As one evaluates the current position of clinical endodontics as a healing art, one is struck by the vast differences in how endodontics is understood and practiced from country to country, region to region, city to city, office to office, and from dentist to dentist within each office...
Common Endo Errors & Discipline Overlap Apical and Lateral Blocks & Whose Job Is It?
Season 5 opens with an early-morning beach segment… See us enjoying the beauty of a Santa Barbara sunrise and be inspired. Next, Ruddle discusses why apical and lateral blocks occur, how to avoid them, and importantly, how to properly manage them. Then, in our debut segment, “Whose Job is it?”, Ruddle & Lisette explore which discipline is best suited to perform certain procedures. Finally, stay tuned for the Ruddle Flashback at the end of the show for some tips on how to win big on a slot machine in Las Vegas!
Show Content & Timecodes00:09 - INTRO: Sunrise Beach Opener 04:35 - SEGMENT 1: Most Common Endodontic Errors - BLOCKS 34:53 - SEGMENT 2: Whose Job Is It? 40:40 - CLOSE: Ruddle Flashback - Gambling Jackpot!
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Extra movie/video content:
Downloadable PDFs & Related Materials
There has been massive growth in endodontic treatment in recent years. This increase in clinical activity can be attributable to better-trained dentists and specialists alike. Necessary for this unfolding story is the general public's growing selection for root canal treatment...
In a previous interview, Endodontic Therapy and Dr. Cliff Ruddle discuss nonsurgical retreatment and the integration of traditional and modern techniques for achieving excellence and producing predictable outcomes...
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: Sunrise Beach Opener
[Video playing – Ruddle family is in the car, driving at the beach. There is a storm coming, and they are discussing how long it’s been since they’ve been to the water]
Welcome to The Ruddle Show! I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing this morning?
I’m doin’ really great. We’re out here – I think we got up about 5:00, and we got down here really early, big 10-minute drive. We’re out here on the end of the wharf. This is the oldest wharf in the state of California and on the entire West Coast, from Canada to Mexico.
I thought it would be really neat, to start our fifth season, to get out of the studio and to get to kind of like a special, inspirational location to launch the new season. So, here we are, and it’s early! I’ve had a lot of coffee, but I don’t feel it yet. So [laughs] --
Well, you know what? We have, to our east -- looking out to the east, we have a sunrise.
That’s where the sun would come up.
And it would be coming right out of the water! And we have fog today, but lookit! It’s breaking! You see the waves, the colors. Just over the ridge is La Mesa, and the birds out there on the sandspit. And back along the old wharf, yep! And you know what? We came out here to maybe do a little fishing.
[laughs] Yeah. We’re out here with the fishermen this morning. And you might be wondering why we didn’t choose a sunny day to come out here for a sunrise. But that’s because in Santa Barbara, in May, there isn’t very – there aren’t very many sunny mornings, because we have what we call “May Gray”, and next month, we’ll have “June Gloom”. So, we just thought we thought we’d come out here in the fog [laughs].
And if the fog swirls, the shrouds our season ahead, and it’s not clear what we’re gonna do, exactly. Only we know!
[laughs] We have some guests, so we’re excited about that. And we’re – some new topics, some new segments that we’ve thought of. So, we’re excited about it. What have you been doing in the offseason?
I’ve been workin’ on that Trifecta project, and we’re gonna have several clips across all 10 shows, probably --
-- having little, uh, things --
-- yeah. Little – little moments of truth, right?
[laughs] Okay. Well, we have a great show, and we’re gonna get started on that in a second. But I would recommend, in your location, that you get out to some special spot for a sunrise, because it’s a great way to start the day, and it’s a great way to start the rest of your life. And for us, it’s a great way to start Season Five. So --
So, let’s get inspired here, okay? We’ll see you on the set, soon. [Music ends]
SEGMENT 1: Most Common Endodontic Errors – BLOCKS
Well, we were just at the beach, but I had something happen to me on the way to the studio, and I got blocked by traffic, which reminds me of my topic today, “Blocked Canals.” Now, if you talk to most dentists, and even endodontists, about blocks, they’ll immediately think it’s the inability to slide a small, stainless-steel hand file to length. But we must understand there’s lateral blocks just as well. And they’re more insidious. We don’t see them. And then, we don’t get to capture the lateral anatomy on our postoperative films.
