A volcanic eruption best characterizes endodontic treatment in recent years. This massive, upward thrust of clinical activity can largely be attributed to general dentists and specialists who are better trained. This evolving story is dependent on...
Retreatment Fees & the FRS How to Assess the Retreatment Fee & the File Removal System
This show opens with Ruddle reflecting on some famous rivalries and why we all love a good, healthy rivalry. Next, Ruddle looks again at the business of endodontics – specifically discussing how to assess the retreatment fee. After, Ruddle stays on the retreatment topic and enlightens us on how to remove a broken instrument with the File Removal System. Stay tuned for the close of the show where we will share a video of all the creative Ruddle Show graphics made by Isaac Kershner!
Show Content & Timecodes00:08 - INTRO: Famous Rivalries 07:17 - SEGMENT 1: Business of Endodontics - Retreatment Fees 28:28 - SEGMENT 2: Broken Instrument Removal - File Removal System 52:34 - CLOSE: The Ruddle Show Graphics Select PDF content displayed below. See Ruddle's complete library of downloadable PDF content at www.endoruddle.com/pdfs See also Ruddle's complete Just-In-Time® Video Library at www.endoruddle.com/jit
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Every clinician who has performed endodontics has experienced a variety of emotions ranging from the thrill-of-the-fill to an upset like the procedural accident of breaking an instrument...
There has been massive growth in endodontic treatment in recent years. This upward surge of clinical activity can be attributable to better trained dentists and specialists alike. Necessary for this unfolding story is the general public’s growing selection for root canal treatment as an alternative to the extraction...
There has been massive growth in endodontic treatment in recent years. This increase in clinical activity can be attributable to better-trained dentists and specialists alike. Necessary for this unfolding story is the general public's growing selection for root canal treatment...
In a previous interview, Endodontic Therapy and Dr. Cliff Ruddle discuss nonsurgical retreatment and the integration of traditional and modern techniques for achieving excellence and producing predictable outcomes...
Instructions for Modifying Needles to make a File Removal System (FRS) in the event the FRS is commercially unavailable...
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Ruddle on Retreatment 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: Famous Rivalries
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you this weekend? I saw that you tweeted about the rocket launch.
Oh, yeah. That was really exciting. I always get up for these things. I remember when I was a kid, watching ‘em take off. So, anyway, yeah. Going to outer space, the Space Station, and all that stuff, it’s pretty exciting.
Yeah. Some members of our household were very excited about it.
So, today we wanted to talk a little bit about rivalries. Probably all of you can appreciate a good rivalry. And if you watch sports, you might have your favorite rivalry that you follow. In the United States, for example, we have the Lakers and the Celtics. What, the Red Sox and the Yankees, to just name a couple.
But some people would say that you and Steve Buchanan have kind of a rivalry going on for a quite a while, now. What is your – like, if we look at dentistry, what would you say your favorite rivalry in dentistry is?
Well, some of these rivalries might not be categorized as favorites [laughs]. But anyway, when I was a kid, that means I was a dentist in grad school, we used to go to national meetings. My mentor, Al Krakow, encouraged that. And the meetings would move, too. So the biggest rivalry in my day was Frank Weine, from Chicago, and Herb Schilder, from Boston. And they had a ferocious rivalry. I mean, it was actually – when you’re a kid, and it’s young in your career, I was very amused by it. It was much like a good fight, you know.
But anyway, then, as the meetings went by, and then, I graduated, and I kept going back and hearing these guys on stage, point, counterpoint. Frank’s veins in his neck would distend so badly, we thought he was going to have a heart attack! I mean, it was pretty mean spirited. The thing that I want to make in the comment is, I mentioned Mark Oliver in a previous show, and I talked to him in the context of having breakfast with him at the Raffles Hotel in Singapore.
In “The ProTaper Story”.
Yeah. And he’s an entrepreneur, but he’s a very smart guy and very – he used to be a pitcher. We called him “Lefty”. So, anyway, he was very resourceful. And when he saw two people that he admired from a distance, because he was not a dentist, he always, when he saw a big maybe hatred or something, he always wanted to solve that problem, because he also coached and managed teams. And he realized, teamwork starts with camaraderie.
So, at the end of their lives, literally, at the end of their lives, he arranged, unbeknownst to either one, Frank or Herb, he arranged a dinner. And Mark arrived first, and Herb rolled in, and they were having this very pleasant conversation. And finally, Herb said, “Why is there a third seating?” He said, “We have a mystery guest.” And the guest did show up, and it was Frank.
Oh, God! [laughs]
That was the beginning of making amends. And they became very, very good friends. And Frank died a few years later. So they died friends.
Actually, I think, didn’t Mark Oliver try to something similar, with you and Steve before? [laughs]
Yeah. You mentioned me and Steve in the rivalry. I never saw it. I think he does what he does, and I do what I do. I think that you just keep growing a pie. It’s not a fixed pie. It’s not me versus him. Steve’s very talented. We’ve had many legendary upsets. We used to practice together. So our relationship could be a curve. If you graphed it out, it could be extremely joyous and profoundly mean spirited.
