When endodontics fails, it often fails before it even begins. In endodontics, technique isn't everything. Your endodontic preparation - I call it "The Set Up" - is just as important as technique for becoming a highly skilled endodontic clinician and optimizing your endodontic predictability...
Obturation & Recently Published Article Carrier-Based Obturation & John West Article
This “packed” show opens with Ruddle getting going right away on carrier-based obturation, when it is indicated, and its benefits/drawbacks. After, Ruddle and Lisette Zoom with Dr. John West about his recently published article in the September issue of Dentistry Today. Phyllis returns for the close of the show to give us some health insight in our popular ongoing segment, “What Phyllis Thinks.”
Downloadable PDFs & Related Materials
I SEE Endo differently. And I THINK about Endodontic Predictability differently. Or let’s say I, at least, think. In my article “The Set-Up: Endodontic Predictability,” my purpose is to introduce what I refer to as the “Think Box”...
Dr. Herbert Schilder used the title, "Predictably Successful Endodontics," to describe many of the lectures he gave over about a 40-year timeline. In the most simple and direct way, these words promise longterm treatment success that is not only possible, but attainable...
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Filling root canal systems represents the culmination of a series of procedural steps that comprise start-to-finish endodontics. Root-appropriate shaping promotes three-dimensional disinfection by removing restrictive dentin, allowing for a more effective volume of irrigant to penetrate, circulate, and potentially clean into all aspects of the root canal system...
Ruddle on Shape•Clean•Pack Supply List and Supplier Contact Information Listing
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: Brief Introduction
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. Hello.
We’re going to get right into our show today, because it’s pretty busy. First, we’re going to talk about carrier-based obturation. And then, yesterday we had the opportunity to Zoom with Dr. John West. And he’s going to talk about an article he recently had published in Dentistry Today. And then, we’re going to close with a fan favorite, “What Phyllis Thinks”. So, does that sound good to you?
Let’s get started.
SEGMENT 1: Carrier-Based Obturation
Today, we’re going to have another lesson how to fill root canal systems. Of course, the way we originally filled root canal systems was using the Schilder technique, warm gutta-percha. Electric heat carriers, in the old days, it was Bunsen burners. And electric heat carriers came a little after that. And then we had pluggers, and we would manually condense. But look at the work he was able to do. The shapes are appropriate for the roots that hold them. And he taught us all about the importance of shaping to facilitate cleaning, so we could get these kinds of results. Really nice curvatures, lateral canals, you can see they’re all here. The anatomy was understood to be existing, way back then, and so was vertical condensation.
And of course, the emphasis in this technique were described to us in two classic articles. The first one, just chronologically, was ’67, and that was filling root canal systems. And then, the most quoted shaping article on the planet earth, it was written in 1974. And so, he gave us kinda the Bible of how to shape and how to clean and how to clean and how to shape. And then, we could fill root canal systems, using his technique. And so, we practiced this. Schilder never gave exact numbers of what’s the last file to length. It was always a concept, and it was building some deep shape and taper to hold not only our irrigations and let our material stay inside the root’s fillings.
So when you have that deep shape, those increasing cross-sectional diameters, that serves to limit our irrigants from getting beyond the foramen, and it tends to hold our warm gutta-percha during packing. So, this was the Bible. And of course, anybody who did this would begin to accumulate some exciting cases. And I show you several palettes of these nine different images, just to show you differences. But you can see how much fun it is, when we warm gutta-percha and compress it into roots. You can see the prevalence of anatomy, too. Got a little offshoot here. Real exciting stuff in this case, multiple recurvatures and POEs. So, the thrill of the fill, as we’ve talked about a lot.
So that’s what could be gained with some shaping and with some ideas with disinfection. Even with a handheld syringe, through the ‘60s and the ‘70s and the ‘80s, you could see we could fill root canal systems. We could do this as easily as you could do lateral condensation and in the same amount of time. It’s kind of funny how so many companies have come along and introduced needless complications to non-existent problems. We can fill root canal systems. We don’t need $100,000 devices, nor do we need $70,000 devices. We just need about a $1.00 idea, a $1.00 idea.
Well, now, that brings me to my dear friend, Ben Johnson. Ben Johnson thought of another way to warm gutta-percha. So, Ben came out of Baylor. That’s a Texas school for you international people. And that was in the late ‘60s, I believe. And then, within about ten years, about 10 years from graduation, he wrote an article in the Journal of Endodontics, 1978, I believe. I think it was June of ’78, “A New Gutta-Percha Technique”. That was his article. And he described a way to simplify the Schilder technique. So, we’re still going to use pluggers, but they’re going to be inside a circumferentially wrapped core. That’s the carrier. And then the alpha gutta-percha’s around that.
So, Ben introduced the article in ’78, and it took another decade for his company to form, in 1988, and it was the Thermafil Company. Okay. And then it became much more than that, within just a few short years. I wanna acknowledge Ben as a dear friend. We’ve traveled around the world a lot together. And when you’re on the road for two or three weeks at a time and you get up and you go in and do your presentations, and then, there’s the evening dinners, and then, there’s the plane rides and the transfers to new cities.
So, I got to know him quite a bit. But he’s quite a hunter. He was a super athlete in his day. He loved it. Drafted by the Dodgers! How about that? Dodgers just won the championship. Played college football. Inventor and the co-father at least, the father or the co-father of NiTi and then, of course, carrier-based obturation. So, Ben, check on all the boxes! You did it all! So, what did he think about? Well, he thought about a way to have a single unitary device with a solid core. It used to be a metal file. That was in the ‘80s. Then it became plastic. I don’t like plastic. Let’s say polymer, polysulfone carrier. And that gave it more rigidity and flexibility with this alpha gutta-percha wrapped around it.
So, you can see, we’ll bring in the acknowledgments. But Jose in Spain did a beautiful case with GuttaCore. That’s the latest and greatest carrier-based obturator. So, the cores have gone from metal to polymers and now, the carrier is actually all gutta-percha. Different formulation for the core and a different formulation for the circumferential alpha gutta-percha. Okay. And then, Giuseppe. I’ve learned so much from these guys. So who has taught me probably the most about this technique and got me to kinda rethink the Schilder idea – love the Schilder idea! It’s as relevant today as it was the day he described it. The technology’s made it easier for everybody.
