Are You Tired of Wrestling with Retraction Cord?

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing the typical protocols, challenges, and nuances of tissue management and retraction for final impressions. Our guest is Dr. Foroud Hakim, who holds a full-time position in the Department of Preventive and Restorative Dentistry at University of the Pacific. He has maintained a private practice for over 30 years where his deep ties with the dental industry allow for beta testing and consulting for new product evaluation and development. Dr. Hakim will share some intriguing new products that every restorative dentist should have in their toolbox that can simplify what is often considered one of the more frustrating processes in patient treatment. Dr. Hakim, it's a pleasure to have you on Dental Talk. Phil, it's great to be here. I always love spending time with you. Before we get started, I would like to let our audience know that Dr. Hakim will be presenting a live webinar on June 1st at 7 p.m. Eastern Time, 4 p.m. Pacific. The title is, If First Impressions Are the Most Important, Why Do They Seem Impossible? I love the title. You can register for this free live webinar on VivaLearning.com. You can register for this free live webinar on VivaLearning.com and at the same time earn live interactive credit. Today we're going to be talking about retraction cord and more on the side of impressions. What are four primary techniques for tissue management and retraction currently employed by practitioners? Yeah, that's a great way to start this, Phil. While there's always one-off techniques, probably if you surveyed a big group, the four most common techniques, number one is always using mechanical retraction. That's used with cord and some kind of a hemostatic solution in tandem with each other. Option two is these cord alternatives that really started to kind of permeate in the market in the last couple of decades. There are various types of paste and gels. Option three is using a laser, diode laser, and doing some troughing, cauterization simultaneously. And the grandfather to that was using the electrosurge, which was a much more, for lack of a better way, more barbaric way of doing the same thing. And then four, I call the H&H technique. I'd probably advise some caution with this. This is essentially a method of driving the silicone impression material through forced hydraulics into that sulcus to displace tissue and blood and fluids and so on without ever really mechanically retracting it. And this is the one that comes with caution. Even the literature vets out that it's the one that's most riddled with some distortions that are often hidden. They're on low scale, but they lead to less than ideal outcomes. You summed that up very well, and I assume you could use some of these techniques together, right? One as an object to the other? For sure, some of them piggyback. Yes, okay. So now that you covered the four primary techniques, what are the advantages and disadvantages of each of these techniques? Okay, so I'll jump in and just say, you know, putting the H&H technique aside, like I said, there's a big caution comes with that. I'm a fan of the first three, and so if we want to talk about chord... and hemostatic solutions in tandem. I'm going to say that's one of the most predictable, tried and true methods. It's what most folks are trained in under schooling, and it's widely accepted and adopted. In other words, it's very popular, it's very effective, but at the same time, it's time -consuming. It's one that tends to frustrate doctors to no end, and a little bit of that has to do with their training and their relative comfort level with it. It's fairly technique-sensitive, takes a while to do, especially if you're doing two-core technique across a big case. eight units in the anterior, 10 units in the anterior. That can be a rough day. Sometimes it's uncomfortable for the patients. Anesthesia starts to wear off. There's these inherent risks with tissue trauma that can lead to recession. And while ferric sulfate, for example, is a very, very effective hemostatic solution, does the job when it comes to stopping the hemorrhaging. When you use it with cord, it doesn't taste great. Sometimes patients don't love it. It has kind of a caustic taste to it. And then there's also this... that comes along later where you can actually get some marginal restaining that we can talk about. If we drop down to the paste and gel alternatives, these, when they first came out, they kind of seemed to be a godsend, especially for all the people that hated cord. Hey, wow, now I got something that I can squirt into the sulcus, fast, easy delivery, less trauma, works to push the gingiva, yada, yada, and it's a good replacement to cord. Sounded great, but there was a bit of a but because they often fell short on performance. Some of them were not that easy to handle. Some of them were stiffer to dispense. Some of them needed dedicated guns. So I personally