Andreasen Tribute & Krakow Study Endodontic Trauma Case Studies & the Cost of Rescheduling

This show opens with Ruddle reflecting on one aspect of the “new normal”: sports without fans. Next, Ruddle remembers Jens Andreasen, the Father of Dental Traumatology, by presenting a couple endodontic trauma cases. After, Ruddle discusses the business of endodontics and the often overlooked costs of rescheduling. The show closes with a return to our favorite reverse psychology segment, Demotivators. Get motivated by others’ incompetence and failures!

Show Content & Timecodes

00:08 - INTRO: Sports Without Fans
05:37 - SEGMENT 1: Andreasen Tribute - Endodontic Trauma Case Studies
28:52 - SEGMENT 2: Krakow Study
43:16 - CLOSE: Demotivators

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INTRO: Sports Without Fans


Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing?


Absolutely terrific!


So, I spent a lot of my weekend watching sports, as you probably did. And I have to say that watching sports with no fans in attendance is interesting.




Probably everyone is aware that, due to COVID concerns, professional sports are being played with no fans or with greatly reduced fan attendance. So – but we’re still hearing fan noise, and I think you had something to say about why we’re hearing fan noise, still.


Yeah. You and I always like to figure out what’s goin’ on behind the scenes. So, when you listen to a game, at least in the United States, and then, let’s just say for fun it’s football, could be basketball or baseball, we do hear sounds, don’t we? We hear applause and everything. Well, what happened is, the NFL, some years ago, what they did is, they decided, with no particular idea for the future, that they wanted to record all the sounds in the various stadiums of the NFL. This is like 8 or 10 years ago, because they just might want to have ‘em. And the only two stadiums they didn’t film, of course, were the LA Rams and the San Diego Charger Stadium, in LA, and then, the Raiders Stadium, in Las Vegas. Other than that, they got all of the stadiums.

And they had NFL Films actually, then, go to these stadiums, and they wanted sound specifics for each stadium, because each stadium – some are closed, some are domes, some are open to the lake, like up in Cleveland. So, there’s different sounds. And they wanted to use this special software called audiokinetic authoring software, and it could very precisely take out extraneous sounds. And they wanted to get applause, boos, chants, and --


Maybe an injury, like gasps?


-- cheers and – yeah. Those kinds of things. So, they got those four kinds of sounds down, and then, of course, you had to be able to do a crescendo or a diminuendo. So, they made like a controller. So, everybody can just think of a controller as like buttons. And the home team always get to control their sound.

So, when COVID hit, they go, “Wait a minute! Let’s use – augment – augmented reality”, because augmented reality is a way to enhance your experience and make it more lifelike, more real, from a virtual world. So, they gave these sound libraries out to all the various teams, and their own person was able to use it. And they were a little rusty at first, because there’d be a big pass play, and maybe they’d hit the pause button, and the guy’s already [laughs] caught the ball, maybe he’s almost ready to score. So, there was a lot of things, pick six, interceptions, a runner breaking through scrimmage to daylight, fumbles, things like that.

So it’s pretty interesting how they pipe this in, and we get to hear – they’re getting pretty good, now. These controllers, when you see the play happening, the sounds are right along with the play now. So, it’s synched up pretty good.


Yeah. And you’re specifically talking about the NFL and American football.




I don’t know if other leagues have done something that’s similar or if they’re just borrowing from the NFL. But I know that some athletes, like LeBron James, said when basketball was paused, and they were gonna – talking about continuing, he said, “No way! No way am I gonna play with no fans in attendance.”


He said that?


And then, he did. And so, I guess, you know, we’re all adapting to this new normal.


Do you think he was intrigued by getting the ring?


But – maybe [laughs]. Probably. I mean, I think that – they wanna play, you know? And the sound is actually great, because it probably helps their rhythm a lot and – as well as augmenting our own experience. And I think you actually have an – know of another way that your experience is augmented by sound. And why don’t you tell us that.


Oh, yeah. Well, that’s great. You know, when we record patient procedures, obviously, we hear the high-speed handpiece, we can hear the low speed. You out there listening, you can imagine ultrasonics, sonics, beeps from electronic devices, beep, beep! You know, all this stuff that happens. Well, we already had that filmed with live patient shoots, but when we make animations, we augmented that visual experience by putting these sounds and overlaying them in that footage. And that really made the animations pop.


I’m actually thinking that it would be nice if you’re in the dentist’s office, having a procedure done on yourself, if all of a sudden you hear applause, you know the dentist is doing a really good job [laughs].


[laughs] Oh, jeez, that’s great!


So [laughs], maybe you even have this kind of sound in the operatory as well.


So, we need to have some controllers in the operatory, and when patients don’t pay their bills, maybe we get boos [people booing on soundtrack].


Yeah [laughs].


And when we finish, we get [people clapping on soundtrack] a round of applause.


[laughs] And I know if I’m waiting in an operatory, and I hear applause in the next room, I’m thinking...


It’s all good! [laughs]


It’s all good! [laughs] Yeah. Okay. Well, we have a great show for you today, so let’s get started. [Music playing]

SEGMENT 1: Andreasen Tribute - Endodontic Trauma Case Studies


So, you are probably aware that dentistry lost a very influential leader this year, Dr. Jens Ove Andreasen, from Copenhagen, Denmark. And he’s known to be the “Father of Dental Traumatology.” And I know that he was a role model for you, and that you had the opportunity to meet him, at one point. Do you want to share that experience?


Sure. It was 1975, and my mentor, Alvin Arlen Krakow, brought pretty big speakers in from around the world, to share with the residents. And because he was such a big name, Al invited Tufts and Boston University. So, Day 1 was the Boston post-grad residents, and we got him for probably about 40 of us, and then, Day 2, which Al said was mandatory attendance, was the next day, and that was for the local general practitioners, the endodontics, and again, the residents. So I got to see him as a face in the crowd, but I did wanna say hi to him. Back then, I still wanted to meet important people. And I’ll never forget my short interaction with him, but he was very kind.