So, today, we’re gonna talk about lateral and apical blocks. It’s quite an enigma. In fact, I’ve written several chapters in international textbooks on endodontic retreatment. And I would say, one of the most common events that we see in nonsurgical retreatment is the enigma of the blocked canal. So, let’s talk a little bit about how they occur, and then, we’ll talk about their prevention and management. How about that? Okay. So, this case is a pretty nice root canal, about 95 percent of the way. But there’s that little problem, right there, and we didn’t see the colleague necessarily show obturation material to length.
So, John West, when he was a resident at Boston University, Goldman School of Graduate Dentistry, under Herb Schilder, that was back in the ’70s, he did a Master thesis on this. And what he showed was, he showed by extracting teeth and using pelikan ink, he could use a centrifuge, and he could stain the teeth that were failing, and he could find out what part of the root canal system was not addressed. These two slides have nothing to do with each other. This is what we see clinically in practice all the time. John West just showed us what it might look like. So, what do you think this is, right there? This, right there, that dark area, that is the fatal flaw in endodontics! That’s dentine mud.
So, we gotta talk today about its production and its management. But you can see where the dye went in, there were multiple portals of exit. So, clinically you might say, “Well, we’re two millimeters short.” I just made that up. It might be one and a half millimeters short. But you can see, to be, in this analogy, two millimeters short, you might miss another millimeter and another millimeter and a half. You might miss maybe four or five millimeters of root canal system, and we’d all start to say, then, “That’s too short. We can’t be that short, Cliff.” So, think about laterally and vertically, not just as the x-ray sometimes shows us, in the vertical extent.
Okay. So, we now see that we can find these clinically. We kinda can see a histological section, showing kind of what happens. And so, the gutta-percha dies out against that block. And then, back to another case. I’m gonna show this next week, because we’re gonna talk about how to manage some other things. But again, this is the posterior abutment of a bridge! And it’s pretty good endodontics. I don’t necessarily like posts in the mesial roots. Maybe if it’s a passive fiber post, but not metal. And then, of course, we’re short again. And of course, there is breakdown, and now we have a lesion of endodontic origin. And then, what to do? What to do about that?
So, we see this all the time. So, whenever I see a filling material short, radiographically, and the patient’s having symptoms, or the lesion’s getting bigger, where there was no lesion, I’m immediately thinking, probably a blocked canal. Let’s look at the blocked canal. So, you get your access cut, right? And then, you take usually your first hand file, might be a stainless steel 10, and you start working that file in. And there’s two problems we have that I’m going to identify today. We have mechanical problems, and we have anatomical problems. When you put those two together, it’s synergistic. It’s one plus one is three.
So, colleagues have been trained for decades to work short of the radiographic terminus. I said, “radiographic terminus”, not “radiographic apex” or “anatomic apex” okay? So, my colleague’s working short; they are making mud. They see it in their file, but they probably don’t notice that it’s getting pushed into space. So as you begin to make a little space, not only is it the mud on the flutes of your file, but it’s also getting pushed into eccentricities off the rounder part of the canals. So, always think laterally. And then, of course, we gotta remember that when we go from the 10 to the 15 file, which colleagues do effortlessly, and they have bought into this, that every file is bigger by .05 between 10 and 60.
So, between 10 and 60, all files get bigger at their tips by .05, .05, .05. So, you go from 10 to 15, the difference is 5. 5 over 10 is 50 percent. So, they don’t realize that the 15 file is 50 percent bigger than the 10 file that preceded. That, incidentally, is the biggest jump in dentistry. So, grinding that 15 in really compacts this, really starts to pack it in tight. Now we have – we’ve gone from a nuisance block to now, we have a serious block going on. And the colleague’s really happy. Because everything’s going fine, and we usually go through a little bit more chair time, and we go through a few more instruments, manual or mechanical, it doesn’t matter. It’s the concept. Blocks can happen either way.
So, we go through a few more instruments. And remember, most colleagues over the decades were trained to get about 30, 35, or 40 to length. So, by the time you grind those bigger instruments to length, the files begin to generate mud. The mud begins to stack up. It actually pushes the larger file up and out of the canal. And you might have wanted to work one millimeter short, conscientiously. Oftentimes, when you’re fitting your cone, you’re two to three millimeters short! And if I were seeing your faces, you would all be nodding.
