The Truth about Warming Composites

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to Dental Talk. I'm Dr. Phil Klein. Today we'll be discussing thermoviscous materials and working with warmed composites. With us today is Dr. Ron Kaminer. Dr. Kaminer maintains two practices, one in Hewlett, New York, and one in Oceanside, New York. He is an international expert in the field of dental lasers and has lectured on lasers and minimally invasive dentistry nationally and internationally. He's also one of Viva Learning's most popular speakers, presenting over 40 Viva Learning webinars. Also with us today is Gregor Connell. He's the North American Director of Clinical Education for VOCO. He has over 30 years experience in the dental industry and has presented numerous continuing educational lectures on dental materials and their clinical impact on everyday dentistry. Before we get started, I would like to mention that Dr. Kaminer and Gregor's webinar titled Life Behind Bars. Breaking Out of Manufacturing Jargon and Back into the World of Clinical Relevancy is now available as an on-demand webinar on VivaLearning.com. Simply visit VivaLearning.com, type in the search field Kaminer, K-A-M-I-N-E-R, and you'll find the webinar. Dr. Kaminer and Gregor, it's a pleasure to have you both on Dental Talk. Phil, thanks again. I'm looking forward to today's session. Hey, Phil. Pleasure to be here as always. So today we're going to be talking about warm composites. Let's begin with Dr. Kaminer. Tell us about your clinical experience using warm composites. I'll talk generalities first. I think dentists in general have been warming composites for an extremely long time. And without the regard of should that composite be warmed, can it be warmed, how it's being warmed. If you look at consistency of material, dentists have taken composite and warmed them in anesthesia warmers. have warmed them in so-called composite warmers, and the temperature, of course, varies, and materials vary in consistency and handling. So if you take a softer composite and you warm it, of course it's going to be runnier. You take a firmer composite and warm it to that same temperature, it will not be the same consistency as that softer composite. So it becomes this total mishmash, and dentists have, as dentists are, and I'm one of them, so I say this. But, you know, we deal with our goods and our bads, and we just deal with our goods and our bads without always looking for something that's out there that could be better. And, you know, today we do have something better, and I'm sure we're going to talk a lot about that today. Gregor, when we talk about warming composites, we're really talking about a thermoviscous material, right? So with your experience as clinical director for VOCO, which is a very fine, world-leading manufacturer of dental materials, what does... thermal viscous restorative material bring to the table from a clinical perspective as far as what's the real benefit to the practitioner? Great question. I mean, when we look at what has been done historically, clinicians have realized that when you get down to the box and we're looking for adaptation, we're looking for elimination of voids, et cetera, the tendency has been to move towards the flowable composites. so that they self-level, they cover off all these surface irregularities, and then we get a nice platform or dance floor upon which to build a restoration on. Now, that involves two products. The TVT or thermoviscous technology basically embodies two materials in one. It's a twofer. So what you start out with is a composite that comes in a cap. It's of a viscous technology, but when you warm it to a certain point, it becomes incredibly flowable for a very short period of time. So what you get is that immediate adaptation to that irregular pulpal floor. But then the catch is how quickly can you get it back to that packable material that you know and love that allows you to sculpt and shape. And that's really what TBT do. It's a flowable and a packable in one capsule. Thermo viscous material is not one in the same from all manufacturers, right? Because... Some materials are designed, or maybe only one as far as I know, specifically to be warmed, which behaves better clinically than an agnostic material that you warm up, like Dr. Kaminer said, you know, in any way you can. Earlier in the podcast, he mentioned different ways to warm it up. Is that right? Yeah, correct. You can warm any composite you want. Whether the manufacturer tells you to do so or not, it's your discretion. And whether or not it actually serves a clinical purpose is also... perception. With TBT, it is the first composite that's ever been made to, it doesn't work unless it's warmed. You have to warm this. It's been engineered specifically to morph and change. There are other products out there like sonic fill that we use sonic energy to change the molecular structure and make it appear more flowable, which is great. But this is the first one that's been designed to work off thermal energy. Yeah, and this material is called viscalor. from voco correct yeah okay yeah i just wanted to clarify that and before i go back to dr