Patient Satisfaction with Rubber Dam during Root Canal Treatment

Background: Patient satisfaction and convenience are an important factor root canal therapy. This study was conducted to evaluate the patient satisfaction with rubber dam during root canal treatment. Materials & Methods: This descriptive cross-sectional study was carried out on the patients referring to a private office of an endodontist (one of the researcher) in 2015. A total number of 70 patients were selected randomly and given a researcher made questionnaire base on satisfaction with rubber dam, consisting of demographic and satisfaction variables, after treatment to complete. Data analysis was performed at both descriptive and inferential levels. For descriptive statistics, the central tendency and dispersion measures along with box plot were applied and for inferential statistics, Mann-Whitney U and Kruskal-Wallis tests were used. Data were analyzed by SPSS-18 software. P<0.05 was considered significant. Results: Most of the participants were aged 25-35. Satisfaction level was not reported to be significant among different ages (p=0.246). Satisfaction with rubber dam among men was significantly higher than among women (p=0.05). Also, different education levels did not show a significant difference (p=0.581). Moreover, satisfaction was not found to be significantly different among different careers (p=0.67) and the majority of patients were satisfied with rubber dam. Conclusion: The results indicated most of the patients were satisfied with the use of rubber dam and men were reported to have a significantly higher satisfaction with it than women (p=0.5). However, no statistically significant difference was found between satisfaction with rubber dam and age, education and career.


Introduction
Rubber dam was introduced by Barnum in 1864 (Ahmad, 2009;Feierabend et al., 2011;Lin et al., 2014) and its application has been improved by dentists through different methods for over 145 years (Al-Abdulwahhab et al., 2012;Kolyaei et al., 2014;Lin et al., 2011 ).Rubber dam is the gold standard for root canal treatment owing to three major factors, including infection control, patient protection and effective treatment (Goldfein et al., 2013;Anabtawi et al., 2013;Hill et al., 2008;Ahmed et al., 2014).There are several advantages for the use of rubber dam during root canal treatments: preventing the possible aspiration of instruments, drugs, irrigation substances and dental debris, enhancing the treatment efficacy by increasing access to the treatment site and helps in retracting the gum, tongue, lips and cheek, reducing the penetration of irrigation solutions into oral cavity, especially those with an unfavorable taste like sodium hypochlorite, minimizing the patient speech during treatment and increasing the duration of mouth opening, isolating the tooth from saliva, increasing the vision and controlling infection (Casto et al., 20012;Lynch et al., 2007;Filipović et al., 2004).
However, few studies have been carried out on rubber dam.The results of these studies indicate that the dentist in United States make a little use of rubber dam (Anabtawi et al., 2013).Eleven percent of general dentists never use rubber dam and 58% utilize it only during root canal treatment.The results obtained in U.K indicate that other techniques like cotton roll are used instead of rubber dam (Anabtawi et al., 2013).Although general dentists believe that rubber dam isolates the given tooth from the rest of oral cavity and protects the patient's oral cavity during treatment, most of the newly-graduated general dentists wrongly assume that rubber dam is the only tool used for academic purposes in educational centers (Kolyaei et al., 2014;Lin et al., 2011).Further, the use of rubber dam by the experienced dentists has been waned; therefore, the incidence of rubber dam use has been reported to decline in many studies (Casto et al., 20012).A review of literature has revealed the major obstacles to the use of rubber dam, which include high cost, being time-consuming, inadequate training, problematic application, lack of patient acceptance, treatment and equipment costs and lack of patient cooperation (Al-Abdulwahhab et al., 2012;Casto et al., 20012).Moreover, anotherreason for non-application of rubber dam is that patients do not like it; however the other researcher has reported no problem regarding the patient acceptance of rubber dam (Stewardson et al., 2002).Kapitán et al., (2015) analyzed three systems of rubber dam and concluded that the majority of patients were more comfortable during treatment with rubber dam than when rubber dam was not used, and the patient comfort was not influenced by such factors as age, gender, treatment history by rubber dam, rubber dam type, and placement and treatment time of rubber dam.Kapitán et al. (2015) and Slaus et al. (2005) conducted a study to see whether patients had a negative attitude toward rubber dam or not.They found that most of the patients had no problem with rubber dam except that rubber dam limited their relationship with the dentist, women were reported to undergo higher levels of anxiety and smokers were more uncomfortable (Slaus et al., 2005) So far, few studies have investigated patient satisfaction with rubber dam.Analyzing patient satisfaction is one of the methods of attracting patient participation in treatment and care and patient dissatisfaction is a major cause of lack of referral or changing the dentist.Thus, the present study was carried out to determine patient satisfaction with rubber dam during root canal treatment.

