Root canal treatment. The mere words would send shivers along anyone’s spine – but not when Rik van Mill is your dentist. He is a guru in the Ield of endodontology. Expats love going to Dental Clinic H.J. van Mill’s whose employees not only speak Dutch and English but also Japanese, Hindi and Urdu...
Profiles in Dentistry & Gutta Percha Removal A Closer Look at Dr. Rik van Mill & How to Remove Gutta Percha
This episode opens with Ruddle emphasizing the importance of documentation in his life and practice. Next, The Ruddle Show premieres its ongoing segment, “Profiles in Dentistry,” with this episode featuring Dutch clinician, Rik van Mill. In the next segment, Ruddle presents how to remove gutta percha when performing endodontic nonsurgical retreatment. The show closes with a rare look at some behind-the-scenes footage; see what goes into creating each unique episode of The Ruddle Show.
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This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: Importance of Documentation
Welcome to The Ruddle Show. I'm Lisette and this is my dad, Cliff Ruddle. Today we want to start off – well I want to start off asking you something about documentation. Is that okay?
Because the other day you said something to me that got me thinking. You said that you wouldn't be where you were today without all the documentation you did. And by documentation we mean all the detailed notes, the radiographs, the photographs that you did on each patient.
So at first, I thought you meant that you wouldn't have all the great content for your lectures, for all of your teaching. But that is not what you meant. Could you tell us what you meant by that and why you think documentation is one of the secrets of your success?
Sure. I used to play a lot of sports and in sports, even back then in the '50s and '60s, some coaches did take some films. Maybe it was a handheld camera and a still image, but they would show you your stance or your step up in the bucket. Anyway, in different sports there's different things. So I learned as a kid how important it is to go back after the game's over and see what you might have done and how you can get better. So it was pretty natural for me to take a few pictures. I should probably tell you; in the old days it was 36 slides I think in a packet.
Of film, like it was not – we didn't just have the iPhone.
No. So we would take all these pictures and sometimes you'd see things you never saw in your life. And we would have a race to get down to color services where it was developed overnight, and the next morning I'd roll in there at 7:00 or 6:30 in the morning, grab my packet and race to the office and my staff would come around. And sadly, we'd put a wastebasket: no, no, no. And there might be 2 or 3 that I could use in my lecture, but I realized this is really important stuff.
We what happened as we got the digital cameras, we could see if we got the shot right at the moment; I'd begin to evaluate my surgical cases; how I took a post out or what I did when I'd get a broken instrument; clean shape pack, different things; parulis, a dark tooth, swellings.
Anyway, I got the staff involved. At some point I didn't do any documentation; they did it. I just kept working. So the patient wasn't really inconvenienced, I wasn't inconvenienced, but I had the benefit when everybody went home and it was quiet – and it might be three days later or three weeks later – I could go back and look at that case, and I saw lots of things Ruddle needed to get better on. There were a lot of little things that I could do better, I saw I missed some things, and then I just saw the esthetics of it all and from a teaching standpoint, how to get a point across. Maybe a film right here; we're always waving our arms and trying to chalkboard it, but maybe we could just show it and then they would see it.
So documentation had a lot to do with my success. I had a fabulous team, obviously I had family support, but the documentation allows you to grow.
I think you also said – at one point, too, I heard you say that it helped you see what was maybe missing technologically; like how you might have benefitted from some innovation or invention that could have helped you.
Well when you're documenting, suddenly in the quietness of the room, the film room, you are looking at things and you're going if I had just had that, I could have done that more successfully, or easier, or easier/faster/better versus not at all. So it did help me a lot with some of the inventions I've done across the years just to see how things really are. There's what we think and then there's what is.
I have also – when I've seen your lectures, I have seen that you have oftentimes 5-year recalls, 10-year recalls, and I've seen even up to 30-year recalls. And when I had a root canal several years back, I got called in 5 years later to come in for a recall visit. And at first I didn't come in because I'm thinking well there's nothing wrong, my tooth is doing well, so why would I need to come back in? But then I felt guilty because I remembered how much you valued those recall radiographs you had and how they're rating your lecture, so then I felt guilty and I went back. So how did get patients to come back in?
Bribery. Well no. I think I would say quickly; I would say that it all starts when the patient walks into the office. In other words people aren't going to come back; they don't even want to be there and they're probably there because they're hurting, in endodontics anyway. Most of our patients have some complaint.