Well, I know he did a lot in his 85 years. He founded the International Association of Dental Traumatology in 1989, and was its first President. He authored over 200 publications and 12 textbooks, I think it is.




He lectured internationally, in 49 countries, and was known to be a very knowledgeable speaker. And those who knew him thought he was very positive and energetic and just extremely empathetic to his patients. So, as a tribute to him, we’re going to – you’re going to present a couple trauma cases, and – that’s correct?


Well, maybe three.


Okay. And so, I’ll let you get started, and I’ll step away.


Thanks, Lisa. That was a very nice tribute to a great guy. All right. So, now that you know a little bit about the man, I’ll give you a little glimpse of how he’s impacted generations of dentists. Okay. So, I wanted to throw another name in here. If you look carefully, you’ll see not only Andreasen, but you’ll see my dear friend Leif Bakland, who is a Professor Emeritus at Loma Linda. But Leif Bakland was one of my mentors at Harvard University. So, really, probably, truth be known, Leif Bakland probably had the relationship with one of his dear friends, okay, and probably it was him that actually got Andreasen to Boston.

So I wanted to acknowledge Leif Bakland, because he’s very involved in traumatology, and they wrote this book. And one thing I’ll say is that they looked at over 40,000 trauma cases, and they talked about how to categorize them, how to manage different problems, because it can happen in all different kinds of ways. And one thing that I got from it, in the first 10 minutes of the lecture, he divided teeth pretty much into thirds.

And there were trauma instances and fractures that involved the clinical crown, but were isolated to the clinical crown. Then there was that moment where the fractures were extending sub-crestal, and the fractures could be categorized as vertical. We could have horizontal. We could also call these transverse fractures, these horizontal fractures. There were oblique fractures. And then, of course, there were comminuted – that’s an ‘I’ – comminuted fractures. So, there were different fractures in different zones. And of course, each one has its own particular way of being treated optimally.

Then, there was the whole lecture part on soft splints versus fixed splints. And then, of course, there was a lot of discussion secondary to trauma. Secondary to trauma, we oftentimes see internal and external resorptions. And sometimes you’ll see these external invasive areas. They’ll be coming into the tooth, and it can be pretty disturbing to clinicians, how we stop external resorption. Internal resorption we know, take out the pulp, and we can usually arrest it. So, that’s a little comment I’d like to make about the book that these guys wrote. Every general dentist should have this manual. They didn’t want to even call it a book. It’s a manual, and you can see there’s a DVD that’s very useful, to help see how these might go.

So, let me show three cases. I was yesterday picking some of these cases, and I noticed that I had about – I have a whole library of prominent cases. So it became difficult, because my daughter said to show two [with emphasis] cases. I said, “Well, I wonder if I could sneak a third case in there. Maybe she wouldn’t even notice if I got a fourth in.” But I pulled the fourth one out, this morning. Okay. Now, when your victims of trauma arrive in your office, there’s a lot of times parents involved, because these are a lot of times kids or young adults. And oftentimes, there’s a lot of anxiety. There’s tension, and of course, somebody went from a beautiful smile, ten minutes ago, to now, they have puffy lips, broken teeth, maybe broken bones, maybe segments lodged in the soft tissue.

And this is my first moment of seeing the patient. It’s blurry, because a lot of these patients, you – this was taken before digital, and you’d get a couple photographs, but the patient’s not very comfortable, and they’re sometimes moving a little bit. So, you can understand, though, that this person is in trouble. So the first thing I did was, I wanted to reposition the teeth and roots the best I could. So, I had the radiographs, a series of them. And I was able to compress the bone, too, because the bone can get broken. We want to reposition that, the best we can, and we wanna make sure they close. When they can’t close, they’re not gonna go home and do well .

So, they gotta make sure they’re closed. And the same day I saw them, while we’re seeing this patient, we’re talking to the orthodontist, who’s in my building, and off they go to ortho for fixation. So, the fixation is to help stabilize and hold the crowns. And when you look at that radiograph, it’s a little bit more severe than the one in the textbook, okay? The one in the textbook was pretty much just a clean fracture, with some separation, in segments. But this one is what is called the comminuted fracture. It’s pieces. And you can start to see, there’s several – several pieces in here, different sections are in here, and the crown is a little bit mobile. But with fixation, everything’s pretty stable.

Now, I saw this case about, oh, maybe a year in. So, I had started in Santa Barbara [laughs], and I was about a year in, and I saw this, and I frankly didn’t know what to do. So, I had a little bit of grace and time, because we had orthodontics going on that same day. And then, you don’t wanna see the patients until some of the lip swelling and the facial swelling and the cuts and lacerations are more healed. In the meantime, you can start pulp testing adjacent teeth. But we know that our pulp testing’s pretty flawed, in the first 30 days. You just can’t rely on your typical hot-and-cold test or your electric test. Some people have said laser Doppler flowmetry can be useful. But even then, you write these numbers down if you do do the test, because it’s a baseline.

And then, over time, when you retest, you have something to compare against. But don’t take too much credence in your pulp test as they are related to the first moments of trauma. But you can start to rely on your pulp testing about three weeks – two, three weeks out, you can start to believe it a little bit. So, you wanna know what happened, because when trauma comes, this is what we all see. But we know this tooth had to get hit. We know that adjacent teeth on the right had to have gotten hit. And so, you really wanna go at least canine to canine, and don’t forget the mandibular. Those teeth down there sometimes, if there’s a blow-up like this, you might see the damage isolated to the maxillary teeth, but sometimes the mandibular.

So, you gotta talk to the family, and let ‘em know that you’re assessing things, but as time goes by, you might see more, and more might uncover. In other words, teeth might get dark, dark tooth, might get internal resorption, might get external resorption, or tooth pulp just becomes necrotic and needs a root canal. Okay. So that’s what happened on day one for this patient. And sure enough, over a little bit of time, probably two months later, we went from a fixed stent to a more kind one, a polymer, a little bonding here. And of course, these adjacent teeth became necrotic, they became painful, and they needed endodontic intervention.

