Tough Questions & SINE Tips Who Pays for Treatment if it Fails and Access Refinement
This first episode of Season 4 (and 2021) opens with Ruddle reflecting on some New Year’s goals and resolutions. Next, Ruddle debuts a new segment, “Tough Questions,” starting with the difficult question, “Who pays for treatment if it fails?” After, Ruddle showcases how the SINE ultrasonic tips can be used to refine an access. Stay tuned for another Ruddle Flashback in the close of the show, this time flashing back to when Ruddle decided to dispose of the Christmas tree by burning it in the fireplace!
Show Content & Timecodes00:08 - INTRO: New Year’s Goals/Resolutions 08:00 - SEGMENT 1: Tough Questions – Who Pays for Treatment if it Fails? 28:26 - SEGMENT 2: SINE Ultrasonic Instruments 51:44 - CLOSE: Ruddle Flashback – Christmas Tree in the Fireplace
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This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: New Year’s Goals/Resolutions
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. You look very sharp today.
Well, over the holidays, I got some help.
[laughs] Okay. Well, since this is our first episode of Season 4, and also of 2021, we thought it might be a good idea to start with maybe talking about some New Year’s resolutions or goals that we’ve made. And for most people, probably the goal is to get in better shape. But what about you? Did you have any resolutions that you’ve made?
Yeah. I made three. I want to improve on my mental and physical conditioning. There are all ways to do that, you know? One’s obvious, the physical part, and we’ll talk about that more later. I always want to improve what I’m doing. So this year, I really want us to improve over our last year of the season, because you’re always giving me really helpful little hints, and so is Lori [laughs] and Isaac, and Phyllis. So, I want to bring them better news, more timely news, and more on-time news.
And then finally, our show’s really geared to helping others. So, I really want to help others, especially in this COVID time, where we’ve gone through so much last year, and it doesn’t seem to be easing in the early parts of this year. So, I like to help others.
Okay. Well, regarding the physical part of your goal, we do have the new gym that Mom made in the --
-- back room of the studio. So, I --
I’m going to go work out. Excuse me.
-- [laughs] on an upcoming show, we’ll have some lifestyle footage to show, just for fun, you using the equipment and maybe the grandkids, too. So, that’ll be exciting. I guess for me, 2020 was a challenging year for me, and – as it was probably for a lot of people. And it forced me to adapt and change my lifestyle a lot and is – what I noticed, is a lot of the changes that I made that seemed difficult at first, actually really suit me. And I ended up feeling that my life is more efficient now and going more smoothly. I changed the way that I shop for the house. I have saved a lot of money from not going out, and --
-- ended up paying my debt down a lot. And I now work from home a lot, with Zoom. So, the Zoom knowledge is good to have. So --
So, it sounds like you took the breakdown and turned it into a breakthrough.
-- right. And going forward, I want to keep, actually, a lot of those little changes I made and maybe even look for new ways that I can make these small, little tweaks to my life, to make it better.
Awesome. Yeah. I think it’s really important in life, when we – sometimes things that are really negative, we can dwell on what’s negative, but it seems like you’ve taken that negative spirit that permeated the whole earth, and you have found ways to find success.
Just little, small changes.
I think you have something you want to say about making small changes. [laughs]
Oh, yeah! All of you out there have made your New Year’s resolutions, I’m sure. So, what I’d like to say to you, is little things make an enormous difference. And – well, I guess I should talk about Pat Riley. He’s a famous professional, executive in the National Basketball Association. He’s a former coach, as you know, because we watched a lot of games together, while you were growing up. And he had some really big success, four-time World Championships, three with the Lakers, one with the Miami Heat. And then, he went on – and I should mention he was a player, and he got a ring with the Lakers when he was a player.
So, he’s an executive, a player, and a former coach, and he’s written several books. The one I like the most, probably, is The Winner Within. God made us great. Everybody has a big dose of greatness inside, and you – Pat Riley will help you discover that greatness. But he also wrote a book, The Disease of Me. And when you have dental offices, and you have teams, that’s an appropriate book, because you have players, and you have disease of arrogance and stuff. He talks about how to make that all work.
But what I want to tell you, in closing, the ’87-’88 Lakers, they won back-to-back World Championships. So, his concern was, at the end of the ’86 season – ’86-’87 season, he said, how do you take these guys, they make – they’re multi-millionaires. They’re known all over the world. They’re in the papers every day. How do you motivate them and inspire them to go out and work even harder, because now you have a target on your back? When you win, everybody wants to play you. And even if they lose horribly in the final season standings, if they’ve knocked off the Lakers, their season was made.
So he said he decided to announce publicly first – remember how we’ve talked about going public? It’s more powerful. He went public and said, “We’re gonna win, I guarantee it, next year.” And Magic Johnson put him in a headlock and said, “Oh, my goodness, we just won. I mean, let us relax a little bit and enjoy this!” And Riley wanted to plant, right at that moment, in their head, “We gotta start mentally preparing.” Remember, mental conditioning? “We gotta mentally prepare for next year.” So, what he did, when the players all came in, the final 12, for that ’87-’88 season, he sat down with every player, with another coach, and they asked the player, could they get better by one percent in five categories? Like, for example, points, rebounds, assists, steals, diving for loose balls, could they get better by one percent in any five categories they chose?
So, they chose the categories. Now, to make this work, he had all the metrics and the matrices from the last year. So he knew how many points they scored, their rebounds, the minutes played. All that stuff, he knew. So he asked them to get better by one percent. Each player did get better by one percent, and there are 12 players. So, 5 times 12 is 60 percent, and they got 60 percent better. He said some of the players got better by 45, 50 percent, by just being aware of something and working it into the team concept. And they repeated. So, my comment to all of us out there that made the goals that Lisa encouraged us to make, about whatever it is, remember, little, tiny things make an enormous difference.
