There has been massive growth in endodontic treatment in recent years. This increase in clinical activity can be attributable to better-trained dentists and specialists alike. Necessary for this unfolding story is the general public's growing selection for root canal treatment...
Medications and Silver Points Dental Medications Q&A and How to Remove Silver Points
This show opens with Ruddle sharing his recent adventures in the ongoing saga, “Field-Testing Prototypes.” Next, in our popular Q&A segment, Ruddle discusses various medications used in dentistry, namely anesthesia, antibiotics, and post-treatment medication. Then, in a nonsurgical retreatment segment, Ruddle focuses on techniques to remove a silver point. Stay tuned for the close of the show where Ruddle will once again have the chance to tell us how he really feels in “Ruddle Rant.”
Show Content & Timecodes00:10 - INTRO: Field Testing Prototypes 06:24 - SEGMENT 1: Q&A - Dental Medications 21:30 - SEGMENT 2: RETX - Silver Point Removal 52:39 - CLOSE: Ruddle Rant
Extra content referenced within show:
Extra movie/video content:
Downloadable PDFs & Related Materials
Endodontic obturation with silver points was introduced during the 1930’s. For decades many dental schools taught the silver point technique and, as a result, thousands of clinicians obturated millions of root canals in this manner...
For more than 50 years there has been universal agreement that the triad for endodontic success is shaping canals, cleaning in 3 dimensions, and filling root canal systems. Further, it is globally accepted that 3D disinfection is central to success and has traditionally required a well-shaped canal...
Ruddle on Shape•Clean•Pack Supply List and Supplier Contact Information Listing
Ruddle on Retreatment Supply List and Supplier Contact Information Listing
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: Field Testing Prototypes
[Music playing] Welcome to “The Ruddle Show”. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing today?
Okay. So, we have mentioned in past shows that you are working on Dentsply projects that involve the Trifecta and – or Triad. And by Triad, we mean that you are developing new technology to handle each area of endodontic treatment, namely, shaping, cleaning, and packing. So, I understand you’ve been doing a lot of field testing, related to this project, lately. Right?
We have. And actually, it’s been complicated, because we’ve been doing all three aspects, the technology that would drive each aspect that you just mentioned. So, the challenges, always, is to create a set of instruments that are anatomically designed, that work synergistically with minimally invasive technologies, that promotes three-dimensional cleaning and filling of root canal systems. So, just to talk about the one we’re working at probably the most intensely right now, just the way the project goes, is – are the files. And it’s been really hard to make a huge improvement over ProTaper Gold, because --
It’s so excellent? [laughs]
-- well, it’s the number-one sold file in the world. And just for the viewers who don’t maybe know a lot about file designs, but it could be anything from [music playing] rake angle, cutting angle, helical angle, tip geometries, taper, increasing percentage tapers, decreasing percentage tapers, centered mass of rotation, offset mass of rotation, alternating offset machining, heat treatment, cross section. There’s a lot of stuff. And so, you start to play with these things. But we are on the cusp of having something really special. And it’s gonna be very big push towards a more anatomically driven shape, but yet, giving us the deep shape that other companies’ files just don’t produce.
Okay. So, just to clarify, it’s you that is doing the testing, and Professor Pierre Machtou, and Dr. John West.
Right? Those are the – who’s doing the testing?
Right. And we get a lot of help from two engineers. I should acknowledge them. Gilbert Rota and Nico Crevoisier.
Okay. And now, you told me that it was maybe like the 50th iteration that you were testing. But then, I think Pierre came back to you and said, no, it was maybe [laughs] over 100 [laughs].
Yeah. Well, Pierre, you know, in his French way, he said, ‘No, no, no, no!’ I’ve tested about 55, and John West has maybe about 55, but since Pierre lives in Lausanne, and that’s 30 minutes from the factory – Maillefer’s factory, Dentsply Sirona has the Maillefer factory, he can go by car. And they might bring him four of the same kind of files but with four different designs or four different heat treatments or whatever. Well, he might eliminate two or three of them, right away. Well, then, John and I just see the one he liked the best.
So, do you test them on – you test them on plastic blocks? Is that what you do for the testing, or natural teeth?
Well, that’s a great question, because we do use a lot of plastic blocks. And I wanna make a very clear comment. We don’t like to use 3D-printed teeth, because although they’re really sexy, and they can be opaque, they can be translucent, and they have curvatures and four canals and everybody likes that, the canals are just too big. Okay? So, when you open up into these teeth, it’s not a really good test of a natural tooth. So, we start off with a very specific block. It’s called an S block. The first curve is about 35 degrees, and the second curve is about 35 degrees recurvature. So, you have a big challenge.
And we like that, because every block’s the same length, same diameter, same curvature. So, if you and I are comparing results, we have frozen a lot of the variables, and now we can just talk about what was different between our results. Then, we go from that to a 90-degree block, and the 90-degree block --
-- it goes up and makes a 90, but it goes about 5 more millimeters to the terminus. So, that really starts to check cyclic fatigue. And then, we go from there, to natural teeth. And we try to choose teeth that are longer, more curved, you know, four canals, and that’s kind of the goal.
And would you say that you are all generally in agreement?
You know, it’s funny, on all the big issues, we are. But I would say more than we have disagreements, we have different observations. And so, if you see something I never saw, it’s not a disagreement. You’re just pointing it out [laughs] to me. And sometimes I’ll see something they don’t see, or Pierre or John’ll pick up something. So, altogether, we get insights that I think really drive design.
Okay. Now, you just said at the beginning of our little discussion that you’re getting close to the final version. When do you expect to launch?
Well, we’ve been following these charts for a year and a half, and we’re down to about six months. I would say, though, actually by Q four this year, they’ll – we’ll launch the file systems. And at one time, the launch was gonna be simultaneous, first time in the world ever, launch a shaping way, a way to shape, a way to 3D disinfect, well beyond the EndoActivator, I might add, and cordless, and really easy for general dentists, affordable, [laughs], and then, filling root canal systems. And we have some really cool things in new designs, with filling root canal systems.