So, there’s not much to say here. Pretty big chambers, as you can see, so you can see the shapes are pretty much reflective of the size of the pulp system along its length. Now, when you look at this, and you look over here, I’m thinking you’re going, “Wait a minute! Cliff didn’t do anything, and this is all kinda happening?” You want a little bit of movement. Andreasen told us that these really hard, thick splints, these stents, that don’t allow any movement at all, you can accelerate and invite external root resorption. So, be aware of that! The tooth needs to move a little bit. So here we are, down the road a few months, and it looks better. I put ice on it, and patient was feeling the sensation of cold, inside their tooth.

So, that was [laughs] kind of an amazing thought. I thought, “Well, I don’t know what to do. So, why don’t I just wait and watch?” Wait and watch. So here they are at six months, and I think if we keep progressing along from how severe this looked, with actual displacement, then the fragments are starting to line up. Now, they’re starting to calcify in [with emphasis], either with connective tissue, sometimes there’s even osseous bone that helps hold them, and sometimes you can get some reapposition of the roots to themselves. So, you can see that.

And if we take one last look at it, at five years, you can see, it’s pretty amazing. There’s a vital response. I guess you can see there’s a little tiny pulp chamber in there. You might see a little trace of a canal going up in through here. I don’t know if you see that. But anyway, pretty pleased with this result. So, this is a good example. Sometimes in spite of Ruddle [with emphasis], patients get better. How about that! Okay. One down and two to go.

How about the guy that gets hit in the bar? You know, he’s watchin’ sports with all of his friends, and all of a sudden -- he’s got some money on the bar table, and all of a sudden, his team’s not doin’ well, and he got hit right in the mouth because of some interactions with his pals. Okay?

So, when he came in, this tooth is pretty loose. But it’s got a pretty good root system, and you can see this is a failing silver point. It’s an example of it’s overextended vertically, but the canal is internally underfilled. So, overextended and underfilled. And that silver point is wedging over quite a bit of length. You might see a little bit of sealer right in here, but more or less there’s gonna be a lot of resistance upon removal. So, we have to think about all this. Is that just gonna pop out? Can we get a tube over it? Can we get lateral to it? Can we work files and solvents? Gotta think about all this, because there’s a lot we have to do.

So, treatment plan for no surprises. And in this segment, we’re talking about scheduling, right? Well, schedule this thing so you have the time to take the crown off and whatever you discover, might have to lay a flap. You don’t know. Okay? We didn’t have CBCT then. And then, you gotta get the silver point out, and then, you gotta provisionalize this thing. And the patient’s gotta walk out with a tooth! [laughs] They can’t look like – you know, we’re approaching Halloween. We can’t have this dragon look!

So, let’s get started. So the crown, with a little manipulation, it’s out of there, and that’s what I see. And you can see the overt fracture. It’s oblique, and it’s heading off towards the facial. And we gotta be careful of our flaps. We don’t want to have this distance seriously compromised, because we want the incisal gingival dimensions of the adjacent teeth to all appear reasonably normal! We don’t want the patient to have a high smile line, the lip goes up, and all of a sudden you maybe have a crown that is a lot longer. And all of a sudden, it looks like Dracula! So, we take that little segment out, and we have a little flap that we’ve lifted. I’ve left the papilla, so we don’t have the black hole disease. And you can see, this is oblique, and it’s a feather fracture, so it’s coming off to a knife edge.

So, I can take a chisel – I have more control, and I can start to ramp the bone into the adjacent teeth, so we have a good healing. Now I’ve landed a margin. Okay. I didn’t put the margin, but I’ve exposed the root so the general dentist can land the margin, in the restorative effort. I’m pushing from the apical field. I’m finally getting that silver point out, that we talked about. And then, finally, we’ll slide this over, and we’ll erase, and we’ll go forward. I’ve got the new Flexi-Post placed, and I’ve just done a little bevel across the end of my downpack. So I fit a cone, downpack warm gutta-percha, backpack, leave the post space, and here we go.

So here we are with the Flexi-Post in. Notice my gutta-percha, and I told you I’d done just an apicoectomy only. You can see, we have the little area that I did my surgical access. We started with a little area. So, that’s normal. And then, here we are, at about 10 years. And at 10 years, gotta get these recalls in, because there’s always those pirates that grab your x-rays, and they just stop right here and say, “Gee, I wonder how that case worked, 30 years later! I bet [with emphasis]” – and then, they go into a whole bunch of – what’s this called? This bias, this confirmation bias stuff we talked about on another show. “Oh! the wall picture is a little off the….” – okay. But at 10 years, no, it’s actually healed apically. The bones fill back in, because endodontics is a regenerative procedure. And properly performed, it’s the cornerstone of restorative and reconstructive dentistry. So, let’s erase, and we’ll look at the last case.

Now, this is a little kid, a little girl, very cute. You know, I have grandkids, so I can get pretty affectionate. I didn’t have ‘em back then [with emphasis], but I had little girls back then. So, I can relate to them. So, you see a little kid like that, and you have a little kid at home like that, you know, you kinda – your heart goes out to these people. Well, she came in, and she had hit her face on the handlebars of her brand-new bicycle! Ha!

Well, everybody sees this crack, right here, and you see it, right there. And I don’t know if you can read it, but it might be going – I’ll try to draw it adjacent to it. It might be going kinda like that. Now, you’ll see it even better. And I could test mobility, and the whole thing was like about a half. So, it was not any real different than the contralateral, lateral incisor. So, I saw that, and I told her parents, you know, “Once we open this thing up and go in here and get our access, there could be something that breaks loose, and we might have to go back to the general dentist at that moment in time. So, I need to call the professional that referred her in, to make sure they can be on stand-by, when I schedule this patient. So, if I need them to help me with the provisionalization, I got somebody there.”

