Clifford J. Ruddle, DDS, examines laser-activated irrigation in endodontic treatment...
3D Disinfection Laser Disinfection and Ruddle Q&A
This show opens with Ruddle describing a morning mountain lion encounter, along with some other wildlife sightings. Next, Ruddle discusses the use of lasers for disinfection and, specifically, takes a closer look at the SWEEPS technology. After, Ruddle returns to Q&A, this time with a 3D disinfection theme. The show closes with a new segment called “Ruddle Rant,” in which Ruddle is free to let the world know, uncensored, how he really feels about certain topics.
Related Materials & Show Notes
In the United States, alone, more than 100,000 dentists perform tens of millions of operative, restorative, and reconstructive procedures on an annual basis. Certainly, these dental procedures are primarily directed toward eliminating carious lesions, esthetically restoring teeth, and functionally moving patients toward optimal oral health...
Today, Photon-Induced Photoacoustic Streaming (PIPS) represents a leading advancement in laser-activated irrigation and disinfection...
For more than 50 years there has been universal agreement that the triad for endodontic success is shaping canals, cleaning in 3 dimensions, and filling root canal systems. Further, it is globally accepted that 3D disinfection is central to success and has traditionally required a well-shaped canal...
There was more change in clinical endodontics from about 1985 to 1995 than in perhaps the previous 100 years combined. In these ten years, clinical endodontics changed forever with the emergence of four game-changing technologies...
There are enormous differences in opinion regarding the potential to three-dimensionally clean a root canal system. Elimination of pulpal tissue, bacteria when present, and their related breakdown products is directly influenced by a series of procedural steps that comprise start-to-finish endodontics...
Cliff Ruddle Shares His Candid Opinions on the GentleWave 3D Disinfection Technology and its Associated Controversies...
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: Morning Wildlife
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. We’re excited about our show today. How are you doing? We’re having a bit of a heat wave.
I’m doing great and I’m also really enjoying sports. The Lakers just won the World Championship, in a bubble. Not so bad.
Yeah. That’s pretty exciting.
Dodgers are playing, very stinky. David Landwehr.
And what else? I guess we have some football.
Yeah. I mean, and that’s – I know, we just had football on Tuesday night. So that was a new thing. Okay. So, anyway, we’ve talked on our show before about how we go out in the morning, I run, and my dad walks. And we usually go out pretty early, a lot of times before the sun’s even up. And we see some interesting wildlife sometimes when we’re out. And that’s why we have this graphic behind us, Santa Barbara Wildlife, that Isaac made. And I think you just had a really interesting experience. And I know you did, because you told me about it. Why don’t you tell them about it, though.
Well, Santa Barbara’s a really great meeting of land and sea. But people think of the ocean, but they don’t think of the back country. So, where you and I go, we go over the first range, and we’re back on the back range. So, anyway, I was coming up this straightaway portion, and it was dark. And I was in my thoughts. I was thinking about The Ruddle Show.
Of course, I was planning another episode with Lisa. And I saw something finally about maybe 30 yards away, and it was – it was kinda big. And I kinda slowed down. I was finally alert. And then, it squared around and faced me, and I saw two really bright like flashlights [laughs]. So, I saw really bright eyes. And then, at that exact [with emphasis] moment, a woman was coming up a cul-de-sac street, and her lights were shining exactly where this animal was. And boom! It bolted away. But what it was is, it was a mountain lion. And she said, “Did you see the mountain lion?” And I said, “Yeah. I was afraid I was gonna get eaten by it.”
And I said, “Thank you”, and I gave her a big hug, because I said, “I think you might’ve saved my life.” I don’t know if she did. Anyway, the – you need to know that these things are pretty big. They’re like about 150 pounds, would be a middle-sized one, they’re about 2 or 3 feet tall. You’ll like this one. They can jump 45 feet with 1 spring, 45 feet, and they need 100,000 acres for a habitat.
Well, I think we actually have a picture that your neighbor took of you, on this morning. Let’s --
When I ran for my life! Jeez, I didn’t know --
-- [laughs] let’s --
-- there was any pictures.
-- let’s see the picture we have. [laughs]
[laughs] Oh, jeez! I think somebody got a little clever with the camera.
[laughs] Anyway, you called me that day, and I didn’t answer the phone. But you left a long voicemail, telling me about this mountain lion sighting. And you know, I’ve – occasionally there are mountain lion sightings on the Riviera, and I – it always is kind of in the back of my mind when I’m out. I – fortunately, I’ve not seen one.
Before light. [laughs]
[laughs] The next day, when I went out, I was very [with emphasis] on guard and alert to mountain lions. And I didn’t see a mountain lion, but I happened to see a coyote and a buck, a male deer with the big antlers. And let’s see that other graphic, Isaac, again. Okay. So, yeah. I think we’ve actually – just the other day, I saw a peacock as well. So, we’ve seen all of these animals that are on this picture, plus others that aren’t pictured. So, I guess there’s bears around here, too. I’ve not personally seen a bear, but --
Yeah. There’s bears here. They’re harder to see. The people that live a little further into the base of the mountain, they do sight ‘em.
