Advanced Hemostatic Techniques for Effective Tissue Management with Dr. Michael Miyasaki

How do you manage bleeding and saliva effectively in challenging dental procedures? Join Dr. Michael Miyasaki as he shares expert insights into the nuances of tissue management, especially in tricky areas like the mesial prep of a back molar. This episode promises to enhance your understanding of various hemostatic methods, from ferric-based agents to advanced laser applications. Dr. Miyazaki reveals personal experiences with these techniques, spotlighting the pros and cons of each, and introduces clear hemostatic agents enhanced with surfactants that avoid the common issue of tissue discoloration.

Discover the practical applications of QuickStat Free, a revolutionary hemostatic agent featuring aluminum chloride, magnesium, and proprietary surfactants, through real clinical cases. Dr. Miyasaki delves into its effectiveness in procedures like intraoral scans and soft tissue recontouring. Additionally, he highlights the benefits of Vista Apex's StatPak Knitted Retraction Cord, which works in tandem with these agents to improve visibility and control during procedures. Emphasizing community feedback, this episode is a must-listen for dental professionals eager to refine their practice with innovative techniques and materials. Join our growing community and elevate your dental practice today!

Chapters

• 0:18 Clear Hemostatic Agent for Tissue Management
• 7:15 Effective Tissue Management Techniques
• 14:52 Advanced Tissue Management Techniques

Transcript

Speaker 1: 0:18

I'm Dr Michael Miyazaki and today's program is called let's Get Clear with Tissue Management. So we know that every day we're dealing with tissue and how difficult that can be. So let's look at this example Working on a back molar, the mesial prep of that molar is is equigingival, maybe slightly subgingival, and we get blood and saliva in that area. Now, even with the rubber dam, if we're going to place a composite, that would still be challenging. If we were in this situation and we were trying to get an impression of this area whether it be an analog with impression material or digital we know that that fluid in that area would compromise our ability to get an accurate impression of our margins. Blood and saliva will prevent a good bond. So if I'm placing a direct composite in this area and I can't control that fluid, then we're going to have issues. If I'm doing a cementation procedure and I'm going to cement an inlay in that area, we're going to have problems. If it's a crown, we'll have problems. And then I'm thinking of another instance. Where this is a challenge is if we're doing a direct pulp cap. So if I get into an area I've removed the decay or an old restoration and I have a very fresh pulp exposure. What I would like to do is maybe do a pulp cap versus doing a root canal. Now, if I'm doing a pulp cap, I'm going to cover that up with some material. I need to make sure that we don't have any kind of bleeding in that area, because that fluid again is going to interfere with me being able to obtain a good seal and that direct pulp cap may not work.

Speaker 1: 1:53

Now, in the past, what have our solutions been? Well, we could use a hemostatic agent. Many times what I would use is a ferric based hemostatic agent, so it was the brown liquid that we put down there in the posterior area. I just wanted it to be effective, and the ferric-based hemostatic agents for me were, I found, to be the most effective. Some of us and I've used them too as a hemostatic paste, where I would inject a paste down there, try to squeeze it into the sulcus, get it over that bleeding tissue, and many times that was a satisfactory solution. But, depending on the paste, sometimes it was hard to get it down in there, especially into the sulcus, and then when it came to take the impression. Ultimately sometimes it would be very hard to rinse out thoroughly.

Speaker 1: 2:39

Another option that I really liked was using a laser I would use. I had an all-tissue laser and I had a soft tissue dial laser. Most of the time in a case like this I would grab the soft tissue laser and use it to trough that area out, maybe like a little gingivectomy, as if I had pat the cord and it'd give me the hemostasis. But using a laser there's a lot more expense. So a lot of doctors never adopted the use of a soft tissue laser and if you had the laser, just the use of the tips because many of the tips became like single-use tips it could add a cost of seven to ten dollars. So it was kind of costly to use a laser.

Speaker 1: 3:17

So here's an example of what I would use is a gel type ferric sulfate hemostatic gel, so a gel so that it didn't get all over. Many of these solutions are acidic so we don't want them to get all over their CJs of the tooth that we're working on or the teeth adjacent to that tooth, so we use a gel so it would stay where it was. This was a 20% ferric sulfate gel and many of these I found to be very effective. This is from Vista Apex called QuickStat gel. So what I found was that if I got this gel in I'd scrub it into the bleeding tissue and then rinse it and if it's still bleeding I'd scrub it again and rinse it until there was no bleeding. And I found that these ferric sulfate types of gels were very effective. And then I was trying to use some of the clear gels or liquids that were hemostatic agents, that were more aluminum chloride based, and I never found them to be as effective and they were more frustrating.