But anyway, I never really got into that, but we did have rivalries. And one time, we were in the midst of a down period, and Mark was in Santa Barbara. Of course, for our viewers, Steve lives in Santa Barbara as well. So Mark called me up one day, and he said, “Hey, Cliff, come on down to the hotel.” He said, “I’m relaxing. We have a lot of work to do tomorrow, but let’s tip back some drinks, and we’ll go to the beach, and we’ll relax.” So, I run down there, because it’s great to hang out with Mark. You always feel so [laughs] empowered, when it’s done. And I knock on the hotel room, and I hear voices talking, as I’m waiting for the door to open. When the door opens, who do you think the first person I saw was?
Steve Buchanan, my coach [laughs]. He says, “I was set up.” Anyway, we had a nice talk, and that took us out of the trough. And I don’t know where Steve would categorize where we are now, but he’s a good guy, a remarkable clinician, inventor. He’s done a lot for endodontics. So, I really respect that part of it, if it is a rivalry.
Well, those are fun stories. I mean, I just quickly name off a few rivalries, and you tell us --
-- you tell our audience what side of the rivalry you’re on.
Will I get points against me, by some of the audience who may live in some of these rivalry towns?
You might get some hate mail. [laughs]
Okay. Lakers versus Celtics.
Pepsi versus Coke.
Star Wars versus Star Trek.
I’m old. Star Wars! [laughs]
[laughs] Adidas versus Nike.
I’m wearing Nike.
Global versus Zeiss.
I’m wearing Nike! [laughs]
Global versus Zeiss. Well, I’ve loved ‘em both, but I’ve been a Zeiss guy since 2000.
Muhammad Ali versus Joe Frazier.
Ali, although I love Smokin’ Joe.
Red Sox versus Yankees.
[laughs] Tiger Woods versus Phil Mickelson.
And one more, John McEnroe versus Jimmy Connors. [laughs]
Oh, that’s pretty easy. I loved ‘em both, but Jimmy is from this area. And he’s at the club where the kids hit and your kids hit, so, yeah. Jimmy Connors.
Okay. Well, that’s pretty much it for rivalries. But maybe all of you have been part of a rivalry at some point in your life. I – especially if you have a sibling. I know me and my sister were very competitive, growing up, and I think it pushed us both to be better.
It was a little bit like that!
[laughs] So, rivalries can be a good thing. They’re exciting for the people who watch the rivalries.
And then they’re good motivating – and very motivating – but motivating [laughs] for the people who are in the rivalries, to be better.
You know, I think rivalries are really awesome, if there are rivalries, because rivalries push you. They demand more from you. It makes you get outside of your comfort zone and try to play up, try to be more than maybe you are and closer to work towards all you can be. So rivalries are good.
Yeah. I definitely agree. Okay. We have a great show for you today. So, let’s get started.
SEGMENT 1: Business of Endodontics – Retreatment Fees
So today we’re going to talk a little bit more about the business of endodontics. If you’re an endodontist or a general practitioner who does root canals, maybe you are pretty confident with what you charge for a standard root canal. But maybe you’re not as confident with assessing a nonsurgical retreatment fee, because retreatments can take longer. They can pose some unique challenges, and they might require some problem solving.
So today we wanted to look at a formula that will help you to figure out in an – in a non-arbitrary way, how to assess the retreatment fee. And we talked about a version of this formula in the first season, when we talked about whether or not to – comparing getting an implant or having a root canal. So, why don’t you review for us this formula, because it kind of leads to the next formula that we’re going to talk about.
Very good. Okay. So, in Season 1, Show 7, we were looking at this formula, which I’ve been using my entire practice years. In fact, I used it in grad school. It was a way we were taught to start thinking about, “What is a fair fee?” And what we’re really talking about, what is [with emphasis] a fair fee? That could be a question. Well, I was always taught that it’s a fee that a doctor receives with pleasure and a patient pays with gratitude, somewhere in there. Now obviously, when we talk about fees, there’s different countries, there’s different regions within countries, there’s different cities within states. It’s all over the place.
So this is just an appropriate discussion for you, based on your community and what’s going on in your area, geographical region of practice. So, the root canal treatment is comprised of time, and then there’s a fee assessed for the time spent. And then, of course, you have to restore that tooth. That could require a post or a build-up. And then, the casting itself, it could be a tooth-colored restorative, or it could be all gold. And then, of course, we always would like that to equal, theoretically, the alternative. Well, what’s the alternative?
If you eliminate the tooth, let’s say, no endodontics could be considered, for whatever reason. You extract the tooth, and now, you have an empty space. So, you can – historically, we’ve put a bridge in. So we have to prepare the adjacent abutments, and then, we put a pontic in, and you all know the three-unit bridge. It could be a four-unit bridge, whatever. The other option is leave the adjacent teeth alone, because this one was extracted, and put an implant in. And then, of course, you might have to do a bone graft, to make it a good site for an implant. And then, there’s the implant itself. Then, there’s osseointegration and then, finally, there’s the restoration on the implant itself.
And so, when you start to think about these, I’ve always said, “Let’s have a balanced equation.” Okay. Let’s balance that equation, as a way to start thinking about what is actually fair for the time, energy, and effort expended. So, that’s a little bit about the first season and how we talked about that formula.
So specifically, it’s the root canal, plus the restoration, should equal the alternative.