So, that’s about how that works. So, we had all the discussions. She’s in pain. You can see that we have kind of a thickened PDL from the injury, but some of this is the pulp’s necrotic. When you put ice on this, she just – there is a no response, but there is a normal limits, and there is another normal limits to ice. So, that’s the culprit! Let’s go to work! So, she comes back in six weeks later and says the tooth doesn’t really hurt so much, but it’s loose! And so, I anesthetized her. We isolated the tooth, and it was loose. I looked at my assistant, and I thought, “Gee, maybe we should’ve taken a preoperative film – a second preoperative film, later in time.”

So, I accessed the tooth, and I put my file in, and it’s not slidin’ up a pretty big system. I mean, we don’t think this is a small system, do we? I mean, this is like road grader stuff! You could take a big tractor trailer, probably, and drive right up that canal, right to length! So, it was odd not to be able to pass a file easily to length. So basically, I saw this, and I said, “Just take the dam off. Gotta get the parents in here.” And I shared with the parents that we have a fracture. It’s an oblique fracture. It’s that Andreasen zone, remember? Fractures in here are the most dangerous! These are the absolutely most dangerous, in terms of prognosis. Prognosis.

So, what are you gonna do? This is an example of something I’ve learned so much about, and I’m so proud of being in Santa Barbara, the multidisciplinary group! Okay? So, you have prosthodontists, you have – or a general dentist, you have orthodontists, you have the surgeon, you have the endodontist. Everybody’s working on this patient, okay? So, when we saw this, I told the patient’s parents that I thought it was probably hopeless, because you’re gonna lose this part. This is a goner. Well, then, you just have this part, and that’s not very much. And they said, “There’s gotta be something you can do. Is there anything [with emphasis] you can do?”

And I said, “Well, we can talk as a multidisciplinary team, and we could drag that tooth down orthodontically. That’ll drag down the bone and the surrounding periodontium.” Because again, we want to have a crown that has incisal edges, gingival dimensions, that are appropriate for the adjacent teeth. Because this little girl smiles, and you see all of that. So, here we go. Introduce my retreatment. So, Ruddle goes ahead and gets the fragment out. That’s my job. And you can see that our most apical extent is right there, and that’s well under the crest of bone. You can see the bones in here. That’s way below the crest.

So we have a job to do. And we go off and do the root canal. I downpack, so I fit a cone, vertical condensation, Schilderian stuff, downpack, warm, compact, press on that thermal softened, drive that into a conical prep, seal the canal laterally and apically in all of its dimensions, leave a post space, because that post space is what Ruddle can utilize for the orthodontist. So I put the post in, made a little eyelet right here, that you can see, and we can get some brackets on these teeth, and we can get some brackets on these teeth, put an arch wire here, and we can tie in, and we can start dragging that down. That’s going to take about a week. A week to 10 days, the tooth is down.

So, the tooth is being actively brought down orthodontically, very fast movement. We don’t have to worry about external resorption. The fibers in there, you’ll just kind of come along with the tooth. And you can see, this has moved from about right here, and you can see this relationship, and now you can see we’re much closer. So, at some point, when can the general dentist land a margin that gives us the ferrule effect, and that we have a biological width, and that we’re gonna have a good periodontal outcome? That’s what we have to think about. So, all that was done. Exquisite general dentist. And you gotta remember, this tooth isn’t getting a lot of loads. That’s stuff, you – you check the protrusion and work, balance.

So, have that patient slide around. And you can begin to see, there’s not a lot of load on that tooth. You can get away with more. You can always put an implant in, here. If this fails or breaks later, we’ve grown bone back apically. Notice how the bone’s come in. We have good bone; we have crestal bone. And I want to show you the aesthetics. I always like to follow these cases in a multidisciplinary way. So, you might look at this crown and wonder how it relates to the actual patient. So, you can see, it’s a little – here’s our gingival area here. So, we’re a little higher up. We’re a little higher up, little higher up, but it doesn’t look outrageous, and this is gonna drop down more, at her age. It’s a canine. You can see the baby tooth behind it.

But that’s the outcome. And notice how modeled – look at how modeled these teeth are! So, I thought the restorative dentist did an excellent [with emphasis] job, capturing that aesthetics, of those adjacent, natural teeth, into the patient’s prosthetic tooth. So, anyway, I hope you’ve enjoyed the trauma cases. I chose three. We could’ve shown you 60 or 70 today, no problem. There’s – they come in every different way. Sometimes they’re on teeth that never needed endodontics. Sometimes the trauma happens in restaurants. People bite down on stuff, break teeth. So, there’s all kinds of trauma.

We’ll revisit extensively traumatology in the months and years ahead. [Music playing]

SEGMENT 2: Krakow Study


Today we wanted to focus on the business of endodontics and how one-visit endodontics is generally more profitable and efficient. If your office is scheduling efficiently and allows enough time for start-to-finish endodontics, clearly you will reduce the duplication of disposables and save time sterilizing and cleaning the operatory. So, let’s look at the time spent to finish the case on a patient versus rescheduling that patent for a future visit to complete treatment. And that brings us to the Krakow study. Why don’t you tell us how you learned about it and what it is.


My mentor was Alvin A. Krakow. And he was Herb Schilder’s “Second Student”, which I always say, for some reason. And that was 1960, when he was matriculated into Herb’s program. Al always thought a post-graduate program should have some business associated with the technical side, because he had seen many graduates from other programs falter. So, he always emphasized the business of endodontics. And so what he did is, him and 4 of his partners, that’s 5 guys, they looked at 15,000 patients. So at some point, this information may not be true exactly for anybody that’s listening, but you can begin to carve out the edge of the truth and see the reality for you.

So what they did is, they looked at these 15,000 patients, and the question they asked themselves was, “If you had a molar, and if it had three canals”, just for an example. I don’t know if there is such a thing, but let’s say you have a three-canal molar. Everything is shaped wonderfully. You’ve followed your disinfection protocols, and your cones are fit and verified radiographically.

Then, his question was, “How long would it take you to finish the case?” Well, in a specialty practice, where there’s a lot of experience and skill, they discovered it was about 10 to 15 minutes. Obviously, it could be this one, or it could be this one. But in 10 to 15 minutes, usually at that stage of treatment, you’re gonna be completely done with the case.