But the fact is, as a teacher and teaching around the world, people want to go quickly and effectively, and they wanna be complete. So carriers can be put in a root, and you can completely seal the canal and its related root canal system in seven seconds! Seven! That’s a lot easier than learning how to plunge in with the Schilder heat carrier, deactivate, take out a bite, and you can go back and watch the other show. So, Ben wanted to make it easier for the masses, and he’s encouraged tens of thousands of dentists to quickly and effectively fill root canal systems.
So, I learned a lot from Giuseppe Cantatore. I was very down on this technique back in the ‘80s, as you might imagine. I was really over in the Schilder camp. But then I started traveling internationally a lot, and I saw Giuseppe’s work, his chapters with Ben Johnson. I started to see the science, the histology, and it got me thinking, “Ruddle was wrong.” There is another idea to warm gutta-percha that everybody can do, and they can do effectively. So just a couple cases. The limitations here is, you’re never going to get your plugger, you know, more than about right in here, because you start to enter the curve. And I don’t know that you can heat gutta-percha that far. That’s too far.
So, we can say one thing about this technique. It is the only warm gutta-percha technique that can deliver warm thermosoftened gutta-percha to the terminus, 100 percent of the time. How about that? Okay. Well, you can read. So, we can have wall to wall. This is going to be thermosoftened in an oven. We can move it in, wall to wall. We’re going to have cross length, because the core is gutta-percha. So this is gutta-percha. And this is a different formulation than the outer, alpha gutta-percha. Okay? You use the post space burr – post space burr to make the post space, okay? So, it’s easy to put a post in.
And right after you seat this thing, there’s plenty of research that shows we can immediately prepare the post space. When I say “immediately”, you might wait like a minute, okay? But you can immediately go ahead with the reparative, the operative procedures that follow. And we can take out the CBOs from GuttaCore, way easier than the carriers that were plastic, the polymers, and then, of course, the ones that were nightmares are pretty much off the market. That was the 88. That’s the metal file that was the carrier. That was the original idea. And then it just got better, like everything else.
So, I wanted to show a really nice case done by a friend of mine, Shawn Velez. You can see, in this case, it’s kind of everything we just talked about. Notice that he put the carrier in. And again, this would’ve been a seven-second fill. Notice that we have a system off of a system, a lateral canal off the lateral canal, if you will. And then, of course, he came in here with the post space burr to create this post space. So you can see in one shot what Shawn was able to do, to go right on to the restorative effort. And then, back to Giuseppe, who I learned so much from, Ben, Giuseppe, okay?
And I want to acknowledge Bill Henson. Bill Henson taught me a lot about this, and I want to mention Steve Niemczyk. You know, Steve Niemczyk, I was the Chair, the faculty Chair at the Scottsdale Center for Dentistry, and I chose faculty from around the country to support my efforts. Steve Niemczyk was the guy I brought onboard to teach carrier-based obturation. Steve is very, very bright. I learned a lot from him. I’ll never forget one session we had at Scottsdale Center for Dentistry, where I was supposed to talk to the graduate Chairs and the undergraduate Chairs from dental schools around the country.
And I looked out in the room. I said, “There’s Steve! I can’t give this lecture! Steve, get up here!” So, Steve came up, and I said, “Would you please just give your presentation to these Chairs, these women and men, so they can go back and introduce this to graduate students.” They did. In fact, we had probably ten Chairs from different dental schools, that particular day, after Niemczyk’s lecture, say they were going to introduce this for the students to begin using on the clinic floor. Well, Ruddle threw his pen. So, I’ll go get it. Okay. So, back to these guys that helped me learn a lot about it.
Giuseppe, when he showed me his clear section analysis and his histology, it was – it was like, look at the webbing in here. Look at this webbing between systems. Look at the cross linkages. Look at the cul-de-sacs. And then he showed gutta-percha in dentinal tubules! Okay? So I became convinced that it was a wonderful technique, and it simplified the Schilder technique. Well, what do you need? You need three things. You need a size verifier, you need the obturator itself, and then, you need an oven. And the oven, we’re always going to work with GuttaCore. We’re always going to work on the first setting, setting one. So, all GuttaCore obturation, setting one. So that’s what you need. That’s your armamentarium.
Well, you look at the last file you carry to length. And just for fun, in this instance, we’ll say that it was a WaveOne Gold. And what it was, was primary, and primary is a 25/07. So if you take a 25/07 to length, and you pull this file out, and you see that the file flutes are loaded with debris, then you can immediately begin to think, “Okay. Then, what kind of a size verifier?” Generally speaking, if you use a red instrument to length, you’ll grab the red 25. Notice its taper is 045. What am I telling you? If you’re using files that are greater or equal to six percent, so, just to say it clearly, because we’re dentists, this is math now. It gets tricky! If it’s 6, 7, 8, or 9 percent, then, when you choose the last file to length and carry it to length and can pull it out, and it’s loaded, you choose exactly the same colored carrier, 25/25, 30/30, 40/40. You get it. Okay?
The thing I’m going to throw a curve ball is, if it’s less than or equal to four percent, then you would select the size verifier that is one size smaller than the last file carried to length. So, if you took a 25 to length, a 25/04, you’re going to pick a 20/04 obturator. If you took a 40/04 to length, you’d choose a 35/04 obturator. Always one iso size smaller, if you’re in tapers of less than or equal to four percent. Okay. I got about five minutes. Whatever your working length was on the file is the working length on the size verifier. The size verifier must go to length, and it must be loose! Loose at length. You must be able to turn the file about a quarter of a degree, just a little bit back and forth, and that would demonstrate that the – there’s no mud down there. There shouldn’t be, after disinfection, please! But second check, okay.
And then, of course, if that is loose at length, it says to you, the carrier will also be able to go to length. And you can adjust the stop, just like you did, so you’re working to the same length. Now, I don’t like the handle. So we’re going to talk about in just a moment how to get rid of the handle. And I also don’t like the stop. So we’re going to talk about how to get rid of the stop. Because if you look carefully, you’ll notice there’s a metric ruler on the core itself. And you can see the first little circumferential depth gauge is at 18, 19, 20. It skips a gap, 22, 24, and you even have lines that you might’ve noticed on the handle, if you’re familiar with this technique. So you can even get 27 and 29 for those really long systems. And your working length then is proportionally long. So, that’s a little bit about that.