Okay. Well, it sounds exciting. And we also have a exciting show for you today, so let’s get started. [Music playing]
SEGMENT 1: Q&A – Dental Medications
Okay. So, we have another Q&A for you today. And this time, it’s gonna center around dental medications, specifically anesthesia, antibiotics, and painkillers. And it’s a little different than the other Q&A’s we’ve done, because we’ve kind of just – you get asked these questions a lot. I’m not gonna read a specific question that a person asked. But it’s kind of going to be in the spirit of what we’ve been asked.
You’ve batched them.
Right. So, the first question is, a lot of clinicians have – are having difficulty achieving profound anesthesia. So, what tips do you have for this?
I am the tip man!
Well, I’ll go to the easy one, first. That’s the maxillary arch. I don’t really get questions around the world, ‘How do you get profound anesthesia?’ Normally, if we’re doin’ molars, in here, we’re gonna give that posterior, superior, alveolar nerve block, and that’s gonna get the molars. Sometimes, use ice. That’s a little tricky. Use ice in the palate, and put the ice on, gets the palate tissue, that really dense tissue, very, very cold, and you give a painless injection there. That’ll give you enough protection. Everything else is just infiltration. It’s just infiltrations. Look at how loose that cortical bone is. That bone absorbs that anesthesia. This is a thin, cortical plate.
So, dentists do not complain about maxillary teeth, rarely. The ones they complain about are down on the mandible. And in the mandible, we have a whole different thing. We have a big, thick, heavy cortical plate. And so, we do have a loose trabecular bone again. But the problem is, is gettng the nerve block. So, when you give that block, and you’re trying to hit the lingula – wow! I haven’t spelled that for a while! You’re trying to get that little foramen called the lingula and put your payload right in there. I usually use 1:50,000 xylocaine, long acting.
I did long blocks at time with patients, two in the morning, two in the afternoon, so I needed anesthesia to last and not be wearing out, halfway or deep into the procedure. And that’s unsettling, to have to take the dam off and repeat stuff. So, be sure you get the block. Everybody knows this, but when you get the block, it’s not just to the midline. There is some cross-enervation, bilaterally. So, it needs to go across the midline a little bit, to the contralateral side of the area you’re gonna anesthetize. That’s a starting point. Everybody has to have that, before we even now go on to the tricks.
So, the tricks would be primarily – you have Stabident. Stabident was one of the first intraosseous injections, and that was the little trephine. You would go posterior to the tooth. So, if you’re gonna do the molar, you would go posterior to the tooth, and you would go about four millimeters below the crest of bone, and you would make a little perforation, through the cortical plate. You’ll feel the perforator fall into the cancellous bone, because it’s a lot softer. And that had a lot of success. People like it, but the problem was, even though you perforated, and there’d be a little bit of blood oozing out of here, people would come in with their needle, and it’s ‘No, no, no, no, no, no!’ They couldn’t find the hole, because the hole’s really small.
So, a new one came out that I thought was even better, and it’s called the X-Tip. And it’s a trephine with a cannula. So, you trephine, and pull out your trephine, and it leaves a sleeve inside. And that sleeve is where you put your anesthetic needle, in that sleeve, to deposit a few drops in the bone. Go slow. Don’t put a lot in, you can cause damage. Just small infiltration. Look. You’re just trying to buy a little time. You’re not trying to have profound anesthesia for an hour, an hour and a half. You’re just trying to get into the pulp chamber on your access. Once you get in here, you can give an intrapulpal, and if – but you gotta get in, without the patient hopping around in the chair.
My last one, that I really like – so, I had the Stabident, I had the X-Tip, and then, I like the I-L-I, interligamentary injection. That is where you take a very short – like I used a 30-, 31-gauge needle, and you go right on a line angle, between the tooth and the bone. And if your hand isn’t trembling, as you try to deposit, you didn’t do it right. There needs to be a lot of pressure, so much that your hand will tremble a little bit, and you’ll see the tissue blanch, and the patient will go numb. They’ll be really, profoundly numb. Last comment, and then, we’re done. We’re out. Once you get the nip – the lip numb, and it’s a hot tooth.
And let’s – by definition, I’ll call a hot tooth what it is. It’s a vital, highly inflamed tooth. You already know, when you go in, it’s gonna really bleed. They’re gonna see a lot of bleeding. So, once you get profound anesthesia, ask the question, ‘Do I have profound anesthesia?’ And take a piece of ice, go right back, and rub that ice back and forth on the cervical, from the DB to the MB, DB to the MB, and that warm tooth will melt that ice. And if they feel that, do not isolate the tooth. You’re not ready to go yet. So, you should always treatment plan for no surprises. And when you tell patients, ‘You’re not gonna hurt’, then keep your word.
And we’ve talked about some tricks today, so I think you can get back into these teeth a little bit easier.
Okay. The next question – we’ll go to antibiotics now. What are the instances where you would see a need to prescribe antibiotics?
Well, there’s maybe three things, three categories on this question and answer. How – how did they present? So, the presentation, how they present. If they come in, and they’re a little swollen, or maybe before you can see it, the asymmetry bilaterally, maybe they say it’s a little full in the nasolabial fold, that little fold. Maybe they’ll say, ‘Right in here.’ Guys might say, ‘Just tight, feels tight.’ Well, those are people that have infections. And if you can do your diagnostics and say that it’s endodontic in etiology or origin, then, they should be on antibiotics, okay?
There is another one. So, how they present, we don’t know. But it also could be an A and a B, and the B could be their medical history. Their medical history. In other words, what if they – they have --
-- scarlet fever, mitral valve prolapse syndrome. What if they have a prosthetic hip, a knee? So, I actually call the physicians. They say [laughs] more than one person’s responsible for a miscalculation? No one’s at fault. So, you call the physician and just say, ‘I’m gonna be doing a non-surgical procedure’, or whatever you’re doing, and just get their coaching. ‘Would you like your patient premedicated on an antibiotic, or not?’