tried all these because I'm lucky to be in a position to evaluate and give feedback to the industry. And where I finally left it was, hey, a lot of these things seem like they're nifty, quote unquote. They're pretty cool, but they tend to kind of overpromise and under deliver and they were effective in cases. but not of a wide variety of cases. It wound up that I was using them maybe 10% of the time, and I kept falling back onto my cord because it was just more predictable, more effective. Then the third thing we talked about was that diode laser, and I'm a huge fan of this technology. I think any contemporary restorative practice these days, it's hard-pressed to do the best work they can without a diode laser. I've grown to use mine more and more, use it across varying indications, but that said, If we literally say our diode laser is just a weapon to trough tissue for impressions, I think we're underselling the laser. And in fact, I'm at the school that I'd rather push tissue out of the way and preserve it rather than just cut it away for an impression. I use a laser often when I want tissue gone. If there's superfluous tissue that needs to be removed, 100%, it's coming out, I'm using the laser. If it's tissue that's healthy in the right spot, I work on my technique to simply gently retract it, whether it's with cord or an alternative, rather than trough and cut away. So I think the laser has more to offer. It's a good adjunct, but it's not the only thing I use for retraction. You mentioned the category of cord alternatives. So I'd like you to embellish upon that a little bit. And also, we've talked offline, that's recently had a big uptick as a result of a new material that's come out. yeah yeah so this is another product now coming from boco and quite simply they've named it retraction paste so i think that what it does is in the name again this is a new entry that is in the category of paste or gels or alternatives. And like I said, those always sounded good, but they always over-promised, under-delivered. So I was asked to try this about four months ago. I got my KOL sample pack and our friends from MoCo said, hey, give this a try. And I said, sure, sure, because I always do that. But in the back of my mind, I already had my biases. I'm like, okay, this is just another one of those things. I know that it's going to seem nifty, but it's not going to work. And so I put it to use. Its backbone is on aluminum chloride, which is probably the second most effective hemostatic solution out there. The delivery method was simple. There was lots of cool things about it, but at the end of the day, what was really nice is, hey, for the first time I had a retraction paste, it actually worked pretty good. Now, in the past, though, there were a lot of these materials you mentioned were difficult to extrude. They were kind of like a clay-like material. if i'm correct i mean i'm a retired endodontist so i i didn't do a lot of impression taking but the material was difficult to it was very dense and heavy and difficult to manipulate right yeah yeah and that that's where a big change has come about with this because that's the fine line remember we're trying to physically displace tissue so something that's really just a pure runny gel might go in there and behave like a static solution but unless it actually moves tissue out of the way you're not getting the retraction you're only getting the hemostasis something that's incredibly stiff or clay-like like one of the former products, we'll go unnaming it, could actually move stuff out of the way, but it was a very complicated gun, needed a lot of pressure. The ampoules would dry out. It seemed like a very complex system for something the cord could easily handle much more efficiently and effectively. So that's what the magic is in this new attraction paste. First of all, you don't need a lot of extra inventory. It fits into your traditional composite gun. There's not a restorative practice that doesn't use composite guns. The ampoules look very much like composite ampoules. but with a specifically designed narrow tip that fits down into the sulcus. The pressure you need to extrude it is very minimal, and it's got a very cool blue color so you can see it and wash it away. So it basically made it very user-friendly in that sense. So what is the actual modification in the characteristic of the material that can actually displace the tissue, but at the same time it can be extruded through a typical composite gun? Yeah, and this material has a phase change technology in it, which is very cool. When it comes out of the tip, it flows out very easily, like a flowable composite, like runny Play-Doh. So with that narrow tip, you can place it in the sulcus and actually feel it or watch it fill up the sulcus. Of course, you always overfill past the sulcus. And before it fully goes through its setting or phase change, I then get a flat instrument, a back of a spoon. a cord pack or anything like that, and