Okay. So, 15 minutes to complete the procedure. Now, we have a chart behind us that breaks down the time that’s going to be required when the patient returns for their future visit. And so why don’t you go over this chart for us.


Oh, okay. Well, Al, you know, said a lot of this depends on your personality. So, if you’re a quiet person, withdrawn, you might talk to a patient for about one second, because your assistant is hired to do those kinds of things. You know the old expression, “Hire your greatest weakness.” But for people like me, I like people, so it’s fun to talk to people. And you begin to talk about, you know, “How’s your family doin’?” And, you know, “I heard you went on a vacation. How’d that go?” And, you know, ‘Is everything else good?’ And then, the Q and A part isn’t Q and A about your life.




It’s sorta like, “Okay. So, I saw you last time”, and when you say to a patient, “How are you doing?”, most patients talk about the world they live in. So, then, you have to say, “Okay. Great. I’m glad your personal life’s going well. How’s your tooth doing?”




So, the Q and A is, “How’d you do last visit? Were you a little sore? Did it go away rapidly?” And so, this easily – the assistant’s wrote down “five minutes”. Now, let me explain this. When the patient was seated, and the bib was put on ‘em, they didn’t start the clock. Al Krakow had to walk through the door, or one of these other four doctors, and wash up and scrub and sit down. And when they made eye contact, the assistant started the clock. And that was how they got to the five minutes. Al warned us, it could be 10 minutes, it could be 2 minutes. It just depends on you.


Okay. And then --


Well, then, last visit, you had the patient in the chair. There was no chitchat. There was, at the beginning, but now you had him in the chair, and remember, you’re ready to pack. You’re just ready to fill the root canal system. So, you have another visit, and what you have to do is, you have to bring the patient back in. You do the same chitchat again, and now you have isolation, gotta isolate the tooth, gotta give anesthesia before that, and you gotta get it. So, giving anesthesia might take 30 seconds, warm carpules, pressure, all these tricks we do to distract patients. That might take 30 seconds or a minute or 2 minutes.

But it’s a painting. So, a mandibular block, you know, maybe 5 minutes, 10 minutes. Sometimes you have the reinforce the block, because it didn’t come across the midline. So, the big ones were getting it, attaining it, and then, isolating the tooth, reaccessing the tooth, and getting back in. And now, you’re ready to do the next – the third thing. So, they said that that was about 10 minutes. And most doctors don’t sit in the room after anesthesia. I mean, you might, and you might just visit. But a lot of times, the doctor gets up and goes somewhere else.


Yeah. I’ve gotten anesthesia a couple times in recent years for fillings. And I have to say it’s longer than 10 minutes, because he actually goes and does other things and comes back, maybe 15 minutes later.


Mm-hmm. That’s normal. And then, the biggest part of this whole thing was removing the provisional, the temporary, and getting back in. What is reorientation? Well, two or three weeks ago, you had files snug at length. You had cones that went along multi-planar [laughs] curvature. I’m just making this stuff up, so I can kinda role play with you. And you took a film, and those cones were right on the money. They were at length! So, when you go back in, maybe the 25 that was snug at length, now it’s a little bit loose. You can tap on the handle, you can displace it. So, you go to a 30. Now, you gotta trim your cone and make sure it’s – and then, take another film, confirm everything’s right.

Well, that easily – that easily is the biggest part of the reschedule, is getting back into those canals, getting the canals – you had this in your mind. You knew the lengths six – two weeks ago, three weeks ago, you knew the curvatures. You were sitting there – it was a game you were playing. You were intimately involved with all the walls and the curvatures, patency, little things that you knew, only you knew. Now, you’re having to rediscover that a little bit. So that can be quite a little bit of a chunk of time. And then, of course, when you’re all done, remember you closed the tooth last time. Well, now you gotta close it again. So, this is quick. Okay. It’s fast.

Provisionalize it. The old days, it was Cavit. Now we’re puttin’ in some kind of a dual tiered polymer or something, more durable. And that’s pretty quick. And then, of course, after you provisionalize, you usually have to – so, we had a good session today, and you give your post-op instruction. ‘You’ll be sore for a couple days. And if it’s more than that, give me a call.’ And you do all that repeat that you did, on a prior visit. And then, of course, “Ruddle, what are you gonna be doin’ now, when you leave the office?” And “I heard you had a ski trip comin’ up. I wanna know all about that downhill run. That downhill run had a lot of meaning, because you knew there was a bottom.” [laughs] Okay. So, that turns out to be about 30 to 35 minutes of redundant, non-productive time, every time we have to bring a patient back.


Okay. And of course, when you bring the patient back, and you’re blocking out a time for them, you’re not gonna just block out 30 minutes, because, you know, some things might take a little longer. And then, you’re going to need to clean the operatory afterwards, to get it ready for the next patient. So you’re probably gonna block off an hour. So that actually brings us to the next graphic, where we can look a little closer at the financial ramifications of rescheduling.


You might wanna cover your eyes.




This is very – well, it could be good news or bad news. You know, a problem recognized is a problem half solved. So, if you look at this table – so it has some meaning, you could put any number here you want. In fact, when this session’s done, and you have time, roll up your sleeves, and go out and talk with your staff, and sit down, if you are doing second-visit endodontics a lot [with emphasis]. It can happen. We’ll go through that in a second. Don’t let me forget. But you could see that you might make 300 bucks an hour, you might make 400, you might make $700 an hour. It doesn’t matter. We just put numbers in here, because throw-away journals say you should be making about 500 bucks an hour in the United States, or you probably shouldn’t be open for business.

So, if you’re making 500 bucks an hour, and let’s say you only see 2 patients a week, endodontic patients, and each time you see those patients, you never finish ‘em, because your training is, “I do 2-visit endodontics.” There’s a whole body of rationale and science behind two- and multi-visit endodontics. So, I said, “multi”, could be three or four. You probably remember back in the day [laughs] --




-- when I was doing [laughs] two and three visits. Anyway, you could take that over, so you have to reschedule twice. So, that’s 500 bucks. So, that’s – if you look at that $1,000 there, twice 500 is 1,000, 1,000 times 48 is 48,000.


