It comprised practitioner-investigators (P-Is) and staff members in outpatient dental practices mainly from five regions: Alabama/Mississippi (AL/MS); Florida/Georgia; Minnesota, encompassing dentists employed by HealthPartners Dental Group (HPDG), Minneapolis, or in private practice; Permanente Dental Associates (PDA), in cooperation with Kaiser Permanente s Center for Health Research, Portland, Ore.; and the Scandinavian countries Denmark, Norway and Sweden. Additional P-Is also were recruited in other U.S. states. The DPBRN provided a means to investigate whether certain dental procedures were performed routinely in everyday clinical practice. The results of a 2010 DPBRN study about restorative dentistry showed that 63 percent of P-Is did not use a rubber dam for any dental restorations. 27 As part of an overall effort to quantify the DPBRN s infrastructure capabilities, DPBRN had an opportunity to include in a questionnaire items about the use of a rubber dam during RCT. We conducted this study to quantify among general dentists who reported providing at least some RCT the percentage of DPBRN P-Is who indicated that they used a rubber dam during RCT, to quantify the percentage who reported using some other form of isolation during RCT and to test the hypothesis that certain dentist or practice characteristics were associated with use of a rubber dam during RCT. METHODS DPBRN recruitment process. We recruited P-Is into The DPBRN at continuing education courses and through mass mailings to licensed dentists from the participating regions. The DPBRN completed a total of 22 studies, which included a broad range of study designs, topic areas and enrollment sizes. 23,28 Although most DPBRN studies involved data collection from dental patients, some studies used only questionnaires. The data for this study were collected and the original manuscript was prepared under the auspices of The DPBRN. That organization evolved into The National Dental Practice- Based Research Network, under the aegis of which we prepared the final version of this article. Study design. This was a cross-sectional study, consisting of a single administration of the Infrastructure Update Survey to all DPBRN P-Is who had participated in one or more DPBRN studies of any type and who were in practice with an active practice address (that is, still practicing at that address). We collected data from December 2010 through May This study was approved by the human participants institutional review board at the University of Alabama at Birmingham and all of The DPBRN s regional institutional review boards. All participants who participated in this study provided informed consent after we fully explained the nature of the procedures. Main questionnaire content. Questions about rubber dam use were included in a questionnaire designed to provide updated information about certain infrastructure capabilities of DPBRN. The questionnaire is publicly available. 29 The main questions of interest for our study were as follows: the first was Do you personally do any root canal procedures? ; those who responded in the affirmative were asked, On what percent of these root canals do you estimate that you use a rubber dam? and Do you use any other type of isolation? and if yes, please specify. DPBRN enrollment questionnaire. Since 2005, as part of enrollment in DPBRN, P-Is completed a 101-item enrollment questionnaire about their practice characteristics and themselves. The distribution of these characteristics for DPBRN dentists has been reported previously. 24,25 Among other items, this questionnaire included practice location, type of practice (solo private practice; group private practice, not HPDG or PDA; HPDG or PDA; public health practice, community health center or publicly funded clinic; or other type), whether the dentist was a generalist or specialist, year of graduation from dental school, and the dentist s sex, race and ethnicity. Data collection process. Before full implementation of the survey, 34 practitioners and DPBRN staff members pretested the questionnaire to assess the feasibility and comprehension of each questionnaire item, as well as its online administration. The DPBRN central office staff members sent by means of postal mail preprinted invitation letters to eligible practitioners, inviting them to participate and to provide them with a unique identification number and log-in code to complete the online survey. P-Is were asked to complete the questionnaire within three weeks. DPBRN staff mem- ABBREVIATION KEY. AL/MS: Alabama/Mississippi. DPBRN: Dental Practice-Based Research Network. HPDG: HealthPartners Dental Group. PDA: Permanente Dental Associates. P-Is: Practitionerinvestigators. RCT: Root canal treatment. 180 JADA 144(2) February 2013

