Dr. Herbert Schilder used the title, "Predictably Successful Endodontics," to describe many of the lectures he gave over about a 40-year timeline. In the most simple and direct way, these words promise longterm treatment success that is not only possible, but attainable...
Tough Questions & Choices The Appropriate Canal Shape & Treatment Options
This show opens with Ruddle sharing the extensive process that goes in to creating an episode of The Ruddle Show. Next, Ruddle explores another Tough Question: What is the appropriate shape of a finished canal preparation. Then, Ruddle discusses choosing to retreat nonsurgically vs. surgically. Stay tuned for the close of the show which will feature another “Good News/Bad News” segment…because sometimes the distinction can get a little blurred.
Show Content & Timecodes00:10 - INTRO: The Ruddle Show Creation Process 06:03 - SEGMENT 1: Tough Questions - What is the Appropriate Canal Shape? 22:37 - SEGMENT 2: NSRCT vs. Surgery 47:45 - CLOSE: Good News/Bad News
Extra content referenced within show:
Extra movie/video content:
Downloadable PDFs & Related Materials
Never in the history of clinical endodontics have dentists been able to prepare root canals with such safety, efficiency, and predictability. Regardless of the current shaping systems utilized, the mechanical and biological objectives for predictably successful outcomes may be found...
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Ruddle on Retreatment Supply List and Supplier Contact Information Listing
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: The Ruddle Show Creation Process
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing today?
I’m enjoying the rain.
Well, great. Okay. So, we thought it would be a good idea to open our show today by letting you know what all goes into creating an episode of The Ruddle Show, up to the moment when we’re sitting here at the desk, filming, because maybe you’re curious. So, we pretty – we – right now, we have a pretty good system in place. My dad and I meet a couple times a week by Zoom, during the season, to brainstorm about the segments. But before we even get into the season, we sit down, and we brainstorm a bunch of ideas and topics that we’re going to cover in the season.
Yeah. My responsibility is educational segments; try to pick them timely, relevant. We look at new technologies or emerging technologies, controversies. We look at guests, featured guests who we are going to have on next. There’s a lot of people to choose from. And then, finally, we do a little bit on lifestyle and community.
Right. And after we write down a bunch of ideas, then we lay out 10 to 20 shows, and we give it to the rest of the Ruddle Team for their approval and feedback.
Yeah. We do do that. Well, when we design shows, we try to design them – every show – we want variety, of course. But “meat and potatoes” is a word I’ve been using around our group, and so, Lisa wanted me to say what is “meat and potatoes”? Well, meat and potatoes is really relevant stuff. It’s not like ubiquitous. So, it means to be critical thinking, need to look at things, like we are going to do later in this show, on diagnostics to make you a better diagnostician. I want you to treatment plan for no surprises. Of course, along the way, we want to grow you, make you better, and create value.
Yeah. We do have a lot of talk about meat and potatoes. For two people who are mostly [laughs] vegetarian, it’s kind of funny.
But we do eat a little bit of meat. But those are, I think, what my dad is looking for, that core educational segments that he wants included in the shows. And so, when we’re planning a segment, I just ask my dad a lot of questions and I take a lot of notes. And then, I come up with a script, but it’s mostly just a general outline of how the segment’s going to go, to help us organize our thoughts and our ideas. And of course, when he does his lectures over at the side board, he plans those himself.
Yeah. I’ve gotten a fair amount of criticism. Can we say “criticism”?
Because I tend to go over. So, we don’t have to reshoot things because there’s a lot of mistakes. It’s because it’s too long. So, my biggest challenge is, most of my 48 years of professional lecturing has been all-day courses. Obviously, when I travel overseas, a lot of them were all-day or week-long courses. But then, you get into some 4-hour mornings or afternoons, 2 hours, and the hardest shot is the 20-minute segment, which we do here. And 20 minutes – I make an error sometimes, because I assume that not everybody’s watching all the shows in continuity.
So, I worry a little bit, do they have enough foundational material, to understand what we’re talking about, right now? Obviously, some of the audience would. So, I get – I’ve got to remember to start on a topic and not go back to the very beginning, as you like --
-- to say. I don’t have to tell them from the – “Well, when I left grad school, it went like” – okay. So, I gotta get a little bit more on point, like I do right now. And then, finally, the thing that really is most challenging, is I – okay. Make the lectures, get them short and tight. It’s the other things we do, in the variety part, that are more challenging for me, because a lot of times, I’m not an expert, as you well know, but I need to read enough so that I can have an intelligent conversation.
Yeah. Like when we did – when we talk about AI, teledentistry, CBD, we’re not experts, but we want to be able to present the information somewhat intelligently, like we have some knowledge. But --
And spark interest.
-- yeah. But it’s not – we don’t claim to be experts. And usually, when we’re meeting for the show that’s upcoming, we decide what we’re going to talk about in the opener that week. And also, we decide what graphics we’re going to need, and then Isaac works on those, and I help a little bit with that. And then, we show up here on Wednesday. Lori and Isaac set everything up, and we shoot. And then, we’re done. We move onto the next show after that [laughs].
Well, we’re kind of done, because our part --
[laughs] Our job is done.
-- our part is done, but then, what we immediately do is, we start hustling, because we hear the fast followers behind us. And that would be Isaac and Lori, because they need to do a lot of post work, to bring it in.