We’ve all had the case where we deliberately and intentionally worked a little bit short. We thought that was the standard of care, working a half or one. Who you are is where you were when, what school did you go to, who was your mentor? That’s how short you were. And because of that, those bigger files get pushed out, and now you’re even shorter than was your intention. So, now you got a serious, serious block. And these can be sometimes addressed non-surgically, but then, the patient has another procedure. Let’s get back to the anatomy. We were all taught to work to the cemental-dentinal junction. That was considered the ideal vertical extent of treatment, endodontic treatment.
But we gotta remember, those blue demarcation is to detect cementum. Cementum covers the dentin. It comes through the anatomical foramen and moves up through the canal. And it ascends coronally! Listen carefully. It is uneven! It can ascend up a few microns or several millimeters! So, when they taught us to work to the CDJ, they were just kidding. You know, it’s not possible! Only a histologist at a workbench can identify the CDJ. A clinician can’t. We have electronic apex locators. That’s really helped us get closer to length on a consistent basis. Schilder made it real easy. He said, “Just work to the radiographic terminus.”
The radiographic terminus would be right there. Even if the file is minutely long, every canal is importantly catheterized. And when you catheterize a canal, now your reagents can go out into tens of thousands, millions of dentinal tubules, lateral canals when present. So you have the ability, then, to address more anatomy. So, to come back to our lateral, apical block, you can see clearly the apical block. Radiographically, you would just see your file is short. And if you went to try to advance it, it wouldn’t go. But you probably never even considered that, unless you had one of these asymmetrical lesions, or you’re already starting to map out the egress of irritants out of the root canal space is gonna cause bone loss.
And if we see asymmetrical lesions, you might map it out in your mind that there should be something there. But of course, when you pack, you probably see nothing, because you have a block. So, work the files – the smallest, most flexible files, to the RT, to keep the foramen open. Said another way, keep the foramen – say it! Now say it again! And now, what are we gonna do, when we don’t know what to do? We’re gonna maintain patency. We’re gonna be patent. That’s the prescription.
So, one thing you can do immediately, if you inherit a blocked canal, even if it’s your own, is do a little body work, and get the canal open coronally. I like to use the SX to do that, in the ProTaper family of instruments. SX can immediately create space. And of course, I wrote about 25, 50 – I wrote 50 pages about this in Pathways of the Pulp, Edition 8. This was Chapter 8 – Chapter 8 in Edition 8, and we talked about all these little tricks. But pre-enlargement gives you quite a few advantages.
You can actually – the – the only thing I’ll talk about here is, you can actually pre-curve a 10 file. You can pass the pre-curved 10 file through the pre-enlarged canal, and the file will arrive curved apically, when you get to curvature. If you have this all packed up with dentin, canyons of narrow dentin, then when you put a curve on an instrument, the canyons of restrictive dentin knock the curve off the instrument, and the instrument arrives apically pretty straight. It’s gonna dig into the outer wall. And now we’re gonna have another segment about ledge management. So, that’s next time, another time.
So, you can do a lot of really neat things with pre-enlargement. So, that’s a trick in block management. So, let’s move on. Let’s look at our tools. We don’t have very expensive tools here. You’re gonna love this part, because it’s – it’s bread-and-butter basic simple stuff. So, what are the tools? You need probably only one hand file. And I’ll just put in here for fun, you might have an 06, and you might have an 08 available, but I find these in block management too skinny, too fragile, cross-sectional diameters too thin, too skinny, and they are gonna crumple, roll over, and collapse. So, you need a little bit more rigidity, and that can be the 10 file.
I’m not gonna, today, talk about C-pilot files and double-tapered 10 files, the 04s, because a lot of times -- yeah. They’re stiffer, but they’re bigger, and we don’t need bigger. We need to pierce through mud with a very delicate, little instrument to break up the debris and get it into solution, so we can flush it out of the tooth. So, probably just need three hand files. 10’s the one I typically use. Now, we have viscous chelators, and by Ruddle’s definition, a viscous chelator is ethylenediaminetetraacetic acid in a methylcellulose suspension. So, that means that we can get RC-Prep, Glyde, ProLube, those are all in the family of what I just spoke about. This is offloaded into a throw-away, single-use syringe and we’ll squirt it right in the tooth.
Two things to consider. I have less experience with Chemet. John West likes it. He wrote an article, I think, in 2005, in Dentistry Today, about it. And it is a succimer of EDTA. So, I’m thinking it’s in the same family, but he likes it, and he thinks it’s a little bit more powerful. That’s another little trick for you. That’s readily available. The next one is not readily available. I’ll see if I can pronounce this, 15 letters in this. It’s trichloroacetic acid. Trichloroacetic acid. And TCA is none other than another form of a chelator, and it is not available, but it’ll be coming soon to market.