3 bers sent a reminder letter after the fourth week to P-Is who had not completed the questionnaire. After an additional four weeks, a final reminder was sent, and this time a printed version of the questionnaire was included and practitioners were offered the option of completing the online or paper version of the questionnaire (87 [12 percent] of 729 practitioners completed the paper version instead of the online version). Data collection was closed after a final threeweek waiting period. Practitioners or their business entities received remuneration in the amount of $50 for completing the questionnaire at the end of the survey if they requested it. Statistical methods. All analyses were done using statistical software (SAS/STAT Version 9.2, SAS Publishing, Cary, N.C.). Statistical significance was assumed for P <.05. In addition to quantifying frequency distributions, we conducted bivariate cross-tabulations to examine the associations between rubber dam use and certain dentist and practice characteristics, using χ 2 and Mantel-Haenszel χ 2 trend tests for statistical significance or Fisher exact test extension for contingency tables in case of small cell sizes. We conducted analyses by using multiple logistic regression to examine simultaneously the effect of explanatory variables (for example, practice type, year of graduation) on the outcome (use of a rubber dam during RCT) after adjusting for the effect of other explanatory variables. Because data regarding use of a rubber dam was coded by using a four-point ordinal scale (none, 1-50 percent, percent, 100 percent), we conducted a preliminary ordinal logistic regression by using that scale. However, the proportional odds assumption required for ordinal logistic regression was violated, so we coded the outcome by using a threepoint scale (none, 1-99 percent, 100 percent). By using this three-point ordinal outcome, the proportional odds assumption was no longer violated. Because type of practice and DPBRN region were redundant for some regions, we did not include both variables in a single regression owing to multicollinearity. There were five types of practice in our study. The results of preliminary logistic regressions showed that one practice type (HPDG or PDA) had a substantially different effect magnitude than did the other practice types. Consequently, we thereafter coded type of practice dichotomously as HPDG/ PDA or not HPDG/PDA. We adjusted preliminary regressions for the following variables: dentist s year of graduation, sex, race and ethnicity. We found that none of these variables were statistically significant nor did they im- prove model fit, and we excluded them from subsequent analyses. The multivariable regression became a regression with only one explanatory covariate (type of practice). RESULTS Characteristics of dentists who reported providing RCTs. Of 1,007 P-Is invited to participate, we determined that 16 were ineligible (13 retired or sold their practice, two no longer had an active practice address, and one was deceased). Of the remaining 991 P-Is, 74 percent (n = 729) completed the questionnaire or almost all of it. Differences in characteristics between respondents (n = 729) and nonrespondents (n = 262) were not statistically significant with regard to the dentist s sex or year of graduation from dental school. P-Is in the AL/MS region had a significantly lower response rate (67 percent; P <.01, χ 2 test) than did those in the other regions combined (79 percent). Of the 729 P-Is who completed the questionnaire, 554 (76 percent) responded Yes to the question about whether they perform any RCTs, and 553 also reported the percentage of RCT procedures in which they use a rubber dam. Of these 553 dentists, 14 were endodontists and 15 reported that they were another type of specialist. All of the endodontists reported that they use a rubber dam for 100 percent of the root canal procedures that they performed. Of the 15 other specialists, one (7 percent) said that a rubber dam was used none of the time, three (20 percent) said a rubber dam was used 1 to 50 percent of the time, four (27 percent) said a rubber dam was used 51 to 99 percent of the time, and seven (47 percent) said a rubber dam was used 100 percent of the time. The remaining 524 dentists, all of whom were general dentists, were the focus of the remainder of our study. Their characteristics are shown in Table 1. Use of a rubber dam and dentist and practice characteristics. A total of 229 P-Is (44 percent) reported that they use a rubber dam for all RCTs they provide (Table 2, page 183), and 80 (15 percent) reported that they do not use a rubber dam for any of the RCTs that they provide. Table 2 also shows rubber dam according to certain dentist and practice characteristics. We found a statistically significant association between the DPBRN region and rubber dam use, with the highest use occurring in PDA or other West region practices ( other West region practices are those in western states that are not PDA practices), and the lowest use occurred in the AL/MS region. We also observed signifi- JADA 144(2) February