So, those are the kinds of things. If they have symptoms, of course, yes. And then, if you’re doing it for medical reasons. Another one is, let’s just say you’re doing retreatment today, non-surgical, and you’re removing a pesty silver point! Silver points are notorious [with emphasis] to have postop flare-ups. It’s in the literature. And a lot of times – we talked a little bit earlier about the corrosion, and we talked about how they can break down, tattoo the tissue and stuff. So, if you have a silver point, and you start to pull it out, and it’s black, I mean, even if they came in asymptomatic, just learn the literature. You know? In other words, you might not give the antibiotic, and they might be fine.
But if they aren’t fine, you’re already probably a day or two behind, by the time they call you and say, ‘I’m swollen. What should I do?’ Now, you’ve got your – you’re from behind. You’re operating from behind. So, what if you have a tooth, and you’re treating it, and it’s necrotic. [makes sniffing sounds] You go in, there’s putrescence, it stinks, and your first file is up here. You know, and there’s a big lesion. Well, you probably just inoculated Avogadro’s number of bacteria, periapically. That’s sometimes when you might wanna consider an antibiotic, because you just created a riot, probably.
So, common sense, you know when you have good control. You know when your length to terminations are a little bit off. If you perforated [laughs] a necrotic tooth, things like that, you might wanna --
I – I just want --
-- for clarification, so, say you did perforate, and you repaired it, but the tooth wasn’t necrotic to begin with. Is it not really necessary to – you wouldn’t just automatically prescribe antibiotics?
That’s a great question. And now we’re starting to make the huge distinction between vital cases versus necrotic, gangrene necrosis, putrescent. When you’re working in vital cases, there’s no infection. There’s plenty of inflammation. So, probably you don’t need – if I perf a vital case, I should be able to repair it, and maybe just the topic you’re gonna talk about next, analgesics. But I don’t anticipate I need an antibiotic.
So, this is really the big thing to know. So, those are the three instances where you should be thinking about medications. I like – in the penicillin family, I like amoxicillin the best. It’s the most prescribed in North America. Pen VK is common.
Well, okay. So, three instances. Whatever the patient might have when they present, then whatever happens during treatment. But then also, maybe if they get an infection post-treatment? Then, is that the third situation?
Oh, yes! I guess I forgot!
Yeah. The – on the third one, let’s say that you do a procedure, and the decision technically and professionally is not to use an antibiotic. And you go home – take you, for an example, and – because you had a root canal by a specialist in town, and it wasn’t – it was not Terry Pannkuk.
Anyway, you had major problems, because they left decay, they missed a canal, and they perforated.
Well, it was a necrotic tooth. So, why – they told you, big pat on the back, ‘You’ll be fine.’ But by the time – and so, you thought you were supposed to be fine. You lost a day. By the second day, you were thinking, ‘I’m in trouble’, and you called, and you get an antibiotic. Well, now, you’re really behind. So, if there is post-operative infection and pain, that’s not normal from an endodontic procedure. When you work normally in endodontics, you’re not using a lot of antibiotics. So, it’s not normal to give them. But if you call me subsequent to my procedure, I have somehow provoked a riot.
Okay. And then, I guess this sorta connects to the last thing we’re gonna talk about, painkillers, or what you prescribe post-treatment. Do you – did you normally send people away with just like Advil or Motrin or something like ibuprofen? Or do you prescribe something stronger?
You know, it’s nice to talk about this, because it’s changed a lot. 50 years ago, when I got out, there was quite a bit of codeine and Tylenol, you know, aspirin and codeine, a narcotic. And that was not necessarily given, but we were thinking along those lines. But over the decades, it’s become very clear that ibuprofen is fabulous. 400 milligrams, 4 times a day, you can even have them double up, 800 milligrams, 4 times a day. So, 800 times 4, 3,200. And I would do that for a couple days. So, I would do one, you know, based on if it was a little inflammation or – okay.
Pain can be mild, moderate, or severe. So, for moderate to – for let’s say mild to moderate pain, it would just be ibuprofen. Advil, you know, is to – is a capsule, for your stomach. It’s got a coating on it, but if you take 2 Advils, they’re 200 milligrams, that’s 1 ibuprofen. So, that’s been very, very good. Really, they’re doing a lot of studies over the last decades, and they’re finding out, even if you use things like hydrocodone, oxycodone, really – Fentanyl, really big opioids, that if you just do two things, like acetaminophen in conjunction with this, it’s like one plus one is four. So, it’s synergistic, and people do really, really fine.
Now, to back up and say it all different, we rarely gave out narcotics. Even after periapical surgery, it isn’t necessary. It’s not an infection. It’s inflammatory. And that’s 48 to 72 hours is maximum peak inflammation. So, if we get in there and do our procedure, we caused an inflammation, but healing should already begin. So, these more mild hitters tend to be more effective. And don’t tell people they’re pain pills [laughs]. Tell them they’re for – to reduce inflammation.
Okay. That’s what I was gonna say, because even if the patient goes home, and they say, ‘I have no pain’, maybe they should take this, anyways, because of – for the – as an inflammatory?
Because if they outsmart you, and they don’t take it, and then a day later, they say, ‘Now it’s startin’ to hurt’, you’re behind again. So, the point would be taken that you wanna get ahead of things. Sometimes they would come in, and we would be – before we’d lean them back [laughs] to do the procedure, the girl – the little gal, my assistants, I love them to death, they’d come with a cup of water and a little envelope with 2 Motrins, 400 milligrams each, and it’d be down the hatch, before Ruddle even gave the injection.
