Over the last three decades, there has been a gradual increase in the use of CBCT in Endodontics (Setzer et al. 2017) with a continuing rise in the number of clinical studies demonstrating the benefit of CBCT on diagnosis, treatment planning, decision-making and reducing practitioner stress levels...
CBCT & Incorporating New Technology Zoom with Prof. Shanon Patel and Q&A
This show opens with Ruddle & Lisette addressing the Producer critiques they have received and how they are always trying to improve. Next, Ruddle welcomes a special guest via Zoom, Prof. Shanon Patel from London, to talk about CBCT. After, Ruddle does a Q&A centered around incorporating new technologies into your practice. Stay tuned for some more philosophical wisdom in the close of the show, this time focusing on the wise words of sports coaches.
Show Content & Timecodes00:09 - INTRO: Producer Critiques 06:57 - SEGMENT 1: Zoom with Professor Shanon Patel 35:21 - SEGMENT 2: Q&A – Incorporating New Technology 45:25 - CLOSE: Philosophical Wisdom – Sports Coaches
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INTRO: Producer Critiques
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. How are you doing on this very rare rainy day we’re having today?
I’m enjoying the rain. It’s quite a process just getting here and staying dry.
It doesn’t rain that often here. So, anyway, we’re in the fourth season of The Ruddle Show, and we’ve completed over 30 shows. And I have to say I think we’re getting a little bit better because, of course, we’ve had a lot of practice, but there are still some things that we need to work on according to our very tough producer who I will call Lori because that’s her name. Anyway, we thought it’d be fun to tell you like what she wants us to work on, what our issues are. So, let’s do that. What are you – what has she told you to work on?
Well as you know, well she wants us to hit the camera when we go 3-2-1 like come with some energy, like bring it, and look like we’re alive and we’re happy.
Yeah, just before we started, she said, “Look alive!”
And the audience doesn’t know, but we have multiple cameras out in front of us, and so another critique is we need to be looking at the right camera, because it’s easy for me to jerk my head like I’m doing now, and it just drives them crazy in posts, so yeah, be animated, be happy, show energy, and look at the right camera.
Yeah, I think –
I have a comment, though. One thing that’s a little harder for us, everybody out there will relate to this, because everybody gets in conversations and in groups they talk to people. When you have 500 people in front of you, you are energized as a speaker, and you can play off the crowd, and the crowd will be excited. In Germany it’s like [knocking on desk]. The first time I heard that, I didn’t know what the Hell it meant, but then I was told it’s very respectful, they loved it. So, you get clapping, you get feedback, and it really gives you juice, it gives you energy. And so, when you and I look out there there’s nobody there and we kind of have to pretend to get that energy because we’ve got to simulate a real-life situation.
Yeah, you almost have to exaggerate it. Like when I watch other people on talk shows, I notice that they’re just very energetic and almost like exaggerated, I guess to get you excited. I mean I know for me I need to also work on the camera thing. Like I have a camera here and a camera here, and I tend to look in-between the two cameras to cover both my options.
Yeah, good coverage.
I also I guess overuse the word “interesting” because I think a lot of things are interesting, so I’m trying to find other words to use besides interesting.
And over here I’m known for like showing up on the day of the shoot and, of course, you know, well first before I tell my story, tell them what we do getting to a Wednesday shoot day.
Well, it’s actually quite a process that I think the rule is that you’re not supposed to come on the day of the shoot with some major changes.
Yeah, that’s what I was trying to say. Well, you know, maybe I read a journal, or I saw a video and I’m used to speaking and I’m used to being spontaneous, so you might have a lecture, let’s just say it’s framed in a certain way, but you’re adding pieces like furniture to the room, so you can always change things. But I am spontaneous, and a lot of times on stage instead of talking about what I thought I was, I just go over here, but when I bring that here, it doesn’t work.
Yeah, depending on how big the change is it has caused some upset, and I, like you, respond to that because you always say, “What? Can’t everyone be creative?” Like somehow that being resistant to last minute changes says that’s a lack of creativity. But –
Well, there’s another thing we’ve been critiqued on. You like to talk about living in a climate that has four seasons. In Santa Barbara we do have one season, and Lisette calls it “allergy season.” So, if you’ve had your COVID test which I haven’t, but I have Lisette pack, you know, pretty much like three, four inches of cotton up both nostrils, then they spray that with some kind of a polymer and no dripping allowed and no sniffing.
Yeah. And also, I don’t know if you guys are aware of this, but we don’t use any teleprompters or anything, and I mean I have in my mind what I want to say, but sometimes if it doesn’t go like how I envision it, then I just tend to freeze and so I’ve been told to try not to just freeze, like try to sort of go with it and like be conversational. Because like if you’re having a conversation and you forget what you’re going to say, you don’t just freeze, like with your eyes wide open. But so, I’m working on that, too.
