See Clearly: Soft Tissue Retraction Options

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. When we think about dental impressions, we typically focus on tooth preparation and the impression material itself. But without clear and accurate access to the tooth structure we aim to replicate, it's virtually impossible to get a precise impression which includes all of our margins. Today we'll be discussing why tissue retraction is so important in achieving the ideal impression and how to think critically about our restorative field and keeping it dry. Our guest is Dr. Lauren Rainey, who owns and operates her own clinical practice. She currently teaches direct restorative techniques to dentists in the U.S. and Canada. Before we get started, I would like to mention that Dr. Rainey's webinar titled, I Can See Clearly Now, Soft Tissue Retraction Options, is now available as an on-demand webinar on VivaLearning .com. Simply type in the search field Rainey, R-A-I-N-E-Y, and you'll see it. If you're looking to up your game in the art of taking impressions and managing the tissue and fluids in the restorative field, I highly recommend this webinar. Dr. Rainey, it's a pleasure to have you on the show. Hi, Phil. Thanks for having me today. Yeah, so we talked a little bit off the air, and I know that you're moving from one state to another, so you've got a lot going on right now. So we really do appreciate your time. And this is definitely a topic that's super important because taking an accurate impression is instrumental and absolutely imperative in order for us to get a good indirect restoration. There's no doubt about it. So let me begin with this question. Some dentists might feel that... soft tissue retraction is not as much of an issue now because of the newer impression materials that can tolerate a damp environment. What would be your response to that? Yeah, I'm going to answer that, I think, in two parts. Like, yes, we're definitely doing impressions, but we're also doing a lot of restorative dentistry that requires just a dry field in general. So even if we do have those products that can thrive in a damp environment, those products aren't necessarily going to be usable everywhere and like all the time. okay and retraction doesn't just have to do with moisture it also has to do with like the movement of soft tissue like away from the hard tissue that we're either restoring or impressing and that movement is is twofold one so we can see what we're doing and two to protect and preserve that soft tissue right that protection of the soft tissue has to be really intentional and not just an afterthought we use like as dentists high-speed rotary instruments very close to some highly vascularized and highly enervated areas and additionally i think we forget sometimes that the oral cavity is like the opening to the rest of the respiratory and digestive systems and i believe that's something that we don't think about on a day-to-day basis until we have like a real situation on our hands On the materials side, though, I think of myself first and foremost as a restorative dentist, not just a dentist for adults or a dentist that performs like minimally invasive techniques. But when you're restoring people's oral health back to a sustainable, predictable level of health, you have to think about the whole kind of picture. And I work with a lot of adhesives like many of us do. So yes, impressions are part of it, but adhesives is also another side. And many of these long-term adhesives tend to perform best when we can see what we're doing. in a field that's primarily dry. So yes, I totally agree with you. Definitely some materials do well in a damp environment, but you know, damp is also kind of a, like, what does damp mean? Right. And when it comes to adhesion though, there are instances many times where we want the dentin somewhat moist. We just don't want it to be, we don't want it to be flooded with saliva, blood, and obviously oral fluids that are going to cause a problem with the adhesive process. So that's interesting because you mentioned retraction as it relates to adhesion. And most of us are thinking retraction is when you're about to take an impression. So how do you use retraction techniques for adhesion? Could you give us a clinical example of that? Sure. I mean, I think about using a rubber dam as a retraction device. I think about using an objugate or an isolate as a retraction device that protects the soft tissue. It holds the tongue out of the way, the cheeks out of the way, and it's acting, again, in sort of a twofold. One, to create an area that I can see what I'm doing, and two, protects the patient from high volatile compounds, whether that be chemical or stuff that's flying off a high-speed handpiece. So it's interchangeable in some ways when you're talking about retraction and isolation. Correct. Okay. Yes, I would say so. Right. Because we are essentially retracting the soft tissue out of the way, and that can be both kind of on a macro level. being like the tongue, the cheeks, sort of the face. And then on sort of on a smaller level, when you're taking that soft tissue and pulling it away from margin and trying