We’re assuming you take about a month off [laughs] a year --


Yeah. Yeah. And if you take them – you know, you might work 50 days a week. You just gotta have bills, when you have a lot of debt. But you might be a more mature practitioner, and in that instance, you might work even a lot less. But you can go through all these numbers. I’ll do one more, just so you got it. So, 500 bucks, and you’re doing 4 patients a week, you’re really an enlightened [with emphasis] general dentist, you love [with emphasis] endo, not as much as these [with emphasis] people love endo. They’re passionate! They’re doin’ a lot of endo!

But – and if you do 4 cases, that’s 4,000, that’s 2,000 bucks, 2,000, okay. 500, 4 – 2,000 times 48, 96,000. So, you can begin to see, looking at these numbers, and you can reflect on this, and you can actually pause me, during [laughs] this video shoot, so you can really write this stuff down or take a picture.




Anyway, it costs a lot of money, and that’s money that you could be using to what? Take time off, give the staff a raise, buy a piece of technology, go to a class and get trained.


Schedule in a new patient?


Buy your wife a bag of groceries.




I don’t know [laughs]. Yeah. Oh, what’d you just say?


Schedule a new patient?


The worst news is not this redundancy time. That’s bad news! This is one of those things where we have bad news – you know, human endeavor, there’s bad news, the alternate’s good news? This is bad news and worse news. This is the bad news. The worse news, she just said it, you’ve denied yourself the ability to schedule a brand-new patient. And that is a whole new fee set-up and everything. So, we – we – you hit it. We’re paying somebody to tear the room down. We’re paying somebody to rebuild the room and drape everything. There’s the price of disposables and PPE. It’s getting to be pretty expensive, now. And then, you didn’t get that new patient in there, where you could’ve done something completely new.

My only – I have one closing remark. You never finish a patient in one visit unless you’ve done your work to each canal. I wanna really make that point. This isn’t about a money game. It’s just scheduling wisely. And if you know you’re always10 or 15 minutes short, sit down with the staff and say, “You know, we’re always just about 10 or 15 minutes away from being complete. What if we just had 10 more, 15 more minutes, and be done?” So, a problem recognized can serve as a – an impetus to get better.


Yeah. I think that it – these numbers are astonishing, to think that you may be losing almost $200,000 a year from – if you’re rescheduling all the time. Probably your office should [laughs] declare a state of emergency and really --




-- look at what’s happening. But I do – probably there are some times where it is best to reschedule, like --




-- if you can’t – or if you’re trying to do something like bypass a ledge, maybe, or something, and you’re just struggling and struggling. Maybe sometimes it might be better to just say, “You know what? I’m gonna come back to this with a fresh mind.”


This is exactly the point you’re making, that it’s gotta be reemphasized, even again. People that come in with swellings, I’m not doing one visit. I’m doing palliative treatment, okay? I always need to emphasize, I generally, as a specialist, always see patients as a consultation first. That’s when I can talk to their referral. That’s when I can check with the physician about a medical issue. That’s where we can determine if the patient can open, if they have TMJ problems. That’s where we can kinda see, can we get in here and work? That’s when the patients can ask questions. Doctors oftentimes feel obligated to start immediately, and patients feel pressured!

So, the consultation, I have found my patients, over 45 years, they love consultations. Now, obviously, emergency patients, send ‘em right over. We see ‘em that moment. But if you can, have a consultation. You’re treatment plan for no surprises.


Okay. But even if you’re trying to find a canal, maybe, and you’re – you know if might --


Close the case.


-- so, just like – sometimes it’s better to just step away.


Your comment about – and I think there’s another show, where we talked about it, sometimes just closing the case and stepping away – Al Krakow said he couldn’t remember how many times in his career he couldn’t find the elusive canal. And so, he would close the case. He learned to do that. And he said sometimes he’d have ‘em back three weeks later, and it was embarrassing. It was like right there! It was like that big! And he couldn’t find it! So, another day gives you another perspective and another way to win. So, yeah. We sometimes just have to close the case, because it’s not done yet. We haven’t been our word to the canal.


So, they’ll – maybe don’t feel the pressure that “I have to [with emphasis] finish in one visit”, but like – to just be [laughs] --


But if you start doin’ it --


-- use common sense. Yes [laughs].


-- if you start doin’ it, you’ll be doin’ a lot more one-visit, and that’s what we’re talkin’ about.


Okay. Well, thank you. Hopefully, this will give you some perspective on maybe a place you could save money. [Music playing]

CLOSE: Demotivators


So, it’s been a while since we’ve done Demotivators on our show. So, we thought it’d be good to close our show today with Demotivators. And they’re these cards that I gave my dad a long time ago, and they have a picture and a word and then, a little saying underneath it. They’re called “Demotivators”, and it says under the title “Demotivators”, “Increasing success by lowering expectations”. So, that gives you [laughs] kind of an idea of what --




-- what we’re gonna talk about today. So, I’m gonna read one, and then, you are gonna tell us what it means to you and maybe even relate it to dentistry. So, here’s the first one. It is called “Overconfidence”. And it shows two skiers, and then an avalanche coming. And I will read it. “Overconfidence: Before you attempt to beat the odds, be sure you could survive the odds beating you.”


Well, what that means to me is, the AAE has an Endodontic Assessment Difficulty form. So when I see the overconfidence, I often wonder about all the cases that got referred into my office over almost 50 years [laughs], and 90 percent of my practice was retreatment, failures. And so, you – a lot of failures just happen, no problem, you retreat ‘em. But there’s a lot of failures [laughs] that get sent in, and you’re going, like, “What happened? What happened to this guy? What happened to this woman?” And so, really, what it means to me is, people jumping into cases with a quick glance at a preoperative [laughs] x-ray, and they’re off and rolling, and they really hope everything goes well.


So, this one is pretty much about referrals – referring [laughs].


Yeah. It could be.