-- yeah. Well, okay. So, that --
So, come to Santa Barbara, and come to the zoo.
-- [laughs] yeah. It’s exciting. I mean, I’ve seen – so, a lot of times, I’ll see a whole family of deer. And that’s kind of fun, too.
Yeah. That’s good.
Okay. Well, we’re gonna get going on our show now, and we have a great show planned. So, let’s get started.
SEGMENT 1: Laser Disinfection
Today, we’re gonna have a little lesson on laser-activated irrigation. I am really excited about this book, and I wrote the foreword in it with my dear friend, Arnaldo Castellucci. I wrote “Foreword One”, he wrote “Foreword Two”. So, we’re gonna talk about this book, and if the camera looks really carefully, you can see a guy named Roeland De Moor. We’re gonna have him as a guest on our show, and he’s gonna talk to us about his 20 years of experience with laser-activated irrigation.
So, with all the enthusiasm around the world at treating root canal systems, there’s been a lot of innovation on trying to do that. And of course, we’ve come a long way since hand-held irrigation, which, regrettably, most of us are still doing. Many people are still putting the reagent into the access cavity with a hand-held syringe. That’s fine! But we gotta do something a lot more than just letting it soak there. So, let’s get started.
Well, you wouldn’t be even remotely interested in lasers or the EndoActivator or GentleWave or EndoVac or any of these so-called innovations, unless you thought there was a root canal system. And I’ve given many lessons and lectures about Hess’ work from the early 1900s, but these are done without lasers. These were done without the EndoActivator. This was just hand-held syringe, putting the reagent into the access cavity, and doing endodontics over some time. And during that interval of time, with a lot of irrigation, we were able to clean deep into the lateral anatomy. A warm gutta-percha technique can move thermal softened gutta-percha and sealer into complex, vacated spaces.
So, before you go out and spend $70, $80, or $100,000, this is work that was done many, many years ago, across the decades. So, we’ve taught many, many dentists. You can see – you can see anastomosing between systems. You can see a labyrinth, a network. You can see a little bit of an offshoot, starting right in here, kinda plays out, multiplanar curvature. Got two here, looks like we got four over there, got a little puff comin’ at us. Looks like we got maybe three there. We got a whole bunch of ‘em here. We got a – look, and in the anastomoses, another whole system, with its own apical portal of exit. And look at this long offshoot! Starts, comes down several millimeters, with its own apical portal of exit.
So, root canal systems always intrigue everybody around the world, and everybody wants to know, “How can I do that better, easier, and faster?” Well, let’s look at our assignment a little bit closer. This is a 3D modeled bicuspid. It’s anatomically correct. Everybody knows, to get the access cavity, everybody knows they have to catheterize and do the big three. What are the big three? You have to get working length. You need to have patency. And you need to have the third one, and that is a secured canal. A secured canal is that canal that has a smooth, reproducible glide path. In laser, it works good for minimally invasive endodontics. So it works perfectly in fully shaped canals, and it works in more minimally prepared canals.
For some of you, you might stop right here. You might say, “I’ve catheterized the canal. I have a known working length. I’ve cleared out the main pathway.” There’s still tremendous amounts of organic material, but you now can start to think about the technology that you might want to utilize. For most of us, we still realize the importance of the shape. You know, a catheterized canal can easily be shaped. I prefer deep shape. And when I speak of “deep shape”, seven, eight, or nine percent. That deep shape gives us resistance form. It’s a capture zone! It helps hold our reagents inside the tooth. It reduces and improves shear wall forces, okay?
So, parallel canals are more like two-way streets, you know? Irrigants can go both ways. But when you have that capture zone, it’s going to help us looking ahead to 3D irrigation safely, to prevent sodium hypochlorite accidents, and of course, filling root canal systems and developing hydraulics. So, you can see a shaped canal can be flooded. We can get our irrigants to all four corners of the root canal system. We can do loops and lateral canals and, of course, it’s quite easy to fill these. You know, we’re workinh on a new trifecta. I’m not even supposed to tell you!
But the new trifecta is going to be a breakthrough in shaping, canal preparation. It’s gonna be a breakthrough [with emphasis] in cost effective, effective irrigation methods, and filling root canal systems in eight seconds with brand-new technology. But without going there right now, that is the trifecta. Some kind of shaping, we don’t agree, some kind of clean, we don’t agree, and some kind of filling. But if you choose the right things to support your trifecta, look at your post-op films. You’re gonna have excitement and new-found enthusiasm! How about that? So, I want to talk a little bit about Frank Paquet.