Yeah. And it’s – what I’m also hearing is, “Be very specific.” Like, in five – don’t just say, “I want to get in better shape.” Maybe look at, “I want to – I’m now walking a mile in 18 minutes. I want to do it in 17 minutes”, basically. So, be very specific --
-- with your goals, and you’ll probably find a little more success [laughs].
So, I’m gonna have you guys turn that into, like, “Be a better diagnostician by one percent.” How about you cut better access cavities by one percent? How about you can negotiate canals, and you get better by one percent? And the shaping gets better! The disinfection gets better! The obturation gets better! The restorative that protects the rest of the seal gets better! And did you realize, in the end of this year, when we talk to them next year, they’re gonna be a lot better in their endodontics!
Very nice. Yes. And it’s exciting. Okay. New year ahead, and you can just make it the best that you want it to be. All right. So, let’s get started on our show.
SEGMENT 1: Tough Questions – Who Pays for Treatment if it Fails?
Okay. So, today we’re debuting a new segment called “Tough Questions”. And in this segment, we’re going to explore a tough question that maybe at first glance doesn’t really seem to have a clear-cut answer. And our hope is that after our discussion, you, our audience, will maybe have a better idea where you stand on the issue. So, the first question for this episode is, who pays for treatment if it fails? Now, there’s obviously some issues to consider, but I think we’re going to start with, when did treatment take place?
Very good. I’d like to open my part of this segment by saying if you would’ve listened to what your mother told you and taught you when you were growing up, we wouldn’t have this segment today.
But it’s a segment that’s often kind of taboo, and nobody likes to talk about it. I did notice on the AAE form, in the last week, there was a long [with emphasis] thing about, do I give the money back? Who pays for what? And I’m going, “My gosh, this is common sense. But anyway, to your point, time. So, I think it’s obvious to the audience that if you did a root canal – I’ll just make it up. Psychodrama, role playing, if you did it like 20 or 25 years ago, and it comes back, and for whatever reason it failed, probably the patient won’t even remember when it was done. They might not even know they had a root canal done.
But to move on quickly, long-term failures are pretty forgivable. Patients are pretty understanding, if you were to have a failure, long-term. I will just say as an aside, when you have a long-term failure, it’s probably not that your endodontics suddenly failed. It’s probably coronal leakage. The problem that you’re really asking me is – we could talk about mid-range failures, and what’s mid-range? I mean, what is success? And is it 20 years, 40 years, 50 years? I have a lot of 20, 30, and 40-year recalls.
So, when you start to define these terms, it’s hard. But you could have a long-term failure, let’s just say over 10. You could have more of a mid-term failure, 5 to 10. And then, there’s short-term failure, and I’m gonna just say less than two years. So probably the biggest thing we want to talk about today is, what happens when it was done relatively recently, maybe a heavily restored tooth, a bridge – new bridge, and now, the whole thing breaks down, and what do we do? So, time is important. So you might – if you – there’s an old adage, “If you must speak, ask a question.”
So, you might ask the patient, assuming you didn’t do it, “Do you recall when this was treated? And about how long ago would you say you had this thing in your mouth?” And then you can start to understand, if they say, “Well, it was done six months ago”, there’s a whole different thing coming out of my mouth than if they say, “Well, it was done about five years ago.”
Well, I guess it’s interesting that you define short-term as less than two years, because when we initially started discussions about this segment, I kinda thought in my mind that short-term was maybe like three to six months, maybe two years, I – would actually be long-term. I guess it depends on if the patient knows the life expectancy of a root canal, like – I mean, if a root canal can last 30 to 40 years, then I guess two years would be considered short-term. So, that kind of brings us to the next issue to consider, when determining who would pay for treatment if it fails, is what was initially communicated to the patient? And I guess this brings us now to the patient-doctor communication.
This is the most important thing that Lisa asked me – Lisette --
-- for the new year. You know, communication is everything, and I’ve been known around the world as I had fabulous recordkeeping, and I didn’t do any of it myself. I mean, in the first ten years, I did it all. But after a while, the assistants were trained, and when Ruddle was talking with the patient, and we had this back-and-forth, they’re over there writing. Now – later, they were typing. It’s all entered digitally. But the point is, everything that was more or less said, those highlights were captured and recorded.
So, if you say to somebody, to play off of Lisette, “Everything looks good here. I can -- think it’ll take maybe a visit. From my experience, I think it’s – we’re gonna have a good long-term prognosis. And you’ll get the tooth restored, and you should keep this tooth for years of your life.” Hold that thought. They come back now in three months or six months or two years, and there’s a fistulous tract, or there’s swelling, or there’s breakdown radiographically. That’s something you better be thinking about, that you told them you thought it was gonna have a good long-term result.
So, you can tell them before treatment, okay? Communicate as well as you can. During treatment, you can communicate things that might be concerning you, and especially if it’s two-visits, and on the last visit, which is – could be the first or the second or the third visit. Whenever the last visit occurs, you could say, “What I’ve discovered during treatment”, and you could be altering things as they became aware to you. So, communication is everything.
If you see things, you have to talk about it. If – I would say, just for simplicity, break it into – if it’s initial treatment, are the roots really long? Are the roots really curved or recurved? Are the canals mineralized and shut down? That would be that category. If you were looking at a case to treat, and you’re communicating with the patient, and you saw it was already treated, now you have a whole field of non-surgical retreatment. So, what’s in there? A post? Is there a perf, broken instrument, block, ledges? Okay. All of that, and then, we’ll just go to surgeries. Was it a tooth that was already surgerized?