Okay. Here’s the next one. It is called “Trouble”, and it has --




-- a leopard or a cheetah chasing another animal [laughs], about to catch it. And it’s called “Trouble”. And it says, “Luck can’t last a lifetime unless you die young.”


I can’t help it, but when we’re in the context of endodontics, trouble, we could have all kinds of trouble from first blocks to ledges. But the broken instrument comes to mind! That’s always an alert to everybody that there’s a lot of trouble [with emphasis] now. And I’m thinking, they probably had the same glide path and had no broken instruments, for quite a while, and then, it bit their ass. And what happened is, they didn’t have a glide path. They had a little bump in the wall. There’s a little bump in the outer wall, a curvature, and the file breaks! And so, that’s where it really caught ‘em. So, in endodontics, you either have to retire very early and have no worries about patients coming back, or you just die.


Yeah. You know, we’re gonna have a guest on our show in a couple weeks, Dr. John West. And he recently published an article in Dentistry Today, and we’re gonna talk about that article. And I was reading it yesterday, and there was actually a couple lines that he said that made me really think of this card. He said, “Anything can work some of the time. In fact, that same thing might work more often than not. That doesn’t mean you’re doing it right, and it may come back to bite you [laughs], if you’re not careful.”


[laughs] Very good.


So, that reminded me of that.


That was a good one.


The last one is called “Conformity”, and it shows a group of zebras. And it says [laughs] --




-- “When people are free to do as they please, they usually imitate each other.”


Well, that made me think of EdgeEndo and Brasseler --




-- right off the bat and a bunch of other people. I won’t even mention their names. You know, there’s people like S.S. White that actually infringe on your patents, when they’re actually alive, and they’re working. They’re valid patents. And they figure, “Well, you know, there’s only three years left. By the time they bring a lawsuit, we’ll be out of this, and their patents’ll expire, and they’ll just – everybody’ll be – live happily ever after.” So, I always think about the infringers.

And then, there’s people, when the patents do expire, okay. They – 20 years, it’s up. But they immediately, as we see in the marketplace now, everybody’s [with emphasis] copying the number-one-selling file in the world. So I really like that, because while they’re copying that, they just don’t know, Lisa, we’re makin’ a brand-new one, and they’re gonna have to worry about that. Doesn’t look like a zebra!


[laughs] Yeah. I guess – I know that – having kids, I hear them say a lot that someone’s copying them, and they’re very offended. But it’s [laughs] – you know, and then, I try to say, “Well, actually, copying someone is a high form of flattery. It means they like your idea.”




But yeah. This could be just about infringing on patents, too. [laughs] [Music playing]


Okay [laughs].


All right. Well, that’s our show today. I hope you enjoyed it. And we’ll see you next time on 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.

DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at

Watch Season 10


s10 e01

Delving Deeper

Progressive Tapers & DSO Troubles


s10 e02

The Dark Side & Internal Resorption

The Resilon Disaster & Managing Internal Resorptions


s10 e03

Advanced Endodontic Diagnosis

Endodontic Radiolucency or Serious Pathology?


s10 e04

Endo History & the MB2

1948 Endo Article & Finding the MB2


s10 e05

Collaborations & Greatness

Crown Removal vs. Working Through & Thermal Burns Q&A


s10 e06

Vital Pulp Therapy

Regenerative Endodontics in Adolescents


s10 e07

Endodontic Surgery & Innovation

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s10 e08

Clinician Influence & Fractures

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s09 e01

Moving with the Cheese & Delving Deeper

A Better Understanding of Change & File Brushing


s09 e02

The Dark Side & Post Removal

Industry Payments to Academics & Removing a Screw Post


s09 e03

3D Tomosynthesis

Special Guest Presentation by Dr. Don Tyndall


s09 e04

Controversies & Iatrogenic Events

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s09 e05

File Movement & Learning

Manual and Mechanical Options & Endoruddle Recommendation


s09 e06

AAE & Endo/Perio Considerations

Annual Meeting & Root Amp, Hemisections & Implants, Oh My!


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Case Discernment & Lateral Repair


s09 e08

Fresh Perspective & Apical Divisions

Fast Healing & Irregular GPM and Cone Fit


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s08 e01

Endo/Perio Considerations & Recent Article

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s08 e02

WaveOne Gold

Special Guest Presentation by Dr. Julian Webber


s08 e03

Microscope Tips & Perforation Management

Q&A and Crestal & Furcal Perf Repair


s08 e04

Knowing the Difference & Calcification

Esthetic vs. Cosmetic Dentistry & Managing Calcified Canals


s08 e05

Tough Questions & Sealer-Based Obturation

The Loose Tooth & Guest Dr. Josette Camilleri


s08 e06

AAE Discussion Forum & 3D Irrigation

Trending Topics & the SLP EndoActivator


s08 e07

Working Length & Microscope Tips

Determining Accurate WL & Microscope Q&A, Part 2


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Artificial Intelligence & Common Errors

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Special Reports


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As Presented at the John Ingle Endo Symposium


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The Importance of Simplicity & Getting Back to Basics


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Personal Interview on the Secrets to Success


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The Launch of an Improved File System


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The Way Forward

Watch Season 7


s07 e01

Articles & Preferred Access

Writing Projects & Ruddle’s Start-to-Finish Access


s07 e02

Patient Protocol & Post Removal

CBCT & the Post Removal System


s07 e03

Avoiding Burnout & Ledge Management

Giving New Life to Your Practice & Managing Ledges


s07 e04

Start-To-Finish Endodontics

Special Guest Presentation featuring Dr. Gary Glassman


s07 e05

Laser Disinfection & Obturation

The Lightwalker vs. EdgePRO Lasers and Q&A


s07 e06

Extra-Canal Invasive Resorption

Special Case Report by Dr. Terry Pannkuk


s07 e07

GentleWave & Microsurgery

Every Patient Considerations & Surgical Crypt Control


s07 e08

Artificial Intelligence & Endodontic Concepts

Update on AI in Dentistry and Q&A


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s06 e01

Comparisons & NSRCT

Chelator vs NaOCl and Managing Type I Transportations


s06 e02

Special Guest Presentation

Dr. Marco Martignoni on Modern Restoration Techniques


s06 e03

International Community & Surgery

Breaking Language Barriers & MB Root Considerations


s06 e04

Launching Dreams

ProTaper Ultimate Q&A and Flying a Kite


s06 e05

Rising to the Challenge

Working with Family & Managing an Irregular Glide Path


s06 e06

Controversy… or Not

Is the Endodontic Triad Dead or Stuck on Semantics?