Yeah. We’re usually about four shows ahead of the launch. And after we shoot, they have to do the Show Notes, Lori does that. They have to do all the editing, get ready to launch the show. Lori does a lot of follow-up with guests. And so, we’ll actually have another creation process opener, but it will be Part 2, and it will talk about what happens from the time we shoot until the time the show launches.
So, that’s what – that’s how we do it. And it’s working pretty well for us, right now. We’re going to keep doing it this way for a while. And let’s just get on with the show now.
SEGMENT 1: Tough Questions – What is the Appropriate Canal Shape?
Today, we have another “Tough Questions” segment for you. And in case you didn’t see the last one, this segment is when we explore a tough question that maybe doesn’t seem to have a clear-cut answer, right off the bat, or it may be a little controversial. But our hope is, is that after our discussion, you will maybe have a clearer idea of where you stand on the issue. So, here we go. Our tough question for this segment is, what is the appropriate shape?
Well, let’s talk about the appropriate shape, because there sure is a lot of controversy out there, and we have everybody talking about different things. They kind of forgot the Bible! The Bible would have been Herb Schilder. I mean, Dr. – Professor Herb Schilder, in around 1960, was doing this kind of endodontics. And when you notice the pier abutment and a long splint, you can see an appropriate shape that’s root appropriate. You can see picking up anatomy. You can see on a molar abutment good concepts, filling root canal systems. And then, of course, two articles, and the one that is the most seminal for shaping, it's the most frequently quoted article in the world, is the 1974 article.
So, then, he finally came along earlier, and it said, “Well, here’s how you film.” But then, we didn’t know how to shape them. So then, he had to tell us how to shape them. But he gave, in his famous paper, right here, he gave the “Five Mechanical Objectives” that, when accomplished, fulfill the biological objectives. Are you ready to look now [laughs]?
Yeah. Let’s see the video.
All right. Well, to illuminate what we’re supposed to be doing, he gave the famous “Five Objectives.” And what we’ll do is, we’ll just look at them in an animation, and we’ll talk about each one separately and how it all ties together. The funnel. The funnel can be stretched out. It can be a big funnel. It can be a smaller funnel. But the funnel can be curved in multiple dimensions. And it can be root appropriate. I want to keep stressing that. He never said a big diameter. He said, “root appropriate.” The next concept was continuous tapering preparation. Now, in a continuous tapering preparation, in general, every cross section of geometry as one moves towards the terminus, is getting smaller and smaller and smaller.
When you look at the companion canal that was not shaped, you can see normal anatomy is generally a decreasing, funnel-shaped preparation to length. So, you go in multiple planes. We look at the mesial and distal dimensions on a film. But remember, canals curve in and out of the primary beam. So, they’re meandering through the root canal. The third objective was, maintain the original anatomy. So, we follow the original pathway, and our files follow perfectly and cut a little bigger shape, to get into the dentin and clean better and to give us a shape that will hold a reservoir of irrigation.
The fourth one was, maintain the position of the foramen. Many dentists, in shaping procedures, start ripping and tearing that foramen. Herb didn’t really want us to enlarge it. “Herb” is Dr. Schilder. He wanted us to just gently, minutely open it a little bit. The irrigant would do the cleaning. And finally, keep the foramen is small as practical. Sometimes these foramina are very small, sometimes they’re rounder, sometimes they’re irregular. We’re not obligated to make a round foramen. Just a few microns up into the bottom of the canal, the instruments will cut a pretty much round shape. You might get a little reverse architecture in that last half millimeter.
So, in general, that was the description he gave us, back in ’74. That’s kind of what I learned, when I was back in Boston, in the middle ‘70s. And if you do those kinds of shapes, you’re going to fulfill the biological objectives, and you’re going to treat root canal systems. Because you’re cleaning the lateral anatomy, almost as if you weren’t even trying, because the shapes are sufficiently appropriate for the root, that we can get reagents in there, and then, we can fill root canal systems, if we’ve cleaned out the anatomy.
Okay. Let’s bring back our question. Okay. So, thank you for that review about the mechanical and biological objectives. Clearly, you need to get all the bacteria out. And you need to do this with a plan in mind. And obviously, you need a shape that’s big enough, so that you’re going to be able to irrigate, to get the bacteria out, and then also, to be able to subsequently obturate. So, I often hear you talk about “deep shape.” Now, can you tell us a little bit more about what is deep shape and why it’s so important?
Well, deep shape is how we fill root canal systems. I’ve always understood deep shape. Steve Buchanan has always understood deep shape. John West, Pierre Machtou, because of Herb Schilder. Everybody wants to talk about how big is the terminus. How big is the terminus? They’re always, “Is it this, is it that, is it that?” That’s not how I think. I think more about a little more deep shape, because what that deep shape will do is, it’ll address the anatomy. The preponderance of the anatomy is in the apical one third. So, fortunately, we have files today that have a conservative body, but give us the full, deep shape.
And I’m not talking about two percent, four percent, and even sometimes six percent. Six percent, you’re flirting with it. Okay? But if you start to get to seven or eight or nine, there’s plenty of science that shows, you exchange irrigants. And so, we have the deep shape, so we can get our reagents in there and clean laterally, off the body of the canal. And of course, if we’ve cleaned the anatomy, it’s vacated space, and that’ll help us push thermosoftened obturation materials into that anatomy. So, that is the importance of deep shape. It’s more a taper thing than it is, how big is the terminus?
What is the easiest way to get deep shape, though?