So that’s almost like strike one is doin’ the root canal, better work. Doesn’t work, you do non-surgical retreatment. That doesn’t work, and now you’re doing surgery. So, I see a surgical failure, I’m thinking we’re about out of bullets. So how you communicate is based on what you see, what was previously said, and how long ago it might’ve been.
And probably it’s a good idea to actually document what was said, so it doesn’t come back around to, “Well, I told you this.” “Well, no, you didn’t.” You know, like you – you probably should write it down. And I know a lot of offices use informed consent forms. And I guess those include what?
Well, every time we see a patient, we should be able to -- based on our training, our experience, and our technology, we should be able to look a patient in the eye – because a lot of patients will say, “Well, what do you think?” Or “Is this is gonna be a good, long-term result? Because my neighbor just had a root canal, and they broke the tooth, and they lost it.” So, you should be able to communicate the prognosis. You should be, obviously, able to present to them alternatives to treatment. So if we’re not gonna do the root canal, because maybe you think you can get five years, but they go, “That’s a lot of time and money for five years. I’ll just look forward right now. I might want the implant today, or the new, restored bridge.”
So, you need to really talk to them a little bit about not only the alternatives, but what those prognoses might be, because maybe there’s some situations with an implant where they have to have a bone graft and blah, blah, blah. So, I’m not an expert in all those things, but I bring up the big categories, and I’ll – I’ve learned, a long time ago, if more than one person’s responsible for a miscalculation, no one’s at fault. So you bring in the oral surgeon, you bring in the restorative dentist, you grab the periodontist, and you have groupthink. And all of a sudden, the best treatment form emerges, and it’s usually in the patient’s – it should always be in the patient’s best interest.
But then, you give them options. So, what’s the prognosis? What’s the alternatives? What’s the alternatives’ prognoses? And is there anything else they should be thinking about? All that needs to be talked about. And I talk about that with every patient, and it goes in the chart.
Yeah. I think it’s a good idea to, even if you have an informed consent form in your office, to – I mean, I know I’ve been to the dentist, and I just sign it. I don’t read through it. So, it’s probably a good idea to actually discuss with the patient the alternatives, the risks and benefits, and give a prognosis but maybe not too optimistic, overly optimistic, maybe just realistic.
You know, we said this together in other shows. But a lot of times, when I saw a patient – just making this up, I would just say to them, “You know, this looks like it’s gonna have an excellent result. I don’t see any reason why you shouldn’t get years out of it.” That’s about all you have to say. But if I see a big curve at the end of the root that goes for a ways, I’m gonna tell them the truth. And the truth is, “I’ve done many of these. I’ve been successful. We have technology that can really be flexible and navigate, negotiate these curves. But you know what? Sometimes our instruments can break. There’s a lot of stress on a file going around a big curve, and then, for more millimeters.”
So, you tell them those things, not to create fear, but to just – like if you were having a friend over to your house, wouldn’t you want to just tell them the realistic expectations? Treatment plan for no surprises. So, we don’t make a big deal and get them discouraged, like when you operate next to the mental foramen, you don’t say “You’re gonna drool for the rest of your life. Your lip’s gonna hang precariously low. But you’re gonna like that, because you got your tooth in your mouth.” No, you’re going to tell them everything that you think.
“And we have a mental foramen. We have a big nerve bundle here. But you know what? We’ve operated in this area. We have a microscope. I normally don’t see my patients have any problem at all. Are you having concerns about this?” If you must speak, ask a question, because the question gives the patient, who’s apprehensive sometimes, a chance to respond and ask a question that they’re really concerned about, that you might’ve missed.
Okay. So, I’m hearing that communication is really key, and probably a lot of problems could be avoided if there was really good communication to start. And I know that seems really simple, but a lot of people aren’t very good communicators. And by the way, there’s a New Year’s resolution for somebody who wants to claim it [laughs]. Better communication. But let’s move on now.
I guess we can look at, now, another factor to consider would be why the tooth failed.
Okay. So, as Phyllis, your mom, said to me, before I came on the set, she said, “Well, every situation’s different. How are you guys gonna talk about it?” So, you can begin to see, was it in the bucket that says initial treatment? Was it in the bucket where it’s already been treated? Was it in the bucket that had surgical treatment, that’s now failing? Why did it fail? Well, there’s intrinsic and extrinsic factors. And the intrinsic factors are out of our control. It’s what the patient brings in that’s attached to their mandible or their maxilla.
So, there can be internal resorptions. There can be external resorptions. There can be fracture concerns. There can be length, curvature, and diameter issues. There can be previous treatment concerns, gutta-percha, silver points, carriers and paste fillers, blocks, ledges, transportations, posts, non-metallic posts, metal posts. There’s a lot to think about. So, it depends on what is the failure? What about a missed canal? That’s one of the most common of all failures, is a missed canal. So, if it’s a case that has been treated, and it’s in my office, it’s easy to talk about it.
But a lot of times, for the general dentist, it’s a patient that you treated, and you have to look at that case honestly and say, “I wonder if there’s a loose end?” That would be an extrinsic factor. That’s Cliff! Cliff might’ve made the mistake. So, be humble, and be kind. And why don’t you treat your patients just like you’d want to be treated? So, if you missed a canal, you might say, “You know, several years ago, I didn’t have a microscope. I wasn’t even using 2.5 loupes. So, you didn’t even have to have a microscope. I now use a headlamp. I now have transillumination devices.”