I further butter it into the sulcus. So I'm driving it a little bit further. So in the amount of time it takes for me to count from one to seven or eight, you know, one, two, three, four, five, six, seven, eight, I've circled around the tooth and deposited the material. Another 15, 20 seconds, I butter that in, and the time I relate to that is maybe the amount of time I've used to pack half of a cord. So it's over very easily, and I'm not pushing heavily onto the patient. I'm not using the sharp end of a cord packer. So the material goes in, and then it starts to go through its phase shape when it expands a little bit and stiffens up a little. That's how it bullies the tissue out of the way. Without that vertical pressure that comes from cord packing, that can be a little detrimental and traumatic to tissue. What's the catalyst to get that material to change its phase? I don't know. I don't know if they'll share that with us. There's something in there that gets set up, but it's probably their proprietary secret. Well, it must be the temperature, right? In the sulcus, the body temperature? Potentially. It's probably something, you know, maybe it has some kind of a setting activation that's not dissimilar to some things that are impression materials or so, but the actual chemicals inside of there that make that happen, I wouldn't be able to tell you. I was just wondering what... made it change phase because you're not really mixing anything together you're just placing it no you're probably right it's probably that heat so it basically conquered the challenge that gps have when they're using these heavier clays and really materials like you explained they weren't really worth the time to use these retraction paste when you can just do cord now what about the hemostasis you said they use aluminum chloride yeah aluminum chloride which is also very effective in hemostasis and because it stays in place it's already built into the backbone of this stays in place the entire time both during the application as well as while you're just waiting and the waiting period is not very long i'm ready to wash this stuff away and take an impression in a couple of minutes this could be used for digital impressions as well as the traditional impression taking 100 100 any impression technique you want to use in fact it greatly lends itself to digital impressions and i'll give you my two cents worth on that but you place it for a few minutes you wash it away that entire time it's in contact with tissue it's stopping the bleeding in fact it's an astringent so it actually slows down any curricular fluid it affects actually the lymphatic system in there as well so when you wash it away you have a very clean dry margin and a very clean pocket of gum line now here's the nuance that you talked about between digital and traditional impressions and i do both i've been doing digital forever i still train my students in both techniques when i'm teaching at school Digital works in my hands 95% of the time. There's 5% where you can't get around it based on angulations and eruption of teeth and where things are. Analog impressions are the way to go. With the analog impressions, yes, you had to retract the sulcus and be able to get that flash. That's how you know you captured the impression. But it wasn't just a tiny bit of flash. If it was very thin and sparse, upon removal, often it would tear away or stick to the cord. So we had to be a little bit firmer with the tissue, pack slightly bigger cords, expand that sulcus so we had a thicker volume of flash, so it wouldn't tear upon removal. Digital impressions are a different game. If your eyes can see it, the camera can see it. So I don't need to retract the tissue unnecessarily a full millimeter when a tenth of a millimeter allows the camera to see it, which means we can use these kind of materials like these pastes to push it out of the way slightly without having to traumatize the tissue. And so while this works great for traditional impressions, it's probably even a better fit for digital impressions in my book. Yeah, that makes total sense and very well explained. This material, as far as the time spent using it to do a typical, let's say you're doing a three unit case posterior, compare that to retraction cord. What are we talking about chair side time? So let's say we're doing three units. Let's call it a three unit bridge. So two abutments in a pontic space. If I double cord packed both of those abutments, And I'm fast. I like packing cord. That's kind of my guilty pleasure, I guess. I'm going to spend five minutes per tooth. So that might be a total of 10 minutes. Let the material work. Take it out. Make sure everything's okay. Make sure the bottom cord hasn't lifted up. Take the impression. If I'm on a good day and it's not a tough patient and they're not bleeding and it's good access, I'm probably ready to start on the impression after 15 minutes. And I know when my students that are more novices do