Well, in the old days, Lisette, I used to use maybe 11 hand files and 4 GG’s. Does that sound like about 15 instruments? And through many recapitulations, through that series, and again, and again, we could carve out a really uniform, flowing shape, and we could do it. Today, the files have these shapes, at least the ProTaper family of instruments and WaveOne Gold. I can only speak about those two, because a lot of files are four percent and six percent. They’re not giving you deep shape. So, we were able to put those kinds of Schilderian ideas and embed them into the file system itself. So, without really thinking about it, we can reduce the 11 to 15 instruments, down to – well, WaveOne would be primarily 1 file, and with ProTaper, you can do it with 3 or 4 files.
Okay. So, the shape needs to be big enough so that you can irrigate. And I guess the taper is also important, to hold the obturation material as well?
A moment of clarity. You know, listen! Everybody – I’m going to say it again. Everybody’s talking about terminal diameter. The taper is what limits the reagent. Just this morning -- I’m going off script. Oh, there’s a huge thing on the Endo Discussion. Massive bone loss with GentleWave use! I thought it was massive healing. I thought it was really quick. But they had another accident! And it got into the nasal septum, destroyed a lot of bone! So, the taper is what limits and restricts your reagent to moving beyond the foramen, and it also holds our thermosoftened obturation material. So, the beauty is, it allows us to clean and shape and pack with great clarity and great control.
Okay. Well, let’s talk a little bit about terminal diameter now, because I’ve heard you say that what students are taught, as far as how big should the terminal diameter be, can vary among different graduate programs. And sometimes students are taught a number, like for example, “Shape to a size 40, and then you’re done.”
Is there a problem with this?
Well, you just described the cookie-cutter operation. So, if I was running a factory, and I was making cookies, I wouldn’t want it to be like a root canal system anatomy, where every one’s different [laughs]. I’d have to have a cookie cutter line. So, that’s not how anatomy comes in. There’s big ones, there’s small ones, there’s short ones, there’s long ones, there’s curved ones, more recurved, recurvature. So, basically, the problem with over-preparing, because 40 would be totally inappropriate, okay, for most teeth.
I mean, start thinking about these guys, down here, mandibular incisors. So, the problem with the big boxes that they made is, a lot of times, as small root forms, you can make a big foramen, but now you’re more parallel, because you can’t keep taking that out over distance, or you materially weaken the root. So, the problem with the big preparations was, we didn’t restrict and limit our irrigation and packing. We lost control, if you will. We had more postoperative pain, more bloody canals, surgeries.
And I think I wrote something about, even the people out there, endodontists now primarily, you love that 30.06, right? That 30.06. That 30.06 is 1.26 at D16. That’s huge! That’s almost as big as a GG5! So, come on, please! Iatrogenically, when you make these big shapes, you rip foramina. You have transportations. You have blocks, ledges, wet canals, surgeries, things like that. So, that’s been part of the problems with the big ones.
Why would you even overprepare a canal? Like what would motivate you to carry a bigger file to length?
Aha! The question behind the answer. The reason most academic schools and programs taught a 30, 35 -- a lot of schools liked a 40. That Wallace review paper that we talked about in previous shows, over 1,000 articles cited, 40.06 was the favorite shape. They taught that if you made it a 40, you could make a round foramen. And since nobody was largely doing warm gutta-percha in that era, the theoretically round gutta-percha cone would fit the theoretically round preparation you just made, and you would get a better seal.
So, they said, “Make it big, make it round!” Hey, when you use warm gutta-percha, you don’t care what the configuration is of the terminus. You’ll mold gutta-percha – thermosoftened gutta-percha, that is, into the configuration. The other idea was you can get reagents there. If you start to make it really big, they had science that showed that they could get their reagents to length. Therefore, it could work for all this preponderance of anatomy is. But they weren’t talking about that. They weren’t talking about that. They were just talking about size, 40, 45, 50, 30. Going too small, underpreparing, that reminds me of kind of modern endodontics. That’s GentleWave, people.
Now, we have great GentleWave clinicians. They understand this, but a lot of them don’t. Just read the – just read the web – the chatter, the chat rooms, and you’ll find out there’s accidents, there’s blood, there’s this. So, when we underprepare, we run the risk of maybe not even cleaning out the canal. Now, the question is, does your technology overcome your deficiencies in training? Will it really suck out the pulp in that apical stump? Okay? So, that’s a problem. And then, of course, more unprepared canals are more parallel canals, and therefore, that’s why we have these sodium hypochlorite accidents.
I haven’t shown you yet, we have to answer. We got an email from Canada, a woman, and she’s working on a molar, and she – her instrument’s two millimeters long, and it’s in the sinus. And she’s surprised the patient’s in agony that night. She thinks it’s her file in the sinus. No, it’s not that her file’s in the sinus. It’s the sodium hypochlorite’s in her sinus! Because when you get that kind of a severe pain, that’s not because you pushed a file one millimeter, two millimeters long. That’s because you have chemistry working. You get huge reactions.
Okay. I guess if you’re underpreparing a canal, and you think, “Well, I can clean it with GentleWave,” but then, how are you going to obturate it, too? That would be an issue?
Thank you for bringing that up. I have said quite regularly on this show, so, don’t conceive that I’m a GentleWave hater, I think the technology’s interesting, and it can clean root canal systems. But to your point, there’s no visual evidence, we have very little research that shows this, I think it can clean well, but it invites under-instrumentation. And that invites parallel canals, obturation overextensions, irrigation problems, bloody canals, things like that. So, there’s really no evidence-based research that shows how to fill these things in a predictable way.