4 TABLE 1 Characteristics of general dentist practitioner-investigators included in the analysis of rubber dam use (n = 524). CHARACTERISTIC (N) PERCENTAGE* Dental Practice-Based Research Network Region Alabama/Mississippi (196) 37 Florida/Georgia (117) 22 Other Southeast (39) 7 Midwest or Northeast (69) 13 PDA or other West (47) 9 Scandinavia (56) 11 Missing (0) Type of Practice Solo private practice (263) 50 Group private practice, not HPDG 30 or PDA (156) HPDG or PDA (72) 14 Public health practice, community health 5 center or publicly funded clinic (26) Other type (7) 1 Missing (0) Year of Graduation From Dental School Before 1970 (14) (132) (176) (111) or later (91) 17 Missing (0) Sex of Dentist Male (408) 78 Female (116) 22 Missing (0) Race of Dentist White (435) 89 Nonwhite (54) 11 Missing (35) Hispanic/Latino Ethnicity of Dentist Non-Hispanic (413) 96 Hispanic (15) 4 Missing (96) * The percentages in each section may not add up to 100 percent owing to rounding. PDA: Permanente Dental Associates. Dash indicates not applicable. HPDG: HealthPartners Dental Group. cant associations between rubber dam use and practice type, as well as between rubber dam use and year of graduation from dental school. The results of the ordinal logistic regression using the three-point outcome scale (none, 1-99 percent, 100 percent) exhibited a modest model fit (area under a receiver operating characteristic curve = 0.59; likelihood ratio χ 2 = 67.4; P <.001). The type-of-practice variable (HPDG/ PDA or not HPDG/PDA) was statistically significant, with a large effect (odds ratio = 10.1; 95 percent confidence interval = ). We included no other variables because they were not statistically significant and did not improve model fit. Other types of isolation used during RCTs. In addition to using a rubber dam, P-Is reported using other forms of isolation. Of the 524 general dentists who performed RCT and reported the percentage of time in which they use a rubber dam, 204 (39 percent) dentists reported using at least one other type of isolation in addition to reporting whether or not they used a rubber dam. We recoded these openended responses into three categories: cotton rolls or gauze, a dry-field illuminator (Isolite, Isolite Systems, Santa Barbara, Calif.) and all others. We evaluated responses from the 204 dentists who reported using at least one other type of isolation by dividing the dentists into three groups: practitioners who reported never using a rubber dam (n = 53), practitioners who reported using a rubber dam but in less than 100 percent of RCTs (n = 126) and practitioners who reported using a rubber dam during all RCTs (n = 25). Among the 53 practitioners who reported never using a rubber dam, 44 reported using cotton rolls or gauze, eight reported using Isolite, and one reported using another type of isolation. Among the 126 practitioners who reported using a rubber dam but in less than 100 percent of RCTs, 95 reported using cotton rolls or gauze, 13 reported using Isolite, and 18 reported using some other method of isolation. Among the 25 practitioners who reported using a rubber dam during all RCTs, seven reported also using cotton rolls or gauze, four reported also using Isolite, and 14 reported using some other isolation method in addition to a rubber dam. DISCUSSION Use of a rubber dam overall. Rubber dam isolation is considered the standard of care for RCT by the American Association of Endodontists. 4 However, only 44 percent of general dentists in our study reported that they always used a rubber dam during RCT, with another 24 percent indicating that they used it more than onehalf of the time. Investigators in previous studies have reported a broad range of rates of rubber dam usage, 5-20 and the finding in our study is within this range. For example, the results of a study of RCT among practitioners in the United Kingdom showed that less than JADA 144(2) February 2013

5 percent of practitioners ever used a rubber dam during RCT; 45 percent reported that they never used a rubber dam. 9 The investigators of a study in England found that 63 percent of respondents never used a rubber dam during RCT. 10 In a study of Belgian dentists, 65 percent reported never or seldom using a rubber dam, and only 7 percent used a rubber dam in all RCT cases. 11 In a national survey of general dentists in New Zealand, a rubber dam was used routinely during RCT by 57 percent of practitioners. 