You’ve seen these on this show, those micro-CTs he shared with me. This is a similar case. It’s not that case. But you can see that Frank showed, in this anastomosing, in that anastomosing, like a flag flying in the breeze, there was the origination of another whole canal. And of course, you can see, in the anastomosing zone, there’s the origination of an owned portal of exit. So, there you go! So that was fun. You know, we’ve looked at this case before. But Frank, in this case, will just look at complicated root canal systems. This is the anterior abutment of a four-unit bridge, four units. So, we have one, we have three, and we have two. So, there’s a lot of things going on inside of a single fused root.
And of course, we have other stuff. I’ve shown you this. But look at the offshoot, a deep mid-mesial. We have a deep mid-mesial, a deep mid-mesial, and then, we have other POEs, portals of exit, and you can see, they’re all available, if we get a good shape, flood it with a reagent, activate that reagent. And with a little bit of time, like 90 seconds, we can get a good, clean root canal system that you’ll have confidence in filling. And it’s been called the thrill of the fill. Oh, yeah! The thrill of the fill!
One last case. Back in the day, we used to do these more complicated cases. They’re not done so much anymore. Most dentists today would probably put implants in everywhere. This is the lone palatal root. The buccal roots have been resected. It’s a pier abutment under a long splint, double abutted, and posterior abutment . But you can see the loop, the bifidity, and you can see a portal of exit at the crest of bone. No wonder, when these aren’t treated, it leads to so many periodontal sulcular pockets, and teeth masquerade around as a periodontal problem, when in fact it’s a lesion of endodontic origin! How about that?
So, just think about the anatomy and the role it plays in successful long-term dentistry. So, that brings us to the assignment. We’ve talked about this before. We’ve talked here about sonics. This would be an example, EndoActivator. I do not like ultrasonics. I do not like it, because it’s metal, and you have to think about curvatures! So, I want a technology that has a polymer, and a polymer is a flexible tip, won’t break, can bounce off of walls and still keep your coveted 2 Alpha. 2 Alpha is that back-and-forth pendular motion that agitates solutions. I’ve talked about GentleWave. And believe me, I have a lot more to say and will say more, as information comes available.
Today, though, we’ll talk about lasers and endodontics. So, when you look at your technology that you’re assessing to integrate into your already successful treatment plan, be thinking about evidence. Is there peer-reviewed scientific evidence to support this technology? We can’t have one paper. We can’t have three papers. We can’t have papers of people who sit on the Board of Advisors. This needs to be independent, collaborated research, done around the world, university based, by learned people, that have good methodology. And when you can see that it’s easy to use, and if it’s pretty affordable and not a one-pony horse – you know, some of these things cost $70,000 and they do one, single thing!
And then, of course, we have the bloody canals, we have the sodium hypochlorite problems; we have issues! So, if you’re gonna get a technology, it would be nice if it could do kind of many, many things. Like an EndoActivator can move calcium hydroxide into root defects. It can remove calcium hydroxide. It can move MTA around curvatures and make it slump [with emphasis] into the apical thirds. Lasers, okay. Let’s look at lasers. This book was written, I just showed it to you, you can see the authors again. But we have many, many substantiated articles. I made this slide two years ago. I don’t know if there’s probably 2,000, 2,500 world users. There’s probably more than 30 papers now. But this is accurate at two years ago.
It’s very easy to use. The tip is placed stationary in the pulp chamber! You don’t take an optical fiber and try to introduce it down into a canal. Some people have tried that. Companies sell that, that optical fiber that’s placed sub-orifice. Here’s our problems. When you have a shaped canal, let’s say it’s fully shaped and appropriately shaped. So, it’s not minimally shaped. There’s very little reagent even in a fully shaped canal. Now, when you stick an optical fiber into that canal, you displace what little reagent was there. That’s a problem. We need the reagent to agitate, to be getting our shock waves.
Second problem. If you stick a laser optical fiber to length or short of length, you’re gonna have frontal pressure. That means you’re going to encourage sodium hypochlorite accidents. Number three, when you have a wand in a minimally prepared canal, if you touch walls, you can have a thermal injury! So, this was a breakthrough, and Divito – Divito described laser-activated irrigation. It had a lot of promise. I got heavily involved in the project. I invested! And then, it was sold out, and Rico went his own way. He did something different. But this never died.
And now, we can talk about, when Roeland comes on the show, we’ll talk about SWEEPS. SWEEPS, shockwave enhanced emission photoacoustic streaming. Okay? PIPS is photon-induced photoacoustic streaming. Slightly different terminology. SWEEPS has replaced PIPS, but we learned a lot from PIPS. SWEEPS is more effective, and I’ll let you look at the physics! But it’s a physical phenomenon that has enhanced and overcome some of the issues that we were thinking about with PIPS. So, back to the game, it’s easy to use, because you only have to put it in the pulp chamber. Anybody can hold something in the pulp chamber. If you could cut the access cavity, I bet you could hold a wand in the center position of the pulp chamber. And it’s safe!