Are you starting to have fun? Are you starting to consider, you might be able to do this? Hey, this is probably [laughs] the fastest growing obturation technique. All those single cone people in a – swimming in a sea of cement, they’re starting to think, “Well, maybe that’s too much cement interface, especially in ovoid cross sections. Maybe I should be wall-to-wall cross length GuttaCore.” Last file to length, red. Grab the red 25, 045, and if you can go to length and turn ‘em a little bit back and forth, good to go. I’ll show this in a movie in just a moment. Okay. We won’t have a discussion about sealer today, because I’m already had it. You can use pretty much any sealer that is available and can be confirmed and validated to use with a warm gutta-percha technique.
So most sealers can. I still use this one. You might call me old fashioned, but you know, we have 60 years of research. I wanna bring your attention to this little note here. Anytime you use a zinc oxide powder with a eugenol base liquid, you get zinc eugenates, and eugenol makes gutta-percha expand about 135 percent! Paul Eleazer, okay, at Alabama, he showed us that in this classic article! So, you get expansion. You know, it’s nice to use a – you know, it’s popular. So, we want to use stuff that’s popular, right? Because we’re right in there with the group! We’re using those tricalcium silicate sealers known as BC sealers. Well, they’re very nice with their alkalinity. There’s a lot of discussion about how alkalinity promotes what? Bioactivity! While simultaneously being antimicrobial in its behavior. So you’re going to like that antibacterial feature.
But listen. Anytime you’re releasing something from a substance like cement, and you’re changing the environment, that speaks to what? A synchronization of solubility! And solubility means you’re losing material, and you’re going to open secondary leakage. And that can contribute to failure. So, we want stable, biologically inert cements. So I’ll just say that this is what I’m still using. And you know what I like about these carriers? Can you put a paper point in a canal to dry? And you’re going, “Ruddle, I’ve been doing that forever! That’s not magic!” Think how easy it is. You don’t have any obstruction up here. You have great visibility. You grasp it at the working length, right? So you know how long to go down.
Well, when we get rid of the rubber stop, and we break off the handle, if you can put a paper point in a canal, you can insert a thermosoftened carrier. And you have great vision! And you don’t have a bunch of pluggers and spreaders and cones coming out and a forest of stuff, and you can’t see through the access. So, this is a very simple, cleaned-up technique. Now, I mentioned some older people, Ben Johnson, Steve Niemczyk, Bill Henson, Giuseppe Cantatore. The modern wave of people that you might want to go to the Web and learn more from would be something like Manor Haas, okay? David Landwehr, Sergio Kuttler, these people are big proponents of CBO obturation, because it’s simple, it’s effective, and it’s fast.
Could I add one thing? It’s reproducible! So the paper point dries your canal. There’s going to be a big change in paper points. No fibers. We’re going to get a huge tamponading effect, about 400 percent more. We’ll be able to dry. And then, all of a sudden, guess what? In comes the cement. You can pick it up on your instrument. A little explorer pressure, take a bead of cement, wipe it around the internal aspects of the orifice only. That’s all you need. Just like a squeegee is used to wash windows, when a thermosoftened carrier goes in here, it’s going to squeegee that cement.
That cement is a lubricant! You have to have the cement or the carrier, with its sticky, tenacious, alpha gutta-percha, is going to grab those walls, and it's not going to want to move. So the cement is the lubricant that helps you seat the carrier in seven seconds. So, there you go. That’s all you use. You don’t use anything more. I put sealer in 1,000 different ways. I won’t even explain it. This is the one I do now. Just wipe it around the orifice. That’s enough. Well, I’ll tell you a trick. I do put sometimes a bead of it on the EndoActivator, take the EndoActivator sub orifice, and sputter coat the walls. And you’ll throw a real uniform layer, Kerr pulp canal sealer, along the length of that preparation.
Okay. You can have the carriers lined up in here. You can push down on the elevator. It’ll push that down into the heater well. So, you hang the carrier by its handle, hang it very nicely, so it’s not skewed at some angle. You want it to go right down into that well. So, push it down. Within 20 seconds -- within 20 seconds, the light will start blinking, and that means you’re ready to go. But maybe you’re drying a canal. Maybe you have two systems that merge. So, you want to block one, so that you don’t inadvertently seal both at once. You gotta seal ‘em sequentially. So, you might put a paper point in one, cut it off at the occlusal table, so it’s out of your line of sight, and then, put the other one in. And anyway, you have 90 seconds – 90 seconds, before this times out and turns off.
So, you have plenty of time, plenty of time. Grab it with your fingers, pull it off the holder, take your cotton pliers, and grab it right at the working length, just above the calibration ring that represents the vertical extent of treatment. Okay? Then what? Let’s go. Then what? That’s where we break off the handle. Now you have this clean line of sight. Now, we don’t have like a big handle up here. Then we don’t have our fingers coming around this handle, trying to grab it. So we have a lot of obstructions! So make it easy! And just grab it! And when you grab it, now you can take it right over, and I like to have you count. 1,001, 1,002, 1,003! Sergio Kuttler says, “Say, one elephant, two elephants, three” – okay. El-e-phant! 1,001! 1,002! El-e-phant! You’re going to get it! Take time to get it down!
It’s a slow, steady, smooth insertion! And that internal plugger is driving gutta-percha into all the anatomy! It’s driving sealer under enormous hydraulic pressure. And unlike the old Schilder technique, you can always, in a well-shaped canal that’s patent, you can drive filling complex, warmth complex, right to the terminus, 100 percent of the time! Only technique. If you have enough swing space, you can move these back and forth and break this right off at there. No problem. If you’re tight, and you don’t have swing space, just take a sharp spoon, pinch it against the axial wall, and it’s out. That’s good.