Well, I guess always room for improvement. I’m a little humbled. You said we did 30 shows, but you also gave me a book about two years ago that I’ve talked about on the show, Outliers by Gladwell, and we have to do apparently 10,000 shows before we become masters.
Before we are proficient, yeah.
So, I hope with some of our background and our experience and our content and some of the knowledge we’ve been able to gather over the years that maybe we can do it in a little shorter period of time.
Yeah, so thank all of you, thanks to all of you for continuing to watch us, even though we might sometimes seem like we’re struggling. But trying to, you know, bring you the best show we can every week. So –
I have one last challenge. Tens of thousands of people have watched this show, and we’re really, really proud of that, and we appreciate enormously your feedback. And in fact, we’re open for suggestions. We’re not giving anything so far like a curriculum, Lesson 1, 2, 3, 4. We have more of a variety show, so we’ll be covering a lot of topics from non-surgical retreatment, many, many things to talk about, surgical treatment, and of course, the rationale and the clean and the shape and the pack, and then all the other stuff, technology, so we’ll be doing that. But we do appreciate your suggestions.
Yes, we do. And we have a great show for you today, so let’s get going.
SEGMENT 1: Zoom with Professor Shanon Patel
So, today we are joined by a special guest endodontist, Professor Shanon Patel, who I s an internationally known authority on CBCT, as well as the first endodontist in the U.K. to routinely use CBCT for the management of endodontic problems. Professor Patel lives in London, practices there, and also teaches future endodontists at King’s College. He has published countless papers in scientific peer reviewed journals, authored textbook chapters and lectured all over the world. So, we are very honored to have you on our show today to talk about CBCT and your research. Welcome, Dr. Patel.
Thank you very much, Lisette. And thank you very much, Cliff, for inviting me to talk on this channel of yours. I’m very excited.
You know, Shanon, it didn’t escape me that you come from a very historical and renowned place, the history of it all. And it started with Jack Rowe back in the day. He was a famous professor that did a lot of important work there, and then I met Dr. Thomas Pitt Ford, and he was really a nice guy, very smart, and did a lot of things to forward the university’s reputation internationally. And now I guess you have Mannocci right? Mannocci?
That’s right. So, yeah, as you know, Tom Pitt Ford was the – one of the big godfathers of European Endo, worked with a lot of North American endodontists, including Torabinejad and supervised Torabinejad’s PhD. And then he passed the baby over to Professor Mannocci, Francesco Mannocci, who’s growing the department, and it’s – I think it’s the biggest endo unit in Europe, maybe one of the biggest in the world. We have about 27 or 18 post-graduates in the three different years.
We’ve got six PhD and post-docs, and we have about 25 specialist endodontists teaching on the endo post-graduate program. So, it's a pretty unique, novel place, and the beauty of having such a big unit is we can publish a lot of research, a lot of good research. We have microbiology labs, we’ve got dental material labs. We’ve got one of the biggest maxillofacial radiology units in Europe. So, it’s a great place to work with nice colleagues and to do some really high level, high impact clinical research.
You know, many years ago I had the opportunity – he invited Phyllis and me to come and spend a day at the hospital, and I remember the tower, and I’d never been to a dental school like this, and we kept going and going. And anyway, our assignment was to sit in front of the residents, and they were told to do retreatment scenarios, and so they broke instruments, they had posts placed, they perforated roots, they blocked canals. And so, all day I sat there with a microscope disassembling teeth. And then I had a very delightful dinner with Thomas, and I cherish that memory.
Yeah, he’s a great guy, and you know, he was very fore-thinking. He’d always gets the most current, the most advanced endodontist to come in and talk to his post-graduates. And he had, you know, that much respect that people would obviously accept his invitation, so that’s great that he invited you.
Okay, Professor Patel. So, I just briefly introduced you, and we’re going to talk about CBCT momentarily. But first, what else do you want our viewers to know about you? Can you tell us a little bit about yourself and your training, maybe give us a glimpse what a typical work week might look like for you?
Yeah. So, I worked – well I qualified in 1995 from Guy’s Hospital. Then did a couple years in practice and some working in hospitals doing oral and maxillofacial surgery. Then I went to the Eastman’s to do a three-year endo post-graduate program. And then I went into practice four days a week and found it enjoyable. But then luckily, I met Professor Pitford at a meeting, I think it was in Munich, and he asked me to come and teach the post-graduates, so from 2003 onwards I’ve taught the post-graduates.
And I was just supervising students, and he’d always try and get me to do some research, and I’d be like, “No, no, no, I don’t do research”. I was quite traumatized by my experience of research at Eastman and I was like, “No, no, no.” I was literally like, you know, when you get these patients who don’t want to sit in the dental chair due to a sort of traumatic incident when they were younger, I was a bit like that with research.