So, it’s fine to say to a patient, “You know, I’m a little better than I used to be, thanks to technology, and I have more experience. I think I missed a canal. I think we can go right through your casting, find that orifice, and treat it. How do you feel about that?” And then, we’re gonna get into the money thing, aren’t we?
Well, I guess there’s also the issue is – if you did a root canal, but it was never restored. If the patient never restored it, then it wouldn’t necessarily be the clinician’s fault who did the root canal, right?
That would be an extrinsic factor, because we must get our patients back to the restorative dentist, if you’re a specialist. We must get those teeth protected from occlusal loads and protected from caries, recurrent K. So, yeah. I mean, sometimes stuff happens in life. I’ve said this before on the set. I’ll say it very quickly. We’re in a mobile society. So, you see a patient that’s in your office as a new patient, and you find out through a little conversation, they just moved from the East Coast. Well, by the time the guy got his family settled into a house, the kids got into school, the wife got the job, and now he’s getting squared away, he realized, “Oh, I never had the root canal tooth treated on the East Coast restored.”
And so, he comes in to see me, and the cavitor, the provisional’s broken, and the thing’s leaking. And so, what do you do? And maybe you start to take out a little gutta-percha [sniffs multiple times], you smell putrescence, and it stinks. So, there’s things coming that I won’t get off on. I just had a brilliant thought about how we’re gonna be able to detect when we have to take the gutta-percha out and how much gutta-percha, and how deep did the leakage go. We’re gonna be able to discover that shortly. But you’re right. It depends on, was it really something that I have to look myself in the eye and say, “Cliff, you made a mistake. It’s – the problem’s here. I can do better, or I can’t.”
Or you gotta look at it, is it the patient’s – I wouldn’t say fault. I don’t like to make people wrong, but they didn’t get it restored, they were chewing on ice. People chew on ice. They break teeth. People hit bones. They hit old maids in popcorn. So, there’s things that are out of our control.
Okay. So when we’re trying to determine who should pay for treatment if it fails, just to summarize, I am – I’m seeing that we should look at when treatment took place, what was initially communicated to the patient --
-- regarding prognosis, and then, why the tooth failed.
Third factor, mm-hmm.
So, maybe if you consider those issues, you might have your answer right there, of who should pay. But say – let’s talk a little bit about taking on a challenging case in the first place. Like, say you’re – I mean, I guess it depends on your experience and the technology you have?
You know, I can’t give any hard and fast rules, but people need to look in the mirror and be honest with themselves. “Do I have the knowledge? Do I have the training? Do I have the experience? Do I have technology?” That’s four things. You know what you have and where you live. You could’ve got a new microscope yesterday and say, “I got a microscope!” Well, maybe you don’t have any experience with the microscope. So, it’s gonna be very awkward for you. So, I’ll have to tell you sometime about my initial introduction to the microscope [laughs] and how awkward it really was in the ‘80s.
Anyway, those are the factors, training, experience, knowledge, and technology. And at some point, it’s okay to refer. I mean, say to patients, if you’re a general dentist, “You know, this might be a little bit more complicated, and I think you’d get better service just by seeing somebody we work with all the time. It’s where I send all my patients, when I don’t want to do it.”
Well, that kinda brings me to the next thought, then. I guess – okay. So, say you start treatment, and you’re going for about, oh, a while, I don’t know, an hour, maybe. And then, all of a sudden, you break an instrument, and you’re all – you think, “I’m in way over my head now. I need to refer the patient.” But then, now, the referral is going to have to remove the broken instrument, and who pays then?
Yeah. Or repair the perf, as you’re chasing --
-- so, there’s all these things you can hear, that we’re thinking about. That’s why this could be – there’s actually courses I’ve gone to where this has been a week-long course, and different speakers, for 5 days, spoke about what we’re talking about in about 20 minutes. So, this is not an end-all – and we might even have to come back and revisit this. You know, do the right thing. I mean, I see dentists refer patients to me across the years, and they bill the patient for 200 bucks, and they perforated the tooth. Or to your point, they broke the instrument, but they billed them for $200, because they accessed the tooth, they had chair time expenditures, they had staff to pay, they had insurance.
Oh, my God! They make up all these stories. Write the check! No, you didn’t write the check. They – don’t bill them, okay? Just say, “Look, it didn’t work out. You’re gonna incur costs somewhere else. I’ve done the best I can. But now I’m gonna get you to somebody who maybe can save your tooth. And let’s not worry about the money here. You’re gonna be spending it over there.” Because sometimes we fight over 100, 200, or 500 bucks. Now think about what I’m gonna say. So we really get into a fight with the patient. ‘Well’, you say, ‘I’m not gonna refund the money!’ And you’re going, “Yeah. But I just got charged $1,000 for a root canal over there, and I got your fee and that fee!”
We fight for that $500, as an example. They go home and tell four people in the workplace. They rant and rave to their family about it. They tell the general dentist you are the most blah, blah, blah that they could ever – the bad will is massive! If you would’ve just written the check, they would’ve been thrilled. It’s behind you. It’s in the rearview mirror. And now, you move forward, serving patients, and then address your deficiencies. We can all have a problem, okay? Everybody can have an [laughs] iatrogenic problem. But really, the best thing to do, a lot of times, is just say, “You know, there’s no charge.”
Okay. So say you do get into a dispute, and it doesn’t seem that it can be resolved. I guess a lot of dental societies have peer-review committees that can step in and help solve the problem as well?