And then, we’re just a few cases, and we’ll be done. So, I’ve shown this case before, but the thing about it is, it’s one of the first cases I did with a carrier. So, it’s a bridge abutment. I hope you can see the furcal lesion, and we won’t describe everything. But we’ve done it before. There’s a mandibular canal. You can see very challenging curvatures. Here’s the size verifier after shaping. Notice it’s loose. It can go back and forth, there’s a little back-and-forth wiggle. Introducing sealer, just like I showed you. Now, you can grab this. I didn’t know the trick, so I used a plier, but you want to use your hand, like I showed you earlier.
Now, you can just break that right off and have better vision than I had. See, I don’t have a lot of vision, but I have swing pattern. I have swing space. So, back and forth, buccal, lingual, and out that comes. And you can see, this is GuttaCore, but it’s before they put the colorization in, to make it pink. So, it’s still GuttaCore, just an earlier iteration. So, you can see the carriers there. You can see them there. You can see them there. So, there’s our carriers. My eraser’s really nice today. And there’s the post-op. I could’ve never got -- in the Schilder technique, my pluggers at most would’ve gotten down to about right in here. But I wouldn’t have been able to go around the double curve.
So, still picking up hydraulics with that central core, it’s pushing that alpha thermosoftened gutta-percha everywhere there is vacated space. That’s the key: vacated space. And then, real quick, David Landwehr does GuttaCore. You can see his pre-op. This is about six months’ recall. But look at all the portals of exit. This is thrilling! One, two, three, and four! And you can see in this case, this is Carmen Bonilla. And look at the work she’s doing. Beautiful! Look at that loop, and then, multiple apical portals of exit! That’s a carrier. Remember, 4-canal molar, 4 times 7, 28 seconds, less than 30 seconds, if I exaggerate. In less than a minute, you’re outta there! And you’ve done wall-to-wall filling.
And a couple more. Rigoberto, this is GuttaCore. This is GuttaCore. And who can obturate thermosoftened gutta-percha around a 90-degree dogleg? Well, apparently – apparently, Rigoberto can. [laughs] And then, that’s my last case, Sergio, I want to acknowledge him. He’s done a big work, a big effort, SCMs, a lot of analysis of obturation done with carrier-based obturators, and it’s all good. And you can see – you know, look at this multiplanar curvature. But you see the lesion’s kinda like that. So you would expect the portals of exit terminate pretty much where you see lesions. So the bifidity makes total sense to you. And then getting and keeping and maintaining that a little abrupt curvature apically, beautiful stuff!
Okay. I hope I’ve got you excited to work on delivering thermosoftened materials, wall-to-wall, internally. And then, you will experience the thrill of the fill, in an economy of time. Best wishes!
SEGMENT 2: Recently Published Article -- Zoom Interview with Dr. John West
Today we are joined by Dr. John West, an endodontist from Tacoma, Washington, to talk about an article he recently wrote and was published in the September issue of Dentistry Today. So, you might remember John from a show we did last season, “The ProTaper Story”, and that he’s part of the ProTaper team, with my dad and Professor Pierre Machtou. So, welcome, John. We’re really glad to have you back!
Happy to be here. A privilege. Thank you, Ruddles.
Have you been doing well?
[laughs] Okay. Great.
Well, between extraordinary and exceptional. It just keeps going up and down, Lisa.
He’s always vacillating between good and great.
There you go!
Okay. So, your article, let’s just get to it. Your article is called “The Set-Up: Endodontic Predictability”, and I read this article, and I liked it a lot. And one of the reasons I liked it so much was because it’s very different from just the average clinical article you read. And in this article, you focus on the mental game of endodontics as being key to predictably successful endodontics. So can you tell us why you saw the need to write this article?
Excellent question, actually [laughs]. I’ve asked that myself – the question, Lisa. But if you look at the endodontic conversation in the world, whether it’s Zoom or meetings or advertisement or journals, it seems like the focus has become on, the machine is responsible for the endodontic outcome, whether it’s shaping, files, cleaning, different irrigation systems, obturation, gutta-percha, sealers, et cetera, the world right now is focused on equipment, instruments, tools. And the distinction I wanted to make, and actually, we touched on it in “The ProTaper Story”, that ProTaper was – is more than a file. But successful and predictable endodontics is more than tools.
And that’s what I wanted to focus on, is to remind ourselves that we are responsible for the endodontic fundamentals. Now, this is not a revelatory concept. It’s been around for a while. The mental state and rehearsal of a skill, the – is, for example, centuries old. “As a man thinketh in his heart, so he is.” Proverbs 23. Or “There is nothing either good or bad, but thinking makes it so.” Shakespeare, 1599. “Whether you think you can, or whether you think you can’t, you’re right.” Henry Ford. “Some men see things that are and ask why. I dream things that never were and ask why not.” George Bernard Shaw. But the best one is, “The Little Red Engine”, “I think I can, I think I can, I think I can.”
And honestly, perhaps my personal biggest discovery in life, and I’ve been able to apply this to endodontics, is to see and think differently, to use my mind to control my brain, to create the outcome that I want. And I’m going to change – I’m going to introduce a title, a subject at this Zoom meeting, and instead of endodontic predictability, I’m going to be talking – we’re going to be talking about, what does it take, to create extreme predictability? Because if we do almost nothing, nature is going to help us heal, 80 percent, 70 percent, 90 percent of the time. The difference is that little bit at the end.
And I’m challenging the viewers of this program to raise your status and me, too, raise our status quo. It’s the last bit in the Olympic champions. They basically all have the same skills, as we do, as endodontists. The difference is the thinking makes it different. And that’s what the article’s about.
I’d like to say something, Lisa. I don’t even know if you’ll remember this, because you’re so damn old, only probably exceeded by my elderly age. But many years ago, you sent me a book by a guy named Timothy Gallwey.
And he wrote a book about the “Inner Game” of tennis. And that book came, I think, in the early ‘80s, but it was written in ’74. To kind of tell how it might’ve influenced your life back in that era, because I – I listened to that tape, over and over and over, and every time he said, “tennis”, I said “endo”. Then, I gave it to my – my son-in-law next-door, Mazzi [sounds like], and he listened to it. And then, I gave it to my grandson, who has great aspirations, Noah, to be a professional tennis player. And so, they were playing that stuff at night, and affirmations and stuff. So really, maybe if we have time, Lisa’ll ask you about “The Inner Game”.