You’re getting back to how do you fill these underprepared canals. So, it’s led to single cone, it’s led to tricalcium silicate sealers, BC sealers, things like that. There’s very little evidence on this. Everybody likes to yell and scream about all their papers. A guy in Canada invented BC sealers, sent me this much information about all the documentation. But you know what? It wasn’t documentation as used as a sealer! It was as a surgical repair material.
Okay. So, I’m hearing – is what I’m hearing – I’m hearing a lot of issues. And I’m just going to summarize them.
I’m hearing that you need to consider the mechanical and biological objectives. You need to consider the anatomy of the tooth. And then, have in your mind concepts like small is practical in deep shape. And then, the answer should be a lot clearer to this question, what the appropriate shape is.
You know, you just said it. And if generations of dentists would learn that in school, they would come out, they could pick their files easier, they could pick a lot of things easier. Because right now, when you see 200 file systems on the market, does that mean there’s clarity with the mechanical objectives? No, it means there’s total confusion. Nobody has the North Star. Nobody seems to have the guiding light to illuminate the pathway ahead.
Okay. Well, this kind of brings us to the next question. I heard you mention ProTaper and WaveOne. Are there certain file systems that maybe might help you achieve the shape you want to achieve? Some – are some file systems better than others? But I know you also made beautiful shapes before WaveOne or ProTaper was even invented.
Yes, there were many, many clinicians, I think, like myself -- I hope I’m in that group, that could make beautiful, flowing shapes that followed the original anatomy. They were root appropriate. They were able to hold reagent. Reagents could exchange. We could fill root canals systems, and the tooth had to be properly restored. So, there are – getting away from that, 11 and 4 GGs, maybe 15 instruments, yes, there are – we said already, WaveOne Gold is a 25.07. Now, the key thing for the audience is, because I don’t expect everybody just to grasp this, the seven-percent deep shape is only in the apical extent of the instrument. Behind the seven percent is like six and a half, six, five and a half, five.
So, you keep the body smaller and more conservative, so we don’t infringe on furcation-side concavities. So, WaveOne has these things and Schilderian ideas built inside the file. ProTaper has a purple, white, and then we have a yellow and a red, two shapers and two finishers. It gives us beautiful shapes. It also has regressive-percentage tapers on the back end. The finishers that are seven, eight, and nine percent, the biggest in the business, okay? But there’s not seven, eight, or nine over distance. They’re just in the apical one third. So, we can still have a conservative body, to maximize remaining dentin, and still have the deep shape.
Okay. Well, thank you for breaking it down in such a clear and methodical way. It’s funny that the question, “What is the appropriate shape?” can be so controversial to so many clinicians, because when you explain it like you did, it seems like it’s pretty clear what you need to consider.
If I get my hands on you, I can make you Herb Schilder in three days.
[laughs] Okay. Well, that’s that – our segment, our “Tough Questions” segment.
If they had desire.
Okay. We’ll think of another tough question for our next time we do this segment [laughs]. But that’s the end of this one. Thank you, and I guess you’re going to give us a lecture now.
Okay. We’re going to maybe talk a little bit more about this, as we apply it to surgery versus non-surgical.
SEGMENT 2: NSRCT vs. Surgery
My topic today is “Non-Surgical versus Surgical Treatment”. Now, let me just make a little explanation. Traditionally, we have said “conventional treatment” to imply you’re the first one in, and the last person out. Then, we have said there is “non-surgical root canal treatment”, meaning not a flap, and it’s already been treated. And then, there’s “surgical root canal treatment.” And that’s obvious, surgery. But many people understand non-surgical treatment as anything short of surgery. Could it even be retreatment?
So, I’m going to say, “conventional treatment” is first one in. “Non-surgical” is, it’s already been treated. And then, there’s the surgical cases. So, we’re going to talk about this today. And thank goodness, we had that “Tough Questions” segment, because that really helped us better understand how to look at cases that are failing and how to make that decision, “Should we use the scalpel this time, or should we be able to disassemble and get back in these teeth?” So, I want to just talk about Frank Paque. His micro CTs are always the Bible. Whether they’re his or somebody else’s, the micro CTs give us a glimpse of what it is we’re trying to do.
So, whether you’re doing conventional treatment, non-surgical retreatment, or surgical treatment, you are always keeping in mind the anatomy of the human teeth, the only thing that hasn’t changed, since the beginning of time. Well – so, here's our first decision, surgical or non-surgical. You might say, well, the history is, the general dentist did a root canal on the central incisors, the lateral. Okay. This is number 23 in the United States, and this guy right here would be number 24. Okay. That didn’t work, went to the endodontist. The endodontist did an apicoectomy on both of them and thought, “Well, gee, the lesion’s big, and it’s wrapping around the canine. Maybe I should just include it, because I’m here.”
That would be a very poor reason to put a retrograde in a coronally empty canal, completely empty. The idea would be that this retrograde would incarcerate bacteria and tissue and breakdown products over the life of the patient. That would be unpredictable. So, what are you going to do? We decided, it’s surgery. For years, we had textbooks this big, and we could use alloy, amalgam, as a root end repair material. And if we had all that histology and we saw all those success cases, then obviously, we don’t have to go in surgically and try to remove this amalgam, because it’s already reasonably biocompatible. So, the idea was, why don’t we just go back through the canine with a careful access?
