Warm it and Fill it! You'll Never Look Back

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. We're all very familiar with the traditional techniques of composite placement. Those are the same techniques we learned in dental school. But recent research is supporting the concept of doing things a little differently when it comes to placing our composite restorative materials. And yes, you've guessed it. This has to do with the temperature of the material when applying it to the tooth preparation. To tell us more about this is our guest, Dr. John Comisi. He's going to talk about why we should consider warming things up in our direct restorative procedures. Dr. Comisi practiced general dentistry and dental sleep medicine in Ithaca, New York, for 35 years before relocating to South Carolina in 2017. There, he joined the faculty at the Medical University of South Carolina, James B. Edwards College of Dental Medicine, where he is an associate professor of restorative dentistry. Before we get started, I'd like to mention that Dr. Comisi’s webinar, titled The Heat Should Be On, Why Some Like It Warm, is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Comisi, C-O-M-I-S-I, and you'll find the webinar. Dr. Comisi, it's a pleasure to have you on the show. Always great to be with you, Phil. Thank you. Yeah, we're really happy to have you back. You have so much knowledge over the years to share with all of us that have been listening to Viva Learning for so long and talking to my listeners now. Please leave a good review on this show. Follow us on the different platforms. And that really helps us keep this show free and at your disposal so you can pick up new things as you nourish your continuing education in the profession that you've chosen. So let's talk about... placement of composite materials, what are some of the problems with traditional quote-unquote cold placement of composite materials? Well, it's really very interesting because in our dental education, we're taught to incrementally layer. our composite one layer on top of the other especially with our traditional composites can that can't be placed greater than two millimeters at a time because otherwise the chemistries and the properties of the material won't cure properly so we were taught about something called an air inhibited layer and which was always going to be available to let one layer of composite go ahead and lie on top of the other and there's some basis to it. But interestingly enough, as time has gone by, we're starting to see, especially with the work of our good friend Richard Price from Delahousie University in Nova Scotia, it keeps on showing us that there may be some issues associated with the incremental placement with a cold composite. Seems to be that when you cure one layer of composite and then add another layer, it creates some forces that essentially prevent them from binding together properly. And they set up in a bad way. And so this way, he calls it the creation of knit lines, which are these little spaces between each layer of composite, which is really fascinating. When I started investigating it as well, I found that this was true. We never knew that because we've never really had the kind of advanced molds that are now available, especially the type that Richard has created. It shows us in a deep preparation how a composite can or cannot fill the void, especially... down deep inside of the box. So that's typically where our problems occur, down in the deepest level of every proximal box creation. If your composite does not extend down properly, and even worse, if the light doesn't get down to cure it, you have a giant emptiness that will create the restoration to fail. Cold composite is something that we've gone away from here at MUSC. We're heating all of our composite now to enable a greater and a more easy fill. David Clark has been talking about this in BioClear for years about heating the composite. So it's just that we've been slow to catch up to his brilliance. So for the sake of argument, what would you say? to a dentist that says, well, rather than change my habits, my workflow, instead of warming up the composite, I'll just use a flowable to get my adaptation. And again, that's wonderful. But the problem is then you have to have two different materials on hand. So you need a flowable and you need a traditional or you need a bulk fill all at once. If you warmed your traditional or your bulk fill composite. you don't need any other materials. So it's a cost savings and it's an overall benefit. And you're going to get the same kind of filler in that composite from top to bottom. So if you like using a specific brand, then you can warm that up and it will flow into the composite restoration as easily as your flowable composite, but at the appropriate filler level to give you a consistency from top to bottom. Okay, so we're talking about improving the delivery of composite restorations, getting better adaptation. So what can we do in the day-to -day practice of general dentistry to improve that delivery? What do we actually do to get that composite warmed? Well, basically, there are composite warming devices that have been created by the various companies that are specifically there to provide a consistent heat. to the composite. They will typically warm the composite up in less than a few minutes of time or you can just leave your composite compules in the warmer all day long. It'll keep at a constant temperature and then when you need that you can just get it. and your assistant can load the gun provided to you you can go ahead and restore and then if that gets cold you need another composite comp fuel you just ask the assistant and they'll provide you with another one it really makes the workflow even easier because you don't have to struggle between one type of syringe and a gun etc and so forth so it it can and it does make the workflow very very easy our students they're saying why did we ever use cold composite and they don't use flowable composite in the way that they used to cost savings and an overall benefit to the final restoration so what happens to the temperature once you put it into the preparation how long does it take for to get back to where you can sculpt it Well, you have to work quickly. And that's the really nice part. When you're working with a warm composite, I always recommend and I always tell my students, inject into the box areas first. Condense, you know, just adapt it into there. And then you can put on your next layer on top of that and the next layer on top of that if you've got a two millimeter increment type of composite. If you're using a bulk fill, you can then just put in the four or six millimeters, depending on the brand that you're using. you know, it's going to get, it's going to cool down. It just does after it hits room temperature, which is why there are devices that you can actually warm, keep the composite warm in delivery guns. And ADDENT had a gun like that. They're hopefully bringing it back very shortly. We got to use that for a while and it was really brilliant. And I'm hoping that the updated version that they will soon release probably in the fall or so will provide a constant heat all of the time. ADDENT. At Dent, the company, yep. And what is that gun called? They had it as one, I'm not sure what they're calling it now. They have not brought it back out. Again, we had a prototype that we played with and it was really beautiful. So when they do release it, I'm going to encourage everybody to look at it because it will enable a