So to have them come back, when they first come in the office we need to get into relationship, make connections that are humankind, people like people like themselves, ask an unscripted question, get them talking a little bit so all of a sudden you're friends. So when you tell them how important it is and you've explained the case as you're going along, they're part of the treatment. They're co-treatment with you. So it's not just me doing the treatment, they're helping me. So I would ask them at the end, you know we're going to have a recall, you'll get a postcard; don't be panicked, don't be concerned, just drop by and take 10 minutes of your time. Well a lot of people would because they liked me and I liked them and I had those relationships, but I would say maybe 30 or 40% didn't. And so then we'd have the receptionist call. A very powerful one was having the assistant that sat with them during the procedure, have them call when it's convenient and they can have a little conversation and get the patient in. And then of course, back to bribery; that always seemed to help. We would give gift cards maybe to Starbucks, maybe to a restaurant or whatever, to make them realize it was important, make it fun, and we all had fun. They got a nice dinner; I got the case.
And you know after surgery, just in closing; one last thing about documentation. That's what led to 48 hour suture removal. I mean we were leaving those sutures in for seven days and then we were taking healing shots post-op seven days, thirty days. But when you started taking sutures out in 48 hours people said you can't do that. Well we showed them you can and the healing was fabulous.
Well great, okay. It sounds like it's important to get the staff involved – I got that – and to get people to come in, just be persistent. Well we have a great show for you today so we're going to get started.
SEGMENT 1: Profiles in Dentistry - Rik van Mill
So today we are debuting a new segment we have called Profiles in Dentistry. Every now and then we want to present a clinician who has really devoted his or her life to making a difference in dentistry and helping others. And we want talk about this clinician in terms of the four facets of the Ruddle Show: education, innovation, community and lifestyle. Today we want to present to you a Dutch clinician, Dr. Rik van Mill, who you have seen on a previous show on his boat talking about Covid-19, and also in a music segment we had last season, you saw Rik playing guitar. So you've known Rik for several decades. Do you remember how you met him?
I do. We were giving seminars for several decades, but in 1990 I believe roughly, we – it was an international class and that was pretty normal, people from all over the world. And I just knew that he was going to be coming; I didn't know that he was coming with his wife, Wilma. And so I knew he was coming, but I guess what stands out is he arrived on – they arrived on bicycles. I'll let you go into that more.
Oh no; you tell the story.
Well, okay. So Wilma says that Rik likes to be completely mentally free and cleansed so he could really dive into the educational knowledge and swim vigorously. So they flew from Amsterdam to San Francisco and then they had their bikes shipped and they got on their bikes with saddles and a little backpack. And they came down the coast, Highway 1, and you know how beautiful that is – Monterey, Big Sur, Carmel, all that stuff – and then they arrived for the course. So I met them on the first day of the course. We had breakfast, which was normal, so they came out to the office with a van. But Wilma was limping and was limping the whole course, and that's how I met them.
Okay, so Rik lives and practices in Amstelveen, which is in the Netherlands, and he's married to you said a great woman, Wilma. Wilma is to Rik kind of like how mom is to you; like the backbone of the operation. So now we're going to show a little video and it's narrated by Wilma and it shows where Rik practices in Amstelveen. So let's look at that now.
[Wilma narrating] "Hi. This is our first introduction video of Rik and Wilma van Mill from the Netherlands. Our dental office is located south of Amsterdam in Amstelveen, which is actually a suburb from the big city. We are surrounded by this little green park which gives a very nice and relaxed atmosphere. Today is the 15th of February, so actually it's mid-winter. But because of the sun shining, it feels almost like it's a spring day. You hear the birds singing; it's a beautiful day."
So what did you think of that?
Well it brought back a lot of memories. I've never been to his office but I've been to Amsterdam many times as a clinician lecturing and I've had dinner with them. I remember one course years ago; it was the first microscope assisted course in all of Europe and I was a keynote speaker. And I remember walking along the canals after the lectures and walking to some great restaurants, and then Phyllis and I have been back. And so yeah, it brought back a flood of memories.
It looks like a really nice location to practice. And apparently he's been at that location since 1982. Now Wilma's going to take us up to the front door of the office, so let's look at a little bit more.