15 Association between rubber dam use and certain dentist or practice characteristics. We observed significant variation in rubber dam use across our DPBRN regions, although region was confounded with practice type because in two DPBRN regions (Minnesota and the PDA or other West region) most of the P-Is were in a large group practice (more than three dentists in a practice). We observed substantially higher rubber dam use among HPDG and PDA dentists (as shown in Table 2 and in the logistic regression results), even though P-Is in other group practices in The DPBRN reported rubber dam use at rates similar to those in solo private practice or public health clinics. One reason for higher use among dentists in HPDG and PDA may be that these groups had a high level of peer review that occurred within the dentist s TABLE 2 RCTs* in which a rubber dam is used, according to characteristic (n = 524). CHARACTERISTIC (n) RCTs IN WHICH A RUBBER DAM WAS USED, NO. (%) None Overall 80 (15) 90 (17) 125 (24) 229 (44) Dental Practice-Based Research Network Region Alabama/Mississippi (196) 50 (26) 48 (25) 52 (27) 46 (23) Florida/Georgia (117) 13 (11) 18 (15) 29 (25) 57 (49) Midwest or Northeast (69) 4 (6) 6 (9) 18 (26) 41 (59) Other Southeast (39) 3 (8) 5 (13) 9 (23) 22 (56) PDA or other West (47) 0 (0) 0 (0) 2 (4) 45 (96) Scandinavia (56) 10 (18) 13 (23) 15 (27) 18 (32) Type of Practice Solo private practice (263) 42 (16) 58 (22) 69 (26) 94 (36) Group private practice, not HPDG or PDA (156) 34 (22) 25 (16) 37 (24) 60 (38) HPDG or PDA (72) 0 (0) 1 (1) 10 (14) 61 (85) Public health practice, community health center or 2 (8) 5 (19) 8 (31) 11 (42) publicly funded clinic (26) Other type (7) 2 (29) 1 (14) 1 (14) 3 (43) Year of Dental School Graduation Before 1970 (14) 7 (50) 4 (29) 0 (0) 3 (21) (132) 22 (17) 19 (14) 35 (27) 56 (42) (176) 25 (14) 34 (19) 44 (25) 73 (41) (111) 15 (14) 24 (22) 24 (22) 48 (43) 2000 or later (91) 11 (12) 9 (10) 22 (24) 49 (54) Sex of Dentist Male (408) 63 (15) 72 (18) 97 (24) 176 (43) Female (116) 17 (15) 18 (16) 28 (24) 53 (46) Race of Dentist Nonwhite (54) 7 (13) 6 (11) 14 (26) 27 (50) White (435) 70 (16) 77 (18) 107 (25) 181 (42) Missing (35) 3 (9) 7 (20) 4 (11) 21 (60) Hispanic/Latino Ethnicity of Dentist Hispanic (15) 1 (7) 2 (13) 6 (40) 6 (40) White (413) 63 (15) 73 (18) 98 (24) 179 (43) Missing (96) 16 (17) 15 (16) 21 (22) 44 (46) * RCTs: Root canal treatments. P <.05; the association between the characteristic and percentage of RCTs in which the dentist uses a rubber dam is statistically significant. Missing data were excluded before the statistical test was done. The following variables had no missing data: Dental Practice-Based Research Network region, type of practice, type of dentist, year of dental school graduation and sex of dentist. The data in this table are limited to the 524 general dentists who reported providing at least some RCTs and who reported the percentage of RCTs in which they used a rubber dam. PDA: Permanente Dental Associates. HPDG: HealthPartners Dental Group. Not statistically significant. own practice organization, which reinforced the reference standard. In addition, because training and emphasis may be different between U.S. and Scandinavian dentists in The DPBRN, we considered limiting this report to U.S. dentists only. However, the results with or without the Scandinavian dentists were substantively the same, leading to the same conclusions from the results. For example, when we excluded the JADA 144(2) February

6 Scandinavian dentists, 70 (15 percent) P-Is reported never using a rubber dam, 77 (16 percent) P-Is used it from 1 to 50 percent of the time, 110 (24 percent) P-Is used it from 51 to 99 percent of the time, and 211 (45 percent) P-Is used it all the time. These findings are similar to the overall percentage distribution shown in Table 2. The literature provides little guidance about the possible role of practice type on rubber dam use. The results of a National Health Insurance System study conducted in Taiwan indicated that rubber dam usage was significantly higher in hospital settings than in private dental clinics. 17 Practitioners in group practices used a rubber dam more than did those in solo practices. 15,30 However, a higher use of rubber dams in private practices was reported when compared with that in mixed practices (mix of private and public patients) and National Health Services practices (68 percent, 55 percent, 45 percent), respectively. 5 We observed that rubber dam use was universal among the 14 endodontists in The DPBRN, which was much higher than that among general dentists and other specialists. Although investigators in few studies have studied this topic, the investigators of a U.S. national study conducted in 1994 observed that 92 percent of endodontists always used a rubber dam compared with 59 percent of general dentists. 13 We did not have information from our respondents regarding whether they had advanced training, such as that from a general practice residency or advanced education in general dentistry program, and, therefore, we could not determine if advanced training among the general dentists was associated with higher rates of rubber dam use. Attendance at continuing education courses about this topic also could influence rubber dam use, but we did not measure that. It also is possible that rubber dam use is higher among general dentists who have their dental assistants place the rubber dam for RCT and other procedures. Dentists in The DPBRN who graduated since 2000 were significantly more likely to have reported rubber dam use than were those who graduated earlier, although its use among dentists who graduated in 2000 or later still was only 54 percent. Graduation year was not statistically significant in multivariable regressions that included the type-of-practice variable. Other investigators observed higher use of rubber dams among recent graduates in studies published in and Investigators in a U.K. 5 and an Irish 19 study found similar findings within the groups of practitioners who were younger than 40 years. These findings are in contrast with those of another study that showed a trend of older practitioners using rubber dams more than did their younger counterparts. 