And then I carried on supervising the post-gradates, and then my turn with CBCT came along in I think ’06 and the practice – Andrew Dawood, who is a great implant dentist at practice. He bought a scanner, and he was using it for his implant work. And he said, “Shanon, why don’t you start using this?” And I was like, “No, no, no.” And then I used it for a resorption lesion, and it was like an epiphany to me, the penny dropped. So, I published this paper. It was the first paper on Cone-beams and Endo, and it was my very first attempt at publishing.
And I was incensed with the referee’s comments about, you know, we don’t need cone- beams in our specialty, blah, blah, blah. And I remember saying to Tom Pitford and I said, “Look, these are the referee’s comments.” And he said to me, “Well what are you going to do about it?” And I remember saying to him, “I’m going to do a PhD, I’m going to prove them all wrong.” And that’s, for me, how my journey into research came along. I had no intention to be an academic and, but I just started publishing, you know, high impact clinical papers on the use of Cone-beam CT and Endo, and it validated its use.
And so now on Wednesdays, I’m at the university where I teach the post-graduates and I also do a lot of supervision of research projects and do a little bit of my own research. And then Monday, Tuesday I work in the practice, a big multi-disciplinary specialist practice, in central London. I think there are about 12 or 13 of us in different specialties here. Then Wednesday is my change of scenery. I’m at University. And then Thursday, Friday I’m back at practice and saving teeth. And then on the way, I’ve just done a few other things, written a few books and published a few, yeah, a few papers, and that’s it, really. Keeps me out of mischief.
You know, Lisette, it didn’t escape me that it was hard to get Shanon booked because he’s so crazy busy, and so I want the viewers to know he just finished a long day, difference in time and geography, he is at his surgery right now where he just finished a long day, and he might even give us a little glimpse of a typical operatory.
Well, it’s not very typical. These are quite unique rooms. So, this is my room. I’ll just spin it around. So, these are the three bay windows, and then some pictures. That’s my surgery there. That’s the chair. And then you can see I’ve got some nice very old furniture, so I keep –
Oh my, oh my.
Yeah, I like that cabinet.
Yeah, I keep my files in there, and –
– I’ve got an old fireplace. And then obviously I’ve got the dental chair there, microscope, and then there’s my halo.
Oh, keep the halo over you, pal.
Yeah, I do when I’m working, I do when I’m working.
Good. It’s very impressive, your layout and your traffic pattern. And I noticed the European surgeries are always quite a bit bigger than in the U.S. I noticed that in the 80’s when I traveled a lot.
And I saw your fireplace, and I was wondering, do you make a small fire before you do the warm gutta percha technique?
No, we’re done now. We have little, cordless things, yeah.
Okay, well Professor Patel, I think you have a couple of cases that you’re going to show us that demonstrate the diagnostic advancements of CBCT, so maybe we should just get right into that.
Oh sure. So, the first is a case of dental trauma, and this lady is basically traumatized the teeth. She fell off a bicycle and saw a local dentist who didn’t really know what to do, so asked me to see her. And you can see on the photograph on the left she’s chipped her two front teeth quite significantly, and the radiographs on the right, you know, show a little bit of displacement on the upper right incisor teeth, but you don’t really get a lot of information from these right radiographs. Essentially, it’s like a shadow graph. It’s like a photograph, so all the anatomy is squashed up into this 2D image.
So, routinely what I do when any patient comes and has some trauma, no matter if it’s a small chip or something fairly significant, I always take a small field of view, high-resolution Cone-beam CT. And in this case, you can quite clearly see on the next slide the – you can really appreciate the true nature of the traumatic incident. So, on the upper right central incisor tooth, that’s the far-left surgical slice, you can see the displacement of the tooth, how it’s been luxated and you can see the blue arrow is indicating the degree of the facial injury. And then you can also see on – the red arrow is indicating the cortical plate is fractured. So, a lot of information.
And on the upper left central incisor tooth you can see, for example, there’s a bifid canal. You got two canals on that central incisor tooth. There’s no way you would work that out from the radiograph or even accessing that tooth. I think, you know, I would have been caught out. And then you can see that the palatal crestal bone is fractured off. That’s indicated by the red arrow there. So, a lot of information.
And then on the axial slice, you can really appreciate the true nature of injury, that the labial plate is fractured off. Now this lady, the dentist was speaking about implants, and I said look, you take these teeth out now what’s going to happen is you’ll take all that labial plate away as well. So, in this case, we save the teeth. We basically just carried out some orthodontic treatment rapidly, and then we treated those teeth and the patient still has those teeth now.
When you repositioned the teeth, did you do any kind of a loose stabilization?
Yes, so in this case because it was two days. It wasn’t fresh trauma. She – I saw her I think on the Monday. She did it on the Saturday or the Friday. So, they weren’t too loose for me to try and reposition. So, in these sorts of cases it’s quite controversial, but I get the orthodontist who happens to be my wife, to put fixed braces on, light forces, and we start repositioning them straight away. None of this, you know, you wait three months and then we position. Straight away we do it very gently and we did nothing – I think two or three months she was in – her teeth were back into the right position and we got all the labial plates back in the right position, and it was a very nice result.