[Wilma narrating] "So I cross over this little bridge and then I'm in front of our office. You cannot see me because I'm filming, but later I will introduce myself. And I'm going inside now where Rik is teaching a seminar of endodontics of course. And in a small setting we have now eight dentists today and tomorrow. Today is theory and tomorrow he is doing a live demo on a patient, and afterwards hands-on training."
So you can't help but notice the bikes that were parked out front, so biking is obviously pretty big in the Netherlands. But he's also giving a course, and he's taken courses from you, right?
Yes, Rik – as you mentioned, 1990 was our first interaction and that was a 2-day course. What we didn't say is that he came back multiple times to take 2-day courses. But then he started coming back and taking my week long course; because I offered a week long course for international people so they didn't have to transfer back and forth over the oceans; so it was more convenient and efficient with their time.
And in recent years he even came to actually help out in the courses.
Well he kept coming and finally after he'd taken every course: Rik, I don't need to say you're a slow learner do I? But no, he was just passionate about endodontics so he came over and over and over. And finally when he signed up again and the credit card information came through I said this is embarrassing. And I said you will never pay another dime for Ruddle's education. But what you can do, since you still want to come, is I'm going to put you to work. So I told Rik, when you come over you're actually going to be a body among the dentists and you're going to actually work with them chairside; you're going to help them.
And so we worked for many more years where he came over as faculty. I went down – I was the chairman at the Scottsdale Center for Dentistry and I had a faculty that supported me. He was one of them that came there. Then when we moved the seminar business back to Santa Barbara, he kept coming.
We actually have some footage of Rik teaching his course; he's teaching it in Dutch. But let's look at that now.
[Wilma narrating] "Here Rick is teaching his seminar on endodontics in our coffee room." [Voices continue in Dutch]
Did you understand what he was saying?
My Dutch is perfect. I'm fluent in many, many languages; English and English and English would be the top three.
Well I'm really proud of Rik because Rik got – he's a skillful clinician; you have to have some skills. But then he had desire, he had a big passion, and he was able to grow. And I watched him grow. He sent me lots and lots of cases that I would review, and I just saw his journey as ascension. So he wanted to know one day if – since I can't go over so often – could he start a class? And I gave him encouragement, and he said but I'm a general dentist. I said there are no endodontists, there are no general dentists, there are just students of endodontics; people who want to learn. So if you have nothing to offer your colleagues they won't come; you don't have to worry, the decision will be made for you. But if you have something to offer and you can make people more successful, they'll come. And if they come, you will have work to do.
So he's been offering these group classes now and people are coming from all over Western Europe and maybe even a little bit beyond.
It looks like he kind of has modeled his courses a little bit in the same way that you did, except for you never did a live demo on a patient in one of your seminars. But we actually have footage of him doing the live demo, so let's see that.
[Wilma narrating] "Here Rik is doing his live demonstration on a real patient; everyone's watching. [Voices continue speaking in Dutch.] We also do video so they can also watch it on the video. Half of the group is watching this in our waiting room by the video screen. And one of the colleagues who has been here before is explaining what Rik is doing."
So I think we should say right now he's doing an endodontic course, but in his office they do pediatrics, periodontics, implants, esthetic dentistry and even orthodontics.
So I guess that is more common in Europe to do that?
Yeah. I don’t have time right now to explain, but historically when groups started coming over even in the '80s to Santa Barbara, they went home and did everything like you just said. There really weren't – if there were, there was a handful of trained specialists in all of Europe. Now that's all changed. Europe has closed the gap; they have post-grad programs and you can go there and train and get certified to be an endodontist. But you're right; it was normal for even your master clinicians to do crowns, follow up crowns and stuff like that.
And they also have quite an international office, too. I think they have a Japanese doctor there; an Indian doctor there.
And they speak multiple languages in that office as well.
They speak Dutch, English, Japanese, Hindi and Urdu. And that's just because of how multi-ethnical Amsterdam is, and in Amstelveen, the little town they live in, there's a big Japanese population there apparently.
Okay, well we have one more video clip that we're going to show you, and it kind of reveals a little bit about Rik's lifestyle. So it involves a luncheon that's being prepared for the course attendees, so let's see that video now.
[Wilma narrating] "So here we have the lunch upstairs in our living room actually, and it's a vegan lunch, very healthy with lots of fruits and vegetables and nice rolls. And this is Mimi.