9 It is possible that many of the general dentists in our study performed RCTs only on anterior teeth and referred patients to endodontists for all RCTs in posterior teeth. Perhaps these general dentists would have used rubber dams on posterior teeth if they provided that type of treatment. Another possible explanation for low rubber dam use is that the general dentists in this sample used rotary endodontic instruments when providing RCTs. With rotary instrumentation, files are attached to a handpiece. Although this circumstance would decrease the likelihood of a patient s aspirating or ingesting a file, the other reasons for using a rubber dam namely, infection control and treatment effectiveness are not obviated. In addition, rotary instrumentation is supplemented with hand files. Other forms of isolation. In our study, other than using a rubber dam, the most common method used for isolation was cotton rolls or gauze squares. This finding is consistent with that of a study conducted in 2009 that indicated that 37 percent of respondents used a rubber dam in some patients, 29 percent used cotton rolls alone or with some other form of isolation, and 3 percent did not use any form of isolation. 10 A total of 25 general dentist practitioners reported using Isolite, a device that simultaneously provides light, suction, retraction and aspiration prevention. We are not aware of any studies in which investigators compared the safety, comfort and effectiveness of this device with those of a rubber dam, although one opinion piece has been published. 31 Our study had certain limitations, and conclusions made from it should take them into account. The main limitation is that the study design relied on information from the questionnaire rather than information based on direct observation of procedures. In addition, although the response rate was good, it is possible that nonrespondents would have reported different behavior. Furthermore, although DPBRN P-Is have much in common with dentists at large, 24,25 it is possible that their RCT procedures might not be representative of dentists at large. Although we measured rubber dam use by using a four-point ordinal scale (none, 1-50 percent, percent, 100 percent), we had to conduct a multivariable regression analyses by means of a 184 JADA 144(2) February 2013

7 three-point scale (none, 1-99 percent, 100 percent), which could have affected these results. Rubber dam use reduces the potential for patients swallowing or inhaling materials or objects used during RCT, as well as pieces of tooth structure, restorative material or necrotic tissue dislodged during access preparation In addition to patient safety and occupational safety benefits, better infection control and treatment effectiveness have been reported. 1-3 For these reasons, use of a rubber dam during RCT is considered the reference standard. CONCLUSION Although they have much in common with dentists at large, DPBRN P-Is may be more attuned to the role scientific evidence plays in everyday clinical practice and be more open to incorporating it. 21,23,37,38 However, even among these practitioners, the use of a rubber dam during RCT is not universal. Our finding of high levels of rubber dam use among certain subgroups was encouraging. The results of previous research from DPBRN suggest that dentists who are performing procedures in a manner consistent with the latest scientific evidence can act as change agents to encourage adoption by their colleagues 38 ; this circumstance may provide guidance as to how to improve rubber dam usage among the group at large. Disclosure. None of the authors reported any disclosures. This investigation was supported by grants U01-DE-16746, U01-DE and U19-DE from the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md. The authors are grateful for the data analysis by Dr. Abu Faisal Hasme and for input from Dr. Paul Eleazer at the University of Alabama at Birmingham. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. The National Dental Practice-Based Research Network Collaborative Group comprises practitioner-investigators and faculty and staff investigators who contributed to this DPBRN activity. Lists of these people are available at fckeditor/file/infrastructure%20update%20survey.pdf and nationaldentalpbrn.org/tyfoon/site/fckeditor/file/ius-faculty% 20and%20staff(1).pdf, respectively. 