to create that restoration that fits at that junction of the soft tissue and the hard tissue or just subgingival. Yeah. So in terms of soft tissue retraction, when we're talking about actual and impression, how do you decide what retraction technique you're going to use? And I assume you're doing that beforehand. So I'm a list maker by nature. I like to plan ahead and think about all the possible outcomes. Yes, it does keep me up at night, I will admit. But when I do go to a case where I know that retraction is going to be an issue, I usually know it's going to be an issue because I've reviewed the pre-op imaging. So I've looked at bite wings. I've also looked at MPAs. I've looked at also the periodontal health of the area. And that gives me an idea of how much inflammation there may or may not be there before I even do anything. Also reviewing what retraction, both sort of on that macro level and sort of at the tooth level, has worked well for the patient previously. Like can they tolerate a rubber dam or an objugate or an isolate or what size bite block kept their cheek comfortable that we could actually do the work we needed to without having to stop and get spit and blood and sort of oral fluids in the area. The radiographs always give me a really good idea of how challenging visualization might be. And that doesn't mean that I'm just looking at the tooth. I'm looking at the neighbors. Are they rotated? Is there a history of food impaction? Are the adjacent teeth heavily restored? Like, am I expecting there going to be a lot of soft tissue inflammation? So a lot of times I do think about it beforehand that I'm using all these little clues. I'm formulating in my head what I think I might run into. And I think the morning huddle is, again, one of those things that I think some of us get away from. We don't use them efficiently, but that can be a great time to highlight some of these cases that are kind of coming up in the day so that my assisting team knows to have the particular products ready to go. And usually the combination, again, of looking at the imaging, the perio chart, and what's worked for them before gives me at least a baseline of like, where should we start? Let's say a dentist just practices this way. A patient comes in, they have the retraction materials, chair side, ready to go, and they look at every patient as the same. Typically, they would put a rubber dam on if they could, and then they would use whatever retraction techniques they use on the local level if they're doing an impression. Why would that not be the same for every patient? And is it a bad thing to just do this routinely for every patient? Then you don't have to plan specifically for a given patient. I don't think it's a bad thing. It's good to know sort of what armamentarium you literally have in your closet or your cabinet. It's dependent, I would say, on the materials that you're using. Like if you're doing the same procedure with the same materials all the time, then sure, I think that can be your sort of go -to thing. But we all know that every tooth is different and every situation is going to be different. If I'm doing an anterior case with composite or bonding and indirect restoration, I don't want to use something. that has iron in it. If I'm trying to control bleeding, because I know that leads to kind of a gray stain on the tissue and can be kind of show through if you have some of these porcelains or ceramics on there, I'm going to choose something with an aluminum chloride in it to help control the bleeding. Something like Voco's Retraction Paste is great for that because I know it doesn't discolor the tissue, keeps it really nice looking. So if you're putting some veneers in, you don't want them to turn gray immediately after leaving your office. So, I mean, knowing kind of what materials you're using kind of helps also dictate what I'm choosing. to sort of set the case up. So how does a dentist best work and train with his or her team to maintain and ensure dry field when taking an impression? Because maintaining a dry field is really critical when it comes to taking an impression. Right. So I think a lot of times those conversations can actually start in your hygiene department and those hygiene appointments. are a lot of places where we start having these conversations with patients about we are going to need to do a crown or we're going to need to do a deep class two restoration. And that can be a fantastic opportunity to review with a patient before they come back for restorative about how to keep the area clean, whether that's flossing or getting a water pick in there to decrease the inflammation before I even have to touch it. It gives not only the patient, but also the rest of your team some agency in helping that restorative visit go smoothly. Additionally, I'm a huge proponent of having a camera in the operatories, photographing your work or hooking up an additional monitor to your restorative like microscope. If you're using one can really help your assistant who's sitting next to you actually see what you see, right? If you just take a photo, a picture's worth a thousand words, right? If you show them what you're