Get Rid of Those Pesky Voids in Your Composites

You're listening to the Phil Klein Dental Podcast So we're beginning to hear more about the benefits of warming composite. For one thing, because of the lower viscosity at the time of application, it's a whole lot easier on your fingers, hand, and wrist. But the real benefit lies in adaptation. And we all know that the better adaptation we get of our composite to our tooth preparation, the less likely we'll see recurrent decay and postoperative sensitivity. To tell us why she loves warming composite so much and how easy it is to make the transition in your operatory to this technique is our guest, Dr. Lauren Rainey. Dr. Rainey is a regular contributor on VivaLearning.com and currently teaches direct restorative techniques to dentists in the US and Canada. Dr. Rainey, it's a pleasure to have you on the show. Hi, Phil. Thank you for having me again. And I do want to mention that you did a great job on your recent webinar on VivaLearning.com. Turn Up the Heat, Composite Warming Techniques and Implementation. I had the opportunity to watch that. I really enjoyed how you covered the basics on composite material and then led the audience into more of the science behind warming the composite. And it made a lot of sense. And obviously, we're going to talk more about that today as that is the topic of this episode. So how did you first learn about warming your composite? And once you did, what really stood out? In other words, what were you seeing restoratively that was different than the traditional application? Yeah, so, well, thanks for listening in. I appreciate that. But I first learned about warm composite from a course I took on injection molding. But really, it was thanks to an endodontist, because the endodontist was the one that told me, hey, you should go start learning about this stuff. He and I were often scratching our heads about fractured teeth, and we saw a lot of mutual patients with those larger amalgams and larger restorations that weren't really carious, but they had these cracks running through them that allowed those bacterial biofilms to get within the tooth and then to wreak havoc on the pulp. So since he'd been kind of exploring some options around crack tooth stuff, that's how he ended up learning about injection molded composites. posterior and then he sort of passed that information on to me. So once I sort of learned that technique and started implementing injection molded composites into my practice, it really became absolutely necessary for me to start warming almost all the composites that I was doing because I was trying to get these materials, you know, in and around like the line angles of a molar or premolar and make sure that I was getting the composites, you know, all the way down to those floor, those deeper boxes. in and around these hairline fractures and trying to kind of cover those up. So from a restorative perspective, it just made a lot of sense that I wanted a material that was going to flow a little bit more than sort of the traditional composites that I was used to sort of packing in and squeezing around and hoping that they would get to where they needed to go. So once you started using warm composites, what did you see when you started applying this to your tooth preparation? What stood out to you? that was different than what you were typically doing? Yeah. So the biggest thing that really started to stand out to me were my post-op radiographs. And I wasn't really in the habit of taking those on a regular basis, sort of like earlier on in my career. But as I started... these teeth that were a little deeper and the composites were a little bit bigger, I started taking these post-operative grafts just to make sure that I wasn't leaving any adhesive behind or ending up having to get down into those sort of tricky areas with a 12 blade before sending the patient back home. But what I was noticing was that I wasn't really having... very many voids on the radiographs. And that made me feel really confident that the work that I was doing was going to hold up for a little bit longer. So I think... both like visually seeing that I could get the materials into those sort of nooks and crannies, but then also taking a peek at those post -operative graphs and seeing those on recalls made me feel a lot more confident that making that switch for me felt like the right sort of tool in my hands. Typically, dentists are a little reluctant to try new things, especially workflow things, things that kind of change their way of doing things. Of course, their staff has it. down pat everything they're doing is grooves really well so when you're taking this other step into the workflow you're introducing a new step how does that affect chair time do you think dentists will see the value in it uh clinically and what's the downside with the extra time involved The time really is pretty minimal. It involves like flicking a switch before our morning huddle to turn the heater on. I mean, we're still using composite. We're still choosing shades. We're just pulling the composite out of the carrier that's warm and putting it into the tooth instead of grabbing it off the table. So it really is not a major... sort of game changer in the sense of, you know, adding another thing to the procedure itself. I think it's like a bigger, it was bigger to go from doing a regular style composite to sort of an injection molded technique. That was a bigger step than the actual heater itself. Let's talk about safety to the pulp. Being an endodontist, I have to ask that question. You know, that's just, it's in my blood. How risky is it for the pulp to have something that's heated placed? in a deep preparation You know, I think that comes down to sort of case selection. If you're, you know, looking at sort of a blushed dentin, I probably wouldn't take a super warm product and like lay it down on the side and feel great about it. I mean, we can always use, you know, a base or a liner to kind of give you a little bit of, you know, thermal protection, if you will. So I don't have a problem with doing that. But, you know, the evidence in the literature does show us that we can heat, you know, the... near the pulp, somewhere upwards of like 40 to 50 degrees Fahrenheit. as long as it's not for an extended period of time. And the amount of time that we're putting the composite onto the tooth, we're not putting something that's 155 degrees and keeping it 155 degrees and holding it there, right? As soon as we're removing these materials out of the warmers, they're starting to