1. Ahmad IA. A Rubber dam usage for endodontic treatment: a review. Int Endod J 2009;42(11): European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of European Society of Endodontology. Int Endo J 2006;39(12): Johnson WT, Williamson AE. Chapter 14: Isolation, endodontic access, and length determination. In: Torabinejad M, Walton RE. Endodontics: Principles and Practice. 4th ed. St. Louis: Saunders/ Elsevier; 2009: American Association of Endodontists. AAE position statement: dental dams &terms=dental%20dams. Publications_and_Research/Guidelines_and_Position_Statements/ dentaldamstatement.pdf. Accessed March 27, Accessed Nov. 30, Soldani F, Foley J. An assessment of rubber dam usage amongst specialists in paediatric dentistry practising within the UK. Int J Paediatr Dent 2007;17(1): Marshall K, Page J. The use of rubber dam in the UK: a survey. Br Dent J 1990;169(9): Hill EE, Rubel BS. Do dental educators need to improve their approach to teaching rubber dam use? J Dent Educ 2008;72(10): Whitworth JM, Seccombe GV, Shoker K, Steele JG. Use of rubber dam and irrigant selection in UK general dental practice. Int Endod J 2000;33(5): Jenkins SM, Hayes SJ, Dummer PM. A study of endodontic treatment carried out in dental practice within the UK. Int Endod J 2001;34(1): Palmer NO, Ahmed M, Grieveson B. An investigation of current endodontic practice and training needs in primary care in the north west of England. Br Dent J 2009;206(11):E22. doi: /sj.bdj Hommez GM, Braem M, De Moor RJ. 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J Formos Med Assoc 2011;110(6): Saunders WP, Chestnutt IG, Saunders EM. Factors influencing the diagnosis and management of teeth with pulpal and periradicular disease by general dental practitioners, part 2. Br Dent J 1999; 187(10): Lynch CD, McConnell RJ Attitudes and use of rubber dam by Irish general dental practitioners. Int Endod J 2007;40(6): Hagge MS, Pierson WP, Mayhew RB, Cowan RD, Duke ES. Use of rubber dam among general dentists in the United States Air Force dental service. Oper Dent 1984;9(4): Gilbert GH, Williams OD, Rindal DB, Pihlstrom DJ, Benjamin PL, Wallace MC; DPBRN Collaborative Group. The creation and development of The Dental Practice-Based Research Network. JADA 2008;139(1): Gilbert GH, Qvist V, Moore SD, et al; DPBRN Collaborative Group. Institutional review board and regulatory solutions in the dental PBRN. J Public Health Dent 2010;70(1): Gilbert GH, Richman JS, Gordan VV, et al; DPBRN Collaborative Group. Lessons learned during the conduct of clinical studies in the dental PBRN. J Dent Educ 2011;75(4): Makhija SK, Gilbert GH, DB Rindal, Benjamin PL, Richman JS, Pihlstrom DJ; DPBRN Collaborative Group. Dentists in practicebased research networks have much in common with dentists at large: evidence from the Dental Practice Based Research Network. Gen Dent 2009;57(3): Makhija SK, Gilbert GH, Rindal DB, et al; DPBRN Collaborative Group. Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large. BMC Oral Health 2009;9: Dental Practice-Based Research Network. Accessed Nov. 30, Gilbert GH, Litaker MS, Pihlstrom DJ, Amundson CW, Gordan VV; DPBRN Collaborative Group. Rubber dam use during routine operative dentistry procedures: findings from the dental PBRN. Oper Dent 2010;35(5): Dental Practice-Based Research Network. Research studies. Accessed Nov. 30, Dental Practice-Based Research Network. 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8 stionnaire%20_version%20of% _.pdf. Accessed Jan. 2, Joynt RB, Davis EL, Schreier PH. Rubber dam usage among practicing dentists. Oper Dent 1989;14(4): Wahl P, Andrews T. Isolation: a look at the differences and benefits of rubber dam and Isolite. Endo Practice 2010;3(2): Thomsen LC, Appleton SS, Engstrom HI. Appendicitis induced by an endodontic file. Gen Dent 1989;37(1): Kuo SC, Chen YL. Accidental swallowing of an endodontic file (published online ahead of print May 12, 2008). Int Endod J 2008; 41(7): doi: /j x. 34. Silva RF, Martins EC, Prado FB, Júnior JR, Júnior ED. Endoscopic removal of an endodontic file accidentally swallowed: clinical and legal approaches (published online ahead of print Dec. 15, 2009). Aust Endod J 2011;37(2): doi: /j x. 35. Susini G, Pommel L, Camps J. Accidental ingestion and aspiration of root canal instruments and other dental foreign bodies in a French population (published online ahead of print May 26, 2007). Int Endod J 2007;40(8): doi: /j x. 36. Govila CP. Accidental swallowing of an endodontic instrument: a report of two cases. Oral Surg Oral Med Oral Pathol 1979;48(3): Benjamin P; The DPBRN Collaborative Group. Promoting evidence-based dentistry through The Dental Practice-Based Research Network. J Evid-Based Dent Pract 2009;9(4): doi: / j.jebdp Gilbert GH, Richman JS, Qvist V, Pihlstrom DJ, Foy PJ, Gordan VV; DPBRN Collaborative Group. Change in stated clinical practice associated with participation in The Dental Practice-Based Research Network. Gen Dent 2010;58(6): JADA 144(2) February 2013