You know, Lis and I did a show and a tribute to Andreasen a few weeks ago. And he would have loved your work. He didn’t have all these tools when he wrote his book, but I mean this is so much more advanced, and Shanon, you know I love anatomy, so when I saw that bifid central, I was just like whoa, that’s cool!
Yeah, because I mean, there’s so much information you just talked to the audience about. Maybe would you say a few words to the general dentists that like obviously this is a compelling reason to have the technology, but what do you say when I say I can’t afford it, but I got to have it.
Yeah, well the thing is radiographs give us two-dimensional information, and we’re missing a lot of information, so for example, if you’re going to do a root canal on an upper molar tooth, before you access the tooth, you want to know where the canals are, how many canals the mesiobuccal have. So, you can see that straight away on your scan. Now there is significant cost involved but you know, over a period of a couple years you’d pay it back because first of all, you’re charging the patients for the scan, and secondly, your treatment time reduces. Not only that, you’re more confident about your treatment, okay, and you can execute it more efficiently and more effectively.
And you know, I’ve been using it since 2006, and I can say confidently, hand on my heart, there’s not one patient who’s refused a scan when I explained why we’re using the scan. You know, sometimes they question radiation, but when I explain, put it in context, they completely understand, you know. As long as you educate your patients well and give them good information, then they will accept having a scan done. And it transforms the way you work.
And a lot of, you know, general practitioners, they’re using it relatively routinely for, you know, root canals, if they do it, or even implant work. I think it’s more likely – practitioners are more likely to uptake scans if they have the scanner on the premises, where if they have to refer out to an imaging center, then it’s a bit more of a headache, to they’re less likely to take the scans. But it’s a slow process, but it’s getting more and more common for dentists, generalists, and specialists, to be using Cone-beam CT scan.
It’s just like, you know, back in the, I guess in the 90’s when microscopes came along, you know, there were a few guys using, guys like you, Cliff, who were using it, and people were still using loops. But then everyone gradually shifted over because it was so obvious what the benefits were, and the same with Cone-beam CT. Most endodontists are using it on a routine basis now.
Two things. One, I have an incoming from our producer if you could maybe just tilt your computer just a little, yeah, or – perfect. And then secondly, I’m wondering what is the difference in exposure if someone had like a full mouth of X-rays versus CBCT? Is it about the same radiation?
Okay, so it depends on the scanner, but a good quality scanner like a Morita scanner, you’re looking at about, depending on the area that you’re radiating, it’s a small field of view you want, so about 4 centimeters cubed, so upper canine to canine, or if you’re going to do the molar region, you can get second pre-molar to the second molar 2, three teeth, you’re looking at anything between 15 to 35 microsieverts. And per radiograph it’s about 5 microsieverts, so but what you can do is reduce the radiation with a Cone-beam CT scan, so the detector and the sensor – sorry, the detector and the X-ray is almost going 360 degrees, you can go to 180 and half the radiation dose.
So, it’s anything between three and I think six times the radiation, but you’re not taking multiple periatricals firstly, so normally you take, you know, parallax views, sometimes two, and then what you also find, guys and ladies who use Cone-beam CT more routinely, they’re taking less intraoperative radiographs, because they don’t need to work out what’s going on and view all that. So, for me, I take one scan, one pre-operative radiograph, one mid-fill, one post-op, right? I don’t do multiple parallax beforehand. I don’t do working links. I don’t do mid-fills, you know, I just do one master point radiograph.
And so, it’s slightly more radiation, but to put it in context, you know, if you fly between here and Santa Barbara and back, you’re going to get much more radiation if you convert the cosmic radiation into an equivalent dose, you get much more radiation. And it’s a one-off. The patient is going to have one scan, maybe another one in a year for follow-up, but it’s not, you know, every day having a scan, so if you put it in context, it’s a minimal amount of radiation. It’s a minimal amount. And also, for endodontists, we should be using a small field of view so a periapical with depth, that third dimension.
Okay. I think you have another case that you were going to show us.
Yeah, so the final case – I’m just going to get it up, yeah, so this is a really interesting case. So, this patient presented with basically pain in the upper canine premolar region and both teeth were quite tender to percussion, and as you can see from the radiograph, there wasn’t anything visible on the far-left radiograph. Vitality testing again didn’t reveal anything untoward, but the patient had really bad chronic pain. When he saw me, he was literally in tears. He hadn’t slept for a couple of nights, painkillers weren’t effective, and it was just like a localized pain in that area, but we couldn’t work out which tooth. And then I took a scan, and you can quite clearly see the tooth in question has got a periapical radiolucency or significant thickening of the periodontal ligaments.