If you go to my website, you can open a folder that will have over 25 articles on PIPS and laser-activated irrigation. And we’re not talking about any laser. We’re talking about the Erbium family of lasers, Er:YAG, okay? And 2940 is the position on the electromagnetic spectrum of light. And at that point, 2940, there’s a tremendous propensity for the absorption of water. Water can absorb this photon of energy. That blows up that water. That is a major component, water, of hard and soft tissues. So you can see the intrigue, because we’re working with organic materials. So, this is a little comment. And then, of course, if we’re talking about how do we actually use it, the protocols have been evolving. The protocols have been changing.
But lasers do all canals at one time, unlike an optical fiber that has to go into various branches, or the EndoActivator has to go into various canals and go through its protocol, okay, its cycle, 90 seconds. This one does everything at one time! So, that’s good. So we turn it on, and we have sodium hypochlorite, full reservoir, chamber’s brim full. We turn it off. The off cycle is huge! Notice we have three off cycles. I’m going to talk about it when I show you a movie. It’s during the off cycle that we get most of our tissue digestion and the elimination of organic substrates. So, kind of nice to see it’s a short protocol. You can flush with water.
You have a very minimal amount of disinfection time to do a four-canal molar or five, or a C-shaped, or whatever you’re imagining. How about a central incisor? So, there’s a little bit about it. You can read the reference. [Video playing in background] So, when you put a wand, a coarse wand in a pulp chamber, photons of light are emitted, at low energy, at low energy, and they’re pulsed in a duration of short microseconds. So, that’s happening right now, photons of light. You can see, as we come down this tooth, you can see where we are.
You can see that we have a photoacoustic and photochemical reaction. Now, photochemical reaction of PIPS is, it disassociates sodium hypochlorite, and it breaks it down into its hypochlorite ions. This is a major [with emphasis], superior [with emphasis] digestant of tissue, has a tremendous capacity to digest pulp tissue. So you can see when we continue on another cycle, we get shear wall forces, we get cavitation, we get these forces that strip mats of bacteria and biofilms off of walls. It’s like shockwaves! It’s like a power pressure cleaner that shoots paint off of masonry brick or concrete. It’s that kind of a phenomenon.
And then when we do our last cycle, and I’ve abbreviated these, just to give you a glimpse of the technique, but every one bubble becomes unstable because of heat and pressure. It expands and implodes. Every one bubble sends out 30 to 40,000 shockwaves, and these shockwaves travel at supersonic speeds! Okay? That means meters per second, in a little tiny tooth. You can see the potential. And you know what? If we were having more time, there’s been a lot of research conducted around the world from multiple universities, very collaborated, of the safety of it all. Okay? Because the pulp chamber – the wand’s up in the pulp chamber! It’s not going down around curvatures within two millimeters of the working length! So, lasers are really fun.
And I want to show you one last thing. This was kind of a Hollywood thing, but the Hollywood thing was based on looking at thousands of SEMs, reading this book about four times, because I’m so slow, I couldn’t understand it. There’s a lot of physics involved. And I thought, with my background in physical chemistry and math, it was gonna be a piece of cake. But I’m on my fourth read, and I’m not done! So, let’s go ahead. Now, I want to set this up.
First of all, Marco Martignoni, a wonderful guy and endodontist in Rome, Italy, lectures around the world, superb clinician. I first met Marco in my office in the early ‘90s. He came over with an Italian group, and he came back several more times. I went to his office. I watched his dad work. His dad was the Pope’s dentist! Okay? So, we’re talking about fun stuff. His dad was the leader. He was Department Chairman at Boston University, Goldman School of Graduate Dentistry. How about that! The Italian goes over for a sabbatical, becomes the Chair! Anyway, I want to acknowledge Marco.
But I wanna acknowledge Augusto! Augusto Malentacca, okay? He’s from Rome. And he described, in the Italian Journal of Endodontics, many years ago, a process where he could get extracted teeth and, using a multitude of various chemicals, in about one week, he could produce a tooth like this, a clear tooth that you could see right into! This tooth has been mounted on a glass plate. There’s no sticky wax placed around the tooth. So, we don’t have any positive versus negative pressure, okay? Normally, a tooth is set in the periodontium, a periodontal ligament, and so you have positive pressure around a root, relative to negative pressure at the access cavity. So we’re working on the bench, and let’s get started!
This is going to be a really beautiful animation that will show you in a histological, natural human tooth the power of laser-activated irrigation. He opened the tooth, he catheterized the canals. Studies have shown that if you don’t instrument, you have a pretty good cleaning, but you don’t get deep, and you don’t get around curves. So we need to catheterize working length and have a patent canal. Say, “patency”! Are you getting used to saying “patency”? I say it almost every show. Say, “patency”! Oh, yes, the cries are coming in from around the world, “Patency, Cliff, patency!” Okay. Then, he goes to work.