seeing and it's a big bloody mess in there, they're going to know, oh shoot, like we've got to get this under control and I've got to open the cabinet and pull out, you know, eight more cords or retraction paste or whatever it is that is comfortable for you to get the bleeding under control. So I think showing the rest of your team why it's important in addition to telling them. can get everybody on the same page. Yeah. So when you're doing a bigger case and you know that that patient has gingival inflammation and you're doing subgingival margins, then you're going to expect bleeding, which is going to be a real problem when you're trying to get a really clean, accurate impression. So how do you communicate with your hygiene team and what kind of preparation do you do clinically for that patient before you go in there and start cutting those preps? I mean, again, it comes down to that. you know, morning huddle. If I know that someone's got a six unit case coming up, I'll say, hey, your 10 o'clock patient is coming back in two weeks. Can you please just make sure that you, you know, drive the point home with them or get in there today and make sure that we get everything super clean before they come back. Maybe we talk about putting them on an antimicrobial mouth rinse before they come back for the next two weeks. But trying to bring them into a part of this because We know that the foundation of a lot of our restorative work does come from the periodontium. And if we don't have healthy periodontium, I can do whatever I want that restorative appointment. But if it's going to be a bloody mess, you're right. It's not going to end super well for anybody. So you have these morning huddles every day where you talk about patients. Yep. Wow. So that's really good. So how do you coordinate that morning huddle, knowing that the patient that your hygiene team is treating is going to be back in two weeks for prosthetic work? I know it's in the schedule, but how do you manage all that where you keep track of this stuff? Well, when I was an owner in California, I had a little bit of a smaller practice that was fee-for-service based, and that really allowed me to know my patients. It really allowed me to know who the people were in the practice and when they were coming and kind of know their story. And I was... about creating a practice like that, but that allowed me by not having a bajillion patients to actually know who's in the schedule. Why are they coming? How can we all work together to provide the best outcome for us and for them? So I felt pretty strongly about having these morning huddles and actually knowing the people that were sitting in our chair. They weren't just a tooth number. It just wasn't a six unit case, but this is Jane. Jane is a teacher. She just retired. You know, this is part of her story is getting her teeth restored, you know, to build that kind of culture with the team members. So the huddle was kind of a natural extension of us just knowing who was coming in and who was retiring and whose birthday it was and who was getting married and who was celebrating a 50th anniversary. Yeah, that's the beautiful part of a smaller practice. Correct. It's really a gratifying environment to work in as a dentist and to get to know the families. I recently did a podcast with a doctor who works in rural. uh, America where the closest specialist to his general practice is like 40, 50 miles away. So he, you know, he had to learn how to do molar root canal using lasers, everything, but he knew every single patient. He knew their family. He treated multiple generations of that family. Uh, and he's very, very happy in practicing probably 45 years now, an old friend. But it sounds like to me that these morning huddles in the environment that you worked in really sets itself up perfectly for knowing the patient and preparing that patient on the hygiene side for these indirect cases. The larger ones, of course, are even more critical. But how does that work now with big business dentistry on the DSO side? How do you see? corporate dental practices that are volume-based, maintaining that level of personal care high enough where we get good impressions because we prepare for this in advance and all these morning huddle interactions that are so crucial to leading the patient down the path to a full body wellness approach. I see that as a kind of a problem in today's large DSO environment. What's your thought on that? Yeah, I don't work for a large DSO, so it's hard for me to say exactly how, like I don't have experience there. But what I can say is I think it really comes down to culture. And there's a trickle down effect there, right? If you're a leader as a dentist on your team and you want to have a culture that supports knowing your patients as people, then you need to do the work and know your patients as people first and then encourage your assistants to also to know them and to your hygiene team to know them. And for your front office team to know them, it has to be a group effort. So we diverted a little bit from the conversation. I think it was worth it though, Dr. Rainey, I really do, because it's so important, like you