And then you look at the coronal view and you can see quite clearly the fracture, a really significant fracture there, but also what that’s telling me is okay, the tooth is infected, but actually there’s quite a significant fracture, and when I showed it to the patient I said, look, we can try and save the tooth, but you need a root canal, and you need some crown lengthening on the palatal aspect and cupel coverage restoration. He just said, look, I’d rather have the tooth out and maybe later on I can think about an implant.
So, we took the tooth out, and you can quite clearly see that was probably the better decision, because there is minimal coronal tooth structure left there. So, you can see how it’s influenced my diagnosis. I know confidently which tooth is giving the problem, and it’s had an impact on my management, what’s the treatment plan, because basically if I tried to root treat that tooth, it’s going to be very, very difficult to do, but possible, but crown lengthening this tooth is going to be more challenging.
So, I think the patient did make the right decision, but he couldn’t have made that decision, he couldn’t have made an informed decision without having all of that information. So, another great example of how Cone-beam CT transforms diagnosis and management.
Shanon, I come from an era where back in the 70’s, we were doing a lot of hemi-sections and root amps. I wasn’t doing them, but I got the referrals. So, I got teeth that were swinging in the breeze, I got pulps hanging out of pulp chambers, I got tooth roots gone, but we did a lot of those, and then they were restored so was, you know, endo/perio cross, and we have 20, 30 still have them running.
But when I look at your photograph, and I see it’s sobering, it’s humbling, because the roots are spindly, they’re thin, which is not unusual for this tooth, and then you look at that oblique fracture, probably sub-crestal, and then you think of the endodontics, the post, the buildups, the core, it’s a lot of work on a pretty thin tooth with – anyway, it was treatment planning for no surprises.
Exactly. So, you’re just – you’re most confident about what you’re doing. You asked if most endodontists are using it on a routine basis, they’ll tell you, “I’m more confident now about what I’m doing, and I’m more efficient at what I’m doing.” And ultimately, you’re giving your patient the best treatment because, you know, if you’re more confident about what you’re doing and you can show the patient what’s going on, it’s a win-win situation. And when you show patients scans, what I’m finding is they can understand what you’re talking about more than when you show them a radiograph.
You know, just coming from the perspective of someone who’s not an endodontist, not even a dentist, even I can see from your radiographs from the CBCT, right, I mean it’s astounding how much more you can see.
Okay, so later in this show my dad and I are going to be doing a Q&A related to incorporating new technologies into your practice, so what advice or tips would you give to a clinician new to CBCT, but who wants to become more proficient? Practice?
Yeah, basically practice, but what I would say is speak to – the best – personally, I think it’s best people to talk is endodontists because we use high resolution Cone-beam CT scans, small field of view as well, so you know, we’re not like a lot of oral surgeons, for example, may do full-arch scans and, you know, as general dentists or specialist endodontists, we’re not trained to assess the anatomy of the spine or the nose or the eyes or the orbit, so I say a small field of view, high resolution.
And then if you’re thinking about, for example, buying a scanner, don’t, you know, with all due respect, don’t just listen to the manufacturers and look at their brochures. Pick up a phone, say, “Hey, Cliff, I know you’ve got this scanner, can I come look at the images that you’re producing?” and have a chat with someone who’s using it on a routine basis and look at their images, because that’s how you really know if that particular scanner is good for you or not good for you.
And also, you need to have some really good training, so you need to know how to – well first of all, what the indications for Cone-beam CT scanning is, how to, you know, adjust the exposure parameters. For example, if you’ve got a young patient you may want to reduce that exposure dose. If you’ve got someone with a lot of metal in their mouth, let’s say lots of posts, lots of implants, you may want to increase the dosage to reduce the amount of scatter and artifact. And then you need to know how to report on the scan and get the most out of your scan, how to upright the tooth and look at the scan tooth by tooth.
So, there’s a lot to do, and you need to find some people to train with. So, I think there’s some endodontists out there in the states who are doing these sorts of training courses. I can send you a link, but it’s very important to get good training. Don’t learn just off your, you know, your own experiences, because it will take you much longer to get up to the summit of the mountain. You know, it’s a very steep learning curve, so learn from others, share knowledge.
I’m smiling, Shanon, because when I started using my microscope in the mid-80’s, there were no courses, there were no articles, there were no manuals, there was nobody to call, and it was the blind leading the blind, but I’m really intrigued. If I was in the London area and with advanced planning, could I take – is there a course that you would offer at the hospital on how to – and then Lise, comment on his article after I’m done, immediately comment on his article to help people start thinking, and we’ll put in the show in the post notes, but could I take a class?
Yeah, you could do. So, I, for example, in collaboration with Simon Harvey a great consultant, maxillofacial radiologist. We run a course at the British Dental Association, and it’s a master class in Cone-beam CTs, about 24 hours, blended learning, so it’s a day and a half of face to face learning and we give some exercises on reporting scans and some pre-course literature, and it gives the dentist, whether a generalist or a specialist, an all encompassing information on the indication of Cone-beam CT, when to use it, how to use it, contra-indications and most importantly, how to report on scans, how to get the most out of your scan.
