Operative Dentistry

Iatrogenic exfoliation of a tooth following abnse of a rubber dam:

a case report
Ami Smidt* / Jacob Ehrlich* *

This report presents a case in which tooth e.xfoiiation followed rubber dam abuse. A
40-year-old patient was refetred to the prosthodontic clinic with complaints of mobility
and discomfort in tooth 44. which had received an amalgatn restoration. While this
tooth was scaied, a piece of rubber dam appeared in the buccal sulcus. Removal of
the rubber piece was followed by thorough scaling and tooth splinting. Tooth deterio-
ration continued, and concern for the adjacent teeth necessitated extraction of tooth 44.
To avoid such undesirable consequences, the integrity of the dam should be verified
on its removal. (Quintessence Int 1992:23:15-18.)

Introduction Case report

The u.se of rubber dam is widespread in dentistry. The
rubber dam is used mainly to obtain a clean and dry
field during dental procedures, to retract gingival
tissues for improved access, and to prevent aspiration
or swallowing of dental instruments or materials.' In
addition, as a partial solution to current concerns
about disease transmission, the rubber dam provides
the dentist with protection agaitist airborne bacteria.
The dental literature includes a number of reports
on the periodontal hazards of the retention of pieces
of elastic materiais, such as orthodontic rubber elas-
tics," impression materials,' '' and rubber dam," in the
gingival sulcus. The purpose of this article is to present
a case in which a piece of rubber dam retained in the
gingival sulctjs led to tooth loss.
Clinical Instructor, Department of Prosthodontics, Hebrew
tjniversily, Hadassah School ot Dental Medieine, POBox 1172,
91ÛI0 Jerusalem, Israel.
Associate Professor, Department of Prosthodonlics, Hebrew
University.
A 4ü-year-old patient with a uoncontributory health
history was referred to the prosthodontic clinic for oral
rehabilitation. The patient had been treated I year
previously, at which time he received several amalgam
restorations, placed with tlie use of rubber dam. Follow-
ing the treatment of the mandibular right first pre-
molar (tooth 44), the patient had persistently eom-
plained of discomfort and increasing mobility of that
tooth. According to the patient, his complaints were
attributed to the new condition in the mouth and to
past plaque and calculus removal and were ignored by
the dentist.
Clinical examination of tooth 44 revealed significant
mobility, deep pockets, and gingival recession (Fig 1).
The radiograph showed severe localized bone résorp-
tion surrounding the tooth (Fig 2). A radiograph taken
1 year prior to the previous treatment indicated that
tooth 44 had proper bone support at that time (Fig 3).
In the prosthodontic elinie, as part of the initial
preparation prior to oral rehabilitation, sealing and
root planing were performed. During scahng with an
ultrasonic device, a black piece of elastic material
appeared in the buccal sulcus of tooth 44 (Fig 4). The
piece proved to be a part of a rubber dam (Fig 5). The
rubber piece was removed, the tooth was splinted, and
deep scaling and thorough root planing were performed.

Quintessence International Volume 23, Number 1/1992 15

Operative Dentistry

Fig 1 Lingual aspeet of tooth 44 at first clinical examina- Fig 2 Radiograph tai<en before scaiing showing reduced
tion. bone level around tooth 44.

Fig 3 Radiograph taken before previous treatment showing Fig 4 The buceal sulcus and the black foreign body ¡m-
adequate bone support surrounding toolh 44, mediately after exposure.

Fig 5 The piece of rubber dam that was in the suicus. Fig 6 Radiograph taken 2 months after the exposure of
the rubber piece In the sulcus.