[laughs] Yeah. I think that it’s a – it’s a book on tape. Is that what it is that he sent you?
Okay. Okay. So, you know, I noticed – I wanna just jump a little bit ahead, because what you were saying, John, made me think of this. But you – you do say in your article that “Endodontic success is 100 percent minus X, where X is the clinician’s ability, knowledge, and willingness.” And I noticed that you did not say that X was also technology. So, you were saying that this is not about reliance on the machine or technology. This is coming from inside you [with emphasis], right? So, do you want to say a little bit more about that?
Sure. Well, knowledge is self-explanatory. If you’re doing endodontics, you gotta know what to do. Ability is the skill to do it. The difference is the willingness, and the willingness comes from the Old English word, here I’ve written it down. “Wyllan”, W-Y – W-Y-L-L-A-N. And if you look it up, it means to wish or desire or to want. So to me, the willingness comes down really to intention. And it’s a fine line, because some of us are at different stages of our career. We have a different mix of patients. And our willingness to take it to the next level is different for everyone. Sometimes, you have to just get the job done, the next patient’s here, you feel underpaid, you feel that dealing with that last piece of anatomy isn’t worth it.
And it has to do with a conviction to understand the biology of endodontic disease, which is the same as any disease. Nature says to us – it wasn’t our rules, it was her rules, or his rules, however you see it [laughs], is that if one has a disease, and the disease is removed, then the consequences or the sequelae of that disease also disappear. In other words, the symptoms are not persistent, within themselves. So, what the rationale of endodontics has simply said and is often ignored, is that any tooth that’s endodontically diseased, it can be successfully treated if the endodontic anatomy, the architecture is eliminated through [laughs] cleaning it, making a little preparation, and filling it up.
So, the willingness varies from person to person, and that is the – probably the essence to think about, if one is thinking about, “I wanna always reach the end of the canal, or I want solid obturations, or I want appropriate fillings.” Then, that has – then, there’s 100 billion neurons waiting to be nurtured and corralled to focus and actually get that outcome. That’s what the article is about. It’s a different article. But, you know, in a way, Lisa, Cliff, Pierre Machtou, and myself, others, this is what we’ve talked about, all along. It’s about the – not the doing as much as the being, the batter, not the bat.
Dad, I know that you have – and I – I’ve seen a lot of your cases from decades ago, before all the latest and greatest technology was available. It’s outstanding work. So, obviously, that technology wasn’t the one factor that can tip you over to greatness, you know? If you’re – you were doing that before you had the technology. So, do you wanna say anything about that?
Well, just briefly, because I want John to be our – the story is. But what I learned from John’s book that he sent me, just to come back and tie that in, there’s lots of other things. But the inner game and the outer game, the outer game is your post-op x-ray.
Did you go around the curvature? You can see that. The whole world can see. You can project it on the screen. You’re short, you’re long, you’re too skinny, the taper’s wrong. That’s the outer game. So in tennis, it’s the backhand, the forehand, the drop shot, the serve, the second serve, all that. What I loved about what he sent me, Johnny, is, the inner game is about overcoming anxiety, self-imposed limitations, lack of concentration. Some people get really close. You know, it’s like six-all [laughs]. And there’s a tie breaker.
And all of a sudden, they can lose their focus. They start thinking ahead, or they’re way ahead, and they start thinking too far ahead, because they think they’re already living in the next game. So, it’s the moment. Teaches you – the inner game, you’re in the moment.
Okay. John, can you tell us a little – I know that in your article you talk about the “think box” versus the “play box”. So, maybe just talk a little bit more about what these terms mean.
Sure. Well, in reverse, the play box is the – is the actual results, in the doing, as Cliff just mentioned. The think box is everything beforehand. It’s the set-up, mentally, for success. And the way I do it is the three-by-five card trick. So, what it is I want – for example, there was -- maybe a few months ago was in the obturations, I had discovered I was having some voids, small voids. And I don’t know where it’s written, but it must be written the first day of endodontics school, “Voids are bad.” [laughs] Aesthetically, they just look like you didn’t get the job done. How did you screw that up?
So, that’s not good for me and not good – it doesn’t make so much difference for the case. But you realize as a referral situation or – every case becomes a signature, and every signature becomes a reputation. And eventually, the reputation becomes our legacy. So, every case counts. So, I wanted to correct this void situation. And so, I wrote on a three-by-five card, “I make solid packs.” So, it’s a first-person, present-tense, “I” statement, basically, six words or less. And what it says is – it says, “I make solid packs.”
It sounds kinda corny, but I put that sign in front of every time I took an x-ray. Then I put it on the monitor. I put that, “I make solid packs”, on the steering wheel of my car. My wife says, “Oh, gee, there he goes again.” It’s right in the mirror, where I comb my hair beautifully.
I had one on the toilet [laughs]. And –
-- [laughs] you have them everywhere, where you bump into them. And before you know it –
Did you have it on your plugger? [laughs]
-- had it on my plugger. Good idea. But if you – if you read the article, it has to do with attention density, actually changing – you can change your mind. It’s that simple. But it doesn’t work out that simple, because you can change your mind about something, but it has to be repetition. The brain can be trained, 100 billion neurons, a few of those can be trained, John, for making solid packs or whatever the heck you want in your endodontic outcomes, your endodontic predictability. That’s how you make the next step is, you corral your brain into seeing it differently. May I share a simple example?
There was a staff member, couple years ago. Her name was Mary. Let’s say her name was Mary. And she messed up all the time, just couldn’t seem to impact – the intent and impact were always different. So, I looked at myself in the mirror, and I said, “Mary’s just doin’ a terrible job. I have to let her go.” And the person in the mirror said, “Well, wait a minute, John! Why don’t you try to see it differently? Why don’t you – for the next half an hour, every time you interact with Mary, you get to use two words, yes and thank you.” So, there I was. Mary and I were interacting, and I was saying “yes” and “thank you”, and I bit – literally had to take a pencil between my teeth and say, “yes” and “thank you”.