So, he’s at the British Dental Association and it’s now in its third year, and every course we do is sold out, but unfortunately with this pandemic, it’s been put on hold, like everything else in the world. But it’s brilliant; we’ve got people from all round the United Kingdom coming. We had one dentist coming from Granada. Amazing, you know, so it’s gaining momentum.
And the novelty about our course is it’s run by clinicians, not radiologists, so we’re on the dentist wavelength, you know, they can – we can relate to each other, so we have oral surgeons on it, implant dentists, periodontists, prosthodontists, myself endodontist and also Simon Harvey is a great maxillofacial radiologist, a young one, who understands what dentists want. You know, none of this territorial business. Because, you know, we’re all there to help patients at the end of the day.
It seems like your reflection and your teaching is your multi-disciplinary clinic that you’re sitting in.
Yeah, it is.
That’s a wonderful thing.
It’s a real, you know, well it’s not novel, but it’s a great place to work, because we’ve got all the specialties under one roof. So, if someone comes in and, you know, I’m not sure if we should do an implant or not, I’ll get Andrew or Fiona who are great implant dentists, come in and we’ll chew the fat in front of the patient, we’ll decide together, you know. And if, for example, like our trauma case, I’ll get my wife Alma’s orthodontic opinion, we’ve got hygienists here, kids’ dentists. It’s great, we’ve got great prosthodontists. And that way you can cross-refer to each other, and it’s more convenient for the patient.
Right, one visit.
And you’ve also got the scanners in the practice, digital laboratory downstairs, so it’s great, it’s a one-stop shop, it’s brilliant, and it’s a great bunch of people to work with, great bunch of people.
Well, that’s all, really. Thank you so much for coming on and giving us all this great information. The article my dad was talking – when we were just planning for you to come on the show, we went on to Pub Med and just searched your name to see if we could find your latest and greatest CBCT article, and it was actually surprising how many came up. You’ve written quite a lot on the subject, and I will try to have a link or something on our website in the show notes about the latest article, Guidelines for Reporting on CBCT Scans. I saw you have the online version that’s out, but it’s going to be in the International Journal of Endodontics.
Yeah, that’s right, yeah. I can ping it over to you, the pdf.
Okay. Well thank you very much for coming on our show, and it sounds like from just some preliminary talks, that we might be actually having you back again soon.
I have one last question.
Because I’m going to have to talk about it in the next segment, so I might as well get an authority like you that’s recognized and respected around the world. So, you only have so much money. Microscope? CBCT? Which could you not live without?
You need both. You need both.
It’s like salt and pepper; you need both.
So, in your world it’s not an either/or, it’s and/both.
Yeah, you need both. You need one for diagnosis and management and then the other one to execute the treatment.
Yeah, that’s it, you need both.
Thanks so much.
My pleasure, take care, guys.
You’re a great guy and it was a big honor for me to have you on here, and I hope we have tens of thousands of people who watch this, and we hope you gave them a little enlightenment on what could be a big difference maker in their practice in the coming year.
My pleasure, and stay safe, everyone, and hopefully we’ll be face to face in the future soon.
SEGMENT 2: Q&A – Incorporating New Technology
Well, we have another Q&A for you today, and this time it’s going to revolve around how to incorporate new technologies into your practice. So, the first question I’m going to ask you, and we asked a version of this question to Professor Patel in our Zoom meeting.
But I’m going to ask you right now. And this is from a clinician. “I am ready to invest in a higher-end technology and I am thinking about buying either a microscope, CBCT, GentleWave, or a laser-disinfection method. If I can only afford one thing right now, what would you recommend I buy?”
Well, they all heard it. What did the professor say?
Both, a CBCT and a microscope.
But see, she’s my daughter, so it’s not going to be that easy. She’s going to – you’re going to press me. I have a make a choice. I only have one choice?
I’m going to get a microscope, and the reason I get a microscope is CBCT with all of its value and virtues for diagnostics, the microscope is diagnostic in and of itself, plus you can go to work under high vision and remember vision is magnification plus lighting. So, anyway, that’s – I think I’d take a microscope.
Yeah, I mean I guess if you have a CBCT, you can get really great at diagnosing the problem, but you kind of need a microscope if you’re actually going to perform treatment maybe.
I’ll play off you. So, you’re CBCT says you have unusual anatomy, and you see five systems in a maxillary molar. But now you go to work with no vision, so you’re chasing over here and you’re chasing over there, and you remember, you look back at those different slices, you know. You chase over here and all of a sudden, you’ve mutilated the tooth, you’ve hogged it out, and the clinical crown is severely weakened.
So, I never had a CBCT when I practiced, but I did have a microscope for many, many years, decades when I practiced. And having a library in your mind of the cases, so if we’re doing a question and answer you’ve got to have an anatomical library in your mind of cases you treated, that others have treated, that you can see in textbooks and Hess’s book, and then you kind of know where to look with the microscope.