Yeah. And maybe you’ll steer me in this, a little bit later. That would be good. That would be a good start. But basically, there’s good – there’s bad news and worse news. The bad news is, think of the time. Forget the fees right now. You can do a crown on a tooth, on one of the adjacent abutment teeth. You can prepare that tooth, you can snap an impression, you can provisionalize. Think of all that chair time. It’s quite quick that they can do this. They can cut teeth down and prepare ‘em in like 10 or 15 minutes. I mean, Omer Reed, like about 50 years ago, talked about the three-minute crown prep [laughs], okay?
So, you can begin to understand that a lot of times the doctor leaves the room, and a well-trained auxiliary can provisionalize the case. So there’s very little time expended. When you’re sitting here doing a root canal, you don’t delegate very much of that. You’re it! You’re there for the access, the negotiation, and all that stuff. So basically, you want your fees to be about equal to the alternative, but you also have to think in terms of the time you’re spending doing the treatment, then restoring the tooth properly, and all that time and fee should be somewhere around the alternative, if the doctor’s really taking care of himself and his staff and his business.
So, how does this formula change for nonsurgical retreatment?
Oh, well, this is a Ruddle thing, that I better look over here, so they can see it. [laughs]
You know, I remember going to AAE meetings when I was like less than 30 years old, and I was doing all these incredible retreatment cases. And people used to say to me, “Well, how can you do that?” I mean, how can you do that? I wasn’t more skillful than they were. I didn’t have better technology than they had. But I did have time. I made time. And what I did to have the time is, I quoted a disassembly fee. Now as you and I were preparing for this show, we talked about it. It’s not just taking a tooth apart.
You brought up some very big points. You might remove the crown, the core, a post, metal or non-metal, the four commonly placed fillers, gutta-percha, silver points, carriers and paste fillers, okay? You might remove those. But on short fills, oftentimes, they’re short for a reason. If you’re lucky, the canal is patent, apical to the level of obturation. But what frequently happens is there’s a ledge, or there might be a blocked canal, that prevents you from sliding to length. And maybe there’s a lesion on that root, so you feel compelled to get to length, so you can reclean, shape, and pack in the lesion that has the capacity to heal.
So, there’s a lot of things you mentioned. But when you encounter a perforation, that’s not disassembly. That’s repair. So, go ahead.
And we’ll get more to that in a second, about where to put the repair fee, if there is one.
So – but let’s look at more, just the disassembly. So obviously, not all disassemblies are equal, like you were just pointing out. There’s different fillers. You might go through the crown, you might remove the crown.
But I guess when you’re looking at the x-rays or the CBCT images, you might have an idea about what needs to be done and what kinda time it’s going to take. But – so, how do you figure out the disassembly fee? Is it like an hourly rate, or is it based on the complexity?
May I digress?
Go ahead [laughs].
So, you know, I don’t really climb on the AAE website. They have a discussion forum. I sometimes feel sorry for the people that are so continuously posting, because I wondered, “When did they get their training? And who delivered it?”
But there are some people – Richard Schwartz is fabulous! Looking right into the camera, Richard Schwartz is top drawer. He’s top gun. But a lot of these people – so, they – so, the discussion that everybody was into recently, this last week, was, “Gee, I scheduled this patient for two hours, and they came in, and the first ten minutes, I noted a fracture! And it was hopeless! And I ate two hours of time. Then, my second patient came in, and we were going to have a nice procedure, and, you know, I got into the treatment, and it was a fractured root, dammit!” So, anyway, this one woman is talking about, she lost four hours of time. And I’m sitting there going, “What was missing, which is always missing, usually, is a consultation.”
So, let’s start this disassembly off. It’s already had treatment. That’s strike one. Now you’re going to consider doing retreatment, nonsurgically, or maybe surgically, that’d be strike two, strike three. When you’re down to strike two and strike three, you really have to line up your ducks. You have to know what’s going on. So we look at images, multiple horizontally angulated preoperative images, three come to mind. CBCT absolutely is in this conversation. So after thoughtful analysis of the x-rays, and based on what -- your training, your experience, and the technology you have aboard, you can begin to communicate with the patient very powerfully what you see is the problem, what kind of time might be called upon to set this tooth back up.
And I made a living out of retreatment. Let me look in the camera. I – from – even up to 1990, over half of my practice was nonsurgical retreatment. From the ‘90s on, out of every ten people that came and saw me, 90 percent had already had endodontics, and a lot of times, they’d had surgery as well, sometimes, nonsurgical retreatment. And that was my pre-op. So, consultations are huge. Consultations, without – okay. I have a real problem with scheduling somebody and setting aside two, three hours of time. And don’t tell me I don’t have patients that fly in. We have patients fly in, just like you have patients that fly in, and they come from great distances.
But there’s ways to get information. And if you don’t have that information, you are feeling a big urge to start treatment. This patient’s come a long ways. The patient is feeling what? Obligated to follow your recommendation, and that – it makes for uncomfortable situations. You haven’t told them about the prognosis. They might have a medical problem that I need to call their physician, if they’re on a blood thinner, and I might have to lay a flap. I have to discuss this with the doctor, the primary physician. Also, I get to call the general dentist.
And I can oftentimes get some – like, so-and-so will say, “Blood was pouring out of a tooth”, but it’s on a little note. Well, if I call ‘em up, they’ll go, “Oh, yeah. I was drilling. I was trying to find it.” Well, now you know it's a perforation. So, the consultation gives me a chance to honestly meet the patient, build value, get into a little relationship called confidence and trust. I can follow up with a physician or general dentist. I have all the information, and I can communicate very accurately to that patient, exactly what I see needs to be done and that we can get started on the next visit.