Materials and Methods
In this descriptive cross-sectional study, 70 patients that visited the private office of an endodontist (one of the researcher) in Kermanshah city for root canal treatment were selected as the study sample.The inclusion criteria included willingness to participate in the study, minimum literacy, being older than 15years old, having good oral hygiene, having no history of allergy to latex and rubber dam was not used previously for their dental treatment.The patients who were not inclined to participate in the study lacked the inclusion criteria and mouth breathers were excluded from the study.All participants who completed the procedure under rubber dam were given a self-administered questionnaire about their satisfaction with rubberdam and were asked to complete and submit it in their next visit.An anesthesia was given prior to placement of the rubber dam and clamps in the first and second molars of mandible.The duration of the procedure was about one hour for all patients.All data was collected during three month.The corner of my lip is hurt because of the wound created on it.9 The research made questionnaire in native language (Persian) consisted of two sections; the first section included demographic information such as age, gender, education and career and the second section comprised of 9 questions formulated to evaluate patient satisfaction with rubber dam according to the studies conducted in this regard (Filipović et al., 2004).To determine the validity of the questionnaire, the views of three endodontists were used and applied.The reliability of the given questionnaire was calculated by Cronbach's alpha, reported to be 76%.To evaluate patient satisfaction, for each item, the score +1 was given to the responses indicating satisfaction and the score -1 was considered for the responses showing dissatisfaction.The scores of satisfaction ranged from -9 to +9.Data analysis was performed at two levels of descriptive and inferential statistics.For descriptive statistics, central tendency and dispersion parameters along with box plot were applied and for inferential statistics, Mann-Whitney and Kruskal-Wallis tests were run.The obtained data were analyzed by SPSS-18 software.P<0.05 was considered significant.

Results
Among the 70 patients studied, 22 (31.4%)patients were male and 48 (58.6%) of them were female.Most of the participants 26 (37.7%) were aged 25-35.In terms of education, 28 (40%) were under diploma and diploma, 32 (45.7%) had associate and bachelor degree holder and 10 (14.3%) had master or higher degree holder.Further, 2 (2.9%) of them were unemployed, 19 (27.1) were homemaker, 8 (11.4%) were student, 27 (38.6%)were employee and 14 (20%) were self-employed (Table 2).The results showed that most of the patients were satisfied with the details of using rubber dam (Table 3).About 65 (92.9%) of the samples did not have a feeling of suffocation.Only 6 (8.8%) of patients stated dental irrigation solution entered their mouth and 62 (91.2%) of them expressed satisfaction that irrigation solution did not enter their mouth.2 (3%) of patients asserted that their gum, where clamp was placed on, became sore.Only one (1.4%)patient with a history of herpes was reported to have ulcer recurrence following the use of rubber dam.Also, 6 (8.7%) of patients were found to develop sore at the corner of their lips due to stretching.
Rubber dam satisfaction between different age groups was not reported to be significant (p=0.246).However, satisfaction was found to be significant between males and females, males being more satisfied with rubber dam than women (p=0.5).There was no significant difference reported when comparing different education levels and rubber dam satisfaction (p=0.581).Furthermore, no significant difference was found among various careers (p=0.67).In addition, the median of patient satisfaction was reported to be 9 in general (maximum level of satisfaction), which indicated a high level of satisfaction with the use of rubber dam among patients (Table 4).