Hello. Mi is helping me with the lunch and she's doing a great job. So I'm going downstairs now and I'm telling them that lunch is ready. And there's my little sweetie doggie! [Speaking Dutch]"
So I did notice a few things that stood out to me. One is that Rik is a vegan, and I know that you've talked to him about that before. Apparently it looks like he lives right above where he works, so that's nice. And then we also got to meet Rik's dog, and I think it's pronounced Luff. He loves that dog; both him and Wilma love that dog.
They actually got that dog in one of their visits to Santa Barbara to take endodontic classes. They arranged while they were over here to get that dog and that dog then flew home with them in the same plane and they have been inseparable since then.
One thing I'd like to say to the group. You're starting to notice that how you practice and what you put around you is a choice. And did you see the technology in his operatory? He had a PROergo, he had Buggy Whip over the patient delivery, he had side delivery; I mean it gets you excited. So for all you general dentists out there, you can be as good as you decide and if you get a little bit of technology around you, you can do some really great things. What else have we got?
Well we also wanted to talk a little bit about Rik's journey, because he hasn't just always stayed right there in that office. Well that office has been there since 1982. But he's also gone out on some charity type missions to bring some dental care to underprivileged people and help out in these communities in Nepal and Oman. So I saw some pictures on his website; I'm going to try to get those and hopefully we can show you those over what we're saying. But do you know anything more about that? I think that's really interesting that he's gone to these faraway places and helped teach there, and do dentistry on people who can't afford it.
You know Wilma and Rik have the biggest hearts, and they're very successful and they've always – I've always understood without even hardly talking about it; they feel obligated to give back. So when they went to Nepal that was more children, so they helped a lot of kids. And they flew in there and they'll work for two or three weeks at a time.
But the one that was also intriguing was when they went to the deserts of Oman and they talked about desert dentistry and got to do some endodontics there. Whereas with the kids a lot of times it’s just caries, cleanouts, and palliative treatment. But they have done that many years and they talk about the camels, the culture, and how wonderful, how beautiful the people are.
Well I thought that was just really inspiring to me. That's one of the reasons why we were even going to choose someone to do our first segment on Profiles in Dentistry, I really wanted to present Rik because of that work he's done in other countries; I thought that was really inspiring.
And speaking of how interesting he is, tell us about what's next. Because he didn't always – he wasn't always a dentist was he?
Apparently he used to be a civil engineer; he made calculations for drilling platforms in the North Sea. And I was actually reading a magazine article that told me about that. It was a magazine article on Rik, and it had a quote that Rik gave that I wanted to read because I thought it was really interesting.
He said: "In our clinic we always start with the pillars. Healthy roots: we use these as a basis to build something that will last a long time. You could compare it with a drilling platform. It would be nothing without a strong and solid foundation."
Wow! You know Rik one night – we were having dinner and I don't know how many beers we had – but he was telling me about the thrill of erecting a platform in the North Sea. Now the North Sea is some of the wildest waters on Earth. So he sits in his office and he does all the engineering that's all supposed to theoretically work. But he said he was obligated to go out and set the platform up, and the biggest move was towing it out horizontal and then deploying it so it came up vertical. And when that moment arrived, he said it was really thrilling.
Well that's the end of our segment on Rik van Mill, but he is going to be – you'll be seeing him on some future shows, and specifically when we talk about laser disinfection.
Oh good. Yes, he has sweeps!
Okay. And you already pointed out that had a lot of technology in his office. And I did read that they actually at one point maybe considered relocating their office, but they decided to save money because they wanted to invest in the latest technology and just be a very high technology office.
For those of you who don't know what sweeps means, it's a laser 2940 Er:YAG. And he is teaching that in his classes so he is not just any dentist; he's a super dentist.
Well that's the end of our segment. We both love Rik and Wilma and I can't wait to see them again soon.
And they're sailing right now.
Right, on their boat.
SEGMENT 2: RETX - Gutta Percha Removal
Endo training, that's what I like to do. Endo training is really fun and I've been blessed because groups have come from all over the world, and here we have Hideki Nomura from Japan who has become quite an amazing clinician. We've done a lot of training together in Japan and in Santa Barbara.
So speaking of training, we're going to talk a little bit about retreatment today, and specifically the topic is how to remove gutta percha in the retreatment situation. Now remember sometimes we even remove gutta percha when there are no problems. Maybe the dentist needs a restorative effort with a post, so he might take out some gutta percha to make a post space. Or typically it's to remove gutta percha to reset the case because it's failing.