this, sometimes it takes an hour and a half to get to that point. with this retraction paste i have it loaded around both teeth within three minutes and it's done its job by you know minute four or five so i'm usually cutting my work time down to one third when they're marketing they say half the time i actually think that's probably underselling i think it's actually faster than that So not only do you say the time chair side, but also it's a less strenuous procedure, right? Because packing, I know you said you enjoy it in some weird, strange way. We won't go into any of the psychology. Yeah, we're not going to go into the psychology of that. But as far as how strenuous it is, and I don't mean like we're lifting bricks here or boulders, but what's the comparison? Is it an easier procedure? Far easier. I mean, less strenuous on the doctor, definitely less stressful for the patient. They don't feel like a pin cushion. Certain teeth are easy to pat cord on around the anteriors. Work on a lower molar where the patient's tongue is fighting you. You don't have the cord fully trapped in there yet and their tongue wants to swat it out of the way. They might taste the ferric sulfate, start gagging and coughing. Anything you can go in and out fast and not traumatize the patient makes for so much more of a pleasant experience. And it is less strenuous, both for the operator and the patient, 100%. Yeah, for a material that sounds so good, they sure came up with a kind of a mediocre name. It's just called Voco Retraction Paste? Retraction Paste, yeah. Simple and sweet. Usually Voco, they come up with some German-driven names that don't always make sense to the U.S. audience. I think they overcorrected this time. Yeah, right. Could have had a sexier name, but either way, the name tells the story. Yeah, no, totally. No, it's a tremendous company. I know some of the people over there. The R&D there is unparalleled. Everything I hear about Voco, they hit the dental industry by storm and just they took a lot of the market share because they provided products based on feedback from evaluators and KOLs like yourself, Dr. Maki. for sure. Yeah, they deliver. Yeah. So is there any indication, and you did mention an example where you wouldn't use it digitally, is there any contraindication to using this material versus packing cord? I wouldn't say contraindications, but I'm not one that overhypes or oversells things. So there are times where my margins are, you know, millimeter and a half, two millimeters subgingival. A person who's on their third crown, each time you're diving deeper and they don't have recession, you physically need that rope. that cord to move things out of the way. So I'm not going to say this fits all occasions, but if you remember early on, I said the early generation gels and cord alternatives maybe work 10% of the time. Now suddenly this is taking at least 50% of my procedures and converting them from cord to just this retraction paste. When I have deep plunging margins, I still get cord involved. I don't always say one thing fits all occasions. And the great thing about this is it can piggyback. Let's say it's more of a typical prep, the buccal and the lingual and the posterior, you've managed to stay high and dry, your equi-gingival, maybe even a little higher. A tiny bit of retraction paste does that, but one area with the buildup in the proximal had an old box that was deeper. That one area is a millimeter and a half below papilla. There's no cord police saying that you can't cut five millimeters of cord and just pack that on top of this retraction paste, get a little extra retraction where you need it. without complicating it 360 degrees. So it works great in tandem with cord as well. Doctors, when they start to use it, will have a learning curve and they'll very quickly realize, okay, this is, I know how to engage this product, use it to my best benefit. Yeah. Do the students at University of Pacific appreciate your teaching capability, your communication skills? You must win like, I'm not trying to patronize you, but like, you know, faculty of the year award, at least every couple of years, I hope. I don't know about that. Yeah, it'd be fun. I mean, yeah, I graduated dental school a long time ago, but and we had some good instructors. I can't say that we didn't, but it'd be nice to have a guy like you in the area up there where we did our clinical. Anyway, that's very nice. It sounds like fun learning from you. And I think the students probably really appreciate it. They should over there in California. I think you covered it very well, Dr. Hakim. Another great podcast. We love doing these with you. Hopefully we could do more of these soon and more frequently. There's certainly enough products that you evaluate that you can fill us in on. So that's a plus. And have a great evening and a great weekend. And thanks a lot for your great feedback. Thank you, Phil. I can't wait for the next time as well. Be well. You too. Thank you.