Discussion
Like any organization where consumer satisfaction is a relevant factor, in dental centers too, patient satisfaction plays a vital role in the quality of treatment (Levin, 2004).The factors affecting patient satisfaction include social characteristics, relationship between dentist and patient, treatment cost and characteristics of the healthcare system (Newsome et al., 1999;Tuominen et al., 1998;Freeman, 1999).The advantages of using rubber dam have been well recognized for both the dentists and patients during root canal treatments (Stewardson et al., 2002).The use of rubber dam is associated with the final outcome of treatment.About believes that lack of using rubber dam is one of the most important factors that cause long-term pain after root treatment (Filipović et al., 2004).
So far, few studies have been carried out on patient satisfaction with rubber dam.Further, patient satisfaction is one of the methods of attracting patient participation in healthcare and treatment and patient dissatisfaction is major cause of lack of referral or changing the dentist.Hence, the current research was performed to determine the patient satisfaction with rubber dam during root canal treatment.
In this study, a total of 70 patients requiring root canal treatment and with no history of having used rubber dam during dental treatment were given a researcher made satisfaction questionnaire at the end of the procedure and were asked to complete and submit it in their next visit.The data obtained from the questionnaires were fed into SPSS-18 software and analyzed using descriptive and inferential statistics.For descriptive analysis, central tendency and dispersion parameters along with box plot were used and for inferential statistics, Mann-Whitney and Kruskal-Wallis tests were applied.The significance level was set at 0.05.
The findings revealed that the majority of patients were satisfied with the rubber dam application during treatment.Satisfaction was not significant among different ages.However, satisfaction was found to be significantly different between males and females, males showing more satisfaction with rubber dam than females.Further, satisfaction was found to show no significant difference among different education levels.Satisfaction among various careers also indicated no significant difference.Moreover, the median of patient satisfaction was reported to be 9 generally (maximum level of satisfaction), which indicated a high satisfaction with rubber dam on the part of the patients.The results of the study by Stewardson (2002) analyzing patient attitude toward rubber dam showed that most of the patients preferred rubber dam for their following treatments and expressed a positive attitude toward their experience with rubber dam (Stewardson et al., 2002).
In addition, no significant difference was found between age, gender, treatment type (procedure) and time of rubber dam placement and duration of rubber dam use, and rubber dam preference.However, long-term use of rubber dam in some patients was accompanied by a negative view toward the experience.The best method recommended by the patients in this study to increase the acceptance of rubber dam was the frequent use of rubber dam by the dentist to obtain adequate skill in this regard (Stewardson et al., 2002).The findings of present study are in line with these results except that in the current study satisfaction level in men was reported to be significantly higher than that of the women.
In another study carried out by Filipović (2004), conducted to analyze patient attitude and effect of clinical factors, it was shown that the majority of patients (69.1%) preferred rubber dam for their subsequent treatments and had no negative attitude toward it.It was also found that the patient attitude toward rubber dam would be affected if rubber dam placement did not last long and dentist had sufficient skill (Filipović et al., 2004).The results of the study by Slaus et al. (2005), investigating whether rubber dam was a problem for the patient or dentist, showed that most of the patients had no problem except that rubber dam restricted their relationship with the dentist, women often experienced more anxiety and smokers were more uncomfortable (Slaus et al., 2005).Kapitán et al. (2015) evaluated three systems of rubber dam and concluded that the majority of patients were more comfortable during treatment with rubber dam than when rubber dam was not used, and patient comfort was not influenced by such factors as age, gender, history of treatment by rubber dam, type of rubber dam, time of rubber dam placement and treatment time (Kapitán et al., 2015).
As indicated in previous studies that dentist skill can increase rubber dam acceptance by the patients (Filipović et al., 2004;Stewardson et al., 2002) rubber dam placement in the present study was done by a skilled endodontist (one of the researcher) and most of the patients were satisfied with it.The median of patient satisfaction was calculated to be 9 in general (maximum level of satisfaction), indicating a high patient satisfaction with rubber dam.The results of this study and previous research indicated that the patients did not have a negative attitude toward rubber dam during treatment and patient satisfaction with rubber dam could be enhanced by selecting a proper clamp, explaining the reasons of using rubber dam and describing the advantages of rubber dam.

Conclusion
The results indicated that the majority of patients were satisfied with the use of rubber dam.No significant difference was reported between satisfaction with rubber dam and age, education and career.However, males were found to be significantly more satisfied with rubber dam than females.

Recommendations
Further studies with larger sample size in several academic centers and private offices are recommended to be carried out in the future to shed more light on this area of research.We recommend dentists should routinely use the rubber dam so as to gain skill in placing it quickly and effectively.

Table 1 .
Self-administered questionnaire: Age, gender, education and job

Table 3 .
Patient's satisfaction from the rubber dam based on questionnaire

Table 4 .
The patient's satisfaction based on age, gender, education, job and general satisfaction