Commentary

Clinical dental research has, at last, started to include patient-centred outcomes, as well as the more usual clinician-centred outcomes, and this paper continues this trend. One of the reasons given for using rubber dam, alongside patient safety and improvement of treatment outcomes and field of vision, is to enhance patient comfort during treatment. The authors report that there is little evidence to support this, and that their study is the first to do so.

The study looked at the stress to operator and patient, of fissure sealant placement under rubber dam, compared with cotton roll isolation, and reported less stress for both with the rubber dam. Yet few dentists use rubber dam isolation for fissure sealant placement in their child patients, even for restorative work.1 The 2009 Cochrane fissure sealant review2 included only one study reporting using ‘rubber dam if needed’, and neither current BSPD3 nor AAPD4 guidelines on fissure sealing mention its use in their recommendations. One possible reason is that the optimal time to seal teeth in high caries-risk children is soon after eruption, when placement can be problematic.

So, should this study lead clinicians to start using rubber dam isolation for fissure sealing? As reported, the operator's ‘personal preference for rubber dam is certainly a bias for the outcome of this study’, giving doubt as to whether it can be considered a ‘fair test’. Also, the conclusions don't seem to reflect the uncertainty in the results; although patients reported that subjective pain was lower for both sides of the mouth, none of their physiological outcomes reflected this. Pulse rate, skin resistance and blood pressure were not different between the rubber dam and cotton roll groups at any time points, and where there was a statistically significant difference on one side of the mouth, this was not found for the contralateral side. The only outcome measure in children consistently showing a statistically significant reduction for rubber dam over cotton rolls was their reports of subjective pain perception, but even this finding is complicated by the possibility that these were influenced by operator preferences.

What is most interesting about this paper is that from the operator's physiological measures and self-report he found cotton rolls more stressful to use and the children's results showed that they did not find either technique more stressful. Given the many advantages of rubber dam, this certainly merits consideration.