16 Quintessence International Volume 23, Number 1/1992


No unusual findings were served, clinically or in the
radiographs taken following the exposure of the rubber
piece, except the great loss of bone and the gingival
recession (Fig 6),
Splinting the tooth to its adjacent healthy teeth and
elimination of occlusal contacts in all movemetits did
not improve the condition. After 1 year of constant
maintenance every 2 weeks, deterioration of the tooth
continued. Because of concern for the future of the
adjacent canine and premolar, tooth 44 was extracted.
The extraction did not reveal why the tooth did not
stabilize after the removal of the rubber dam piece.
Discussion
This case report focuses on possible localized destruction
of the periodontium caused by subgingivally retained
dental elastic material. Similar cases have been re-
ported in the dental literature in conjunction with
tninor tooih movement, retained impression material,
and rubber dam (although in those cases extraction
was not required).
The use of elastic bands as a technique for bloodless
extraction of teeth in hemophiliac patients was des-
cribed in the 1930s by Dahtsch*"' and Birch and Snider,"
In 1952, Massler and Aguirre' offered some situations
iu which the use of elastic bands for teeth exfoliation
might be preferred to extraction. Bloodless extractioti,
describes exfoliation of teeth by means of orthodontic
elastic bands that are placed subgingivally. This method
is based on the elasticity of the rubberband and its
tendency to slide on an inclined plane from a greater
to a lesser diameter. The elastic band, in its tendency
to move toward the narrower diameter of the root,
exerts pressure, resulting in atrophy of the periodontal
attachment, which leads to tooth exfoliation without
hleeding. Birch and Snider" estimated the procedure
to take from 4 to 109 days.
Cases of bone loss around teeth induced by improper
use of elastic bands for space maintenance or closure
of diastemata have been reported,'"
Impression materials are frequently used in restora-
tive procedures. Tissue irritation or significant injury
may result from a patient's allergy or an operator's
error, and sometimes the tissue reaction is irreversible.
The problems after placement of the impression ma-
terial in the gingival sulcus generally are mechanical,
chemical, and thermal injuries and allergic reactions.
The most common is the mechanical injury that results
from the penetration of the impression through the sul-
cus, creating a pocket. But the response of the tissue to
Quintessence International Volume 23, Number 1/1992
operative Dentistry
a foreign body, thermal burn,s following improper use
of reversible hydrocolloid impression material, and al-
lergies also oceur.
These problems are most often associated with sub-
gingival preparations. Proper registration of these
preparations dictates adequate retraction followed by
immediate injection with pressure into the crevice.
However, it can never be known for sure that no piece
of material is left deep in the tissues after the removal
of the impression,'' Although polysulfide impression
material is considered more irritating than polyethers,
silicones or vinyl polysiloxanes, the risk of embedment
still exists, mainly because of the technique that is
used and not the material.^
Techniques for inducing periodontal lesions in vaiious
animal models are known and have been used by several
investigators,""" Use of either a ligature placed in the
gingival sulcus of a tooth or orthodontic elastics will
result in marginal periodontitis with some of the
characteristics of a destructive lesion.
In this case, the factor affectiug the periodontium
was the rubber dam, A bandiike piece of rubber dam
was left hidden around the treated tooth. The patient's
complaints were ignored, and pressure atrophy took
place, resulting in a partial bloodless extraction.
Two aspects made the correct diagnosis difficult.
The fact that the rubber dam is radiolucent made any
attempts to detect it through radiographs impossible,
and the relative health of the surrounding gingiva of
the tooth and absence of bleeding masked the pressure
atrophy. The bandUke piece of rubber left undetected
around the tooth caused irreversible destructive
changes in the attachment apparatus of the tooth.
Although the piece was removed, it was too late to
preserve the tooth, as no improvement or stabihzation
in its status was observed.
The advantages in using rubber dam are clear, but
the hazards should not be ignored. Thus, safe removal
of the dam can be executed by using a curved scalpel
or a scissors to cut each interproximal section after the
rubber is pulled out to the side. Attempts to pull the
interproximal parts occlusally are not advisable in
cases of tight tooth contacts. The integrity of the rubber
dam should be verified on its removal from the mouth
by checking for any potentially missing rubber dam
pieces, Delection of tears or missing pieces should act
as a "red flag," and a search should be instituted in the
sulcus of the respective tooth.
17
Operative Dentistry
References
1. Heling 1. Sommer M, Ko! 1: Rubber dam — an essential
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menl of an clastic b;ind: report of a case. J Periodonlol t9B8;
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3. Kern WA, Shillingburg HT. Tow HD; Impression m;itcrial
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hazards of retained impression materials. Quimesser\ce ¡m
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Assoc iy34;21:t804.
7. Dalitsch WW: Removal of teeth by exfoliation with elastic
ligatures. Dem Digest 1939;45:3tÜ.
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Periodomoi 1980;51:6. •
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