kaminar as an endodontist i no longer practice but of course thinking in this in the world of endodontics we're all about the pulp health when i hear about a material that's being put against a deep cavity prep that's being warmed or some people use the term heated and i i think warmed is more justified it would make me feel more comfortable that the material is being warmed in a controlled environment so that the temperature can't get too hot where the pulp could be damaged so my question is will warming the composite with the system for instance viscalor system have any effect on post-treatment sensitivity great question again uh viscalor is designed as i said it was engineered to be warmed so there's some finite parameters that one has to work with when you design such a machine and essentially what we're looking at is a rapid uptake of thermal energy to create that flowability but the key here is the rapid disbursement of that temperature, get rid of that exothermia as quickly as possible and get it back down to body temp. That way we do not jeopardize the vitality of a pulp. I mean, a deep class one or class two, and you've got maybe a millimeter of solid dentin before that pulp chamber, you certainly, I mean, most people will throw a liner in there just as a thermal insulation blanket. So you have to be cognizant of that. And when you warm a regular composite up to 55 degrees Celsius, you know, you're getting up. upwards of 140 degrees Fahrenheit, and that's very dangerous. A pulp can withstand about 105 Fahrenheit for about two minutes, and then it starts to get a little wiggy and starts to go south on you. So this material warms up, flows, and then sheds. I'm not going to quote, but I'm going to say somewhere between 12 and 14 seconds. It goes from like 155 Fahrenheit down to like 97. So there's absolutely no issue. with preserving a vitality. So has there been studies that have substantiated that claim that post -treatment sensitivity should not be an issue? Should not be an issue. Pulp vitality is key here. We have to maintain that. Yeah, without doubt. So Dr. Kaminer, have you used Fiscalure? I was actually on... original testing team for VOCO, and then have used it extensively in the market. And to what Gregor said, which I think is really important, is when we heat the material, and Phil, you alluded to this, but we haven't discussed it, we're not just talking about a material, we're also talking about the heating system. So there is a cap warmer that VOCO has designed to heat it to the exact temperature that... material will react to there is a brand new uniquely designed dispenser or a gun using infrared technology that will heat that compute to the exact temperature so that's actually delivery, immediate delivery. And we've controlled that aspect, or VOCO has controlled that aspect. So it's not just a random heat. So it's not just an anesthesia warmer. It's not these things. So you get that flow ability. And as Gregor said, you get that rebound very, very quickly, not just because of the material, but because of the way VOCO has designed for the material to be heated. Right. So it's somewhat bulletproof, as you're mentioning, on the clinical side. Correct. What are the steps to apply the material and what are its typical indications for use? So, I mean, viscalor comes as viscalor with multiple shades. If someone wants to incremental fill, it also comes as a viscalor bulk if someone wants to bulk fill. So that's, you know, it's have it your way like Burger King, right? You know, you could do it any way you want, depending on the material. But in essence. you're going to use this as a regular material. So I'll give you Ron Kaminer's methodology because I think there's some credence to what I do. So if I'm going to use this material and when I do use it, I will have that material, put it in the caps warmer. If I'm using the caps warmer right before I prep the tooth, if I'm going to use the infrared gun, I'm going to select a vetch. I'm going to place my adhesive the way I normally would. I'm going to put it in the gun. and press the button on the gun as I'm applying the adhesive. And the reason is it's about a 30-second heat in the gun, and by the time I agitate my Futuravon universal adhesive air-dry light cure, we're about to 30 seconds, the gun goes off, I immediately apply. The other unique part of this is the Compuil has this elongated tip that's very thin that you can place at the base of the box. So as Gregor said, you have that irregular pulp floor. Not all boxes are made the same. We can place the tip at the floor of the box and literally backfill the entire preparation. Once again, as was previously mentioned, 12 to 15 seconds, that will begin to rebound. And now we can begin to condense, carve, play with it, put our initials in it, whatever we really want to do in order to finish that restoration. That tip that you use, that really helps in eliminating voids, I assume, by backfilling it. 100%. So again, like Gregor said, it acts as a flowable. But it's really a packable. And by being able to place that tip deep in the box, we're going to avoid any kind of bubbles or anything like that that we're