And I try to schedule these, basically, always in one visit. And I can – I have learned over the years that I can take any tooth apart on Planet Earth, in one hour. So, whatever an hour of your time is, could be your disassembly fee. Now, Lisa brought up a good point. What if we take out something, like a post, and you realize blood’s coming out of the canal? And that would be your perforation. So, when we say “disassembly”, maybe think of it in terms of a disassembly repair fee, but that’s going to be based on the complexity of the tooth.
A central incisor is not a second molar. There’s a lot of numbers of canals, angulation of the tooth in the mouth. Is it a strategic tooth in the most funereal sense, or is it a tooth that can be parted with, and there’s options and alternatives that are more effective for the patient? So I really stress the consultation, the careful inspection of the films, and then, sitting there with the patient and building the relationship and the trust that allows me permission to go in there and maybe fail. So part of the consultation is, you have to very candidly, based on your abilities – you have to look in the mirror and be honest.
Don’t look a patient in the eye and say, “Let’s try this, and see what happens.” Let them know, very specifically, what you think the prognosis is. And sometimes, you have to say to a patient, “You know what? What if I can only get three to five years out of this? Would that make sense to you? Or would you rather entertain an option or an alternative?” And then, of course, these fees should pretty much, again, be balanced with what is the option. I mean, a lot of times, when you say, “The implant’s going to cost $1,500, bone graft $500, you’re going to get a $1,500 casting on top of all that.” And they start to hear $3,000 for a restored implant, you know what?
They might say -- you know what? My patient said, “Well, can we save the tooth? I know it’s not 100 percent.” I know, getting up and coming over to the studio today, you went through a risk. You got [laughs] in your car. Life’s full of risks.
I just had a couple questions. Would you say that it’s pretty standard that you would go through the crown, or would you remove the crown? Because I’m sure that whether or not you could reuse that crown still would probably matter to the patient, as far as cost goes. So --
Absolutely. These are all things you discuss. I didn’t go through all this. In fact, we have a marvelous series of DVDs online that you can get. But we go through this in great detail. So, just have a heads up, there’s information. But quickly said, if the crown is aesthetically pleasing, if it fits marginally, if there’s a good adaptation of the soft tissue to that margin, because they got the ferrule effect and the biological width, we normally would go right through that crown. And that would theoretically save them the cost of another crown.
But oftentimes, when there’s endodontic failure, there’s coronal leakage. So, sometimes, you have to assess for that. And if the crown doesn’t fit well – what if the crown is aesthetically pleasing but fits terrible? You have to call that to the patient’s attention, and that would be part of the left side of this formula.
Okay. Well, I – I’m hearing that when you sit down to actually start retreating the tooth, it would’ve been a good idea to already have had a consultation, maybe talk to the referring physician, so that there’s no surprises when you start, and you kind of have --
And the dentist.
-- an idea how long it’s going to take you, to even be able to assess the fee in the first place, So say besides the disassembly, maybe the problem why the tooth is failing was that it was simply a canal that was missed. So then, that’s just going to be – involve finding the canal and then cleaning and shaping it, and all that. But I’m just wondering, so, say the other canals have already been filled, and then you find the one canal that was missed. Are you going to redo all the canals, or are you just going to redo the one canal that was missed?
Wow, she’s asking tough questions, just like you used to ask, when you came to Santa Barbara and took my seminars. We used to talk about this stuff for four hours. Because – I’m going to answer your question, but what I’ve learned is, the reason nobody’s doing retreatment at a high level – I like to think we did it at a high level for 25 years – is because we talk to people. We make relationships. I share with them my concerns. It’s written in the chart. So, a missed canal, that’s how I met my third or fourth receptionist, like many, many years ago.
She came in. Endodontist number one did a second molar, cleaned, shaped, and packed. Failed. Endodontist number two went back and did it all over again, and she was in agony. She was referred to an oral surgeon for an extraction, and she was referred to me from an oral surgeon. I found out in the first 10 minutes, before I ever entered the tooth, when I was at distance, through diagnostics, we knew she had a missed canal.
So I had to say to her, “Look, you’ve had a lot of work done, and you’re in agony. I know you want to get out of pain. That’s number one. How would you feel if we just treated the obvious problem and then reevaluated?” What that means is, I’m trusting the three other canals, by the other two endodontists. I’m trusting that they’re up to Ruddle’s speed. And I’m putting my ass on the line – you know, you draw a line. Oh, geez, this -- I didn’t – I knew I’d use this. Oh, this is going to be the favorite part of the day!
He feels an urge to draw. So, we’re going to do that. [laughs]
That’s called having your ass on the line! Yeah.
So when your ass is on the line, normally, you treat everything. So if you’re going to try to help the patient financially and time wise, you have to share with them that you’re only doing the one. But if your symptoms were to persist, then I would like you to know I might have to have permission to go back in and retreat the other ones that we were thinking were okay. So that does happen, and it happens way more than you think. Now, if you’re going to have a brand-new bridge put on that tooth – see, these are all considerations. And that’s why we can spend four hours talking about it.
If you get better at communicating to patients and honestly telling them all your concerns and why you’re doing this, your assistant’s typing or writing this in the chart, you’re going to do a lot more retreatment. And you’re going to get paid to do it! And then if you do it, it’s going to save, I’m going to say thousands and tens of thousands of teeth that are otherwise moved to surgery, okay, or extracted.