This is splinted, as you can see. And let’s make a careful access and go ahead and treat it. So, here we are, at about five years. You can see the bone is coming in nicely around the 24, the number 24, a little scarring here on 23. We’ve pushed the retro out of the way. We pick – remember, tough questions, narrowest cross-sectional diameter apically, packing into resistance form, developing hydraulics. Out with the lateral canal and notice the healing. Notice all the bone repairing, when we just did the right tooth. So, there’s our first example of the decision tree. What’s next? Well, this amalgam has been placed a little better.
And again, this is bread-and-butter stuff. This happens all over the world! So, it was sent to him to do surgery, because there was pain. And since these are all splinted together, when you percuss, nothing really hurts. But I looked at this case, and things that don’t look right usually aren’t right. So, if I’m going to go in here and do surgery on this, shouldn’t I do a preparatory visit first, and see if I can improve on the seal? And so, what we did is, we did the tooth over here. It has amalgam up the canal a little bit, but are you noticing – are you really looking? I know you CBCT people, you’re going to go, “Yeah. I saw it!” Do you see the infrabony pocket? Okay? Do you see something’s wrong in there?
If you look carefully and thoughtfully, with a discerning eye, you’re going to see a lot of early lesions. So, we slide it over, and you can see out with two significant portals of exit. And remember, the portals of exit are pathways for breakdown products to egress through. So, if you want to treat lesions of endodontic origin, we don’t want to just try to worry about the apical portal of exit. Look at the size of this, and the very small in there. Right to the base of the infrabony pocket. So, lesions of endodontic origin form adjacent to portals of exit. You can take that home. That’s Biblical, in endodontics.
Another case sent in. Surgery, non-surgery? It was sent in for surgery! The dentist said, “You know, he was in a lot of pain like a month ago, and I did the canine.” Incidentally, the canine is like from a zoo! I mean, can you believe how long this is! I thought it was a gorilla! But then, I realized there was a patient attached to the tooth. But this thing, from here to here, is about 28 millimeters of fun, for that dentist. Anyway, he did that. And he said, “The symptoms didn’t go away! And now I think you should do surgery, because there’s a developing lesion.” But if you look carefully at my preop film, what do you notice?
We’ve had other segments about the rules and laws of symmetry. And if you look at the distance from here to the cavosurface, and then if you look at something over here like this, you can see there’s another whole root on this tooth. So, the prescription on a napkin is, if you’re going to do surgery here, at least have all your conventional work done, first. So, we slide it over. You can see, Ruddle just treated the system there by itself. This would be the buccal. Ruddle treated the lingual. That’s this one. That’s this one. Little different shapes, as you compare the shapes along the cross-sectional diameters. But that alone took care of the patient’s swelling in their vestibule. That alone took care of their symptoms. We can always do surgery at another time, right?
So, make yourself the patient, and you’ll have the answer. We don’t have to rush in and do surgery on every radiolucency. Let’s be patient and get a good history, and then let’s follow things appropriately. Okay. I’m having a lot of fun now! Non-surgery versus surgery. I’m just warming up! I’m to my eighth slide! All right, what’s wrong with this case? Well, it’s one of those cases that has a three-rooted, maxillary, left bicuspid. You can see there’s some evidence of something in here. I think the endo was done for laughs. It was just a pretend endo. But if you’re the patient, are you going to go in and approach this surgically?
There’s three roots, so you’re going to have your classic buccals. And then, you’re going to have your palatal back in there. Are you going to be able to come through this crown and get into all those different pathways? So – you know? We just thought we should just do the right thing. Careful access cavity, find the orifices, get that paste out of there, those paste fillers. Sometimes they’re brick hard, aren’t they? Get those out, the cleaning, the shaping. And remember in the first “Tough Questions,” keep the foramen as small as practical [heavy emphasis on the last four words]! I better write that out, because a lot of people around the world are trying to go with “possible.” A possible would be a 0.06 file! That’s not what Schilder said! Practical! It might be a 20 or a 25 or a 50. It depends. So, that’s how we handled that case.
So, going back to that animation I showed you on the “Five Objectives,” let’s go back here for a second. In a classic shape, it’s about 10 percent, about 10 percent taper. In other words, this is one millimeter, this is two millimeters, this is three millimeters, this is four millimeters. 4 millimeters back, we have a 60 file. But we held the foramen really small with the more flexible files. What’s emphasized is deep shape! So, if you get bigger by 0.1 millimeter every 1 millimeter, that sounds like you could do the math. It’s 10 percent. So, you now can pack and clean into resistance form. Well, what if they’re bigger? They’re -- a lot of times, they’re bigger. We have to know how to handle that.
So, when they’re bigger, we simply have to flush those disks out of the foramen in our minds, and we can travel to a bigger instrument. But you really only capture the true diameter of the foramen, if [with emphasis] and only if [with greater emphasis] each sequential subsequent file uniformly steps up out of the canal! Boom, boom, boom, boom! Half short, one short, one and a half, two, two and a half! Okay. When you have that in your mind, because you can prove it on your files, hey, listen. Just throw the files in. After you’ve shaped, okay? You’re all done shaping.
This is a trick, a Ruddle trick. Gauging and tuning – from a long time ago. When you’re all done with the shape, ask for the last file to length. And let’s just say for fun it was a 20. Tap the handle, take it out, it’s at length. “25, please!” 25 comes in, loose. When you feel resistance, take your plier, push the stop down. 30! 35, 40. 45, 50. Push the stops down. Push. Those files are stepping, each one, away from length. That means you can see in your mind’s eye the deep shape, and it would look just like that. Well, they’re not all 35s, are they? Sometimes they’re even bigger. And when they’re bigger, we start to get into a little dilemma.