So, I’d be getting blood levels, while I’m working, and when I’m done, I have serum levels. Isn’t that cool? And then, we’d say, ‘Take – take Motrin, 400 milligrams, q.i.d., for 2 days. And not – not for pain. ‘You’re takin’ it to reduce inflammation.’
Okay. Yeah. I have – I’ve had three root canals, and I did have the one problem, with the one. But even when that one was retreated, on the night of my first two root canals, and on the night of the retreatment, I could chew fine on those teeth. I mean, I didn’t really have any pain. It was pretty much like – I could chew normally. But I just was careful.
That’s the difference of going to a master clinician, Dr. Terry Pannkuk, and going to another one, and that’s Dr. – oh, I didn’t say his name.
Dr. X. Now, maybe in a future show, we’ll out Dr. X.
[laughs] I don’t know [laughs] that that’s necessary.
Well, we’ll have to take our meds first.
Okay. Well, that’s the end of this segment. Thanks, Dad, for another great Q&A, and that’s it. [laughs]
Thanks. And listen, keep your questions coming, because you would think these are pretty rudimentary, but they come in enough that, finally, we said, ‘We better address it.’
So, thanks. [Music playing]
SEGMENT 2: RETX – Silver Point Removal
Today, we’re gonna have a little lesson on how to remove silver points. Before I got started on this little assignment, Phyllis, my wife of 53 years, said, ‘Does anybody do silver points anymore?’ So, maybe just a little bit of background. In the ‘40s – the late ‘30s and ‘40s, a guy named Jasper introduced silver points to our profession. Soon, in the United States, it was taught in most dental schools. Thousands of dentists were taught how to replace them. Millions of patients received them. And the profession became pretty enamored with these radiopaque wires traveling through underprepared canals, but they looked good radiographically.
But the problem is, there was wide abuse, and silver points fell out of favor, because why? They leak internally, they’re round. It’s an elemental silver, as we all know. So, it’s round, theoretically. Canals are never round. So, there’s a great reliance on the sealer. So, if the sealer would begin to wash out, then the silver points could corrode, and these corrosion products have been known to stain tissues. You’ll see tattoos, okay? You’ll see absolutely tattoos in the attached and lining mucosa, if you practice for a few years. And those are, a lot of times, from a fistulous or a sinus tract.
Silver points can basically be thought of as three kinds. There’s many more, but three kinds. We have pretty thin ones and really very small silhouettes. And sometimes just on the manipulation of trying to remove them, they can disintegrate. Then, we have some that, on the opposite end [laughs], are like a post, and they’re huge. And then, of course, we have the sectional silver point. We’ll look at that right now. A lot of times, if a dentist was gonna do a post, as an example, they would take a silver point, notch it, place the silver point in a linear motion to length, then rotate the top, and they would break it off, right there. And that way, a post could go in, if deemed necessary.
So, we had thin ones, post-sized-like ones, and then, we have basically the sectional point, or the split cone. So, of course, techniques begin to evolve to address these three kinds of silver points in retreatment. And still today, many dentists around the world will send me cases and want coaching on how to remove silver points. So, even though they were taught many, many decades ago, and used probably through the ‘70s -- I knew people even in the ‘70s and early ‘80s that were still using them in certain kinds of cases – probably in today’s world, we’re not seeing any silver points placed to any large scale.
So, probably the removal of them will go down over more years, but we still see them. They’re one of the four commonly placed obturation materials we find in the canals, gutta-percha, silver points, carrier-based obturators, CBOs, and paste fillers. Well, when we retreat, we have to think about the silver point up in the chamber, because that part can easily be hit with a bur when we’re reintroducing our armamentarium to get access. And of course, the access cavity, as we drill down and brush away tooth structure or metals or composites or cements, it’s easy for that bur to inadvertently hit the top of the silver point, and all of a sudden, it can get shorter. And then, it’s much harder to get out, because there’s no handle.
This is the handle that we could use to get a purchase on it, to actually remove it. So, be careful on your access, and plan it thoughtfully. A lot of times, there’s a casting on this tooth, and if there’s a casting, you don’t see any of this. So, you just see a silver point going down sub crestal. So, be very careful on the access. It’s thoughtful, it’s planned, and you brush your way in. We don’t drill into the teeth. We brush cut our way, as we move towards the roof of the chamber, where it used to be, and finally, to uncover. So, the techniques that have emerged are quite a few. And we’re gonna go through all of these.
So, the list seems maybe a little formidable right now, but just get the list kind of in your head. And then, we’ll give examples, examples, and examples, and we’ll work our way through the list. This is not the complete list. And in fact, when I used to teach this class to people that traveled in from around the world, and in Santa Barbara, we gave a 2-day course, 10 hours each day, we were on silver points for 2 hours. Today I’m on it for 30 minutes. Okay. Let’s look at grasping pliers. Stieglitz are still one of the very best pliers that can be purchased to extract or extricate a silver point from a root canal system. They are too big. They’re a little bit too big, up in this area.
So, what Ruddle likes to do is modify them in a laboratory. So, I can go to a general dentist’s office, and they have lathes and wheels, and I can trim down these wings and make a smaller silhouette. I’m pretty careful not to really change too much the most distal aspect of the instrument. But this means you can introduce these down through a restrictive access, say, and then, you can open them and get over the silver point and close and get the purchase. Sometimes it’s hard to get them open if you have these wings. So, that’s a little trick. Of course, we can use direct and indirect ultrasonics to remove silver points.
Let me be very, very clear. We use direct ultrasonics – direct ultrasonics on cements, composites, amalgam fragments, to blow them up, to disintegrate them and uncover the head of the silver point. We never use ultrasonics directly on a silver point. Again, I said it was elemental silver. It is. It’s very soft, easy to abrade, and all of a sudden, an ultrasonic instrument can completely knock off and wipe out the handle that would’ve been where you grabbed it for the purchase to extricate it from the canal. So, we have coated tips. These are the ProUltras. They’re called the ProUltras, and these are from Dentsply Sirona. This has a zirconium nitrite coating.