Okay. So, if you had to do a repair, like repair a perforation, is this going to be included? Is the repair work or maybe the extra work to find a canal and maybe redo the other canals, is that going to be included in the disassembly fee?
Like – okay.
I liked how you – when we were brainstorming this show -- and it takes a few sessions of her and I behind the scenes, to talk about what we want to talk about and what is the most important. But I think it’s really important that you – you have a fee. That’s the concept. And I did my repairs, I did everything underneath the disassembly fee. And I charged an hour for my time. So whatever one hour of your time is worth, maybe you can’t get the post out and the broken instrument out in one hour and take out the crown, the core, the post and all that stuff. But as you do this, you get better and more efficient. You learn to observe lots of cases, and you begin to bring your experience in, and you can’t teach experience. And so, I could always do that.
Now if it’s this tooth, and it has a big silver point in it, Hell, you can rattle the silver point out sometimes in five seconds or five minutes, and the tooth’s shaped! You just have to use the EndoActivator and throw your reagent around and disinfect and pack. It might even take less time than if you were the first operator in. So, all this can be factored in. I would rather you quote this fee and then say, “Mrs. Jones, it went a lot better than I thought. In fact, we’re going to be able to save you some money!”
Oh, I – now, that’s another thing. Because I would think that --
I did that.
-- patient communication is very important, especially in the retreatment situation, because if I’m coming in to – to have nonsurgical retreatment on a tooth that’s already been – had treatment, and I’ve already paid a lot of money for a new crown and my root canal --
Oh, you’re – you’re hittin’ it on the head.
-- and now it’s failing. And so, I’m going to really want to know, like, how much more money do I have to spend, to get this right? So, I mean, I guess that it’s – and is insurance going to cover it, maybe? You know, like that’s a whole ‘nother issue.
You know, Lisa’s bringing up a problem or a challenge that we have, redoing other people’s work. People don’t come in smiling. They’re not thrilled to have another --
-- procedure on a tooth that they already, as you said, they went – they missed work, probably. So there was time out of their office or something in their private life. They already paid for this work. And sometimes, they sacrificed to pay for it, or they put it on a credit card. It might not even be paid off yet. And now, they’re back in my office. Do you think I’m their best friend? No! But my job is to make ‘em my best friend, and we need to get their attention off of what happened, because that’s what negative, and give them the steppingstones towards success.
And as soon as we can focus away from negative – it’s a choice, and focus on what’s ahead, then people start to warm up. They start to be friendly, and they – you gotta be compassionate with ‘em. And you can’t say negative things about other people, okay? So when something’s filled two millimeters short, and it’s failing apically, with a lesion, I’ll just say to the patient, “You know, I need to get all the way to the end of the canal.” And then, they’ll say, “Well, the other person didn’t get all the way to the end?” And then, you have to say – a little storytelling. “You know, back in the day when your root canal was done” – you can honestly say this.
[laughs] Back last week [laughs].
“We were actually – many people were trained [laughs] last week, to be two millimeters short.” And that worked for the vast majority of people! But in certain cases, like yours, it didn’t work, and that’s why you’re here. So we’re going to need to get all the way to the end of the root.’
Okay. Well, thank you. That’s some good information. Hopefully, this formula will help everyone to better assess the retreatment fee, so it doesn’t seem so arbitrary, and so that the patients also have an understanding of what’s happening and how the fee’s being assessed.
And as Fabio Gorni trained me to say, many, many years ago, in the early ‘90s, regarding getting to length, “Ci vediamo all’apice!”
SEGMENT 2: Broken Instrument Removal – File Removal System
Okay. Today, we’re going to revisit a very old lesson. And what we’re going to talk about today is broken instrument removal. Now I’ve talked about this several times on this show. I just did a World Congress for IFEA, okay. That was just a couple months ago. And then, there’s been some other Zoom sessions, where the audiences and the meeting organizers wanted Ruddle to talk about broken instrument removal. So here we are again. Now, before we get into this, I want to acknowledge publicly that we’ve already talked about the ultrasonic option. That is always your first line of offense, in my opinion, on retrieving broken instruments. So, let’s get started.
As you would expect, I’m going to emphasize lighting and magnification. It can come in the form of transillumination devices. It can come with magnifying glasses, and it can come with the microscope. The microscope is clearly the way you’re going to be in the game to a maximum level. And you need to have good imaging. We always talk about three, well-angulated horizontal films, and we also can enroll CBCT, to give us those three slices, so we can see things and treatment plan for no surprises.
So we’ve talked – you’ve seen these very graphics, this very graphic, before. And we talked about the importance of radicular access, because to get to my topic today, you still need to have good access, coronally, and you still need to have good radicular access. But the radicular access should be, optimally, no bigger than it would have otherwise been, if there was no [with emphasis] broken instrument. So there’s already a pretty good pathway in here, because remember, somebody was working a mechanical instrument, and it broke. So we can say, right to the head of this instrument, we have a really nice glide path, right there. So we already got that.
And then I emphasized last time, there’s three tools that I like to use. You can use lots of different ideas. I like three tools, and I like the three Gates Gliddens. You’ll notice the 4 striper. So, this is the 4, this is the 3, and this is the 2. That’s what I use for radicular access. Let’s take a look. The 4, it’s confined so that it’s no more than one head depth below the orifice in furcated teeth. I’m talking about the tough ones. The buccal roots of upper molars, the mesial systems of lower molars, thin roots, 4, one head depth below, is appropriate.