Of course, I didn’t mean them. That was early in the morning. And then, around noon, I looked in the mirror again and -- came back in the bathroom, and I looked in the mirror. And the person in the mirror said – I said to the person in the mirror, rather, “Mary is doin’ a great job today!” And the person in the mirror said, “John, as you change the way you see things, the things you see begin to change.” And that’s – that’s a cool statement, except it has to be very frequent. So, the three-by-five card trick is the way to keep telling the brain differently, and the brain will, because of its neuroplasticity, it will change.
And if you read anything about neuroscience, which fascinates me, because it’s – it’s the only way I’ve been able to grow is to intentionally put the “I” statement in front of me. And when I do that, I even did with this – this Zoom meeting. I saw myself having a great time [laughs], being joyful, and making a contribution that someone could actually hold onto and impact their endodontic predictability.
Yeah. Dad, I know that you’ve done – said some – you’ve always had this kind of thing where you – you tell us to write your goals down, post them someplace where you see it all the time, just to change your thinking, or to keep your thinking on that track. I know when I started working at the office, you said, “Every time – before you answer the phone, do a big smile, and make sure you’re smiling, when you answer the phone. Because it’s going to change everything.” Like, it’s – and look at yourself, even if you need to look at yourself in the mirror smiling, you’ve even said.
And I remember sometimes I’d been so angry, and you’re like, “Just smile.” And I’m like, “Yeah. Whatever. Not now.” And you’re like, “No! Smile. Really smile.” And as soon as you smile, you kinda laugh a little bit, and it starts to change. So, you’ve always been kind of about that, too, like really focusing on your thinking and to make positive change.
Yeah. We’ll have to do another thing with Johnny. We’re not done yet, but it would be on attitude.
I love the – Phyllis sent me something. It was like a pyramid. It was all about attitude. And to just play off of John, I mean, everybody wants to take a course, John. You’re in big demand. You got the IDEA thing up south of San Francisco, I-D-E-A, Idea, that’s the organization. He’s the endodontist. And everybody comes, they wanna get better. But what John offers is not only how to improve their skills. He’ll hold their hand, and he’ll show them pressure and tactile control. But he also works with their mind. And a lot of the growth we’ve seen in our seminars and people exiting is because they don’t see it quite the same anymore.
So, John, you do say one thing in your article that is kind of related to this changing your thinking. You – and I’m going to quote, exactly. You say, “Whenever you are stuck, for example on your way to the apex, rather than do more or less the same, ask yourself, ‘What do I need to do differently?’” So --
Lisa, so, where that begins is the visual outcome exactly what I want in the endodontic radiograph. So, I would study the radiograph and see the outcome I want. I would feel that in my gut. Yeah. And then, I would think, “You’re enough. You’re good enough. You’re more than good enough to do this.” So, I’ve got that in mind. And then, I’m sliding down the distal buccal of a maxillary molar, and 4 millimeters from the end, the 10 file begins to slow down. So the natural reaction, because of our millions of years of DNA, flight or fight, survival of the fittest, the first reaction, it’s not my fault, it’s not your fault, the first reaction is to push a little harder.
So, it doesn’t go further. So then I have to do something different. So why would a file not go further? Four reasons, four reasons. One is dentin mud. So we have dentin that’s clogged beyond the file. And two, it could be what? Collagen. And dentin mud and collagen, as Herb Schilder used to say, are the fatal flaws of endodontics. And when those – when the mud is present, the only way to slide through the mud is through three words, “restraint”, “restraint”, and what’s the third word?
[laughs] And “restraint”, again. So --
-- delicate, gentle, a little curve in the file, touch, irrigate, come back out, touch, irrigate, come back out. And you’re not three millimeters from the end. You’re actually a fraction of a millimeter, because it’s only blocked a few microns, almost. And then, suddenly, you slide to the end. Or if it’s collagen, then it acts like a trampoline, bouncing against it, bouncing against it. And the clinician says to themselves, “I’m a baad [sounding like a sheep or goat] dentist.” Well, you’re not a baad [sounding like a sheep or goat] dentist. You’re just bouncing against collagen. And that requires ProLube and viscous chelators and so forth, and again, the delicacy. So, that’s one reason I can’t go further.
The second reason is I have the curve of the file. So, I gotta do something different, so the curve of the file doesn’t mimic the curve of the canal. It’s a big curve, and I have a hook on the file, or I have a big curve on the file, and there’s a hook at the end of the root canal system. So, I have to – so, in – I have to do something different, in order to follow the canals. They are just waitinh for John. So, you make a curve on the file, try it out, no. Curve and then rotate, and another curve. So, it’s got multiple planes of curves. So, that’s a second possibility of what I could do differently. The third is, the file’s too big at the tip. So therefore, I would go to a smaller file.
And the fourth possibility is, I have restrictive dentin, holding the shaft of the file. And the only way to remove that is early coronal enlargement or envelope of motion. And Cliff and John and others have many videos and conversations about that, exactly how to do that. But those are four things you would do differently. So, that’s the key is, if we keep doing the same thing, we’re – you know, it’s best to – we wanna solve the problem early. We don’t want to solve it later, because if it were a block, back to that example, we’d have three millimeters of blocked dentin. And that’s just three times harder. So, the answer is, there – honestly, in endodontics, really there’s no problems. There’s just situations requiring smart thinking, and that’s what this article is about, being smart.
Are you sayin’ there’s different values of X?
Yes. Carry on. Say more.
Well, we started this off with success could be 100 percent minus X, and I always understood X was Ruddle. So, it’s my frailties, my insecurities, my lack of training, my mistakes I might do, lack of focus, concentration. So, we have X’s to deal with.
I think in John’s article, he talks a lot about building your own confidence, and writing these little notes that you are good enough, and you are capable, so that when you do run into a problem, you don’t just immediately have a meltdown and not be able to think clearly about how to problem solve. You just keep trying the same thing. And I think you want to try to have the mental preparation to then have the clarity of mind to be able to problem solve [laughs], when you run into problems. Is that correct?
Yeah. The seminal point – this is not visualizations or affirmations or kumbaya or hope. This has to do with intentionally changing our minds, to change our results. If I may, I’d like to read that Harvard MBA study. May I take two minutes to do that, Lisa?