concerned about as we backfill the preparation. So let me ask you this about bases and liners. For pulpal protection, bases and liners are effective. And I know you're getting the mobility of the material and the flowability through the system. Talk to us whether we need a flowable and or do you still use a base or a liner? That's a great question. So I think, again, this is going to be dentist's choice a little bit. Do you need it? No. But if you have something deep near the pulp and you wanted to use a calcium-based liner, Volco's got a great one called Calciumol that you want to place as your liner just because you want calcium release. You can do that, light cure it, and then backfill your entire preparation with Viscalure. bulk. You do not need to place that flowable because the material is going to act like a flowable. If, in fact, you're going to use the traditional viscalor when you want to incremental fill, you could fill a few millimeters at a time, hit it with the light, and continue your filling process. But the only reason you would need so-called that baser liner is if you wanted something else to happen, calcium release or anything like that. So, Gregor, the company that makes this, VOCO, talks about the restorative material being designed to go through this thermoviscous cycle so that it can perform clinically the way we're talking about it today. Can you give us a simple synopsis of how the science works? And let's get down to a little bit deeper understanding of what this material does to make it different than a standard restorative material that's warmed in a different way. Certainly. With a standard composite, we understand all composites. We have glass particulate in there, and then we have a resin matrix around it. warm a conventional composite, the material becomes more fluid. But there's certainly surface friction between the glass particles and the resin. And understanding, it's like running an engine without oil. You know, there's a lot of friction there and you're going to throw something and you're going to blow that engine. So essentially what we did with... tbt with the viscalor is we and it's called surface functionalization so what you do is you pre-coat all of the glass particulate with a chemical lubricant and then what happens is when you bring the temperature in to warm it as ron had said the resin starts to flow but the resistance and friction is non-existent between the glass particles and the resin which means it's almost like a lubricant so it kind of slides very easily and that sliding of that mass material is called a flowable that's what we assume a flowable is so that's how we get that adaptation it's a surface functionalization it's a specific proprietary formulation that goes on the resin goes around all the glass particles and it changes the way those glass particles function inside the resin as it becomes more fluid and that's how we get that adaptation that we're looking for so if another material is being warmed in another system Does the temperature required to get the similar flowability of another material, is that temperature going to be higher than what's needed for Viscolor? In other words, could we get the same flowability at a lower temperature, even though it's still warm, it's safer for the pulp? Is that the case? You know, you could rev two different car engines at 6,000 RPMs. The one that has the oil in it will continue to run at 6,000 RPMs. The one that doesn't have any oil, which is conventional, will blow up. So when you take a conventional composite and warm it, there is still that friction there. So it is going to flow to a certain degree, but you may have to take it to an elevated temperature to get that viscosity change. Whereas we get to a pulp-friendly temperature, and then with the internal lubrication system, that's a really generic way of saying it, simple way of saying it, but with that lubrication system, we get that effortless flowability. And then we get this rapid shedding. of exothermic value, which of course protects our friend the pulp. What are the options to warm the material? I'm talking about viscalor. Is doing it one way advantageous over another way? Ron mentioned that he talked about the fact that you could have anything from a compule warmer for anesthetic to a gun that we make to a regular caps warmer. I mean, the most popular warmer on the marketplace is probably a product from CalSat, and many people have them. You can put a syringe in it, you can put a cap in it, you can put an anesthetic compule in the back, and then you've got three different power settings or three different temperature settings. The beauty of the caps warmer, if you want to call it that, is the fact that you can put a syringe or a cap in it, and you can have maybe four or five syringes or four or five caps, so you're doing a multi-shade, multi-layer restoration, and you can warm them all at the same time. But it will take three minutes to get there. And then you've got about 20 seconds to place the material. You can stay at that temperature, you know, for a long period of time, but you've got 20 seconds to place it. When you go to the gun that... was