And you can see that we operate at a low rpm, and we work in a brushing motion, to take away triangles of dentin and to eliminate these and get ‘em out by a brushing motion with the 4. Then we go to the 3. The 3’s going to going to take us lower, and it can be used a head to two heads deeper than the 4, and again, it’s going to be used at slow rpms. You should be able to see these flutes turning. So when you pull the GG out, and you look at it, it’s like the blades on a plane before you get up the rpms, you start to see that prop, okay? And then, it starts to get a little bit blurry, and then, it – you don’t see it. So I want you to see the blades turning. That means you won’t have these things grab and get inadvertently sucked into the canal, where we might then inadvertently overprepare the root, maybe even have a strip perforation.
And then, we go on down to the 2. But the problem with the 2 is, these Gates Gliddens come to kind of a point. So, the idea – what lies next would be ultrasonics. So when we talk about ultrasonic instrumentation, we need to put that ultrasonic tool, the insert tip, it needs to be lateral [with emphasis] to the instrument, not on top. When you’re on top, it’s very inefficient. So we sometimes talk about modifying a GG2, and we talked about, on another show, this little staging platform. And when we have that staging platform, then we can move off the top of the instrument, get lateral to the instrument, and now, we can start in a counterclockwise motion, rotating around the head of the broken instrument.
Again, if you take your segment and divide it into thirds, I’ve always said, if I can uncover about one third of the overall depth of that broken fragment segment, then it’s Ruddle’s! And even if it lies around the curve, if I can get straight-line radicular access to its head, that’s a good thing. And really, in a perfect world, if we could just expose about two to three millimeters of the head of that instrument, you’re going to have a great chance, a wonderful opportunity, to get it out. Okay! That, we have all talked about. I’ve already introduced all the instruments that you might use. You know, these are definitely going to be too big, but this would be more like the middle one third, this would be more into the apical one third.
But if you want longer lengths, and if you want narrowing cross-sectional diameters, you have to do to titanium. So, these colored ones, up here, are titanium. Let’s get a good dot on that I! All right! And then, you can bolt these onto your handpiece. And then, we have piezoelectric energy. So, we’ve talked about this. And of course, once we have radicular access, 4, 3, 2, staging platform [makes burring noise], we can use the Stropko. The Stropko blows air out! So we have continuous vision, at all times, while we’re working. We don’t work blind. So, that’s the Stropko and a little shout-out to Johnny, Johnny Stropko!
Now let’s look at some adjunctive ideas. And of course, at a World Conference that we gave, there’s many ideas beyond just ultrasonics. But we pretty much all agree in the profession, to be redundant, we start with the ultrasonic removal option. Then, there’s been many, many other things that have been described, loops and different mechanized ideas. But a really powerful one is a really simple one, and let’s focus today on tube mechanics. I’ve written a lot about it, and many years ago. And this wasn’t the first time I wrote about it. It was just the first time it got into the Journal of Endodontics. And at one time, the Editor of the Journal of Endodontics told me it was the most downloadable article in the JOE for over about a 10-year period of time.
So a lot of people want to know how to get out broken instruments and posts. You’ll find a lot more information there. Now, we started this a long time ago. And it started with a friend of mine, Malentacca. Augusto is a Roman endodontist, and a very smart guy, and we used to do workshops in his office for one week, for Italian colleagues. And we used to make these things, okay? So, they can be made, when they’re not available. But in any event, the big tube, the black one, is going to work pretty much up in this region. It’s one millimeter. It’s not really made to go below the orifice. It’s made to grab things that stick up and extend into the pulp chamber, like a silver point, like the shaft of a Gates Glidden, okay? Like a carrier-based obturator.
So that’s where that one works. Your 8/10 can work right down to the middle one third. So with a good, appropriate shape, that’s root appropriate, you can actually get this tube, because these are outside diameters! The yellow one one is the 6/10 of a millimeter, and it's made to go really deep. It can get into the apical one third. Okay. There’s a screw wedge, a screw wedge. It has threads. These threads mate up internally with threads in the handle, and it’s a left-handed turn. It’s counterclockwise. Better write that down, counterclockwise is the threading pattern. That’s what tightens it up. So you can pick this up, and you can slide it down the tube. And then you can run this whole assembly down the canal.
But first, I want to make a comment. You’ve already used ultrasonics. You’ve already trephined. NiTi’s going to lay on the outer wall! Always wants to, always will! It’ll go to wherever there’s space. So we do a lot of our ultrasonic work on the inside wall, to save tooth structure. And that’ll make room for the beveled tip. You notice this tip is beveled at 45 degrees. So when you run this thing down a canal – let’s load this up. So, chairside, you just drop it in, no threading yet, just drop it in. Then carry this assembly over, and we’ll introduce it so it comes right down in the canal.
Now this is important. I want the long side of this bevel – I want the long side of the bevel to be on this outer wall, because what’ll happen is, that long side of that bevel will tend to scoop up the head of this broken instrument. And so, when you bring this down into the canal, long bevel to the outer wall, you might have to rock it a little bit and jiggle it and jump over the head of the broken instrument. And then, you have captured it, okay? This is strictly tube mechanics – mechanics! What most of you haven’t learned yet is to rotate [with emphasis] this tube 90 degrees, and another 90 degrees, until you have the window facing the outer wall. Let’s see that happen. Rotate it!