I’ve said this before, but when we invented these, some years ago, what made them unique is, they were the first contra-angle instruments in the world, just like all your other tools. So, they actually fit easily over the mesial marginal ridge of a lower molar, into the MB or the ML systems. They were the first instruments in the world to be coated, so that they were abrasive, and they could actually cut more efficiently. And the third thing is, they were pretty much just – we’ll do two lines, parallel. This is tapered. But as you get down to the 4, the 5, and 6, 7, and 8, these are pretty much the first ones in the world that were parallel.
So, if we drop them in a canal, you could have a line of sight, a corridor of vision, alongside the instrument, so you could see the tip of the instrument engaging and working. So, that’s just a little bit about that. So, we’ll use ultrasonics on build-ups and cores that are hiding the silver point they’re entombed inside. And then, we’ll use indirect [with emphasis] ultrasonics. So, here we are, using the tapered number 2, and it’s a pretty stout instrument. It’s tapered, it’s strong, it’s effective. Notice that there’s no visual obstruction by a big head of a handpiece. A lot of times, I watch people in workshops, and they’re trying to see, because they’re using their high-speed handpiece, when they could eliminate that head.
Always chip out on that leading edge. If you’re breakin’ up a slab of concrete, and you’re in construction, and you’re runnin’ a jackhammer, you don’t start in the middle of a slab. You get out on a leading edge, and that vibratory sinusoidal wave will split, break up, and disintegrate even the hardest of cores. And as you begin to expose the MB, the DB, you can now work between the axial wall and the silver point. But if your instrument’s profile is a little bit too big, it’s okay to go to a smaller instrument that can fit into the space between the silver point and the axial wall. And that’s what we’re gonna be doing here in just a – right here. So, we switch tips. It’s a more appropriate size tip.
I can get a little bit deeper, and we wanna completely eliminate all the build-up from the pulp chamber and have the silver points visually identified. Okay. You can grab it with a plier, but a lot of times, I’ll have the assistant grab my plier, double pliers. That’s an idea. Think of fulcrum mechanics. That’s another trick. Double plier, first trick. Second one, fulcrum mechanics. In other words, don’t – indirect ultrasonics, okay? So, while you’re pulling and doing a little rocking motion, have the assistant hit the engaged Stieglitz with ultrasonics, and indirect [with emphasis] ultrasonics, you’ll send a powerful piezoelectric wave of energy down through the Stieglitz, into the engaged silver point.
Again, don’t just pull straight up. It’s a little rocking motion. Try to fulcrum off of something. Try to fulcrum a little bit. Fulcrum mechanics. Very powerful adjuncts to removing silver points. Little trick. When you uncover your silver points, and you just drop in, and you find everything, grab the silver point that’s exposed with a plier, and just test it. Give it a – a firm, little pull, vertical, out of the tooth. Judge the – the path of insertion is the path of removal. Pull on that axis and see if anything moves a little bit. If it’s not moving, don’t start grabbing it and really manipulating, because you’re gonna break the handle.
So, you’re pulling intentionally to see if it might move a little bit. If it does, then you can go ahead and do fulcrum mechanics or indirect ultrasonics or the double Stieglitz trick. Ha, ha! All right. So, we’re making some progress. Next -- I’m gonna pause this, if I can. I’ll set this up. This is a maxillary molar. We’re in the DB. It’s a sectional silver point. There is a four- to five-millimeter fragment in the DB. I presented this many years ago at the Chicago Midwinter Meeting. Phyllis and I were at the University of Illinois, about 20 or 30 miles away, and they used the Super Bowl truck, literally, that they use for the Super Bowl, to beam our signal to the McCormick Center, where there was a core audience of about 750 people.
So, I’m explaining to the audience how to remove a sectional silver point that’s deep in the DB. And we’re gonna be using some files, and we’re gonna be using some solvents. So, the solvent can be xylol or chloroform. You use a straight, stiff 10 file, and it’s pick, pick, pick, pick, pick, pick, pick. And you begin to undermine the sealer. The sealers are miscible in the solvent, typically. And so, as you begin to dissolve the sealer, the silver point becomes more free. So, after we use the 10, go right to the 15, put a little bit more solvent in the pulp chamber, and that’ll follow the pilot hole to the 10. Don’t take the 10 out, too quick. Try to get quite a bit past the head of the silver point.
Try to get good overlap, several millimeters. Now the 15 goes into that hole, same motion. At some point, you can start to actually insert the file on different orientations around the silver point, north, east, south, west. And a little bit more irrigation with the solvent, give you a little bit of visibility. Now you’re looking deep into the apical one third of that DB, that high magnification, we can push in, and we can see we have space. What you’re doing with these hand files is, you’re undermining the seal of the silver point, and you’re taking away material. That means you’re making vacated space. That vacated space has potential. We can talk about Hedstrom displacement.
Many years ago, I first talked about this, back in the late ‘70s. But if you can make some space, by removing sealers that were placed in that era -- they’re usually a Grossman type sealer, zinc oxide and eugenol -- then you have space lateral to the silver point. One of the most potent ideas to remove that silver point is Hedstrom displacement. Typically, you take a 35 or a 45, somewhere in there, and they have a positive rake angle. Silver’s very soft. So, you can take this Hedstrom, and this is not how you use them, if you were using them as a shaping file. But in a retreatment, you actually screw the Hedstrom gently but firmly into that vacated space, and you’ll see – you’ll actually see the Hedstrom form threads. It’ll actually make cutting grooves on this silver point.
When you get a pretty good overlap going, that means you have a better purchase, and sometimes then, if you go to pull the Hedstrom, the cutting side on the plastic, in this case, or in the dentin, it can be really hard to pull that Hedstrom up. So, if you’re having trouble pulling the Hedstrom up, I’m gonna show you a trick. But anyway, this is how it works. So, just keep watching, and you can see we’re beginning to slide that thing up. We’re beginning to haul it up and out of the tooth, and out it goes. So, that’s an idea. Make space for a more efficient instrument, Hedstrom displacement.