[Video playing in background] Franklin Tay and David Pashley talked about 5.88 millimeters of mercury. That’s the venous pressure in the systemic body. So if we exceed 5.88 millimeters of mercury pressure, we’ll have accidents! They show that lasers always stay underneath 5.88. So, therefore, you can begin to see how this cleaned out. I want to go back and have you look at something again. [Video playing again] So, I want to come back to this little, fine loop that emanates off of one of the systems. Notice the ability of shockwaves and shear wall forces to get in there with the reagents and progressively cleanse that out.
So you can see the importance of photon energy, completely cleaning that loop, and notice the clean root canal system. Pretty fun stuff. So I think that gives all of you a lot of excitement about seeing lasers on histological human material that really shows a lot of promise. Marco did this many years ago, so this is not new to him. He’s been playing with lasers for a long time. Lasers are not new, as we all know, and Er:YAG is not new, the 2940 nanometers of light. So, in closing, I have another palette of nine cases. None of them were done with any of the modern ideas! No EndoActivator, no EndoVac, no lasers, no GentleWave.
What am I trying to show you? I’m trying to give you excitement, all you people out there. You can treat root canal systems! I might go into a rant, later! Sometimes we have this impression, we can only clean root canal systems if we have something that cost 100 grand. So, this should give you some hope. And in closing, what I’d like to do is, I’d like to introduce you again to my friend, Dr. Rik van Mill, from the Netherlands. I told you and promised you earlier he was going to be chairside, using SWEEPS. So, we’re gonna show you a little clip of him doing SWEEPS, chairside with a patient. And I told you what SWEEPS was earlier in this show. And then, of course, he did some beautiful cases, him and his partner, demonstrating the ability to clean and fill root canal systems. [Music playing]
Okay. So, today we had a little lesson on laser-activated irrigation. I hope all of you have become extremely excited about cleaning root canal systems and lasers, unlike other technologies, can do many, many things! They can remove caries without anesthesia. They can do frenectomies. They can do bloodless incisions. Okay. So, there’s a lot of things that lasers can do, besides disinfection. But that’s what we’re showing today, so I hope you enjoyed it, and I hope you get ready to treat root canal systems.
SEGMENT 2: Q&A
Okay. So, today we have another Q and A segment for you. We did one a couple shows ago, you might remember, and we got to just a couple questions. And I just want to tell you a little story. When I was a kid, and I needed help with my homework, and I kinda thought I knew the answer, but I wanted to make sure, I’d go to my mom if I wanted a quick “yes” or “no” answer. If I really wanted a really thorough understanding of the subject, I’d go to my dad, because the first thing he would say is, “Go bring me a tablet and a pen” and it would require pages and pages of drawings and --
-- analogies to the outside world. And eventually, I would – when I walked away, I had to say I understood it very well. And hopefully, you had a similar experience, the last time we did Q and A. So, we’re gonna try to tackle a few more questions today. And these are going to be focused on 3D disinfection. So, are you ready for the first question?
Ready! I’m ready. But I’ll try to be really brief, after I heard that opening.
[laughs] Okay. I’m – yeah. Okay. Well, no, we want people to understand, too. So, okay. So for irrigation protocols, is there a minimum time that the irrigant should be in the canal for vital teeth versus necrotic teeth? Is there a difference in time that you keep the irrigant in the canal?
First, I’ll acknowledge the question is a good question, because we get similar kinds of questions like that, and I think it comes from the – what I call the “ancient literature”. But it probably is the traditional literature. In the traditional literature, there’s a huge distinction between vital versus necrotic cases. Vital cases are largely filled with collagenous tissue. Collagenous tissue is sticky. It’s a sticky mass. It’s hard to extricate from fine loops, cul-de-sacs, fins, anastomoses, things like that. So, the analogy for the audience is, perhaps you remember Elmer’s Glue. But glues before the newer version of glues, they were harvested from the hoof of the horse, because it was rich in collagen. So, collagen’s like a glue-like material.
So, necrotic cases, it’s putrefaction. It’s necrotizing necrosis. So, that stuff just flushes out. So it’s the vital tissue that’s more tenacious. However, I will say that when you’re in this tooth, and you’re working, you know, you’re developing some kind of a shape. And I guess the minimally invasive people would like me to make the shape a little smaller, but it’s just a concept. But if you’re shaping, you have a big bath of sodium hypochlorite in here. And the idea from the old literature to today’s literature is activating your irrigation. I’m not talking about artificial intelligence! If you activate your reagents, you can reduce digestion times dramatically.