s06 e07

Endodontic Vanguard

Zoom with Dr. Sonia Chopra and ProTaper Ultimate Q&A, Part 2


s06 e08

Nonsurgical Retreatment

Carrier-Based Obturation Removal & MTA vs. Calcium Hydroxide


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Watch Season 5


s05 e01

Common Endo Errors & Discipline Overlap

Apical and Lateral Blocks & Whose Job Is It?


s05 e02

Post Removal & Discounts

Post Removal with Ultrasonics & Why Discounts are Problematic


s05 e03

EndoActivator History & Technique

How the EndoActivator Came to Market & How to Use It


s05 e04


New Disinfection Technology and Q&A


s05 e05

Exploration & Disassembly

Exploratory Treatment & the Coronal Disassembly Decision Tree


s05 e06

Advancements in Gutta Percha Technology

Zoom Interview with Dr. Nathan Li


s05 e07

By Design... Culture & Surgical Flaps

Intentional Practice Culture & Effective Flap Design


s05 e08

Workspaces & Calcium Hydroxide

Ruddle Workspaces Tour & Calcium Hydroxide Q&A


s05 e09

Cognitive Dissonance

Discussion and Case Reports


s05 e10

50 Shows Special

A Tribute to The Ruddle Show’s First 5 Seasons


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s04 e01

Tough Questions & SINE Tips

Who Pays for Treatment if it Fails and Access Refinement


s04 e02

Endodontic Diagnosis

Assessing Case Difficulty & Clinical Findings


s04 e03

CBCT & Incorporating New Technology

Zoom with Prof. Shanon Patel and Q&A


s04 e04

Best Sealer & Best Dental Team

Kerr Pulp Canal Sealer EWT & Hiring Staff


s04 e05

Ideation & The COVID Era

Zoom with Dr. Gary Glassman and Post-Interview Discussion


s04 e06

Medications and Silver Points

Dental Medications Q&A and How to Remove Silver Points


s04 e07

Tough Questions & Choices

The Appropriate Canal Shape & Treatment Options


s04 e08

Q&A and Recently Published Articles

Glide Path/Working Length and 2 Endo Articles


s04 e09

Hot Topic with Dr. Gordon Christensen

Dr. Christensen Presents the Latest in Glass Ionomers


s04 e10

AAE Annual Meeting and Q&A

Who is Presenting & Glide Path/Working Length, Part 2


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Watch Season 3


s03 e01

Treatment Rationale & Letters of Recommendation

Review of Why Pulps Break Down & Getting a Helpful LOR


s03 e02

Profiles in Dentistry & Gutta Percha Removal

A Closer Look at Dr. Rik van Mill & How to Remove Gutta Percha


s03 e03

Artificial Intelligence & Endo Questions

AI in Dentistry and Some Trending Questions


s03 e04

How to Stay Safe & Where to Live

A New Microscope Shield & Choosing a Dental School/Practice Location


s03 e05

3D Disinfection

Laser Disinfection and Ruddle Q&A


s03 e06

Andreasen Tribute & Krakow Study

Endodontic Trauma Case Studies & the Cost of Rescheduling


s03 e07

Ruddle Projects & Diagnostic Imaging

What Ruddle Is Working On & Interpreting Radiographs


s03 e08

Obturation & Recently Published Article

Carrier-Based Obturation & John West Article


s03 e09

Retreatment Fees & the FRS

How to Assess the Retreatment Fee & the File Removal System


s03 e10

Research Methodology and Q&A

Important Research Considerations and ProTaper Q&A


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s02 e01


Product History, Description & Technique


s02 e02

Interview with Dr. Terry Pannkuk

Dr. Pannkuk Discusses Trends in Endodontic Education


s02 e03

3D Disinfection

GentleWave Update and Intracanal Reagents


s02 e04

GPM & Local Dental Reps

Glide Path Management & Best Utilizing Dental Reps


s02 e05

3D Disinfection & Fresh Perspective on MIE

Ultrasonic vs. Sonic Disinfection Methods and MIE Insight


s02 e06

The ProTaper Story - Part 1

ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos


s02 e07

The ProTaper Story - Part 2

ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos


s02 e08

Interview with Dr. Cherilyn Sheets

Getting to Know this Top Clinician, Educator & Researcher


s02 e09

Broken Instrument Removal

Why Files Break & the Ultrasonic Removal Option


s02 e10

3D Obturation & Technique Tips

Warm Vertical Condensation Technique & Some Helpful Pointers


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Watch Season 1


s01 e01

An Interview with Cliff Ruddle

The Journey to Becoming “Cliff”


s01 e02

Microcracks & the Inventor's Journey

Ruddle Insights into Two Key Topics


s01 e03

Around the World Perspective

GentleWave Controversy & China Lecture Tour


s01 e04

Endodontic Access

What is the Appropriate Access Size?


s01 e05

Locating Canals & Ledge Insight

Tips for Finding Canals & the Difference Between a Ledge and an Apical Seat


s01 e06

Censorship in Dentistry

Censorship in Dentistry and Overcooked Files


s01 e07

Endodontic Diagnosis & The Implant Option

Vital Pulp Testing & Choosing Between an Implant or Root Canal


s01 e08

Emergency Scenario & Single Cone Obturation

Assessing an Emergency & Single Cone Obturation with BC Sealer


s01 e09

Quackwatch & Pot of Gold

Managing the Misguided Patient & Understanding the Business of Endo


s01 e10

Stress Management

Interview with Motivational Speaker & Life Coach, Jesse Brisendine


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