talking about the viscalor dispenser it's all near infrared technology and it's a single cap so you're doing it one at a time it's one in the breech and that's all you get one shot and of course when you finish dispensing it you grab another cap snap it in it takes 30 seconds to get to 155 degrees fahrenheit so it goes from room temp to 155 in 30 seconds and then holds it for two and a half minutes while you play with the material So there are distinct advantages to both. It really depends on the clinician. This clinician's call on this one. So Dr. Kaminer, let me ask you this, two questions to wrap up this podcast, and it's been great. information. You guys have really given us a tremendous insight into the benefits of a warmed composite technique. The first part of the question, Dr. Kaminer, is do you see a trend in dentistry among your colleagues? Because you teach a lot and you do a lot of traveling and you're in touch with a lot of clinicians. Are we moving towards an era where restorative dentistry, especially class twos, are going with warmed composite techniques? And the second part is with that, if you could give us some recommendations on maintaining good contact using warm composites so um great questions phil i think i'm going to tackle the second one first and then we'll talk about the trends so again i'm a big believer in sectional matrices and if you use a sectional matrix and there's a lot of good companies out there that make them and you had you wedge properly You should get proximal contact if you put butter in the preparation. Reality is. But don't forget, as this material recovers and you can condense it down a little bit, once you have that sectional matrix in place, with a good wedge, obviously, because you don't want anything to flow past the margin, so you want to make sure the gingival margin is sealed. Then you're going to do some slight condensation and you're going to get a rock solid contact every single time. So I think sectional matrices really become a key. And for class twos, we should be using them anyway, in my opinion. To the first question about trends and warming. And I think this is a very interesting question. I think the ones that have warmed will love the new solution of consistent warming. I think. In schools, they're not really teaching warming. So the young dentist out of the school has to learn. How are they going to learn? They're going to go to a CE course. They're going to log on to the Viva webinars. They're going to say, this looks interesting and realize, all right, it's a composite. I'm just going to place it differently. And it makes a lot of sense why I would warm this. So I'm not so sure there's a trend yet, but I think there's a need for it. And if there wasn't a need for it, Volco wouldn't have just created this. composite amongst their outstanding plethora of composites so there's obviously a need for it people are using multiple products don't forget today with overhead being critical in dental offices being able to cut down on an extra material can only help the dentist if he's looking to watch dollars and cents, and if they're not looking to watch dollars and cents, they should be. So being able to cut down on that flowable when you don't need to use the flowable, when you just used it as a crutch all these years, I think is really, really critical. I also want to point out, which I think is really, really important, is that when Voco first brought this to market, this is a true testament to Voco. A bunch of us tested the product, and we said, guys, it's not good enough. And it wasn't good enough because it wasn't aesthetic enough. It didn't handle. Before they released the product, they went back to the lab and redesigned the product and made it not only that it handles the way it should, and we didn't touch this, but it's important, but it's super, super aesthetic. And it polishes as nice or nicer than almost anything else on the market. So by heating. We're gaining the advantage of the flowability and we sacrifice nothing with the aesthetics and we gain gorgeous aesthetics. It's great that you evaluate these products, Dr. Kaminer, because you really do get to have a feel for what's the pathway to get to the final product where it's released into the market. So again, to our audience, let's thank Dr. Kaminer and Gregor for their great expertise in this podcast. Guys, we hope you come back and do a lot more with us. Dr. Kaminer is up to 45 webinars with Viva Learning now. I'm the league leader still. Yeah. And you get incredible attendance. Listen, you connect to the clinician. They come to listen to you because they could go back to their practice and say, yeah, I heard this guy, Ron Kaminer, and he did this thing. Let's see. Let's try it. And you've helped a lot of people with their challenges that many of us have. And that's why this digital information is so. useful to our audience. And again, thank you very much. Thanks for doing this on a Friday. I know you cherish your Friday afternoon. So I appreciate both Gregor, great insight and the great work you're doing as clinical director for VOCO. Have a great weekend, everybody. Thanks, Phil. Pleasure.