Yes, go ahead.
It’s a great example of how written, planned goals affect later outcomes. And it was a 1979 Harvard study. And they asked the students, “Have you set written goals, and created a plan for their retirement?” And 84 percent of the entire class had no goals at all. 13 percent of the class had written goals, but no concrete plans. And three percent of the class had written goals and concrete plans, by whens, et cetera, like that, milestones along the way, measuring their progress. And the results were simple. One, 10 years later, the 13 percent of the class that had set written goals, but no concrete plans were making twice as much money as the 84 percent of the class that had no goals at all.
The kicker is, the 3 percent of the class that had both written goals and a plan were making ten times as much as the rest of the 97 percent of the class, underlined, combined – combined. Now, this article, “Endodontic Predictability” is not about money. But you can apply the same thing. The same concept is to have the three-by-five card trick [laughs] that I’ve been talking about. And so, let’s say – let’s just say what I want – let’s say I break files, and that worries me. So, I don’t want to break files. So, I don’t want to say, “I don’t wanna break files”, because the brain hears, “Break files.” So, what I’m going to write down is --
-- “I am safe with NiTi.” How about that? That is a different thought process, when I’m treating the patient, when I’m drilling with my rotary and reciprocation files [makes drilling noise], and what’s on my mind is, “I don’t wanna break this. This is my friend, the dentist. I’m doing treatment for my friend, the dentist. I don’t wanna break” – Oh! Oh, my God! That’s what happens to the brain.
So we have to say – tell the brain, it’s just sitting there waiting. The purpose of our brain is to keep us alive until tomorrow. It doesn’t want to do something different. It’s so content. Homeostasis is working perfectly. John wants to be safe with NiTi. I never [with emphasis] want to bust another one of those damn things! And so, I have to take a bunch of these neurons and take a cluster and change the thinking so that when I – when I’m stuck in a slide with NiTi instruments, I have this different level of knowing this confidence, and it shows up in my predictability. And what I want is, I want – I am – I am experiencing extreme predictability. You write that one down, “extreme predictability”.
I think you did – we did that -- we’ve talked about Harvard study, I think, Dad. I think you talked about it maybe in the first season. So, it’s good that – actually, thank you for reminding us about that. We’re about out of time. But I wanted to ask both of you to comment on this one thing in closing that John writes in his article, that really struck me. You say, “You might even ask yourself the ultimate critical question: would I refer myself to me, if I needed endo?” [laughs]
Do you think you would? [laughs]
It’s a great question for the audience to ponder for their selves. And you don’t have to answer to anyone this question. But would you refer yourself to yourself? You have – you need endo on a maxillary first molar. They’re really curved canals, and you can’t even see ‘em on the x-ray. And the CBCT says there’s four orifi. Indeed, there might be four canals. And the question is, are you the best – your best, not am I better than Ruddle, or anything like that? It’s am I my best? And if I am my best, is that enough to have the confidence to refer to myself?
What about you, Dad?
And if it ain’t, change your thinking.
[laughs] Do you have any closing comments, Dad?
Well, that’s a great rhetorical question. I don’t think it needs to be answered. But I think most dentists know, honestly, their skill level, their abilities, their training. So many times, you’d have a dentist who never referred to you, right, John? Never –
-- never refer, until it was his wife or him or her.
Really, and that happened.
And you know, you got the case. They’d say, “Well, you know, this one really has to work.” And of course, in my mind, I’m always thinkin’, “And the others don’t.” But [laughs] anyway, I think what John started this whole thing off with was so excellent, because we’re doing a lot of projects together, right now. And so, it makes me think a lot about what we’re doing. But we always come at it that this is the solution, you know. If we just had a little better one of these, and we – we’re old enough, after 40 plus years, almost 50 years of practice, that it isn’t always about this. This can make it more fun, it can make it easier, it can make it safer, faster, and all that stuff.
But I think I would just close by saying that I was talking to Ben Johnson yesterday, and we were talking about training and the residents in grad school. And what he said, unprovoked, on “Howard Farran Live” – he did it there as well, is he just didn’t see the love, the passion. And that’s something that is not in a book. And so, you don’t get that with this. So, a lot of the joy and the beauty of endodontics and the harmony and really get excited in life is about how we see it, how we get ready for like John said, mentally prepare to do it, prepare to win. And it’s all about – a lot about attitude.
Yeah. And [crosstalk] --
So, it gets pretty long.
-- and John --
So, for most – for most of us, we don’t need necessarily a new tool. But don’t get me wrong, I love technology and anything that is present, that’s out there or in here that’s going to make my job better, I’m engaged and enthralled. But most of us, rather than buying a tool, just need a check-up from the neck up.
So, Lisa, we should ask John, what is the three-by-five card he’ll show the audience in leaving? What would it – what would be the message? We’ll give him a minute, because he’s doing that Johnny Carson, you know, he’s thinking.
-- I imagine it’s going to be something like, “Simple is better”, “Adapt, have fun”, “Focus on what you can [crosstalk]
Well, it is – it all – it is all those.
-- [laughs] I got all those messages from your article [laughs].
Well, for me, what I’m going to write is, “I am extreme predictability.”
Extreme endodontic predictability. That’s levels I never even thought I could see, be, do, or experience, that I, like you, want to experience my best self. And the only way to do that is, it’s not over there. It’s right here. Right here. Look in the mirror.
Okay. I just want ti say thank you for joining us, and if you haven’t already checked out the article, please do. It’s in the September issue of Dentistry Today. And we’ll at least – we’ll have it in our show notes or at least a link to it. So, thank you for joining us.
Thanks, Lisa. Thank you, Cliff.
CLOSE: What Does Phyllis Think?
So, here we are again, for our popular segment, “What Phyllis Thinks”. And before the segment, my dad actually came to me and said is it all right if he doesn’t be in on this segment, because it’s about Mom. But I think that we actually want him here, because we want to see your reaction. And you guys have such a nice chemistry that we like to see how you guys relate to each other. So, if you don’t hear my dad talking a lot, be sure to just watch for his expressions.
Because he doesn’t know what I think. So, this is the only time --
[laughs] This is a surprise.