Now you have the file, which has shape memory. It wants to be lying to the outer wall. It’s going to tend to lie in the window. Let’s talk about this, just briefly. This is about one millimeter. This is about one millimeter. And your cut-out window is about two millimeters. You can see why exposing two to three millimeters is really important! Because if you can get over the first millimeter, then you have this little section, that’s your second millimeter. And the head of that file, you’d like to see it in here, you know, like – you like to see it up in here. And that way, when the screw wedge comes down, it can tend to push this out. It can tend to push it out.
So, let’s see the screw wedge. It's down here. And you don’t want your screw wedge to inadvertently go out the cut-out window. You want the head of the obstruction to go out the head of the window. So by rotating the tube, you’ve already encouraged that to happen. Now, the screw wedge tends to stay inside the canal. And by turning this counterclockwise, these threads line up, they grab, and you can – under a lot of pressure, with one hand – you got a mouth there, and you can start to do this. Your assistant can take your tube with pliers and just help you steady it. She can rest on the occlusal table, let her pliers come across, and just steady the tube while you’re doing that motion. Okay.
Now, turn the whole assembly counterclockwise, and that’ll tend to back the instrument up and out of the canal. So, this isn’t used every day. It’s not even used sometimes every week. But I get cases from all over the world, where somebody says, ‘I got a silver point out. I got a carrier out. I got a fragment, a segment silver point out. I got a broken instrument out.” So, people do use it, and it’s used when everything else basically fails. I want to come back and say a couple things. You can blend your deep shape and remove the staging platform and have a smooth-flowing prep that receives a gutta-percha cone easily to slide around curvature and to length. Okay!
So, I’m going to show you the first case I ever used this concept on, clinically. We didn’t have – we did not have, at that time, a file removal system. The precursor for this was called the Instrument [laughs] Removal System, the IRS. We didn’t have those! That came from this idea. So what we did, in commercial, we went out and bought spinal-tap needles. The most important ones, again, were 19, 21, and 23 gauge – gauge. That corresponded to an OD, an outside diameter, of 1 millimeter, 8/10 of a millimeter, and 6/10 of a millimeter. We took these spinal-tap needles, they were like this, and they had an insert, a plunger, if you will – a plunger. And we took these and we beveled them.
So now, it looked like this. Then, we made the cut-out window about half the distance of the diameter of the tube. And so I made my own, chairside. It’s not hard to do. Literally, I can bevel this microtube, spinal-tap needle. I can make the cut-out window, chairside, in about one minute. But a lot of people said, “Oh, it’s hard! I didn’t want to have to go get the spinal-tap needles from medicine! And now, I have to use a medical – over here in the dental world!” Well, so, we made one. But sometimes, because of manufacturing issues, and it doesn’t sell a lot, some big companies, like the current one that sells it, Dentsply Sirona, they go, “It’s a small product. Lots of fees for regulatory. So, you know, it’s really a loss leader, Cliff.”
So I just want you to know, you can make your own. Okay? So, you can also – if you make your bevel, and there’s your cut-out window, you can also say, “You know what? I don’t want it beveled so much. I want it beveled less.” You can say, “I want it 90-degree beveled.” That – these are tricks that modify the bevel to help you. In any event, here it is, coming out. You can see, right in here’s the cut-out window. This is just mechanics. In the old days, we used to run a K file through the top, okay? A K file, though, has taper. So sometimes, as you went to reach deep through the tube, you would begin to bind proximally, coronally, before you could get the instrument deep enough to engage the broken segment.
So, that’s why we made a parallel insert tube, so the parallel plunger can go through this tube. A K file has taper. And as you have taper, you might exceed the lumen diameter and render the file non-useful. And the thing that’s fun about this stuff is, when you get out an encumbrance, like a broken instrument, a silver point, or a sectional silver point, or a carrier that’s been manipulated and broken deep, you can get a lot of stuff out of roots, if you just have a few ideas. You gotta start thinking! These aren’t necessarily surgery cases. These are like $50 a tube, okay? And an insert wedge, so the whole assembly’s about 50 bucks! If you have to schedule ‘em for surgery, that’s probably 1,500 U.S. dollars, or it’s an extraction, and then, an implant or a bridge. So, it can save a lot of pressure and tension and money, for your patients.
All right. So, a nice pack, we pick up some portals of exit, three POEs. That’s the fun of endodontics. And I want to now mention this, tube and glue. I just talked about tube mechanics, and now I want to talk about tube and glue. Listen, I talked about tube and glue in the ‘80s, the ‘90s, and the first decade of the 21st century. I’ve been talkin’ about it a long time. I’m going to bring you something that very few people know anything about. I’ve presented this only three times or four times in the world, ever. Maybe I think we wrote a paper about it. But other than that, quiet.
So, I see with great exuberance on the discussion forum – I hate to keep pickin’ on AAE. But they talk about stuff we did 25 and 30 years ago! It’s not even appropriate! And they’re thumping their chest; they’re having problems. Let’s look at something that really works! So you have a broken instrument, and I’m just going to demonstrate this on an extracted tooth, so it’s abundantly clear. You can see that one is screwed in, then busted off, broken, and it’s well beyond the foramen. So it’s binding probably pretty tight, right in this zone. We can say that with a lot of confidence.