Now, back to this case in Chicago. We screw the 35 Hedstrom in, and then, this is called the Ruddle Post Removal System. It has extracting pliers. If you’re pulling on that Hedstrom, and you got both feet on their chest, and you got your assistant, you know, who’s a Nautilus gymnast, you know, very, very strong upper body, and you’re both pulling with all your might, and you can’t get it, take the extracting plier. By turning the screw knob clockwise, these two jaws begin to separate. And these two jaws, one pushes down on the tooth, one pulls up on the handle of the Hedstrom, and you can -- very control-y method, you can screw the knob, and you can jack that silver point fragment right out of the canal.
Let’s take a look and see how that’d work. So, you can see we’re mounting up on the extracting plier. And then, here we are, pop goes the weasel! Up comes that silver point, and that’s a real big thrill. So, crawl, walk, run. You don’t just jump into these cases immediately and start doing them. But you start with your gutta-percha removal. We talked about that. And then, you can start with some silver points and maybe some simpler teeth. I wanna come back to the Ruddle post-puller kit, and I wanna talk about microtubes. I’ve talked a lot about microtubes.
And what I’m not gonna talk about today, I will just say right now, I’ve talked in other segments about the File Removal System. It has specifically designed tubes that are designed to go over an obstruction. They can go over – over an obstruction to get a purchase. I’m not gonna talk about those, but I use that idea a lot in wispy silver points, the really small diameter ones, the ones that are – you know, you don’t wanna start wiggling the head of it, or you might break it. So, I wanna introduce another kind of a tube, and it comes right out of this kit. This is the number 1, and this is the number 2. And what’s important is the i.d., in this case, the inside diameter.
So, any silver point that’s sticking up into the pulp chamber, that is greater than 6/10 of a millimeter, that means almost all of them, you can tap it. It’s very soft silver. You can turn counterclockwise. This tape turns – okay? It’s not clockwise. Counterclockwise engages. Reverse screw, okay? And you can jump this over the head of a silver point that’s exposed. So, let’s take a look at this. So, here’s a preop. And you can see a silver point left in the mesial system. What you don’t see is that there were two silver points. One was in the DB, one was in the DL. Endodontist number one took those out Endodontist number two got it out of the ML. Okay?
The patient was upset with the first one, got upset with the second one because it was taking too much time. Maybe there’s just a communication problem. It takes as much time as it takes to be successful, right? Within reason, if you got the right technology, a little bit of training, and some experience. So, this is my preop. I took out the provisional, took out the cotton pellet. And you can see, there’s not much left. Here’s the floor. So, there’s not very much sticking up above the floor. What do you see? What do you think this is? I don’t draw right out. I’ll draw parallel to it. What do you think that is? What do you think that is? That is a shelf of overlying dentin. That’s pulpal roof. This is all pulpal roof.
So, if I can take that off with ultrasonics, brrr, brrr, okay. And I can take off, I can actually make the silver point appear to be longer. So, instead of being like this, now it’s like that! So, I have a bigger handle, a longer handle to grab. So, here we go. So, we have the movie, but these are just some still grabs. So, here is going back and forth, back and forth, back and forth, right up to that axial wall, right to the axial wall, and it’s gonna end up looking about like that. So, now, I have about two millimeters of silver point supra orifice level. I’m thrilled. I’ve also gone around a little bit, carefully, to expose it circumferentially.
Now, because it’s about 7- or 8/10 of a millimeter, I can bring in the number 1 tubular tap, tubular tap. And remember, it turns counterclockwise. You will then engage with its distal end the silver point. You can either pull straight up, or you can use the extracting plier, and, in a very controlled way, jack that silver point out of there. How about that? Well, retreatment’s fun, because it’s mechanical, so you’re always thinking. It's not this or this. It’s neither – either or, it’s usually and both. Lots of ideas. Once it’s out, then it’s cleaning and shaping. And what was kinda fun is, we ended up with gettin’ a third system.
So, there’s three – three portals of exit on the mesial root. And somewhere in the body, there’s another whole branch that Ruddle didn’t know. I was putting my files here. I was puttin’ my files there. I wasn’t aware of this one, whatsoever. Of course, we had two in this distal, so we got five portals of exit on that molar. And we still have good tooth structure, and we can go ahead and get the ferrule effect, and we can restore the tooth and have predictably successful results. Well, this was the last one on my list. Do you remember that? So, I want you to think about silver points. They corrode. And when they corrode, corrosion products leak out, and it causes osteolytic activity, bone loss. We sometimes will see a fistula develop. We can see a tattoo, as I’ve mentioned.
And sometimes these cases notoriously flare up, as we mentioned in a previous part of this same show. And this is sometimes – when you start to take a corroded wire and start manipulating it, maybe you used some chemicals, now you’re – brrr, and you use the ultrasound, you’re starting to get all the players together to create a riot! Okay? And maybe an insurrection [laughs] below the roots! You don’t wanna do that. So, let’s think about when we might use antibiotics and when we not. Just be careful. This is obviously draining, and the good news here is, we have laterally condensed gutta-percha.
So, everybody knows how to get gutta-percha out. Well, when you get that gutta-percha out, that silver point coronally is gonna start floppin’ around. And you’re gonna go, ‘Whoa! I think I can get to it. I think I might be able to extricate it.’ So, then, you only have to think about, is it gonna be a modified Stieglitz? Am I gonna grab it with my Stieglitz and hit it with ultrasound, indirect [with emphasis] ultrasonics? Is it gonna be tap and thread? Is it gonna be Hedstrom displacement? See, now you got some ideas. So, that’s how we looked at that case.