Yeah. When I came to Santa Barbara, back in the ‘70s, I thought a good way to meet dentists would – and I was asked, I didn’t raise my hand, but I was asked, would I be on the Santa Barbara Ventura County Dental Society’s Peer Review Board. And most dental societies have peer review. It’s a committee of specialists and general dentists that meet, and they do many things, but one thing they do is, they look at patient complaints. And so, a lot of times, rather than getting attorneys involved, you – if a patient’s upset, they can be offered the opportunity to go before peer review. And they get a chance to present their case, and of course, the records are all there, what was said, not said, what’s missing, what’s there.
And the – and what I noticed, it was really a good outlet. It kept attorneys out of it, it reduced cost and blood pressure, and the peer review committee often did take the side of the patient. And the most common reason for taking the side of the patient was failure to communicate. The patients didn’t know, or the instrument that was broken in the tooth, they weren’t told, or the perforation -- they were told they were looking for canals, but they couldn’t find the one they were looking for, but they didn’t disclose, that I perfed, looking for a canal. Like the endodontist that was searching for your MB2 on your maxillary molar, never told you.
[laughs] No. No. Okay. So, we’ll – that’s all. I think that that’s a lot of useful information, and I think it will be helpful to a lot of our viewers. So, thank you.
Yeah. I want to say just one last thing. This is a very big field. It’s multifaceted. I gave seminars in Santa Barbara for decades. This came up frequently. You can spend hours on this. And the thing is, it’s every situation, to Phyllis’ point, is unique and different and needs to have good common sense. And to close it out, for me, I’ll give you one of Schilder’s favorite quotes. Dr. Herb Schilder, Professor Schilder, said, “Make yourself the patient, and you’ll have the answer.”
SEGMENT 2: SINE Ultrasonic Instruments
Today’s lesson in endodontics is on access refinement. And we’re gonna show several little tips and tricks that will help you find those elusive orifices. That’s what ultrasonics is a hero for, in the non-surgical arena. So, let’s take a look how we might use double-diamond composite-coated tips with different shapes and configurations, to find those elusive orifi. Of course, anytime you’re working in endodontics, we’re working in very small spaces, so vision is very important. And of course, vision is comprised of magnification plus lighting. So, that would be a microscope for Ruddle.
But many of you are using your loupes very successfully. You’re using transillumination devices. That’s all good. But I like the idea that when you combine microscopes with ultrasonics, I coined a word many years ago, micro sonic techniques. So, we’ll talk about a lot of micro sonic techniques or micro instrumentation. That means doing little jobs very precisely with the right tool, at the right time. So, if we were talking about accessing any tooth on Planet Earth, I think you’re looking at the tools that could come into play for almost anything you can imagine.
You have your bur block, and you can see that there’s different burs in here. You have a couple round bur diamonds, round bur diamonds, the two and the four. And that’s for getting through tooth-colored restoratives. You have a little bur in here that you’re going to see in play in just a moment. That’s the trans metal bur, and that’s going to get us through non-precious metals and precious metals and through castings of all kinds. So, it reduces a lot of the chatter and vibration, very efficient bur. But you notice the length of the burs definitely gets bigger as we go to the number two and four round bur, surgical-length carbide round burs. Those burs are longer, so they kick the heavier handpiece further away from the occlusal table of the tooth, and you have preferable lines of sight.
So, you can pretty much always watch the bur work. I like to say on stage, to make you laugh a little bit, “Even when I perforate!” Ruddle watches himself perforate a tooth. It’s a great pleasure for me. All right. And then, I’ll skip the Endo-Z bur. It’s used very popularly in dental schools, because young students like to put the bur right on the pulpal floor, so it’s safe ended. But it cuts only laterally. The one that is the hero, that you’re gonna see pretty much all day long in the clinical ops, is the surgical-length diamond. And when we invented that bur, many years ago, it was the only bur at that time in the world that had 13 millimeters of cutting grip. That means it could cut the entire length of the axial wall, pulpal floor, occlusal table, in one pass.
And finally, what might look like a Gates Glidden to some of you, is actually an X-Gates. It’s a different geometry, a little longer, sleeker profile, but it’s an orifice opener. So, that’s pretty much how we get into teeth. But then, how do you find these hidden canals, these aberrant canals, these calcified, more mineralized canals? Well, that’s what we’re gonna talk about. And of course, don’t forget your Stropko. It’s been talked about in previous seasons, but I’ll come back in a little bit more. You can take any triplex syringe on the market. You can quick connect, take out the connect that comes with the tip, that comes with the actual device, and put the Stropko in, quick connect in, inserts, has luer lock threads internally.
So, you can take different cannulas from industry and screw them in, and they’ll lock. So, when you press down, in this case, on the air, you won’t drive this thing off like a bullet, and it goes across the operatory. You could have a serious injury. So, that’s the safety feature, and the Stropko is the hero of instruments. If you look at the SINE tips – you know, I named them SINE because in the day, I was a physics major, and I took a lot of math. And we talked about SINE Soyo waves going through light, material, water, air, okay? SINE Soyo wave. It also stood for my grandkids, Sophia, Isaac, Noah, and Eva! And then, there was the fifth one! So, I have to call it the SINE L tips, for Luca! We don’t want to forget Luca.
Anyway, just for fun, it’s actually to do with the sine wave. Different tips, pointed. This is a 35-file radius at the tip, a number 2 and 4 round bur ball. Then, we have a football, and that would be a number 2 GG, and we have a 4 – number 4, GG, and that means 7/10 and 1.1 millimeters. So, these different configurations give you a lot of possibilities in different kinds of teeth with their anatomical presentations. Then you have the handpiece. These thread on. There’s a little wrench to cinch them down. And you’ll deliver in ultrasonics somewhere around 35- to 40,000 cycles per second, CPS, and we also say hertz, okay?