How big can a foramen be, and we can still get shape, coronal – get shape, coronal to the foramen, so we’re packing into resistance form, so our reagents are limited, because of the capture zone. When you get, in my experience, to about a 50 or a 60, you still can do conventional treatment. You still can do conventional treatment. Oh, I love writing! This is a big writing area! Conventional! But when you start to get bigger than 50 or 60, we have to start thinking about a barrier, something that can go in the apical third, to block and be a backstop, so we don’t push stuff out, and also to control bleeding, so blood doesn’t come in.
So, that’s what we have to think about, is a barrier technique. Well, look at this case. This was referred in to Ruddle. It had been to the general dentist. This case had been going on for four months. Antibiotics! Anti-inflammatories! A few narcotics sprinkled into the cocktail! If you look at this, this dentist could never keep this tooth closed. This dentist could never keep the tooth closed! Every time he provisionalized, within 48 hours, the patient was in agony. It was referred finally to an oral surgeon, Ashamalla, here in town, and then Ashamalla recognized it wasn’t a fractured tooth, which the general dentist said, “It’s fractured. Take it out,” because every time the patient went on an antibiotic, they became asymptomatic.
You can’t have a fractured tooth that becomes asymptomatic on an antibiotic! No chance! So, when I saw it, I said to the lady, “We’re going to go ahead and finish this in 30 minutes.” She said, ‘Oh, no, no, you can’t, because every time it’s closed, I – I have a lot of pain!’ I said, “We’ll schedule you at 7:00 in the morning. If you have a problem, I’ll see you at 10:00, and we’ll take care of it. But we can’t just keep open, close, open, close.” So, what do we do? First of all, I’m pretty close to the monitor, but I think this is the foramen, the – or the apical one third. The canal has been kind of like that, pretty parallel. It’s pretty big. In other words, every time the patient flared up – let’s just psychodrama, roleplay.
So, say the dentist after visit one had a 30 at length. So, the dentist had a 30 at length, at the working length. Well, then, you know what? Come back two days later, it’s hurting! 35, 40, 45, 50! Now we have a 50 at the working length! Oh, they’re still hurting! 60, 70! And there’s no end until we run out of files. That’s kind of what happened in this case. So, the guy said, “I had my biggest files. They didn’t – they weren’t even engaging. They were – they were floaters!” Those files were floaters in there! They weren’t binding! There was space! Well, how about that? Listen, this is gettin’ to be pretty parallel! This is kind of parallel! But there is a little taper.
And you notice I have just a little taper in that apical third, enough that I can get on here with heat and pressure, and I can mold rubber into something that’s probably more like 100. They don’t even – I don’t even have them in the office. Notice the lateral canal’s probably a 60 or a 70. Notice the control with thermosoftened gutta-percha and how it can be pressed into place and corked! How about corkage? Love the corkage. Incidentally, I called the patient that night. She said it was the first time in three months she didn’t hurt. I said, “Stop your antibiotics. Stop everything. In fact, don’t stop living.”
Well, we have another case. Surgery or non-surgery? You look at this case, and this kid works in a garage. He rolls under cars all day. He fixes engines. His wrench slipped, and boom! He broke part of the tooth! I think there’s a coaching assignment here. Boy, I’m getting good at this. Thank you, Isaac. Isaac is the navigator of technology, and I’m picking up what he forgot. Okay. So, I look at this. We have a broken bridge. The bridge isn’t fitting very well. The guy doesn’t care about aesthetics, because he’s in a garage all day. But he does have a girlfriend. So, I said, “Let’s make her happy.” So, we sent the patient back to the general dentist to disassemble the bridge and put it back on provisionally, so Ruddle can get it off easier.
So, we’re going to take this off, and we’re going to address this. Now if you look carefully, the end of this root goes like this, and it goes like that. Remember I said, if we are about 50 or 60, I’m feeling like we can push gutta-percha into narrowing cross-sectional geometries. See, narrowing cross-sectional geometries. But if you get greater – if you get greater than that, we have to have another idea. So here, the patient comes back. I take the bridge off. I’m using ultrasonics – ultrasonics, to blast out the core, the composite, and I’m exposing the head of the post, which is buried up under the crown. That’s all fine.
Now this should make everybody around the world stop and go, “Hmm.” You mean when I’m doing surgery on these teeth, and I’m trying to put a little cork in here, and I’m trying to get this seal, are you thinking how much stuff is left behind, that wasn’t taken care of in initial treatment? This is why Ruddle did so much work for so many decades, developing and extending the game of non-surgical treatment. And so, that is a bunch of junk inside the tooth! Well, with a little bit of flushing and cleaning, you’re looking at the foramen. You’re looking right to here! Ladies and gentlemen, you’re looking through the microscope, at not a large power, and you can see the foramen, that little blow is the periapical side.
So, that’s big! In fact, it’s so big, that in the operatory, when we speak to each other, we have to whisper, so we don’t get an echo [whispering]. Right! Well, enough of that bull [bleep]. Okay. Let’s show you what we’re going to do. We’ll have other segments on this, but this is how to deliver MTA. So, I like to use a microtube – a microtube, and I can deliver little segments and columns of MTA, two- to three-millimeter segments. And once I get three or four segments in here, I can then take gutta-percha cones, and I can trim them at appropriate diameters, to make them flexible pluggers! So, I can now start shepherding this mass of MTA towards length, even when I have massive reverse architecture. Oh, I’m sorry! Too close. Massive [with great emphasis] reversed architecture!