mentioned, to really know your patient. Now, when it comes to retraction options, are there any magic bullet retraction options that seemingly work every single time? And maybe that's why you chose the Voco brand. I don't know if that's the reason or if it does or not. But what's your thought on that? Is there a magic bullet out there for retraction options? I mean, wouldn't that be just like the best news if I could shout that from the rooftops? I wish I could say like, yes, and it works every single time. You know, like you said, I have been very impressed with the vocal retraction paste. I thought it was, when I first heard about it, like too good to be true. I've used other retraction paste in the past where you put on a cotton roll and kind of like dab it in there. And some of them are really hard to rinse off once you've got it all dabbed in there. And then you irritate the tissue by trying to rinse it off. But this one. You know, I gave it a shot and it works really well. It expresses easily out of the carpule. It is one of those sort of like hygienic single use products. So that's really great in our sort of post-COVID or concurrent COVID times, being really mindful of hygiene. And then it washes off super easy after like one to two minutes. So I wouldn't say it's a magic bullet and it works like that one product works every single time. I mean, it clearly really depends on your individual restorative situation and what materials you're using. But I have been really impressed by that product in particular. particular. But again, I think it depends on your patient. It depends on, you know, the lead up to that appointment. Like we've talked about knowing your materials, like no, like you really got to read the package inserts and understand what is working, you know, how long you're supposed to leave products on the tooth. Are you supposed to air dry them or not? And then whatever outcome you're expecting or need. Also, it comes down to how much time you've got. And I know that's, you know, can always be really variable, but kind of like planning ahead. beforehand in order to be successful, I think. Yeah, well, absolutely. Now, what about cord? Do you use cord with this retraction paste? I love cord. I love cord. I was trained as a two-cord gal, and I will probably continue to be a two-cord gal. With the retraction paste, usually I'm still putting a cord in there. I love ultra-dense cords. They're easy to see. They're easy to pack. They come in the little container that has the little cutter right on there. I'm a huge fan. I have a hard time not using cord, I think, because it's just ingrained in me. But I don't usually have to put two cords in there. If I can get away with one, you know, triple zero cord just to kind of get the tissue kind of pushed out of the way and then pump the paste in there, give it a minute or two and then rinse it off. We're ready to go. Yeah. And we talked again off the air briefly about soft tissue lasers. I know you're not a current user of a soft tissue laser, but what's your feeling about it? having one around. I think they're a great adjunct. I mean, I've had a laser, I've used a laser, I was trained as a resident on using a soft tissue laser, and I think there's definitely instances to do so. And we would be remiss if we didn't bring up soft tissue laser as a retraction option for sure. But there's a little bit of a learning curve on them and bringing teams up to speed and with the changing of team members, which is something that we've all faced a lot in the last two to three years, especially making sure that everybody is safe when using a laser is a little bit more learning curve than here, put this in the dispenser. squish it out on the gum line. But yes, I absolutely think soft tissue lasers should be in your armamentarium of things to consider with soft tissue retraction. Yeah. And we'll be coming out with a whole bunch of podcasts directly on the topic of lasers. Fantastic. On those podcasts, I interviewed Dr. Scott Benjamin, who is past president of the Academy of Laser Dentistry. who is really one of the world experts on the use of dental lasers in clinical practice. And of course, he dedicates quite a bit of time to talking about how lasers are used in tissue retraction. So speaking to my audience, look out for those episodes coming up soon. Well, listen, we really enjoyed this, Dr. Rainey. Thanks so much for taking the time. I know you're on the move right now between states. I wish you the best. Thank you. with your new venture into whatever dental practice you decide to work in. Thank you very much. Yeah, that'll work out great. And we're going to definitely have you back on the show and talk about that, possibly that transition and how you've made that work and other things you do in your practice to streamline getting the right treatment plan on board with the patient and actually following through to have really good, effective, predictable clinical results, which you apparently have had over your career. Thank you so much for joining us, Dr. Rainey. Well, thank you for having me. today. I appreciate the opportunity. 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