Speaker 1: 4:12

So I was using these ferric sulfates on a posterior tooth, as I mentioned before. It'd be no problem. But when I dealt in the anterior region of a tooth, let's say I was doing the centrals or a lateral and I was placing maybe just a direct composite that was slightly subgingival and there's a little bit of bleeding there and I had to control the bleeding to bond the final restoration there satisfactorily, I would use a ferric sulfate and what that would ultimately do is it would give me the hemostasis but it also discolored that tissue and when I was done placing that restoration, the patient would be excited because the front tooth and I would kind of hesitantly hand them a mirror and they'd look at it going, wow, that tissue. What's going to happen there? You know they never saw the composite restoration I placed where I got the shade matched, I got the contours and everything polished up. Nice, all they saw was that dark tissue there, and so that was not one of my favorite things about the ferric sulfates.

Speaker 1: 5:08

Well, there have now been developed and they've been around for a while, but I have just learned about them clear hemostatic agents that work really, really well. What makes them work better is the things like surfactants, which are chemical compounds included in the hemostatic agents, that decrease the surface tension so that our hemostatic agent can actually get into those broken blood vessels where the bleeding is coming from. So if you forgot about surface tension, here's a liquid. I'm putting a food dye in that liquid and you can see that it's circular. Why is it circular? Because there's a surface tension on the outer liquid that does not allow the inner liquid to spread out. If I break that surface tension by using a soap, an emulsifier, watch what happens. So I place the soap in there and boom, it explodes All of a sudden. Without that surface tension there, my food dye is able to penetrate the outer liquid. Same thing with the surfactants.

Speaker 1: 6:07

Now, with the surfactant. We can put a surfactant outside of the blood vessels. The surfactants help this hemostatic agent, astringent agent, get into those vessels and we get the effectiveness that we've always wanted, but using a clear hemostatic agent. So what I use today is Quick Stat Free. It's a clear hemostatic gel. So again, it's not a liquid. It stays where I put it, but it uses astringent hybrid technology and surfactants, has some aluminum chloride and magnesium in it and the combination of these three main ingredients really contribute to its effectiveness. So it's got the proprietary surfactants for better penetration into those vessels that are bleeding.

Speaker 1: 6:50

So let's go back when I was using the ferric sulfate-based hemostatic agents. The way I was taught to use them was apply them to the tissue, scrub, scrub, scrub, scrub, rinse If it's still bleeding, scrub, scrub, scrub, scrub some more of that hemostatic agent in there and rinse. If it's still bleeding, scrub, scrub, scrub, scrub some more of that hemostatic agent in there and rinse. If it's still bleeding, take that ferric sulfate-based material, scrub, scrub, scrub into the bleeding area and then rinse. And ultimately I found that at some point I would get the bleeding under control.

Speaker 1: 7:16

What I find today is using QuickStat Free. What I do is I just apply it to the tissue. I don't even scrub it into the tissue. I use these stat flow tips, which are very nice, I'll describe them to you in a minute. But I apply the hemostatic agent to that area and most of the time when I rinse it off I have my bleeding controlled. So I don't have to do it multiple times. I don't have to vigorously scrub it into those broken blood vessels. I just apply it to the blood vessels, rinse it off and I get my controlled, get the control of the bleeding and of the corvicular fluids. It works very well. Again, what quick stat free is? It's a combination of that clear aluminum chloride with some magnesium and the proprietary surfactants. And I'll tell you, vistapex spent a long time, years and years and years, to develop the surfactants that were suitable to penetrate those vessels.

Speaker 1: 8:09

So here's an example that a clinical case of mine where I was working on this lateral and you can see the central just broke off. It decayed at the root and number seven I wanted to try to save. So I carried my margin all the way down, almost to the bone. I know, you know, getting down to the biologic width. This patient was not going to tolerate OCS, crown lanthanine. So I was doing the best I could. There were a lot of other medical factors and things involved and so what am I doing? I'm way down below the tissue. I'm trying to get an intraoral scan. I got my margin down there. I have a ton of blood pulled up around my preparation. I take the QuickStat Free. It's looping around so it didn't re-bleed. This is the original case, where it started. You can see I'm just applying the QuickStat Free into that tissue area. Imagine the aluminum chloride, the magnesium and the surfactants are penetrating into those bleeding vessels and I rinse it off and I was able to get my intraoral scan and we were able to get a very nice crown back onto this tooth. So look at that. All the bleeding stopped. We rinse off the remaining blood and we were able to scan. I mean it's amazing how this quick stamp free works.

Speaker 1: 9:22

I'll show you another clinical case. This is a case that we just did. This last week. The two centrals had these old PFMs that were very dark. If you look at the tissue heights they were slightly different. The patient's right central was slightly more incisally positioned, not apically positioned like the patient's left central. So we knew we were going to do some soft tissue recontrains, shorten the incisal edge of the left central so that the teeth wouldn't look too long.