So when you look at this case, I want to just say one quick thing. I spent a lot of years of my professional life in the world of retreatment, and I've written chapters in at least five textbooks around the world, you know like 50 pages. So when I look at retreatment, I want you to look at it like I like at it, and I want to look at it like you look at it, and together we'll learn.
So we're thinking about removing gutta percha, but what you can see in a retreatment case immediately is there's usually more than one issue. So we have a casting, a porcelain fused metal crown; we see that we're going to have to take a post out. If you look at the rules of symmetry, the gutta percha is not centered in the root so there's probably another branch in here. We've got a short fill, okay? So there's going to be things like blocks, ledges, post removal, extra canals; those are the issues. And then of course we have a big fercal blowout. So we're not going to look at this case right now, but I want to get you thinking gutta percha removal.
Now there's many ways that I've taught to remove gutta percha. You need to have your bag full of secondary and tertiary tricks. So when we look at removing gutta percha, I think we can identify several different ideas, and I'll go through these very quickly. Of course the easiest and the most efficient is to use a rotary instrument. And rotary causes sufficient heat, that heat causes friction – or friction causes heat I should say – and through that heat wave, we begin to soften the gutta percha, load it onto the cutting flutes so we can auger it up out of the canal. So that would be our first choice.
But a lot of times the rotary instrument in a very small prepared canal, underprepared canal, the rotary instrument's going to cut dentin before it starts to auger gutta percha. Remember, when we take out gutta percha, we should be thinking just gutta percha. Shaping is another idea and we'll do that later.
So heat transfer. The limitations with heat is sometimes these electric heat carriers, because of their taper, begin to have restrictions and you can't plunge them deeper and deeper because our canal is tapered. So as we get down to smaller diameters, or maybe we even have more curvature, maybe we have abrupt curvatures, then maybe this would be considered dangerous. We probably would never get heat devices that deep so we have to have other ideas. Hedstrom displacement is a really effective idea when it's poorly obturated. In other words sometimes the Hedstrom can go into the thermal softened gutta percha and pull the whole cone out in one motion and one move. That's nice, particularly useful when gutta percha is over extended beyond the foramen. Like think of a Powell root of a maxillary molar and there might be gutta percha in the sinus; good way to maybe extract the whole cone.
Files and solvents. Oftentimes in tight canals, various squigs of sealer and gutta percha, insufficient material; we're going to have to use small sized hand files in the presence of a solvent like a chloroform or a Xylol. Xylol is an excellent solvent and it can be used along with chloroform. I'm going to use them interchangeably. So files and solvents.
The EndoActivator can be used with its polymer tips in a big reservoir. It's brim full with solvent and we can throw that solvent so that it can penetrate, circulate, and it can help absorb the gutta percha. It can soften it and put it into solution so it can be subsequently flushed out of the tooth. So another idea.
And finally, wicking. What is wicking? When you put paper points into a fluid filled solvent canal, the paper point wicks. It absorbs material that's in solution laterally to central. It pulls things out of cul-de-sacs, fins, webs, anastomoses; and it gets it into the body of the canal where you can flush it out.
So here are some of our ideas, and the paper points – I'll show this in a little bit – but these are our main ideas. You oftentimes use several of these ideas in concert.
Well rotary files. You can use any generic file you want that is mechanically driven, but in the Pro Taper world we actually made specifically retreatment files. Notice that we have the 30/09, the 25/08, the 20/07. This is basically working in the coronal part of the canal. This is working in the middle one third, and this is working deeper, maybe into the apical one third. So that's kind of how to think.
This is an active tip; be aware of that. That's really good for brick hard resin paste. Russian red; how about that one? On the Pacific Rim, we see a lot of brick hard pastes that are very hard to get, so the active tip not only is good for gutta percha, but it's also good for other methods that we will try and show a little bit later. Not today; hey come on! I have a lot to do today just to get you good with gutta percha.
So that's a little bit about the files. The thing to add here is maybe consider something like a rotational speed of 900 – 1200 rpms. This is way faster than you would be shaping or preparing canals. But you need that extra speed to create more friction because the byproduct of friction is what? Heat. And heat thermal softens gutta percha.