And why the EndoActivator? Because there’s anatomy in these teeth! You can’t see more than about 50 microns of resolution, so you don’t often see lateral canals on films. But you see evidence of lateral canals, because you see a lesion of endodontic origin, a LEO. And the LEOs form adjacent to the portals of exit. So, we road map this. And by road mapping, we can almost – in our mind’s eye, we can build a library of cases we’ve treated over the years, and we would expect a lateral canal. So, when you’re using chemical, as an example, you can get a slurry of chloropercha, and that can block or occlude the opening to the lateral canal.
Now your reagents don’t get into the lateral canal, and you can’t clean the lateral canal, and you leave stuff in the lateral canal. So, when you pack, you can’t overcome stuff left behind. So, what’s our major problem in failures, is we have residual tissue, after pulp death. So, we gotta get everything out. So, we need to have some idea to get these chemicals agitated, to get the slurries out, so we can open up the lateral anatomy and get our materials to flow in. Here we go. This is the EndoActivator. In the United States, it’s about $550 U.S. It uses a polymer tip. The polymer tip doesn’t cut. It fractures liquids.
Go to another segment and watch the shows. But we have 19 peer-reviewed scientific papers that validate its clinical use. You can choose the tip that you want, but when you’re – you can put these in chloroform or xylol! Ruddle said you can put them in chloroform, or you can put them in xylol! They will not melt. These are the most impervious tips in the business. They’re made of Delrin. That’s used in medicine. It’s used by orthopedic surgeons. So, go in here and agitate. So, after you get that silver point out, you can get the laterally condensed gutta-percha out, get all that out. Now you have a loose point. You’ll choose your method to get it out, get it purchase.
There’s not so much shaping to do, but there is some cleaning to do. So, fill this thing brim full with chloroform, hit it with the EndoActivator, do that for about 30 seconds, and then go right to your EDTA 17 percent, and do that for 1 minute. Now pull that out and use sodium hypochlorite. Well, I guess, gotta get everything in here, sodium hypochlorite, and you do that for one minute, okay. And now, you have the opportunity to clean laterally. Now, when you down pack, out with the lateral canal, back pack, and then watch the bone fill. So, here we are many, many years later, probably a couple decades, and notice how predictably successful endodontics is.
So, remember, it’s not just the silver point. It’s retreating the root canal system. So, real quick, we can finish up. I’m just coming back to some cautionary notes. You see these silver points. They’re not so easy to see, but maybe – maybe you see this one, in here. Maybe you kinda see this one, in here. They’re not so easy to see. So, when you’re tunneling back in, be careful, brush in, mesial to distal, buccal to lingual, as you progressively work towards the pulp chamber. You’ll see maybe a little shiny silver dot. Stop, get out your ultrasonic unit, brrr, start blowin’ out that build-up. The short one is the MB.
The lesion – here’s the radiographic apex. I’m reading the radiographic apex as right here. It’s kinda like that. But the canal comes up and ends over here, and we know that, because that’s where the lesion of endodontic origin is. It’s over on the side. So, we expect this to actually go up, could bifurcate, but probably it’s gonna come over like this. And then, we gotta do a little bit more work in the DB. It’s not properly shaped. It’s pretty much a parallel canal. I think the minimally invasive dentist will just love that shape.
If they could just imagine – I love this word, ‘imagine’. We’re gonna reimagine it’s not a silver point. It’s BC sealer. Now you’re lovin’ it! It’s a nice, skinny shape with BC sealer. All right? And so, a little endodontics, improve the shape, get to length. Notice that abrupt curve we made. I mean, rrrr, goes just like that, and the lesions do form adjacent to the portals of exit. We just beat that to death. There’s a couple systems in here. It’s a fin, a fin off the MB. So, that’s complete endodontics. And we got a good, straight-line access, right there. So, following the tenets that lead to success.
Now, this is a case that was shared to me by a dear friend of mine, Mike Scianamblo, Michael J. Scianamblo. Michael J. Scianamblo. We were classmates together at Harvard Forsyth in grad school, under my mentor, Al Krakow. And this is one of those heavy split-cone cases. I showed it as my first slide today. And you can see what’s going on is, there’s a little laterally condensed sealer, probably. But that is a massive [with emphasis] [laughs] distal end of a silver point. It’s like a post that was pounded in with a sledgehammer.
Notice where the lesion is! It’s not just apical. It’s a wrap-around lesion! Lesions wrap around, not because they’re trying to crawl up a drain, like we learned in dental school, a long time ago. They form there because we must anticipate there could be lateral anatomy. So, Mike gets back in here, drills down carefully. You can see, he identifies somethin’ shiny. Okay. Something shiny. He stops. Now he’s got to do ultrasound circumferentially around that, expose it more. Then he can use a 10 file, a 15 file, and he can work his way laterally, maybe – maybe you can see it. Maybe right there, you see just the end of the file.
Now I’ll get this out of the way, so you can see it. So, he’s bypassed the whole segment, 10, 15. Well, you can put a 25 Hedstrom in or a 30. I said 35 or 45, but if you don’t have the room, you could always drop down a little bit. And pop goes the weasel, and you can see, I don’t know, one, two, three, four, five, six, seven. And remember, A still does equal Pi R squared. So, that is a significant [with emphasis] foraminal diameter, probably more like 150, 160. But the key is, Mike has deep shape! He has deep shape! Every cross-sectional diameter’s getting smaller and smaller and smallest.
So, when he’s packing, he’s packing into resistance form. His reagents have limitations to how much they can move in an apical direction, because of the shape. So, deep shape is one of the biggest keys to predictably successful endodontics. So, there we go! Mike turned something that was a lemon into lemonade. And the last case, one of my referrals, he came in with a little problem, he said. He waited so long that he’s lost the crest of bone. He has a little infrabony pocket. So, he has a little infrabony pocket. You can see it’s probably scalloping around, like this, got a little furcal problem. It’s an old silver point case, very thin ones, medium-sized one, quite thick one, and all entombed in a build-up.