Okay. So, this kind of is related to our next question. “I have purchased a microscope, but still feel very awkward using it. How did you go about incorporating your microscope into your practice and what tips can you give to me to help me feel more comfortable utilizing it?”
Well for the colleague who’s in today’s world, as we both know, you can take courses, you can read articles, you can read textbooks. They even have books on chair positioning for each tooth, where the assistant is. So, all of those things are present today, so that would go a long way to getting you comfortable. But I think I’d like to tell you a little story, because all that comfort still comes back to one thing you and I talk about.
Let’s assume we got the microscope, let’s say we got it hung on the right spot, and I took a Ruddle class or Gary Carr class or whatever class, and I’ve read articles. Do you think I’ve very proficient? I am really dangerous and awkward and slow, and I’m going to take more time to do things I did with my eyes closed. But if you sometimes give up those hard fought for proficiencies, you can get to the next level and have a little bump in your game.
So, what I did is I was intimidated by the technology and it slowed me down initially, and so, you know, those schedules are non-stop. Dentists have terrible pressures with schedulers, all these patients and on time. So, what I did is I enrolled the staff. It’s really critical. What you really are saying here, more than all that, which is important, you’ve got to get your staff around you, you’ve got to paint the picture, you’ve got to commit to it as a team, and a team helps you.
And pretty soon they’re start putting explorers in your hands and you’re pushing for an MB2; it’s pretty safe you’re not going to really destroy a tooth with your explorer, I hope. And then a little bit later, maybe the handpiece comes in and now you trim up an axial wall and you get a better line of sight into something. Get the staff involved; they’ll really help you at all levels, handing tools into the field rhythmically to benefit the economy of time. It’s a staff thing. It’s a team thing.
And just practice and time, I imagine.
Yeah, countless repetitions.
Okay, 10,000 cases with the microscope and you’ll be proficient. Okay, so another question. “What are the most common mistakes dentists make when trying to incorporate new technologies?”
Well, I think what I have noticed personally is a lot of colleagues yearn or desire, strongly desire, to do something. Let’s just say, for instance, they went to a John West class and they noticed that John mentioned, and I don’t know if I’ll have the number quite right, but I’m very close, 2.9 portals of exit per shape canal. Okay, it might have been 2.8. Well, the point is, you hear that, and you want to go home, and you go I’ve never seen a lateral canal in my life, or I’ve seen one twice a year. It’s infrequent. So, you want to improve.
So, oh, I’ve been reading about GentleWave or lasers, so the colleague will rush out to get that, because that’s probably how you do it. The fact is, many of us, thousands of us, did it for decades without any adjunctive help, except a one-dollar let’s call it an irrigating syringe, and we would use this to dump solutions into our pulp chamber. So, the big mistake can be is not understanding the fundamentals. And then the technology should be an adjunct. It should only facilitate what you’re already doing and know to be true.
So, if you’re just getting the piece of technology to cover up deficiencies and primary training, you’ll be not very successful, you’ll be disappointed and when I go to Doc Matters, the website for GentleWave, there’s a lot of disappointment. There’s a lot of people that go, well I was already getting lateral canals and I’m getting fewer, I’m getting the same, I have bleeding problems, I have to build a platform, so there’s time and indignities and cost associated with all these technologies.
So, I would say if you really wanted to incorporate technology, get your staff involved, but also, we didn’t talk about mentorship. You know, you can go take courses, but you can also go into your town and hang out at your endodontist’s office and kind of see what they’re doing and see how that benefits their office and then you can say, well model success, success leaves clues.
Yeah, I really like what you said about not counting on technology to make up for your deficiencies in training. That’s been obviously a common theme on our show through all of our seasons so far. Let me see, do we have time? I think we have time for another question. “What kind of microscope do you recommend and why?”
Well, there’s a lot of different microscopes, just like there’s cars on autobahns or freeways that we see. So, the first thing is I can maybe give you the top three in my opinion. So, I have – okay, from 1990 to 2000, for one decade, I had Global. From 2000 to now I have the Pro Ergal Zeist. So, we have Zeist Pro Ergal, or we can have Global, and then Leica is a really good scope. Leica I’ve used frequently when I go to Italy and different parts of Europe. All those scopes are good. Each has their benefits.
Maybe some of them have a little more ease here and there, so you need to take a course and try them. At microscope courses sometimes they’ll have like 20 students and they might have six Zeists, six Leicas, six Globals. The microscope companies come in and furnish scopes. You just sit down, but then you and I agree that halfway through the course, would you please switch and go over here, I want to try your microscope, you know. So, you can do stuff like that.
Okay. Last question. “All of the new dental technology coming to market every year is exciting. How do I know what to buy and what to pass on?” Maybe we should switch back, you think?