So now you have everything you need, to get into a tooth. Now you gotta have the skill. Here’s the generator. This is a Saddle AC generator, probably the best piezo electric box in the world. It’s private labeled for Dentsply Sirona. We had a few more things we wanted them to build into this box, so it would – okay -- so it would be tuned perfectly for the SINE ultrasonic tips and the ProUltra tips, from Dentsply Sirona. They need to be tuned with the box, so they don’t prematurely break. So, not just every tip goes on every generator in the world. You think like that, and they can work like that, but you’ll have a lot more breakages. When you break a $90 ultrasonic tip, you’re not a happy person.
Try to work pretty much always at one and two, for what we’re talking about. In fact, I have, even after all these years, I have the assistant start at zero, and we like to come up to the proper power level that will do two things. We want to be efficient. Okay? We want to be efficient, time, and we want to be safe. So you come up on the power, where you can work efficiently, with an economy of time. If you start getting up in here arbitrarily, or where you knock a post out of a tooth, you’re gonna break tips right and left. So, a little comment about starting at a zero power. And then, if you do a close-up of these SINE tips, you can see that there’s a nice coating.
When I invented these tips, they were the first – well, we did the first coatings in the world, like 10 years before these, 15 years before these. But anyway, we did the first contra angle tips, the first coated tips in the world, and now, everybody does that, contra angle. Everybody does coated tips. Everybody copies everybody. But one thing about this that is not like the other look-alikes, the other me-too products, is the company, Micro Innovations, they did a coating on these tips that’s proprietary. It has patents. And you can see that – here’s the competitors’, okay? So, here’s the competitor’s.
The competitors have very few tips per – if you’re comparing the same real estate, 450. At 100 microns, you can see in this bottom, if you do a computer count, there’s 140 diamonds per unit area, as compared to 50, for the competitor’s, like a buck tip. Okay? So, almost three times as many diamonds, what’s this mean? They’re going to cut very efficiently. They’re going to cut very quickly. That’s good. And you don’t have to put a lot of pressure on them. Just paint. Think of laying the bristles of the paint brush in the paint and painting the canvas! That’s ultrasonics, painting the canvas!
Okay. So, we’ll go forward, and we’ll look at what we’re gonna do. So, the task at hand is to access a root canal system. Many of you think I’m gonna access a tooth, I’m gonna access a canal, I’m gonna access something very simple and straightforward. Change the words. How you speak is how it is. How you communicate is the world you create around you! Say “systems”! I’m listening! I don’t hear you! But if you say, ‘I’m accessing a system’, you’ll have a different concept and access. Well, complete access, okay? So, we used to argue about this, even two years ago. In a previous segment in Show 1, about 30 shows ago, we talked about the Ninja access, really small, you know, we’re gonna be conservative! We’re gonna save precious tooth structure!
Yeah. That’s important. It’s also important to do a good job endodontically! Or how good is it to save tooth structure and lose the tooth, because you missed the canal. All right. So then, we’ve talked about orifice directed. So, there was the Ninja access. Then, we had the orifice-directed access. But how about this? How about this? Even the people that purported those were valuable ideas and concepts, they’ve shifted back! The pendulum’s already, in two years, has shifted back! And they’re saying, “You know, probably just get the roofs off these pulp chambers, eliminate them. Probably the entire roof, don’t even leave cornices or lips of dentin.”
And the next thing I want to talk about is – that concept is deroof. The second concept is triangles of dentin. These triangles of dentin are exactly what kicks the hand file off axis. So if you had a handle up here, you see your handle off axis, you want the handle to come over here and be on axis, so you can go right into the canals. When you are – you’re telling me, “Oh, but my files are heat treated. They’re so flexible, not only the tip, Cliff, they’re really flexible up here!” Great. So, I’m gonna make a point that I almost never make, and I’m gonna make it like a sledgehammer.
All my enemies that don’t like these kinds of accesses, they harp and harp on precious, precious peri-cervical dentin! We don’t need the precious. Peri-cervical dentin is their message. And they want to really protect that! So, they’re saying, “Come in! Leave the triangle!” I want you to notice where the canals are, anatomically. This isn’t a Cliff thing. Look at thousands and thousands of histological sections, and what you’re going to notice is, these canals, because of the entry angle into the pulp chamber, they’re always closer to the furcal side concavity. Canals are not centered in the mesial distal dimensions of the root. They’re not.
So, if you just drop a file in here and start cutting, this is gonna be just like dropping a rock in a pond of water. The first file, the second file, but the preparations are going to drift towards furcal danger. I want you to brush out, away from furcal danger, and end up with preparations that are more centered in the mesial distal dimensions. This is a huge concept! If you lock onto this, you’ll save a lot of vertical fractures over the years ahead. And this is a new year, so wouldn’t it be good to not have so many fractures this year? I don’t really see it, but I hear that there’s a – an avalanche! There’s a tsunami of fractures out there!
Well a lot of them, we do, right? Because we don’t know our ideas and our concepts. Well, let’s get this tooth isolated and get to work. And isn’t it nice to throw a rubber dam on that. I said in the previous show, I use two clamps. I won’t review that, but here’s a 26. And then if you look right down to this accessed tooth, that’s the completed access. This group of authors basically said the size of the access compared to Ninja access and more – they called it “traditional access”. I call it complete access. They said that there was no statistical difference! The – in fracture resistant teeth, the most important indicator was, had the tooth already had an MO, an MO restoration? Had it had a DO restoration ? Maybe it’d even had an MOD. But the size of your access cavity is really not a big deal.