Measure twice, you can only cut once. So, basically, you know, we got them out. Do a lot of irrigation. If you looked very carefully, there is a little bit of communication, out here. There’s a little communication. Larry passed away, so I never saw him again, but I was always wondering, ‘I wonder how the bone worked at the moment he did pass away’, because it was about two years later, but he had the tooth. And that’s a little lesson today on retreatment. We talked about silver points, and in that context, may you get your silver points out, may you have some ideas and some ways to think about doing it, and have some fun. Crawl, walk, run. [Music playing]
CLOSE: Ruddle Rant
Okay. So, we’re gonna close our show today with another Ruddle Rant.
And if you haven’t seen the last one we did, it’s where my dad, Cliff [laughs], has a minute to talk about a topic and to say whatever he feels that he needs to say about it. Okay. Don’t start it yet. And we have this little timer here, that’s a minute. So, he gets to talk until it runs out, and then, he gets cut off. He has to stop.
He can’t even finish a sentence. Okay. So, here is the first topic for you. The first topic is leaving bacteria behind.
Oh, that makes me really angry. You know, I went to Boston for graduate school. And of course, the whole emphasis is, remove the root canal system, like the extraction! But then, we have clowns out there that write articles, and they want to leave bacteria behind. And there’s a new model for learning, and there’s a new healing model, and there’s a biological model that’s emerged just in recent memory. And now, we can leave bacteria behind.
Talk to – talk to them. [laughs]
Oh! So, anyway, I love how we fight about leaving bacteria behind. Have I left bacteria behind? Course I’ve left bacteria behind! Because I don’t think we get them all out. But I’d never advocate, ‘Let’s try to leave bacteria behind! And let’s work on a different biological model.’ It’s pretty – it’s small thinking, because make it easy. Extract the tooth, and the bone will grow back in, and everybody’ll be happy, and the patients will smile. Leave bacteria behind, and you have to be God, chairside. You have to decide, ‘This person has to have bacteria! This person gets a clean root canal system!’
Oh, so – okay.
Time’s up. So, just – to just summarize really quick, is that one of the reasons why root canals fail most often is because bacteria’s left behind?
[laughs] I have a lot to say that I couldn’t say.
100 percent of all endodontic failures, regardless of etiology, is microbial. That’s bacteria. So, if we start with the end in mind, we might wanna eliminate the cause of failure.
Okay. Next topic is the AAE Discussion Forum.
Well, the AAE Discussion Forum is, in the purest sense, it’s a wonderful model for colleagues all over the world to come online [with great emphasis] and pose a question [yelling] and get an answer [yelling]! And that’s really nice. The only problem is, it’s always about the same three or four people that are doing all the answering, and there’s people lurking. You can tell, there’s lurkers, because all of a sudden, they come up [yelling]! You know, the go – they come --
-- out of nowhere! And they ask another question [yelling] about calculus on the roots! [practically screaming] And I’m going, ‘My God. They talked about calculus – okay. So, you grease the flap, and lift up the flap, and some people saw calculus. It looked like calculus, it smelled like calculus, it had the appearance [with emphasis] of calculus.’ Then there was a periodontist. He goes like, ‘There’s no calculus [yelling] on roots! That’s a misnomer.’ Well, I’m sitting here going, ‘Doesn’t anybody biopsy anymore? All’s we do is cut off the end of the root and send it off to histology. Histologists come back and say, “There’s calcoferrites [sounds like]. There are calcium deposits on that root!” That would be calculus.’
So [laughingly], maybe you need to insert your comments into the Forum. [laughs]
I would never pose a question on the Forum, because I notice – well, it’s quite civil now. You know, it used to – they took it down, as you know, for months. We had that discussion. And now that it’s been re-resurrected, I almost feel like there’s policemen.
I almost feel like there’s a guard, like on every block. Maybe it’s like Washington, D.C., we got the razor wire around – to keep out the bad questions, the bad people, the people that spark a little controversy. Keep them out!
The policeman is Mom, over your shoulder [laughs]. I don’t think you should jump into this [laughs] mess.
I will say, though, the – the concept of the Forum is excellent, and there are some good people. I’ve mentioned Richard Schwartz. He’s a dear friend. He’s a very nice guy. But sometimes I wonder, also, by the questions, ‘Did anybody go to grad school?’
All right. The last one is more of a personal topic for you.
And it’s the Las Vegas Raiders.
Thought you weren’t gonna get personal. Well, my problem is, having ran a business for almost 50 years, and looking at organizations around the world in dentistry, how come some practices are always doing well, and some are always struggling? And then, I think of my Raiders! Formerly the Oakland Raiders, now the Las Vegas Raiders, pride and pose, silver and black, commitment to excellence! Right? Well, that was like 20 years ago! [yelling] So, how come you can have like the New England Patriots, they’re always in the games. They’re always going to the playoffs. The Green Bay Packers! The Lambs, I mean the Rams, I mean they even got to go a couple times.
How come an organization can’t get back? It makes me think it’s an ownership deal. At some point you could say, ‘Well, we didn’t have a quarterback. He broke his ankle. Oh, our wide receiver, he burned his feet, by God! He went into that sauna, and he just burned those feet, and he couldn’t get his feet down to run the flight path!’ Oh, you can blame all that, but you know what? It’s probably the Coach, the owner, the Quarterback Coach, the Linebacker Coach [yelling], the Defensive Coach! It’s about leadership!
Okay. Time’s up.
Yeah. It sounds like there might be a little bit of a defensive problem there. But they fired their Defensive Coordinator [laughs]. So, maybe it’ll be different next year. [laughs]
They should be able to get back to the playoffs! You know? A little bit better every time, like in endo, you get a little better, every case. Right?
Well, next year. [Music playing]
Next year. Yeah. That’s what we always say, ‘Next year for the Raiders!’
[laughs] Okay. Well, that’s our show for today. Hope you enjoyed it. And see you next time, on “The Ruddle Show”.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.