When you look at an x-ray you can begin to see the width of the shape in two dimensions; like mesial to distal. Of course you can take CBCT and you can actually get the axial slice and see how much circumferential dentin you have. But with the rotational speed, you put it on the gutta percha and you just start spinning. You're going to use a bigger instrument; like that 30:09 will be used on the coronal. Remember each third is about 3-5mm. So we're going to use an instrument that works in the coronal one-third, we're going to use a smaller profile instrument that works deeper into the body of the canal, and then if we still have gutta percha in the apical third, we'll use the smaller instrument to work in the smaller diameter. It should be making sense.
So you can see how this ropes and comes out; it's fast, it's efficient. And if we can not use chemicals that's a good thing. Because chemicals soften gutta percha, gutta percha slurry gets into the fins and eccentricities off the rounder part of canals, and so that just makes it harder to eliminate those precipitates after the bulk of the material has been eliminated. Chloroform or Xylol; watch the paper point come out. So even after we've augered out all of the gutta percha, even when the file looks silver – no more pink gutta percha in the flutes – we can still do wicking and we can eliminate a lot of gutta percha off the rounder, crust sections of the canal. Lots of flushing, lots of wicking, and off we go to the next case.
Heat; Touch'n'Heat, System B, Calamus; I'm using Calamus by Sirona. I set the temperature at 350°. When your finger touches this activating cup, you're bringing heat to the tip. I think this is a runaway lecture so we'll stop for just a second. There's a 30 tip; there is a 50:05 and there is a 60:06. I'm telling you there's three tips; this might work best, more effectively in the coronal area. You might have to change tips to get deeper and get your heat wave to pass towards the foramen, the terminus. And you might need the smallest tip then to get as deep as possible. But a lot of times again in retreatment we're restricted because many times the failing case has been underprepared and an underprepared canal does not receive all the armintarium we've talked about. That's why you have to have multiple ideas.
Plunge, deactivate the cup – take your finger off the circumferential activating cup on the Calamus as an example – thermal softened gutta percha from Calamus accepts a rotatory file; the rotary file goes into that thermal softened material even more effectively, and then here we are doing more stuff. You can do ultrasonics. Ultrasonics is another way to produce heat – the byproduct of ultrasonic energy is heat – so some colleagues like to plunge in and make a hole. I would probably just use the Calamus, but I want you to understand; this is in the family of heat transfer devices. Pick the appropriate tip that will fit in the cross-sectional diameter of the orifice, and obviously because these tips as they start to get pretty parallel and narrow, they're ineffective and they'll break and they're real expensive. Maybe go back to your Calamus and think Calamus.
All right. So back to Calamus; we can even plunge deeper in the same canal. And once we've plunged deeper, that thermal softened wave allow us to what? Take a 30, 35, 40, 45 Hedstrom that has a cross-section of a positive rake angle. The barbs of a Hedstrom will easily turn into thermal softened gutta percha. You can take the heat and put it right on the instrument; the heat will transfer through the instrument to thermal soften the gutta percha deep. Then you can pack around it a little bit, wind it up, and pop goes the weasel! Very effective way. Hedstrom displacement is what I called that about 25 years ago.
You can see chemicals are really going to be important because in failures, in cases that are failing, a lot of times the gutta percha might kind of terminate at the junction of the middle and apical third. Sometimes there's just a squig of sealer in the apical third, or maybe a very thin cone and sealer. So rotary's not going to work, heat transfer's not going to work, Hedstrom displacement's not going to work, ultrasonics is not going to work. You're going to need files and small size files. Not a 6, not an 8; you need a little bit more rigidity. The rigidity allows you to pick, pick, pick. Look at that! What you pull that file out, the file is clean, no more gutta percha; but believe me, when your file is clean, know with total confidence there is residual, remaining gutta percha sealer complex B.
So if we look at a case what do you look at? I want you to start looking at the cross-sectional diameter of the canal. You've got a really big canal here, you've got pretty good dimensions here; so you could probably say well at least to about this level I think I can do rotary and the DB and MB. I could probably do rotary quite a bit higher. But kind of make sure when you're using that rotary instrument, you want to see gutta percha. If you're not seeing gutta percha, you're probably starting to cut dentin. Remember cutting dentin and shaping is completely a different entity than removing gutta percha. I'll say it again: we remove gutta percha crown down. I didn't say that did I?