So, make your access big enough to be successful and small enough to respect remaining residual dentin. All right. What do you see here? You see a little shelf. You see a lip, a tongue. This is dentin! Okay? So, that’s what’s throwing those file handles off access in your mechanically driven files. And if we look at our preop film, you can see right here exactly what we’re talking about, the triangle of dentin. Little triangle back there. So, you can see, when you cut your opening into this tooth, and you eliminate the pulp chamber, you’re going to be looking right down on that lip of dentin. Does that kind of remind you of this split screen idea? We just talked about it.
That triangle is looking down occlusally from a different perspective. That’s what you see. This is where micro instrumentation is really good, because that handpiece has a big head. It’s hard to visually see around it. When you use ultrasonics – I didn’t mention this earlier, but you have an unfettered line of sight! You can visually look right down and watch your tip move and work. It’s a thing of beauty. So, let’s cut into this tooth. I got in here right now a – I think it’s a trans-metal bur, and I talked about this. I already started roughening it. Just rough your access opening and make it about 80 percent of what it’ll ultimately expand and become.
Now you can switch to surgical length round burs, because that gets your handpiece a long ways away from the occlusal table. So now I can watch that bur, and it’s just a sweeping, mesial, distal, buccal, lingual, taking away a few microns at a time. And all of a sudden, boom, you think you’re in, and you probe a little bit more, and you realize it’s not giving. The probe’s not falling in. So you come back and do a little more brushing, and you’re starting to expose the tip of the proverbial iceberg that took down the Titanic! All right? So, you have to use surgical length diamonds. See how the headpiece is out of my way? Learn to move the patient’s head a little bit and orientate it so you do have those lines of sight.
But when you get down like that, then you can go to sound and ultrasonics, and you can blow these big stones out. And they’re pretty thick, sometimes, occlusal gingivally. And now, we can reach for the P5 handpiece, and we can begin doing a little bit of work between the MB and the ML. Now, running burs in here is – the smallest tip – ultrasonic instruments are about 10 times smaller than the smallest round bur. So talk about minimally invasive ideas, here you’re using the appropriate instrument to save tooth structure. And in between the MB and the ML, there’s oftentimes – there can be a mid-mesial, and that mid-mesial needs to be prepared smaller than its counterparts, because we have a furcal side concavity.
So if you come back and just look at concepts, if you did a cross section through the root, you can see the mid-mesial is always smaller at every cross section than its MB, ML counterparts. Because why? There’s a big furcation concavity! All right? So, we gotta shape always away from furcal danger. We need to intentionally move these canals, and that’s why we use micro instrumentation and access refinement tips, so we can get those triangles of dentin out, eliminated. Whoa! This was a tough one! This is a block of dentin, but not really. My training as a kid in the ‘70s [laughs] was, “You’re obligated to make an occlusal access. Don’t assume, ‘Oh, the radiograph says it’s a block of dentin.’”
I know. Some of you are goinh, “Excuse me. Excuse me. Got my hand up. Can’t you see it, Cliff?” Yeah. Yeah. Yeah. You got a CBCT, don’t you! Okay. Good. But only about five percent or less of all North American dentists have a CBCT. So, I’m not teaching for you CBCT’ers! I’m teaching for the masses that do everyday endodontics. And incidentally, if you do CBCT, you’re going to want to know all about micro instrumentation, aren’t you? So, when you look at this, you might say to me, “Well, Ruddle, you know, maybe, maybe I see something. Maybe [with emphasis] a little hint. Oh [with emphasis], there might be a little dark area, maybe.” But those are guesses, kind of.
So, I gave a lecture earlier -- if you’re watching the shows, want to get you to tell your friends about the shows, because we’re helping a lot of people, based on feedback. But we talked earlier about what? We talked about taking three well-angulated films. We’ve talked about that. We’ve talked about the 14 ideas to find previously treated and missed or previously missed, aberrant, and calcified canals. So, one of the ideas was, take the casting off. If you take the casting off, you have better orientation. So, we took the casting off. Now that the casting’s off, you’re closer to the pulpal floor. You can see the circumferential margins of the natural tooth. You’d have better orientation.
You can take a perio probe and go around that tooth and sound, so you can stay inside those walls. And I’ve already tunneled down. Now what should we do? How about some ultrasonics? Boy, I wish I had my sound up! Anyway, beautiful sound, taking these stones out, just brushing. Sweep that number two or four ball, mesial to distal, watch that stones chip, disintegrate, and jettison out. Now, right over the orifice, a little bit of refinement on the elliptical shape, long orifice, buccal to lingual, stretched like a flag flying in the breeze, and getting – oh, another stone! And that takes us right to the recall.
So on the recall, you went into a tooth that seemingly was quite difficult, but with a little bit of ideas, get the crown off, make the tooth shorter, get better orientation, good magnification and lighting, micro instrumentation techniques, stopping and taking a working film to see where you are, and then finally, you can get the bifidity. Even these calcified canals, jeez, they have the lateral anatomy just like everything else. So, the thrill of the fill’s still present. I’ve shown this case before, but let’s come back to it. You can’t see much. The restorative covers the pulp chamber. You see that there’s a lesion.
And the lesions always have proximity to the maxillary sinus. And I said earlier that 20 percent of all sinusitis is endogenic in origin. You’ll have to go back and watch that show. So, here we go with the casting off for better orientation. I am just checking out the MB. I’m looking at its orientation. I’m gonna have to pre-enlarge that, get that restrictive dentin out of there, move that canal away from furcal danger. That’s what you’re gonna see right here. You’ve already opened it up. We’ve moved that canal away from the furcal concavity. Now I’ve taken a number two ball – look at the Stropko, ch, ch, ch, ch, ch. As I’m sanding, I’m generating dust, dentinal dust. The Stropko, ch, ch, blows it out, so I have continuous vision. So, the assistant’s holding the high-speed. She’s holding the Stropko, ch, ch, ch, and the dust is goin’ up the hose. It’s a thing of beauty.