So all the protocols that were made for the EndoActivator, 1.5 minutes per canal, were based on 9 different universities looking at vital and necrotic cases. So the answer, shortly, is if the patient isn’t swollen, if they’re pretty much asymptomatic, I don’t give a care whatsoever if it was necrotic versus vital. I do them the same way, if I have adequate chair time to do all the steps thoroughly. There’s been no evidence that shows we do a better job in two-visit endodontics. So, the whole thing is: activate your irrigants.
I do have one question, because I’ve heard you say something about heating the sodium hypochlorite. Is that correct?
Yes. Yeah. For many years, we actually – when people flew to Santa Barbara, took our course, there was like this little hotplate we got, and there was a cord that went over here and plugged in. And you cut put your beaker on here, and it could have solution, and what we would do is, we’d put syringes in here. They were preloaded – preloaded with sodium hypochlorite, and the water bath would heat ‘em up to just about 60 degrees centigrade. So they would then use warm irrigant inside the canal, because all reactions in life, you probably even know this from your college chemistry and stuff, all reactions are accelerated in the presence of heat. It’s like an accelerator for an enzymatic reaction. So you can get more digestive capacity with heated sodium hypochlorite.
So, would you do less time if you’re – if you have warm reagent? Or still --
The thing about warm reagents, I kinda quit dismissing it, when we really got involved with activated solution.
So, we had the EndoActivator, and then came GentleWave, and lasers have been around a long time. But all these, you’re getting quite a bit of heat in here. Those implosions, those bubbles, they’re unstable because of the heat and pressure. They expand, they implode, and when a bubble implodes, it sends out shockwaves.
Okay. All right. So, next question, and I think you touched on this a little bit in the presentation you just gave. But maybe you can go into it a little bit more --
-- in a little more detail. Why would I buy the EndoActivator, if I could use ultrasonics to agitate a solution?
[pause] All right. [sighs]
You know, ultrasonics, sonics, okay? Ultrasonics by definition means you’re gonna activate a metal tip. Metal tips can’t go around curvatures, and virtually every canal we see has some curvature. Certainly there’s straighter canals, but most canals exhibit curvature, and some of them, dramatic. This isn’t even that dramatic. So, you can’t put a metal insert tip around a curve. Some people say they pre-curve it. Please! Are you gonna rattle and shake a pre-curved ultrasonic instrument that’s vibrating at about 40,000 cycles per second, and think you’re not hitting the walls? What we have seen from an iatrogenic standpoint are what? Broken instruments, we’ve seen ledges, we’ve seen blocks, and we’ve seen perforations.
But probably more important than all that is a pendulum at rest, hangs. Its maximum displacement, the angle is called alpha. Its maximum displacement is equal and opposite, and that’s alpha. So, 2 alpha represents your back-and-forth pendular motion of your tip. When metal touches dentin, you lose 2 alpha. 2 alpha is lost, and you have a tip that’s not working nearly like you thought, and you’re generating debris. Ultrasonic instruments cut dentin and the very thing you’re trying to remove, mud, debris, inorganic contents, it’s being generated.
So, we don’t believe in ultrasonic energy, and we use sonics because we use a polymer tip. This means it’s non-cutting, it won’t break, and when you’re around a curve, and you’re vibrating around a sharp curve of a root, in a shaped canal, the sonic tip can go around the curve. You can push as hard as you want, anywhere. You can even bend the tip 90 degrees, and the tip of your insert tip will give you your 2 alpha. So, there’s no dampening. You do not lose 2 alpha. You keep it. So, polymer, 2 alpha, you can work in curvatures, you don’t generate mud, you don’t cut dentin. So, I think that’s the thing we’d wanna stress.
Say that you have just a pretty straight canal, and it’s – I saw that – those iatrogenic things that can happen. But say you’re using an ultrasonic tip in a pretty straight canal, and it’s just kind of gouging the walls a little bit. But then, you fill it. And so, your final preparation doesn’t have a smooth, flowing shape. It’s kind of gouged. But is that actually going to be a problem?
Probably not. I mean, my mentor used to say to me, “Cliff, are you” – we’d be looking at some little nuance, you know. And he’d say, “Cliff, are you treating the patient, or are you treating the x-ray?” So, probably the little gouges, to your point, don’t matter. But if you’re thinking about minimally invasive endodontics, and you have a tooth in here like this, and let’s say it’s pretty straight, to your point, well, you can have little transition things, little bangs, out like that. Probably in the scope of life, you’re not losing a lot of lateral dentin, but the thing is, we know ultrasonic energy works. In straight canals, you get streaming, and you get cavitation. So, people just love these words. I mean, they – they worship [with emphasis] these words.