consistent heat, quick reheating of the new. comp oil as you put it in, great disinfecting capability with it. So when that company brings it back out again, I can't wait to show it and use it. And just for the record, if you're interested in learning more about AdDent, you can visit their website at adent.com. That's A-D-D-E-N-T .com. They do have a warmer that's known as the CalCet composite warmer. So they've had that a while. That has earned many awards, top 100 products, dental advisor, top. rating and also Celeron Best of Class Technology Award. So you're using the gun to dispense it, right? But it also warms it. How does it do that? The handle is typical, like your regular composite placing gun, but up in the upper area, it has a warming compartment that you put the composite into, the comp you'll into, and then you can directly inject it after just about a minute or so of heating, and it's ready to go. And it keeps it consistently warm. while you're operating, which is the change, the main difference between the typical composite warming devices that you put on your countertop and this device. So I'm looking forward to playing with that one again. The students that I had play with the prototype, they absolutely loved it. Is it a battery operated? It's a rechargeable battery operated item. You put it into a USB cord or a micro USB, it charges it up and it's ready to go and it goes for quite a while. So what do you say to dentists that say, well, I think the warming concept is good, but I have other ways to warm up my composite. Could you give us an example of other ways that a doctor could warm up their composite or do you even recommend that? I don't recommend anything outside of an actual composite warming device because if you were to use something, you know, some people talk about coffee warmers and I'm like. You're going to use a coffee warmer? How do you know that there's even going to be any consistent heating there? You know, every time I've ever used a coffee warmer with a cup of coffee, it was inconsistent in the temperature. So if I couldn't get a liquid through a ceramic mug to warm up properly, how are you getting this little compule? on there to even be a consistent thing and the temperature that the readout is probably won't even be what the actual temperature needed to cause the liquefaction of the of the composite to be as effective as this you need to bring it up to at least 155 degrees fahrenheit to make it work and flow properly uh so you don't know if you're getting that or not yeah so okay i cut you off but you said anything used off label you would recommend That's correct. Yeah. So what about the material itself, Dr. Kamesi? Is there a special kind of composite you need to use or be wary of when you're warming it? Or could I use any composite that I normally use cold? From everything that I have researched and read so far, all composites warm well. And so you don't have to switch to anything new or different. So you can continue to use the materials that you've been using for as long as you like to use it. It's just that now, instead of needing two different materials like a flowable and a regular type of composite, you can one size fits all in this situation. One copy of your material will be able to... flow very smoothly and into your preparations without needing the expense of additional materials. Yes. There's no question there's a movement towards reduction of inventory without a doubt and simplification. You know, you remember the days when the kits would have, you know, 552 shades in it and we'd all be looking for the shade we want and layering and watching. DVDs, which don't exist anymore, about how to do all this layering. And, you know, the dentist just realized this is just not realistic. What is the expression? The juice isn't worth the squeeze or something like that. That could be. You know, you want to work smarter, not harder, which is the other terminology that I like to use. And again, if you can use what you always like to use and get it to work for you in a more effective and easy manner, why not do so? the composite makes sense. So Dr. Comisi, I have to ask this question because I'm an endodontist. What's the risk of hurting the pulp due to the rise in temperature? Has that been researched? Is that a concern of yours? And should that be concern of our doctors who are warming their composites? Very interesting because the actual heat dissipation as the dentin gets, you know, you're always going to put a liner down if you're anywhere near. down into the pulp chamber so i always recommend putting a liner down we like to use the various products we use limelight enhanced by pulp dent here at the college for our liner and it works out quite well uh and then you know we we know and i've seen that the it as soon as the warm composite touches the tooth it begins to cool and it really doesn't generate the kind of heat that would cause any pulpal damage. So there's nothing in the research, there's nothing in the practical knowledge that I have seen that causes a tooth to die because of a warmed composite. So it sounds pretty interesting, this concept of warming, which things start off as a concept which is discussed and you hear it at a dental meeting and you listen to it on a lecture. And then within five years, 60% of the dental professionals are warming their composites. These things take a while to catch on. They have been around for a little bit. I think it's been several years since we've been doing this, right? By all means, again, warming composite via these mechanisms have been available for a long time. As I said, David Clark has been advocating for a warm composite placement for years with his BioClear technology, and it works really beautifully. It simplifies and enhances the overall workflow as we go forward. We're teaching it here at the school. If you institute it at the educational level, and the evidence shows that this mechanism works well, it improves the overall polymerization shrinkage, enables the cure to be faster. There's so many different mechanisms that are improved by warming the composite. And we'll be talking about more of that, again, on the webinar that we do for Viva Learning. You can learn more about that as well, and I encourage folks to listen to that as well. Regarding Medical University of South Carolina, where you teach at the College of Dental Medicine, are they primarily doing bulk fills or are you doing layering? we are currently in the process of going i finally have convinced them and showed the evidence that bulk fill composite is the way to go so we're in the process of switching from traditional two millimeter increment uh composite materials to a bulk fill and we'll be moving to that within the next few months because you know everything at a college has to be done by committee and you investigate which one you want to do but we've we've narrowed down some choices and we'll be instituting bulk fill as our restorative mechanism in a very short time. Are other dental schools following suit on that or they have already done it? Many schools have already done it. And again, I think you're going to find it to be a methodology that more and more of our graduates will be very familiar with and enjoy using when they get into clinical practice. Excellent. Excellent stuff. Okay, Dr. Comisi, you came through again, another Home Run podcast as usual. Thank you so much and have a great evening. Thank you very much. Pleasure being with you again. We really appreciate your support. See you on the next episode.