So let's go over that again. Coronal, middle, apical third. Today's lesson is – without drawing it all out for you – every third is about 3-5mm. So be thinking about how to get gutta percha out here. Take a small size hand file, okay – 15 is what I like to use, even in a pretty big orifice – and it’s pick, pick, pick; okay? It's pick, pick, pick, pick. And it takes a few moments; the gutta percha will start to soften; and go down about 3, 4, 5mm. You have a pilot hole. Now bring in a 20, a 25, a 30, a 35, and start cutting central to lateral. And pretty much remove and eliminate the gutta percha in this region of the canal. Now flush – new bath, new solvent – and 15 file comes in, and now you can pick a little bit deeper, 3, 4mm, 5mm. I've got a pilot hole.
Now go 25, 30, 35, 40. Go up through the sides serially and sequentially, and you'll be getting to move gutta percha laterally, but at a controlled depth. When I have everything out of the upper two-thirds, I re-flush, and now I have a bath full, chamber full, big bath of solvent, and now I'll work my 15 deep. But don't work your 15 deep if there's no gutta percha on the radiograph, okay? If the AP one-third has never even been entered previously, then maybe it's time to get out your sodium hypochlorite and negotiate the terminal diameter; the terminus of the canal.
So be sure to crown down. Why? If you start softening stuff and trying to go all the way up in one big path, this is when we extrude; chemically soften gutta percha and we incite a riot post treatment. You know these are patients. We provoke inflammatory responses and that shows up as post-op pain. So I have learned – the hard way – when I was a kid I used to try to go right to length and take it all out. Then I started learning, you know what? Do it in a more sequential manner. Your post-op pain – if this is pain and this is time, your post-op pain is going to be really low. It's going to be called discomfort; it's going to be called two aspirins.
Okay. So now that we have looked thoughtfully and carefully at a pre-operative film, we can begin to think about what is the best removal method that we might be able to use here. And if we can stay away from chemicals I've said repeatedly, that would be a good thing.
Well when you get back into these teeth you can start to anticipate. We know that about 91% - that's clinically; I didn't say histologically – clinically, we know we'll find the famous MB2. So the most common cause of failure in a maxillary molar is failure to find the MB2, but in this case we have a frank lesion that you can see. The gutta percha is under-filled and under-extended vertically; there are still remnants; there is pulp tissue probably still left in this little region and it's coming out of the end of the foramen and it's perpetuating the lesion of endodontic origin. So what we have to do is be thankful, the crown down idea, use the bigger rotary instrument here, use a smaller rotary instrument and then a smaller one. So now you've really got it. I'm beating this in because you can do this stuff. Remember? May your reach exceed your grasp. If you've a general dentist out there – if you're an endodontist you're laughing because you've been taking gutta percha out of teeth for like your whole professional career – but if you're a general dentist, many of them say to me in class; you know, I'd like to venture into some simple kinds of retreatment. Because I see a lot of gutta percha cases that I treated. And I'm not so intimidated by removing gutta percha; I'm leaving the silver points and the broken instruments, the ledge, the blocks, the probes, the transportations, the post removal; I'm leaving that for you, Cliff. But I can be comfortable I think with gutta percha. So I'm talking about things that many of you can do with just a couple ideas.
All right. So you find an MB2, and that's another story. This is my first invention; it was a handle, then there was a contour angle, then we clipped a K-file on the end. So when you have a handle that blocks your vision looking into the access. Then if you grab it with your fingers you have more obstruction. So we had an offset handle so we had good vision, and we can snake that in, unimpaired, see perfectly; and just a few little strokes and you have some space and then that's another lecture.
Well I'm using rotary; I'm using the big one – that would be the 30/09; I'm using that in the body of the canal, my primarily upstairs 3-5mm. Be sure you see in your mirror gutta percha spiraling up those flutes and augering ever upward into the pulp chamber. If you're not seeing gutta percha, you're cutting but you're not doing the right thing in the right sequence. Here we are getting it out of the DB. Notice we've already shaped that canal. It's got a separate apical portal of exit we're thinking. And then finally the MB comes out. So you just go around the horn with the big one. Then drop down to like the medium one; that would be something like a 25/08 – if there's room. Or even something with less taper if it needs to be selected so it fits passively within the gutta percha; wall-to-wall gutta percha. So out with the MB.