There’s the microscope view at high magnification, and you can see we’ve exposed, through Gates Gliddens, radicular access, 4, 3 2. We’ve exposed and made the access. We’ve exposed and trephined, with ultrasonic instruments. And it’s driven by Pease electric at probably just one or two. Use low power, only come up in power if you’re not accomplishing the clinical task, if you’re not cutting well. But don’t start off at some arbitrary power. You’re going to break a lot of stuff. Okay. Well, we have a clean-up to do on the board. So, I’ve talked about this a long time ago. And before you put it in a textbook, you’ve written articles a decade before that.
So I don’t want to date myself, but I’ve already given you these dimensions. I’ve already told you that this is pretty much like 23, again, 21, and again, 19 gauge. So if you’re going to go get something, you just get the gauge of the tube. You want less than one millimeter for wall thickness! And make that 0.1, because you want a thin tube, because there’s not a lot of stress on these tubes, pulling out an instrument. It’s mainly a tensile stress, a little bit of torsional, a little bit of torsional, as you unwind it. But wall thickness has to be thin. Otherwise, you defeat the purpose.
Dentsply Sirona makes the SmartLite Pro. The SmartLite Pro is a well-accepted instrument that’s used internationally, all over the world, very popular. But this is what I want to bring your attention to, the Smart Dentin Replacement material. This is loved internationally, for restorative dentistry, because you can put in more material at once. You don’t have to layer it so much. It polymerizes beautifully with light, with the light source. So that’s the material; that’s the light source. So how do we get glue in here? Well, let’s take a further look. Why don’t we take a tube and demonstrate radiographically that we could actually place the tube over the obstruction, at least about two to three millimeters of the exposed instrument.
If you can demonstrate – and I don’t know if you can see this, but if you look really carefully, you can see, there’s a little segment of that file, not even up to the window, but it’s up inside the tube. Remember, I said you could cut the bevel off, if it gave you a little more apical reach. All right. Now that you’ve demonstrated you can do it, you can now put glue in it. So don’t put glue in the tube, until you know you can do it. So we put – we mix this up, and we easily syringe it right into the cut-out window and the tube. And now, go ahead and take it on up. Jump over it. How do you get light up there?
You’re probably wondering, ‘How do you get light up there?” So, I had Phyllis go to Radio Shack, and for like less than ten bucks, you can get wands that are anywhere from 2/10 to like 6, 8, 9/10. You can get what you want. You can easily slide a 4/10 wand through 0.6-millimeter OD tube, outside diameter, and you can put that all the way up. And we’re going to use that now to help transmit light. You can see, here’s our wand. So here’s the fiberoptic wands. We’re going to put this wand – we did, right down through the tube, right here, right down the tube. So it comes against your material that is yet unpolymerized. There’s our first cycle. So you’re going to do three, 30-second cycles – three, 30-second cycles.
The light’s coming through the wand. It absolutely makes this rock hard. And this is the message. Compared to cyanoacrylate, Krazy Glue, and most of the things that you’re using out there, core paste, it had 70 percent more pull-out. That’s Michael Wefelmeier! That was the JOE article that I showed you, right here. He gets the credit. He did it on the bench, and he did it with big tubes and vises, and none of it would transmit to the clinic, except the idea. So I’ve perfected it to work below the orifice in real teeth on patients of record. So, there you are. Everything’s out.
And notice this again. Everybody says they were having trouble with this, or this doesn’t hold, or that glue doesn’t work. We tried cyanoacrylate. That was the ‘80s. Then, we tried other things, and core paste, and we kept going through the materials as they got better and better, technologically. And then, finally, this article, some years ago, made me think, maybe that SDR – that’s Smart Dentin Replacement – maybe that’s the prescription. And it turns out, in the literature, with good research, they were showing massive, bigger numbers. Okay. And the last slide, here’s a carrier. A lot of cases get referred in that are failing.
We talked about the retreatment disassembly fee. It -- might want to pay attention to that. That was part of this show. But in any event, you can come in and use solvents and get some of your gutta-percha out of here with solvents. And now, you have the core exposed. Sometimes you can reach down. Sometimes you can use a Hedstrom. I get it. There’s lots of ideas. But certainly, don’t forget about the file removal system. And here it is. You can grab a lot of these things. In another show, I’ll show you how we got this one out. It was in the apical third, because I broke off the top. But there’s the whole segment, right there. You can see how it’s captured in the cut-out window with the screw wedge. So, isn’t that neat!
So, I’ll leave you with the old message, retreatment – retreatment, you [with emphasis] can do it! So go out, have fun, and start takin’ stuff out of the teeth, and live to play another day!
CLOSE: The Ruddle Show Graphics
So, that’s our show for today. We’re going to leave you with some eye candy. We’re going to show you a video montage of all of The Ruddle Show graphics, or a lot of them.
You’ve probably seen on our show that we have these really cool graphics behind us. We think they’re neat. And they’re all created by Isaac, who is your grandson, my son. And – do you want to add anything?
I think they’re super cool. They’re nice segues between topics, and you go, Isaac! Lots of talent, and thanks for those assists that you did on the colors and the scheming. Quite an effort.
Okay. So, enjoy the little video, 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.
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To be determined - Check back soon!