I can use the EndoActivator! Brrrp! Hey, how many of you in dental school, when you went to pour up an impression model, did you go to the lab, mix some stone, use a vibrator, brrrp, and you got that stone to flow into the intaglio of the prep, it was a wonderful thing, so you didn’t have voids? We use that same concept with the EndoActivator, to move mud. If you worked on construction, we vibrate concrete! So, you can vibrate this passively to length. Then, you can – if you have too much, or you could use the whole canal with MTA, but if you want a post space, or there’s another indication, you can take some of it out with a big reamer. Just go in there and collect some.
Then take your barbed broach – your barbed broach. Wrap it on – a cotton pellet around it, around the end. So, here’s your broach in here, and you can clean your walls, shepherd it down, and level it out, and kind of tighten it up. Now we need to have a cotton pellet on this side that’s moist, a moist pellet. Needs moisture to set up. The moisture is fulfilled on the periapical side, and that can happen after four hours. MTA will set up after four hours. So, practically speaking, usually a second visit. So, that’s what we did. With all this out and all this clean, and with reversed apical architecture, there’s no way I can make this the smallest diameter. It’s like a trumpet, right? It’s like a trumpet.
So, I have to do a barrier technique, and then I can go ahead and show you the results of vibration, even vibrating mud through a massive lateral canal. I put the post back in. We ran it through the autoclave and sterilized it, put it back in temporarily, and then here we are, at five years. So, at five years, we have – we went from a – I don’t like threaded posts. These threaded posts build up a lot of pressure. That’s a Flexi-Post, Flexi-Post, and this is a cast gold post, as you can see, new bridge. I don’t know if he got married. I don’t know how it ended. The tooth ended very, very well, so I’m assuming the marriage thing really happened, got married and probably lived forever after, maybe he’s an endodontist!
Okay. Begin to think, when you see these failures, what have I learned from Segment 1 about the “Mechanical Objectives”, and can I impart those into the failing teeth, to set them up for victory, for long-term, predictably successful endodontics? Then, there’s the final thing. Now obviously, if aesthetics was an issue, if it wouldn’t have been a gasoline guy or a garage guy or somebody who doesn’t really care, we would’ve wanted to do a ridge augmentation, because you want these gingival incisal edge dimensions to all be about the same. But there was not a high lip line. This is the guy we treated, and this is, of course, the false tooth, the pontic.
So, we have a little bit of unevenness in the incisal gingival dimensions. In this case, very acceptable. And then, the last case. Are you ready for the last case? All right! I could show you cases all day long, surgery, non-surgery. That was pretty much my life for over 40 years. I didn’t think I said this, this segment, but probably the last 20 years of my practice, about 90 percent of everybody that saw Cliff Ruddle for the first time had already had endodontics. Sometimes they’d had retreatment as well, and sometimes they’d already had surgery, as you’re seeing. And so, we got pretty used to shaking these down.
And I can tell you, I did plenty of surgeries that didn’t work, because I wasn’t smart enough, when I was young, to – I was trusting somebody else’s work, up in this area. And you’re just looking at a little window here and trying to be very definitive there, when there’s a bunch of stuff going on there. So, I learned to take teeth apart. Okay. This has been to the oral surgeon. Boom! Apicoectomy! That was pretty stupid, because you almost can’t even see a root canal filling! So, basically, apisecting the root just lost crown root dimensions, if you kind of line this up with this other guy, over here.
And now we have a shorter tooth, and it’s carrying a load, and it’s wide open! This is wide open! What are you going to do? You going to do surgery? Are you going to take it apart? We can disassemble, we can take out posts, risk versus benefit, talk to your patients, give your patients the information. Let them co-treatment plan with you, okay? Co-diagnose and co-treatment plan. So, when we get in here, we had the sinus tract, so it was draining. Patient was comfortable. And we developed this idea many, many years ago, back in the ‘70s, we were breaking files. You know, take the handle, break it off. You could take the useful part of the file, put it in this little chuck, right here.
You can use your hemostat and turn that, and that’ll cinch down on the collet, and that’ll grab your file. Now you can take that file and stick it back up into this tooth and do some reverse cleaning. So, here we are with the cleaning done. You can see I’ve removed a little fragment of disintegrated gutta-percha. And then, what? Well, get the rest of the seal. Sometimes you could put all MTA. Sometimes you might anticipate a future problem, and you might want a little gutta-percha in here, as a little barrier between that and my retrograde material. So, there’s another case that we’ve set up.
And I want you to look at these cases and treatment plan for no surprises. So, remember, we can put that flap back. It’s already had surgery. We make a really nice flap. We’ll come back and talk about these different kinds of flaps and how we can keep papilla -- not elevate them. Scalp your incisions to follow the scalp of the teeth. And it – flap would reposition like gears. I’m showing you a split screen. This is the scar. This is the scar from the previous surgery. You shouldn’t get scars from doing surgery in the aesthetic zone, if you know how to do surgery, microsurgery, micro blades, beveled incisions! No semilunar flaps, please! No semilunar flaps! Those things scar, they bunch up. Even patients will say, “Gee, it feels like there’s a ridge right here!” Don’t do that.