Well when you get all the gutta percha out, most clinicians are saying well my files are silver, like NITI. I don't see any residual gutta percha. Flood this with solvent and activate it with the EndoActivator. The EndoActivator has three sizes of polymers; choose the one that fits. Listen; you're thinking that a polymer will blow up in a solvent. This is Delrin. Delrin is the most pure form of a polymer in medicine. It's used, implanted in the body. You can lay a tip in a dappen dish of solvent and it will not distort or melt. I didn't say for two days, but easily for an hour or two it'll be intact as it's impervious to absorbing a chemical that would destroy its physical properties. So this is a great way to move a solvent into all dimensions of the root canal system. Then you can wick it out and pack it.
Now remember last season I ended by talking about vertical condensation. We're going to talk about carriers and other ideas in this season and the seasons beyond. But notice the hydraulics; notice when you get a heat wave and it goes up that cone. You can get in here with a pre-fit plugger and you can create loads – look at this – one, two, three portals of exit. Notice we have a bifidity deep; the materials are spiraling across each other – super imposed, okay. So that's a nice result on this professional volleyball player. I saw this volleyball player after she had had endodontics by an endodontist. So these 45 minute molars are okay if you can do them exquisitely. I don't care how long it takes you to do them; do them well, do them right, and grow; get a little bit better.
Let's come to our last case. I could show you many, many cases, but remember; think about this. Rotary removal, heat, Calamus your ultrasonics, files and Hedstroms, Hedstrom displacement, solvents and chemicals, and the EndoActivator. Okay? These are the ideas. So my friend comes in; he wore a mouth guard, he was a golden boxer, Golden Gloves boxer out of San Francisco when he was a kid; and he had a lot of trauma – short roots – you can see all that. But he had two root canals, one done in Boston about 1975, and this one was done in Boston in 1974. This was done by endodontist #1 and this was done by #2. So while he was in grad school with me, my classmate, these were both done; and this is my pre-op 30 years later, and I'm now in Santa Barbara and he's in San Francisco; we're both practicing. You can see we have a composite. If you look at the incisal edge roughly and you look at the apex – I'm pretty close to the screen, but about halfway up. So you're going to have a long access; plan carefully, that's my point. And we don't want to get any bigger this way because we already have limitations on our wall thickness.
I noticed we had internal resorption, and that day I didn't know if it had perforated. There was no palpation problems, pyloral or facial; but the truth is in the actual clinical performance. So in this case, you're not going to use chemicals. If you start to soften this you're going to get a slurry of poor percha out into these areas, and how are you ever going to get that out? So stay away from chemicals; plan very carefully; be thinking on your pre-op what's my modus? You could use rotary; rotary might have worked. I thought why not plunge in here with heat and get a heat wave in that remnant of gutta percha – you know it's to here and the apex is right in here. So plunge in, plunge in, there's my Hedstrom; take a plugger and pack the thermal softened gutta percha to maximize the surface area contact between GP and the instrument; and pop goes the weasel.
Well this isn't initially too exciting because this means to me there is a perforation. And it turns out – I'll show you – the perforation was facial. Here it is a little bit later in time. I did this in one visit – a little bit later in time means an hour and a half later – had perfect hemostasis. We'll talk about that at another time; we're just talking about gutta percha, and the idea here was Hedstrom displacement; no chemicals. And now you can see it's dry, so now I can fit a cone. I can fit a cone. If you want to squirt some gutta percha with your syringe laterally into this space; if you want to throw a supplemental cone in and get another cone in here so you can improve your hydraulics so when you sear this off you put your plugger here and you push, you'll have the maximum cushion of rubber. And that means you'll deliver 2000 pounds per square inch sealer hydraulics. And I know from my research, the adaptation of gutta percha to dentinal walls is about on the order of 6, 7, 8 microns. So we can get wall-to-wall GP and the sealer interface that is very, very thin.
Listen, I've had a lot of fun with you. I hope you've learned quite a bit about removing gutta percha. I hope you lock onto those six principles or methods, and be prepared to use them in combination or singularly. Because remember: You can do it! So that's what I want you to do is learn to train a little bit, think about these things, grow your practice, and deliver a higher level of service to your patients.
CLOSE: Behind-the-Scenes Footage
That's our show for today. We're going to leave you with a rare look at some behind the scenes footage so you can see what goes into creating each unique episode of The Ruddle Show.
So we'll see you next time. And I promise you we'll continue to learn more about endodontics together.
[Showing behind the scenes video clips]
And that's a wrap. Okay Dad!
I thought you said it was a wrap. I have a feeling we didn't stop. Oh my God!
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The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.