Speaker 1: 9:49

So I got in there with my soft tissue dilator. I did my soft tissue recontouring, trying not to violate the biologic width but to raise the gingival height. Now this patient you saw from the original photo has a really low lip line anyway, so they weren't going to really show this area. But you never know. Some of these patients have just positioned the lip to hide this discrepancy and as soon as you take care of it they're going to smile big again. So what I'll do is I'll go back in there, I'll do my soft tissue re-contouring and you can see we don't have much bleeding. We have a little bit of redness just from the amount that we had a laser off.

Speaker 1: 10:20

So we got ourps, I got my margins as level as I could, again without violating the biologic width of the patient's right central, and I was pretty equigingible and so I was doing an internal scan. I wanted to make sure I had a good, clear uh scan of the margin of the patient's right central, so I packed some cord. Now I I did this basically illustrate what I'll do is I'll take the quick stat free and I'll put a little bit in that area where I'm going to pack the cord. It is like the lubricant. It makes the packing of the cord much easier.

Speaker 1: 10:53

Now this is a knitted cord from vista apex and because it's a knitted cord it's able to absorb the hemostatic agent. If you pre-soak it it doesn't really have memory, so you're not going to be packing the mesial area and have the tail of that cord curling up and coming back out. It's knitted so it soaks up the hemostatic agent again. I pre-wet that sulcus with some hemostatic agent. I just take my cord packer. I take a circular serrated edge cord packer and I roll that cord up into that sulcus and let it sit there. Now again, this hemostatic agent gives me the hemostasis and this tringident causes the tissue to kind of pucker up a little bit so it helps me see my margins even more. So I get that and you can see that before and after Now when I place the temporaries.

Speaker 1: 11:42

You can see the temporaries I just made kind of from the pre-op impression of the patient's two centrals and you can see on the patient's left central. I shortened that up a little bit but the redness that's at the genital tissue right now is more because I made the temporaries and I took a little burr up there just to make sure I didn't have any overhangs. I want that tissue to heal up nicely so I want to make sure there wasn't any excess of acrylic up there and the patient was really happy about this. So when we did the tissue management, some of the things I just showed you was the knitted cord. Now the knitted cord the one that I used in that example, is called StatPak Knitted Retraction Cord. It's also from Vista Apex I used is called stat pack knitted retraction cord. It's also from vista apex.

Speaker 1: 12:25

I use the purple cord, which is a triple o. It's knitted and it soaks up the hemostatic agent. I I wet the sulcus with some hemostatic agent, then just roll that cord into that area. Because it's knitted it doesn't have memory, which means I can pack the mesial and the distal tail doesn't pop back out. That's one of the frustrating things about having cord. But this knitted cord is able to conform to the sulcular anatomy and then it kind of expands a little bit once you get packed in so that once you pull that cord out to take our impression, whether it be analog or digital we're going to have a nice space up in that area. This is the packer I use Now. This is a thin edge packer that will compress the cord and make it easier to get into the sulcus. But the thing I like about this is it has a serrated edge and so with the serrated edge it kind of grabs onto that knitted cord and helps me hold onto it and push it up into the sulcus and because it's circulate in shape, I can just kind of roll it up there so I get the serrated edge on the cord, just kind of roll it up there so I I get the serrated edge on the cord, I push the cord up in this into the sulcus and I kind of roll it. And I roll it as I go and advance it through that sulcular area and it makes the placement of the cord so much easier.

Speaker 1: 13:31

Now the human stack agent, the quick staff free. I use these stat flow uh hemostat brush tips. They're really nice. They're pre-bent 19 gauge tips that are made to deliver the human stack agent. They're curved to make the accessibility to the sulcus much easier and to optimize the visibility because it has such a long tip. If I'm working on the, the mesial, that posterior molar, I can see where I'm placing my hemostatic agent. It's a padded tip, it's not gonna irritate the tissue and cause more bleeding and it has a universal lure lock hub so it can go onto my QuickStat free syringe and it's very easy to use.

Speaker 1: 14:10

So again, this is a QuickStat free, clear hemostatic agent. It's clear. It uses the syringe hybrid technology which includes that proprietary surfactant to get the better penetration into those blood vessels that are bleeding. So you can get in a bulk fill syringe. You can get in these little syringes. I use those little syringes on the lower right-hand side of the screen right now, kind of where my face is, and I just put the stat flow tip on there and just again apply it to the tissue where where it's bleeding. I don't rub it in there vigorously, I just apply it to the tissue and then rinse it off. It has worked great for me and um handling my tissue management situations.

Speaker 1: 14:53

So I would encourage you to try quick stat flow. I would encourage you to try the knitted cord, also from Vista Apex, the circulate serrated cord packer, the quick stat free with the stat flow tips. All this will make your tissue management so much easier. Hey, we love bringing this information to you. I'd love to get some feedback from you. I'd love you to try the products and tell me how it works for you. We've got a community growing here and I'm very excited about that, so thank you very much for joining us and I look forward to seeing you during our next presentation. Thank you very much. Take care.