See, a lot of the newer technology doesn’t even work like this. The EndoActivator does not work by streaming and cavitation. It works by implosions! So, it’s the implosions and the break of a bubble that sends out the shockwaves that radiate out. And that’s what gets into all corners of the root canal, and the polymer tip will not do that. So – and it’s cheaper. The EndoActivator’s like $500, and a generator is about $1,500. But we can use the generator for a lot of things. So, ultrasonics is good for broken instruments, for troughing between MB1s and 2s. So, we love linear motion in ultrasonics, but in disinfection, we don’t want metal.
Okay. And I also really get what you said about the dampening thing, how a polymer tip will keep going when it hits a wall.
Yeah. I showed in a clip a while back, I don’t know if it was on the show yet, but I showed many years ago for the AAE meeting in San Francisco, that I was bending the tip with an explorer at 90 degrees, and you were still getting 5 millimeters of 2 alpha. I understand the five millimeters will be dampened by the constriction of the walls [with emphasis], but you’re slappin’ those walls hard mechanically, and you’re making bubbles. So, there’s two ideas going on.
Okay. I think we have time for one more question. Okay. Here’s – here it is. I use the EndoActivator routinely for 3D disinfection. Yet I’ve heard you say that there are several additional applications in which the EndoActivator is clinically useful. Can you explain?
Sure. That’s a great question. You probably remember I said something about a one-trick pony.
So a lot of times, you can buy a technology – well, you can buy a car, right? And you can drive and get places. But you can get groceries in the car. Oh, you have a trunk! You can put in something bigger! So, you have multiple applications with a car. Well, with sonics, as an example, we’ve talked about 3D disinfection. That’s what most people know it about. But I mentioned earlier that when you have these teeth that come in, and you might have an internal resorptive defect, what we can do is use the EndoActivator’s polymer tip. We can go down in this canal, and we can put MTA – we can introduce MTA in with cannulas, and we can drop off a few cylinders in here. And then, we can hit this, and that’s how you move stone in dental school! Right?
So when you snapped that impression on that patient, then you ran to the lab, and you used a vibrator, and you poured stone, and the stone would flow perfectly into the mold, so you didn’t have voids. We use the same idea to vibrate stone, so we can get intimate contact inside. We can use it for calcium hydroxide – calcium hydroxide. We squirt calcium hydroxide with a cannula, but then, you adapt it. So, calcium hydroxide, we should probably say “adapt”, not to actually place it. And then, we should probably say what? To remove.
Because on the second visit, or at that visit, when you wanna get calcium hydroxide out, it’s been stated in the literature that probably the only way to get calcium hydroxide out of here, if – assuming this is now calcium hydroxide, not MTA, has been ultrasound.
Oh, is that the Endo [laughs]?
Yeah. Because the vibration breaks all this up and kicks it out. And so, now you have a clean wall. So, the EndoActivator can be used to adapt MTA, to adapt and remove calcium hydroxide. Some people use it – they’ll take the tip, and they’ll pick up a bead of sealer on it. They’ll take the tip and stick it down the canal, [makes burring noise] 2 alpha, and as you kinda go up and down, you sputter coat the walls, so you get a pretty uniform distribution of sealer in here. And then, you stick your cone in, and pack. So, there’s several things that colleagues have thought about and that I’ve thought about. So, it’s not a one-pony horse for 500 bucks. It can do a few things.
Great. Okay. Well, thank you. And we got through a few more questions, and we’ll do another Q and A soon.
I’ll try not to bring so many pages of paper, next time.
CLOSE: Ruddle Rant
So, we’re gonna close our show today with a new segment called “Ruddle Rant”, and it’s sort of a little game where my dad will have the opportunity to tell you what he really thinks about certain topics.
So, here’s a couple rules. I have this one-minute sand timer. And so, I will name the topic, and then, you have one minute – I’ll turn it over, and you have one minute to say whatever you want about this topic. The only other rule is maybe try to keep the profanity at a minimum. But [laughs] --
Ooh! I don’t know if I’ve ever used profanity, have I?
-- if – like if you’re ranting, and you get really heated, you might be tempted. So --
-- you also might want to say your most important ideas first, so you don’t run out of time.
So, are you ready?
I think I’m ready. [laughs]
Okay. Here we go. The first topic is copycats.
Well, on copycats, I love all the files that have come to market that are replacing ProTaper. I really like that! You know, ProTaper launched in 2001. By 2006, we were the number-one file in the world, and we’ve continuously sold as the number-one file, most-used file in the world, and every [with emphasis] file that comes out now, “This file replaces SX. This file replaces the ProTaper S1.” They actually say that! So, it’s very irritating! These people have no [with emphasis] imagination, no [with emphasis] creativity, and they are bankrupt with vocabulary! Because they copy our words! They copy slogans!
Things that I’ve been using, that are kind of like Ruddleisms, that I’ve been using for 45 years, suddenly they’re in magazines by files – other companies’ files. So, no, I don’t like that at all! And I’d – minimally invasive endodontics, please, please, please! Let’s say “tooth structure”. Very nice!!! Round of applause! But you know something?