Well, I guess what are your needs? I mean what are you trying to accomplish? How many cases a week do you do? You know, we looked at some statistics yesterday, me and a bunch of doctors, and we were looking at Germany compared to North America, and we were looking at number of cases GPs do per week. And of course, there’s differences culturally and there’s reasons for that we won’t go into.
So, I would say basically, if you do two or three cases a week, you probably aren’t going to find the advantage of buying a one-horse pony like maybe say – I hate to keep beating on, but GentleWave. It’s a disinfection unit. If you get a laser, you can take out caries, you can do frenectomies, you can do bloodless incisions, you can do disinfection, you can knock instruments, broken segments, out of canals. In other words, multiple reasons to buy because and maybe you want to start doing other things, so maybe it even grows you.
So, I would say cost is a factor, what are your needs, how many cases a week do you do and what are you struggling with that if you just had that, it would be all the difference in the world? And for me, I’m still going to tell most dentists, get a microscope.
Okay, well thank you for those nice answers, and that’s it for the segment. We’ll do another Q&A soon. Thanks.
CLOSE: Philosophical Wisdom – Sports Coaches
Now we’re going to close our show today with some more philosophical wisdom. You might remember in the past we’ve talked about some Chinese proverbs. We talked about Murphy’s Law. And today we’re going to get some wisdom from sports coaches. And it may be a quote, or it may be a concept, but why don’t you get started?
Well, I particularly like John Wooden. He’s passed away now, but he made his career first at Indiana University and IU and he was a very, very well-known teacher, schoolteacher, and a basketball coach. And what he did over a period of many, many years, he identified traits and characteristics that develop behavioral patterns. And he put all these over a 10-year period into what he called a Pyramid of Success. You know, you can Google this or we’ll have it in show notes, but it’s just all the characteristics that make people successful. It’s the pathway to being a better person.
So, anyway, I liked him. He won 10 championships out of 12 years, 10 out of 12, never will be done again. His players have gone on to be icons in business and successful in life because they probably were following this. And the two cornerstones of the pyramid are hard work and be enthusiastic.
So, what I chose, was something that I actually got from one of Isaac’s Little League coaches for baseball, and he’s not famous, but he talked to us – at the first parents’ meeting, he talked about the ideal praise to criticism ratio which is 5 to 1, and he explained that for every negative you give the kids, like as far as critique goes, you need to follow it up with 5 positives. And the reason being is the negative can help change behavior, but it doesn’t really motivate people to want to do better.
But the positives kind of reinforce what they’re doing well, and the studies have found that people actually tend to be, when you give them a positive, they tend to do that with more creativity, more vigor and determination. So, this is actually a good thing, because it doesn’t just apply to teaching or to coaching kids in baseball. I mean it’s good for relationships, too.
Are you talking to me? Like when you broke an instrument, but your access is phenomenal. And in fact, you found all of the orifices. And your negotiation was quite nice. And I can see a pack in my mind that’s going to be phenomenal if you get out the broken instrument.
Yeah, so that praise to criticism ratio is just – it’s really important if you want to bring out the best in people.
Do you have anything else?
Well, I have a whole bunch of notes I took. I liked Vince Lombardi. He’s a famous football coach with the Green Bay Packers. He’s deceased. A lot of these guys I should say to the audience, they weren’t just coaches. They’ve had many successes in their lives.
Okay, so Vince Lombardi. I liked his quote where he said, “Winning isn’t a sometimes thing; it’s an all the time thing.” He went on to say that, “You don’t just win some of the time and you don’t just do the right thing some of the time; you do them both all the time. Winning is a habit.”
Well, I actually just want to comment a little bit on that, because I guess like even if you actually lose, but you learn a lot from your loss, then it’s like you’re winning still.
Well, I think winning isn’t good or bad. I mean everybody on this show that’s watching this, we have lost a lot and we’ve won a lot, but it’s the losing and then what you do when you lose, and you make the adjustments that puts you on a new trajectory towards greater success. So, if we never lost, I don’t know if we’d ever win.
Okay, well that’s our show for today. Hope you liked it. See you next time on The Ruddle Show.
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Tough Quetions & SINE Tips
Who Pays for Treatment if it Fails & Access Refinement
Assessing Case Difficulty & Clinical Findings
CBCT & Incorporating New Technology
Zoom with Prof. Shanon Patel and Q&A
Best Sealer & Best Dental Team
Kerr Pulp Canal Sealer EWT & Hiring Staff
Ideation & the Covid Era
Zoom with Dr. Gary Glassman and Post-Interview Discussion
Medications & Silver Points
Dental Medications Q&A and How to Remove Silver Points
Tough Questions & Choices
The Appropriate Canal Shape & Treatment Options
Q&A and Recently Published Articles
Glide Path/Working Length and 2 Endo Articles
Hot Topic with Dr. Gordon Christensen
Dr. Christensen Presents the Latest on Glass Ionomers
Annual AAE Meeting and Q&A
Who is Presenting and Glide Path/Working Length, Part 2
The Ruddle Show
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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.