Ruddle has continuous vision. Now I’m starting the file in a very restrictive canal. As soon as I’ve made a little space, I can go to a Gates Glidden 1, 0.5 millimeter, at its height of contour, and I can move my handpiece in our orbital arc, and I can flare that orifice. And listen! Anybody says, “I could do that one!” Well, if you could do what I just did, you could do more cases, starting this year. Here’s where we are. Most of you are probing like crazy in that little groove! Oh, punch! Punch! Punch! Pretty soon, you go, “Uh, rule it out! There’s no MB2.” This is the lip of dentin! The orifice is back here, as you can see!
So, by sanding this away, using a tapered length diamond and truing up the axial wall, now we have systems that are observable, they’re identifiable, and they’re treatable. Isn’t that good? It’s a good night when you drive home that day. So, put the casting back on, provisionally. You can see they got an MB1. It’s bifid. You can see the MB2, separate portal of exit, DB, palatal, regular kinds of stuff, nothing too dramatic. And we’ll look at the last case. Okay. This case is not hard because it’s mineralized. It’s not so hard because it’s overly long or maybe even overly curved. It’s like, look at how this porcelain’s built up on the contact point.
So, it’s kind of like, do you start here? Do you start here? Well anyway, here’s what I did. You can see that Ruddle’s goin’ in kinda like this, and then, there’s an adjustment internally. And ultrasonics really helped me, after I got through the metal, and I got the diamond and got my hole roughly roughed in. But then I found ultrasonics, and then I had all the fun of treating a good job on an anterior abutment of a little bridge, and that’s endodontics. And all of you have that potential to do this, if you have a little bit of training, if you have some technology, and you have the desire.
So, in closing, we just looked at these tips. You can go to our website and download these for free, and I’ll show you the back of the same card. Because today, I took you through, I think, one, two, three, four, five. We got to about right here. But the things we didn’t talk about is cleaning the pulp chamber post-treatment. We didn’t talk about eliminating carriers, smoothing and finishing restoratives, overhangs and stuff. We didn’t talk about getting to caries interproximally, in tough-to-reach places. We didn’t talk about disassembling restorative segments in the retreatment and disassembly game. And nor did we talk about how to repair root defects in a surgical flap-up.
All of that will be talked about in the segments ahead. Thank you very much, and may you have good success in this new year, making a great access!
CLOSE: Ruddle Flashback – Christmas Tree in the Fireplace
So, it’s time for another Ruddle flashback. And since the holidays just passed, what story could be more relevant than the time you decided to dispose of the Christmas tree in the fireplace? So, I think our viewers would love to hear this harrowing tale. Do you mind telling it?
Well, this is supposed to be a spontaneous deal. I never thought I’d be asked a question from the ‘70s.
Okay. So, you were pretty little, and it was the mid-‘70s, roughly. And Christmas – it was Christmas Eve, and usually we kept the tree up a little bit longer.
And I don’t know why, but we decided to take the tree down at the end of the celebration. And I thought -- because it was a cold winter night in Santa Barbara, we had a little fire going, you know, a little bit like this.
And I thought, “Well, I’ll just stick it in the fireplace.” The only disclaimer I’ll make, in fairness to me [laughs], not to be defensive here --
-- but our fireplace at our house is massively bigger than that. So, when you hear I was gonna --
-- when I was gonna put a Christmas tree into the fireplace, it might seem stupid to you. But I did. And it was a thing of beauty for about 30 seconds. And then, I remember the roar was incredible, and the fire was expanding relentlessly. And then it started leaving the hearth box. It started licking its way up on the vertical part of the stone. And long story short, the tree in the house – the tree did burn down. The house was saved. But we did have a stone that I measured this morning. It’s 6 inches thick, and it’s 10 feet wide. It cracked that stone, and I had to pay to have that redone, so Phyllis would forgive me.
Now, in your defense, you did cut it into a couple sections [laughs], correct?
I absolutely did. Thank you [laughs].
So, you didn’t just stick the whole thing in, all at once. But I do remember watching that happen, thinking, “Is that okay? Is that okay, that the flames are coming out of the fireplace?” [laughs]
She went into counseling after that.
But it does remind me a little bit of our “Tough Questions” segment, because in that segment, we encourage the – our viewers to – before starting a challenging case, to ask themselves, are they qualified?
So, did you feel you were qualified? Would you do this again, to do what you did?
Well, if the Christmas tree was a preoperative film, I was exuberant with energy and felt for sure I could take it on! And as it turned out, I almost burned the house down [laughs].
Yeah. I don’t remember Mom’s reaction. I just remember it being kind of scary and exciting, at the same time [laughs].
Yeah. I think the moral of the story is: always refer your Christmas tree disposal to those who dispose of them.
Exactly. Good advice. All right. Well, that’s our show for the day. See you next time on The Ruddle Show.
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Articles & Preferred Access
Writing Projects & Ruddle's Start-to-Finish Access
Patient Protocol & Post Removal
CBCT & The Post Removal System
Avoiding Burnout & Ledge Management
Giving New Life to Your Practice & Managing Ledges
Special Guest Presentation featuring Dr. Gary Glassman
Laser Disinfection & Obturation
The Lightwalker vs. EdgePRO Lasers and Q&A
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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.