-- he finds out. Yes.
Okay. So, these questions are going to be kind of revolving around health and fitness. Okay. So, what do you think about exercise?
I think it’s absolutely crucial for good health, in general, physical health and mental health.
Okay. And what is your exercise program, now? Is it – and how has it changed since the pandemic has arrived?
Nowadays, I’m just doing walking on my own, with my Fitbit, which reminds me every hour to get my steps in. And also, my back DVD, which I’ve been doing since the early ‘80s, “Say Goodbye to Back Pain”. It was created by a doctor who also treated John Kennedy, President Kennedy, with his back issues, way back in the day. And it was originally through the YMCA, back when I did it, and saved my life. I highly recommend it. It’s a combination of meditation, stretching, and strengthening, 30 minutes. It’s great.
It seems like I remember my whole life you doing back exercises.
Like pretty routinely, like you don’t miss them.
No, it makes a huge difference, and the only time I didn’t do ‘em, I ended up in surgery. So, I stick to it.
[laughs] Okay. So you’re currently involved in a remodel, related to health and fitness. What is this project, exactly?
Well, since all the gyms closed, and we have kids – all the kids in the family, everybody’s working out these days. So, we had one extra room here in the studio that wasn’t being used for anything, and I said, “That would be a great place to have a family fitness center.” So, that is being worked on. We’ll probably be finished by the end of this month.
And what – what all is it going to have in it?
Treadmill, a reclining bicycle, a rowing machine, weights, a chin-up bar, a balance bar thing along one wall for putting the straps around, that you do your strengthening.
To do your ballet? [laughs]
To do my ballet. I think that’s it.
Lots of mirrors.
Lots of mirrors, and it’s a good-sized room. So it will be fun.
[laughs] Okay. Well, then, I plan to see – I think I’m going to see a lot of pictures of you taken in the mirror for – posted on social media, working out.
Very solid! Very solid!
Yes, we’ll do a whole show in there. [laughs]
Okay [laughs]. Are there certain foods or beverage cravings that you give into, regularly?
I love cheese in any form. That is something – dairy, I lived on a farm when I was a child. I love any dairy products. So, I have to modify it a little bit, but that’s my favorite go-to thing. It gives me energy.
I think, for me, cheese is a definite --
-- necessity as well [laughs].
Well, you guys have that French thing in common, where you both spent time in France. So, yeah. You never met a cheese you didn’t like.
You do have your cheese, yeah.
Cheese and bread, for sure. Okay. Are there any foods or beverages that you like, but for whatever reason you avoid, pretty much always?
Desserts. I only eat desserts when we travel. This year, not so much.
No travel. When we – when we’re on the road, I always order dessert with a meal, pretty much, when we go to a restaurant. But not – not home.
Sometimes first [laughs].
[laughs] Not at home.
Okay. And – okay. Do you take vitamins? And if so, what vitamins?
We both do. I have my little organizer things that I do for both of us. Vitamin D, zinc, lysine for good immune system, and vitamin C. He takes vitamin C. I can’t take it, but I have fruits every day.
Why can’t you take vitamin C?
It gives me a stomachache. And anything with vitamin C in it, instant stomachache. It’s a great diet, because then, you can’t eat --
Okay. I think I pretty much overdose on chewable vitamin C, every day [laughs].
You are definitely a student of Linus Pauling.
I love chewable vitamin C. [laughs] Okay. So, besides diet and exercise, what else do you think is important to do to be in good health?
-- I swear by my chiropractor. And I know not everybody likes a chiropractor. But especially during this whole lockdown thing, when I couldn’t work out with a trainer, I stuck with my chiropractor. For me, it was a – an essential business. And so, I go once a week and have my spine adjusted, whether or not I need it. It just keeps everything flowing right. And also, a positive attitude. That’s – those are crucial for me.
Okay. Yeah. That makes sense, too. And how do you keep your attitude really positive, in 2020? [laughs]
She lives with me! God! [laughs]
I’m fortunate. I’m pretty positive in general.
She excels in attitude. Phyllis is always, always happy, and she’s always a can-do person.
And everything’s funny for me. So that helps [laughs].
Yeah. You do sometimes laugh, and I go, “That’s not funny.” [laughs]
[laughs] Kinda like right now.
[laughs] Okay. So, here’s the last question. If someone said they were too busy to exercise or eat right, or were just leading an unhealthy life, in general, what is the first thing you would encourage them to do, to get on a better path, without being too overwhelmed?
Obviously, the first thing is to make a decision that you need to change, whatever it is. And then, I would say, very small baby steps to start out with any kind of resolution or program. Decide you want to do something, and then, take very small steps, and just start paying attention to what you are currently doing, what you’re currently eating. Just keep – kinda keep track. It’s an education. This is what I’m currently doing. I did that with my Fitbit thing. I had no idea how many steps a day. So, I just started letting it keep track, and I realized every hour it was reminding me. And I’d look, and I’d go, “Hmm, not going to make my 250 this hour!” [laughs]
And I did that the first part of the whole lockdown thing, and then, I finally got myself moving every hour, just baby steps, keeping track. And then, start from there, you know, add in more – cutting back on things, or paying attention to what you’re eating. And the other big part for me, that I’ve done my whole life, you can’t consider it an optional part of your life. It has to be necessary. It’s not something you say, “Oh, I don’t feel like doing it, today.” It really can’t be optional. It has to be something that you do. And then, be positive, again.
I guess I’ll throw out, the audience might wanna know steps. So, how many are we talking about? She’s trying to get 10,000 steps a day. 10,000.
I’m not – I’m not quite there, yet. I did one day, and my knee hurt. So [laughs] --
-- we have to build up to that. So the treadmill will come in very handy for me, once it’s in. [laughs]
Well, yeah. Right now, you’re just kind of walking around the house, right?
I think in the Zoom shoot that we saw, I think we saw Phyllis taking steps behind us, while it was happening. [laughs]
Oh, she’s notorious for breaking into the scene. [laughs]
Steps are important! [laughs]
Okay, Mom. Well, thank you for joining us and giving your – us your opinion. And that’s our show for today.
Thank you again, everybody.
See you next time on The Ruddle Show.
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The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.