Oh, I had something to say! Okay!
[laughs] Next topic is false advertising.
Well, then, there’s the company, Vista Dental, that used my actual name and put it in a full-page ad in the JOE, on their product! And it assumed [with emphasis] I endorsed it! That really made me mad, because I do not like their ultrasonic technology in curvatures! Blocks, ledges, perforations, transportations, cost us $50,000 to get an attorney, to just get my name off their product! And I really like that company, because they’re really, really good.
Listen to this. They put little asterisks by all their claims. You go to the bottom, and there’s references. Their references were 10 to 15 years before their product actually launched! Had nothing to do with their product, except there was some vague [with emphasis] similarities. So, I don’t really like that! And their claims, a lot of times, had nothing to do with the actual product they were selling. So, I hope you know that! Well, then, there was ridiculous cyclic fatigue claims. I love the cyclic fatigue. “Our file runs for 10 minutes!” [yelling]
Okay. So, now, those were kind of dentistry-related rants [laughs].
Oh, yes, they were.
Now, I know that there’s a couple things, on a more personal level, that we’re going to do to close the show. So, the next topic is going to be leaf blowers. [laughs]
Okay. So, many years ago, I had a patient. And we got into this conversation about gasoline-powered leaf blowers. And so, this guy and I decided that he [with emphasis] – we anointed him – he was gonna go to the city and get an ordinance passed so we’d have no gasoline leaf blowers [with emphasis] in the city of Santa Monica! So, you could wake up at 6:00 in the morning [makes loud burr noise], and they’re cleaning, they’re blowing [bleep] everywhere, dust is going in the air! How about allergens, pollens, dust, danders? And my favorite is the great fires in California! And there’s ash everywhere!
So, what do they do? [makes loud burr noise] They’re out there with their leaf blowers, blowing it over the fence to my property! So, I’d like to blow it back over to their property. I hope they inhale a lot, and I hope they get Black Lung Disease! Do I have any more time? Yes, I have more time. Well, I love it that people just discovered root canal systems! For 45 years --
-- we’ve been talking about --
Okay. And stop.
-- root canal systems!
Okay [laughs]. And that made you think of root canal systems [laughs]. Okay.
And the last topic is remodeling.
You know, when I was growing up, and that would’ve been the late ‘40s and ‘50s, the trucks were about this big. Pick-ups! And men arrived on the job in little pick-up trucks! And two or three pick-up trucks could do a whole house!
Now, we have a kitchen remodel down the street, and there’s 15 trucks that show up! And the trucks are big trucks! They’re elongated trucks! There’s seats behind the driver’s seat! So, they’re stretched, and they have beds that can put a sheet of plywood in, and they block the driveway! They block the deliveries! They block egress and ingress! So, I don’t like construction. Did I mention the noise?
The noise runs [makes loud machine noise], he has saws going like crazy! You’re like, “Well, I think it’ll stop in three seconds.” But no! They’re sawing for hours! And I’m trying to plan “The Ruddle Show”. So, I don’t like a lot of noise! And I still have more time! So, we’re talking about what? I’m really upset about this!
All these leaf blowers and – oh, it’s on this page! Okay. That’s why I can’t find it.
Oh, your time’s up.
Oh, time’s up.
Well, everything’s fine.
No, I know what you mean about the remodeling. I ran recently around 6:30, and there was already like 20 cars in front of this one house. And it was – the sun was barely coming up.
I know [laughs].
[laughs] They’re all in their cars, waiting to start work. Okay. Well, thank you for that rant. And I know a lot of us feel – felt some of it in our own lives, too, because of -- [Music playing]
It was COVID inspired and being shut in for all these months.
-- [laughs] okay. Well, that’s our show for today. Hope you enjoyed it. We’ll see you next time, on The Ruddle Show.
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Tough Quetions & SINE Tips
Who Pays for Treatment if it Fails & Access Refinement
Assessing Case Difficulty & Clinical Findings
CBCT & Incorporating New Technology
Zoom with Prof. Shanon Patel and Q&A
Best Sealer & Best Dental Team
Kerr Pulp Canal Sealer EWT & Hiring Staff
Ideation & the Covid Era
Zoom with Dr. Gary Glassman and Post-Interview Discussion
Medications & Silver Points
Dental Medications Q&A and How to Remove Silver Points
Tough Questions & Choices
The Appropriate Canal Shape & Treatment Options
Q&A and Recently Published Articles
Glide Path/Working Length and 2 Endo Articles
Hot Topic with Dr. Gordon Christensen
Dr. Christensen Presents the Latest on Glass Ionomers
Annual AAE Meeting and Q&A
Who is Presenting and Glide Path/Working Length, Part 2
The Ruddle Show
The Ruddle Show
The Ruddle Show
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.