And if you watch, you can just see, at 30 days, you cannot even see any evidence of surgery over here. Ruddle’s incision, of course, was like this and like this and like that. So, there’s no scarring, whatsoever. So, in closing, per usual, let’s train up, let’s get more knowledge, let’s work on our experience, and let’s get better! You can do it!
CLOSE: Good News/Bad News
Okay. We’re going to close our show today with another “Good News, Bad News” segment, because every coin has two sides. So, I’m going to say a topic, and it could be about dentistry, but it might also be about something else. And then, my dad’s going to tell you the good news about it and then, the bad news about it. So, here’s the first thing. The upcoming AAE Meeting.
Oh, the good news is, we’re going to have CE. We’re going to have speakers. We’re going to have topics. We’re going to learn things, and that’s always exciting. The bad news is, it’s virtual. Sorry! But in this world of COVID, we are not going to be together as one, which means we’re going to miss a lot of hugs, a lot of handshakes. We’re going to miss little break-out sessions, “What are you doing? What am I doing? What’s this one doing?’ And a lot of learning happens outside of actually the large ballroom. So, it’s always too bad when we can’t have them. But we have something.
Okay. The AAE Discussion Forum.
Oh, the good news is, a lot of people have opinions. The bad news is a lot of people have opinions.
[laughs] Okay. New technology in general.
New technology in general. Well, you have the opportunity to get into maybe a new level of case and a level of difficulty, and maybe the technology makes it easier, better, and faster. The bad news is, you might pay a lot of money, like 70 grand, you might buy a GentleWave, and you might notice that with all this glee of maybe cleaning out a root canal system for the first time in your life, there’s some blood coming up through the canal. And then, maybe there’s some postop pain, and that’s what we saw in the Discussion Forum, just this morning.
Okay [laughs]. All right. The Los Angeles Lakers.
Oh, you’re leaving dentistry. Okay. The good news is, we won the NBA Championship last year, 2020. The bad news is, we are – we’re tasked to do it again this year, in 2021. And we need healthy players, and we have three people down.
Oh! The good news is, we can reach out and make relationships and keep patients safe and not put anybody at risk! So, that’s really a new thing. It’s good; it’s fine. The bad news is you cannot do a root canal by the telephone.
[laughs] How about Daylight Savings Time?
Well, I guess they’re going to go back. So, yeah. Spring back --
No, spring forward.
-- spring forward! Oh! So, we’re going to have an extra hour. I won’t be walking in the dark. The good news is, I will not be doing my morning walks for one hour in the dark. I’ll be watching the rising sun, and it’s going to be a massive victory. The bad news is, it’s going to be pretty short days, at the end of the day.
No, no, no, no! [laughs] That’s not what’s happening! [laughs]
Oh, I got mixed up on this one! Yes, we’re – I’m going to be walking in the dark permanently! Because I have been walking in the dark, and now they’re going to move the time, and I’m going to walk – continue walking in the darkness!
[laughs] So --
But at the end of the day, I’m going to be able to hit the ball, I’m going to be able to play tennis, I’m going to see the seams and the rotation on the ball. Very good news with more daylight, yeah!
-- I guess the bad news is for me that I’ll be adjusting to that, for two months [laughs] --
Yeah. Well, I think we’ll have to adjust.
-- to that hourly change. Okay. AI in dentistry.
Well, the good news is that there’s big promise with AI. And as we’ve explored a little bit in our research, we can probably prognosticate that many good things will unfold, after that and during that. The bad news would be that we need enormous amount of data, and we don’t have it. And we have it maybe on radiographs, and we’ve talked about some of these things, where we have it, but we don’t have it across the board in sufficient N, like big sample sizes, where we can extrapolate from that and do wonderful things that make a difference for patients.
I guess the long-term bad news could be some people might not have jobs anymore.
I could be replaced.
Okay. How about social media?
Well, I think it’s really good, especially for families, friends, girlfriends, boyfriends, lovers, and – I mean, the inquisitive people, curiosity, all that, that’s fabulous. The bad news is, for me, the questions and the – and I love questions. I gotta clarify. Questions are good, but you just get bombarded. And perhaps the coaching would be, we have a website. We have an enormous amount of information there. If people just did a little bit of work, they’d probably arrive at the answer with more knowledge than expecting an email back. But questions are good, but let’s do our homework.
Okay. And the last one will be having your son or daughter follow you into the dentistry profession.
Well, I meet people all over the world, Lisa, and they’re thrilled, because Johnny finally grew up, became a dentist, and he’s now working in the operatory adjacent. And then, another one’ll run up, and – and here’s my daughter, and we’re working together. So, I know that’s a thrill. It’s a big honor. It’s a huge accomplishment. The bad news is, if you don’t like your kids, you’re working with them for a very long time.
Or they might set up a competing practice, right down the street. [laughs]
And wipe you out! Completely wipe you out! That’d be bad news!
[Music playing] Okay. Well, thank you for your ideas, and that’s it for today. We’ll see you next time on The Ruddle Show.
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Apical and Lateral Blocks & Whose Job Is It?
Post Removal & Discounts
Post Removal with Ultrasonics & Why Discounts are Problematic
EndoActivator History & Technique
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Exploratory Treatment & the Coronal Disassembly Decision Tree
Advancements in Gutta Percha Technology
Zoom Interview with Dr. Nathan Li
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Intentional Practice Culture & Effective Flap Design
Workspaces & Calcium Hydroxide
Ruddle Workspaces Tour & Calcium Hydroxide Q&A
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The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.