cool in that first 30 seconds. By the time you get it into the tooth and start manipulating it, it is cooling incrementally. So again, I heard about warming composites from an endodontist and a PC. to think it was a good idea. So you mentioned 40 to 50 degrees Fahrenheit. Is that raising the temperature you were talking about from the pulpal temperature? Yes. Okay. Yes. Because I know the actual material. reaches what, 150 Fahrenheit, 140? Well, 155 are the couple of the heaters on the market come up to 155 degrees Fahrenheit. There are a couple of warmers that have multiple settings on it. The Voco Caps warmer has three temperature settings, one at 98 and one at 130 and then one at 155. So depending on the actual materials that you're using, and you'd have to talk to your distributors and make sure whatever composite you're using, like whatever the manufacturer says is the sort of ideal temperature. Um, but I haven't seen anything over 155. So the idea, you're not going to take that composite and, you know, lay it on the pulp and keep it that hot. Right. So the idea behind this, I would think I'm not a restorative dentist, but is that the idea is adaptation, right? Because we're getting the benefit of a flowable, but we have a bulk, a bulk film material that we could use, which, so talk to me about that. How do you. uh sculpt the tooth like how much do you have to wait to start sculpting the tooth once it flows in with that higher temperature um that depends on the material that you're using. There's one product called Viscolor and that's made by Voco and that when you heat it turns into just like you're talking about a flowable It acts like a flowable. And as it starts to cool and get to body temperature, it turns more to a sort of sculptable material. So you can put an instrument on there. And if you try and put an instrument on a flowable and kind of pull the instrument back up, you'll kind of like see that kind of like honey consistency and you'll end up putting voids in the flowable. With the Viscular, you can actually kind of use your... instrument and it doesn't kind of pull back up it tends to be more moldable sort of like that play-doh consistency so that's a really great product that is designed actually to be heated to give you that sort of dual what's called viscosity is that sort of like thickness of the liquid but if you're using you know one of the more standard composites once it's in the tooth and it's already been warmed and starts to cool like very slowly It is very sculptable and spreadable. I don't want to say like butter. I'm a baker. So the consistency of butter could be all sorts of things and that can be ambiguous. But it is very easy to, you know, push it into those line angles and make sure that it's adapting well to a matrix, to the side of the tooth. Ease of use is really great. Yeah. So the key benefits that you're seeing is reduction in voids, if not... virtually eliminating voids yeah just the elimination of voids and that's just huge right that's the cause of recurrent decay in many cases it is one of the major causes of recurrent decay yes um you know additionally some of the materials out there um literature does show that heating your materials can actually increase the surface hardness of these materials. So if these composites are warmed and they are cured when they're still above body temperature, they're finding that surface hardness of the final product, once they're cured, some of them are nearly as strong as those pressed ceramics on the market. So that's another really great benefit that's kind of hard to overlook. So if I'm a dentist listening to this podcast, And I have a heating pad in my office. I'm going to go back to my office tomorrow, take my typical restorative composite, what I've been using all along, whatever it is, and heat it up. Am I going to get the same results or do I need a specific material? And do you recommend a certain warmer or does it matter? There's plenty of people out there that are using heating pads or like a coffee mug warmer to sort of warm their restorative materials. And some people warm their anesthetics to make them sort of less painful for injection and for making the composites easier to work with. I will say a heating pad, coffee warmer, you know, some people put it in the light above their chair to warm it up. That will absolutely help with the ergonomics and the extrusion force of the composite, meaning it will make the composite. a little bit softer and you can squeeze it out of the carpule much easier, putting less stress and strain on your hand. But if you're looking to get the properties of increased surface hardness and sort of that change in viscosity, I don't know how effective that would be depending on how hot your heat pad is. If you're putting a towel on it, how much of the heating pad like cover is absorbing the heat versus getting to your composite. So it's just not as predictable, I think. But to answer that second part of your question, yes, there are warmers out there that are made for this purpose. There are composite warmers that have, you know, multiple holes in them, multiple heat settings. Some of them, the heater is within the carrier itself. So it kind of just depends on what you're looking for. If you like to use flowable composites, some of them have, you know, little holes for flowable. Some of them have drop in areas for instruments. So depending on how you think you're going. going to use it there are a number of products available out there that are specific to composite warming yeah and it seems like for workflow efficiency you certainly want to use something that's kind of designed we're doctors we're not carpenters so you want to having a makeshift heater doesn't seem to make any sense to me if you're have such a big investment in your practice and you have patients coming in to get premium care, you want the best small equipment you can have in your operatory. You did show on your webinar something that was really kind of nifty. It was a heater system. You showed a couple of them, but one of them was very, very interesting. It's the one that went with Viscalor. Can you talk about how that heating system works? So the Viscalor can be heated in two ways. in either a regular or one of those sort of like drop-in heaters that you can put the composite like carrier they were kind of like standard composite carrier you can drop it into the little hole like the holster and you can put individual capsules in there so you can use the viscalor in that kind of heater or you can also use the viscalor it comes in its own dispenser and it's like a has a little stand on it so it stands up on the countertop and then you plug actually the it in from underneath and then it holds a charge in the battery, in the holder itself, and you load the composite into the specific visceral or carrier. And inside there, there's a heated piece within there that heats the composite sort of as it's extruding it and around it. So you know how the back of a composite carpule has kind of that, you can like push right in the center. So the heating element kind of gets in and around the composite. carpule in that specific carrier. And with that one, if you're using vis galore in that carrier, it takes 30 seconds to heat up. So if you're putting that on a heating pad, I have no idea how long your composite would have to sit on a heating pad versus if you put it in something specific, these heat up between, you know, vis galore specifically 30 seconds. But if you're using another composite in that carrier, you know, three to seven minutes and your composite is fully heated through in the carpule. So if you had a typical class one in a molar, do you need to heat up the composite or are you going to use this system or are you just going to put it in without heating it? So that's interesting that you asked that because I did. I was like, oh, well, this is just an easy one. I'll just like go back to what I was doing before. It felt like. My hand was like in a cramp trying to get the cold, cold, relatively speaking, you know, room temperature composite to squeeze out of that little thing. And, you know, I shot the carrier, the composite, you know, across the room trying to squeeze on this thing super hard. And I have, you know, tiny. I'm a small person. Like I wear extra small gloves. I don't have, you know, a giant hand that's, you know, monster fingers that I'm squeezing this thing with. So once I started using warmed composite, it just made ergonomic sense for one, my size and stature. But also it was so much easier on my hands that there's really no reason not to. I mean, the heater gets turned on in the morning. We talk about it during huddle. We put whatever shades we need for every individual patient. one at a time. Workflow, there's really no downside to having it plugged in and turned on. These warmers that are made for composite are very sturdy. I'm going on three and a half, four years on one of them that gets turned on every single day at the beginning of the day and turned off at the end of the day and it's been a real workhorse. So how long have you been warming your composite? And the second part of the question is, do you think we're moving into a time where direct restorative composite dentistry will be state-of-the-art, will be warming the composite prior to application? So I've been warming composites since probably the end of 2018, plus or minus. And do I think that's kind of where composite dentistry is headed? You know, that's a hard question because there's so many different ways people choose to practice. I think that... know, patients are interested now in having things done, you know, as efficiently as possible, you know, same day treatment. And if this is something that you can get done efficiently and quickly, I think with the... bulk fill composites that also makes our appointments much more efficient when we're not putting multiple layers, especially in the posterior. So the combination of a heated bulk fill is, for efficiency, really, really great. So I think it just depends on if you're your patient demographic. That's a hard one because, you know, some people are into milling and scanning and like moving away from direct composite. I think there are practices that are definitely moving more toward sort of an indirect approach as opposed to direct for everything. Yeah. I mean, I think direct composites will be around for forever. Yeah, I don't think they're going anywhere soon. I just don't know if that's like the future of where direct composite is headed. Yeah. So what have you seen as we wrap up this podcast, Dr. Rainey? It's been very interesting. What have you seen regarding post-operative sensitivity? Have you seen because of the better adaptation, less post -operative sensitivity or maybe the same or maybe a little bit more because there's a heating element to this? No pun intended. Yeah, no. You know, once I started implementing sort of an injection molded composite protocol in my practice, I saw post-op sensitivity decline rapidly. You know, I also at the same time was being much more intentional about soft tissue retraction, making sure that the field was very dry. There's a lot of great materials on the market, but you just have to read the instructions and make sure that you're following the manufacturer's instructions for whatever material that you're using. So I started doing that and paying more attention when I started warming my composites, making sure that the composites that I was using were okay to be warmed. So I have not seen. an increase in post-op sensitivity. In fact, it's gone the other direction. And I think it's because I like those post-op radiographs. I'm just getting better adaptation, less voids, and I'm just being much more meticulous about the work that I'm doing. Yeah, and less muscle strain. on your hands. Absolutely. Absolutely. I see you smiling. Yeah, the audience doesn't see you smiling because it's a podcast, but I'm actually doing video with Dr. Rainey. So when I said less muscle strain, she's she lit up like a bulb. Dr. Rainey, thanks so much for your contribution. Great conversation. And certainly, I think it's something our audience should Look into. I mean, if you're not warming your composite, check it out. Do some research. Google it. There are a couple of companies. We mentioned one, which is Voco. Great company. I know the people there very well. I guess, Dr. Rainey, could they reach out to you? Do you have a... or something? Absolutely. Yep. You're, um, you're welcome to reach me via email. I'm at Rainey, R-A-I-N-E-Y D-D-S at gmail.com. Or you can find me on Instagram at Rainey D -D-S. It's again, R-A-I-N-E-Y D-D-S. And I'm happy to answer any questions or help you kind of troubleshoot what might not be working and, uh, share with you what's worked for me. And once again, I'd like to recommend Dr. Rainey's webinar on VivaLearning.com on this topic. Turn Up the Heat, Composite Warming Techniques and Implementation. Dr. Rainey, thanks so much and we'll talk to you soon. All right. Thanks so much for having me. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.