And we’re gonna have Dr. Terry Pannkuk tell us more about that. He’s got a whole library of beautiful cases, and he swears by early negotiation, when things are tough, when it’s vital, when you have collagenous tissue. You can get shrinkage of the tissue and then, by shrinking the tissue, you make space for your file to slide into. So, in any event, you’re gonna be using something, and probably it’s right here. It’s readily available. It’s inexpensive. And it’s a chelating agent. It’s gonna help you get through the mud. So, let’s now look at – we’ve looked at the anatomy a little bit and what some of the problems are there.
In other words, not understanding the CDJ and thinking it’s a perpendicular relationship to the long axis of the canal when really, it’s escalloped. The north wall’s different from the south wall, east wall, west wall. Invasion of cementum in an irregular way, through that anatomical foramen. When you look at these files -- we’re talking ISO files – they want all manufacturers to make sort of the same files, so we don’t buy a file from one company that’s different from another company’s. So, all 10s, at the diameter, at D0, the tip of the file, is a 10, a 15 and a 20, you know that. If you go up millimeter by millimeter, 2, 3, 4, up to D16, that’s the diameter of 16, then, all files have a taper of 32 hundredths of a millimeter over the 16 millimeters. If you have 32 to 10, if you have 32 to 15, and 32 to 20, you get the D16 diameter.
So, chairside, you can begin to appreciate, when you got a 10 file in your hand, you can make significantly more space than the number on the handle says, because it’s almost a 42, at D16. And even if you only have so much of it below the orifice, you’re probably at a 35, you’re making quite a bit of space. So, that’s a good thing. All right. So, what else should we know about these files? Starts to look like we could have a formula.
So, every file tapers two hundredths of a millimeter. It gets bigger, by two hundredths of a millimeter every one millimeter we go up the file. So, it’s a 10, a 12, a 14, a 16, and if we do that 16 times, starting at 10, we’ll be at 42. Said another way, if you divide 16 into 0.32, bring the point up, and you’re gonna have .02, and if you move it over, because it’s a percent, these are 2 percent. So, that’s how you get to two percent. You might have known that. Okay. So, how do we use these ideas that we just talked about?
I would do a little pre-enlargement. You can see we’ve done that. I would put viscous chelator into the tooth with a syringe. That’ll give me slip and slide! It’ll start to take down collagen and prevent its re-adherence. It’s sticky, it’s collagenous, it’s the glue. And what are in these blocks? You know, I’d better come back and talk about it. Could it just be all pulp tissue, a pulp stump? Will that pulp stump stay vital over the life of the patient? Oh, gee, I don’t know. Then, why don’t we take it out!? Why are we guessing? This is a patient here we’re working on.
Okay. So, could it be necrotic tissue? Oh, yeah. It could be necrotic tissue. Could it be a combination of vital and necrotic tissue and maybe some bacteria? So, it’s usually a cocktail of junk. And that’s why we should never allow a pulp stump to be resident in the tooth, post-endodontics. That’s not endodontics! That’s flirting with endodontics! I want you to be more than you are and closer to all you can be! So, back to the story. Just slide in the pre-curved 10. Try to start doing a little reconnaissance. Pre-curve it a little bit. Slide down passively and just bump into it. You’ll feel it, a little block.
Just bump it, tap it a little bit, gently. Pull back, rebutter the flutes of your 10, slide back in. Drag more viscous chelator deeper. Just touch it, touch it, touch it, maybe touch it 10, 15 times. If nothing’s really happening after 10, 15, 20, 30 times, literally, then I want you to get a little bit more aggressive. It’s a pretty tight block. It’s not a nuisance block. You would’ve already broke through. It’s a serious block. So, now, I want you to use short, vertical amplitude strokes, and it’s like, pick, pick, pick, pick. And I’ll put a brand-new, straight 10 in. A lot of times, it’s not even pre-curved now, because it’s not a nuisance, it’s a serious block.
And if I’m in a root that’s curved – if I’m in a root that’s curved, when I pull this file out after 10 or 15 of those little picks, I’m looking to see, is the file a straight line? If it’s a straight line, I’m on my way to what? First a ledge, and if I really keep working hard, a perforation will result. Oh, that’s great! Now I can do something else. Remember, we’re looking for things to do. Okay. I guess we talk about that in the next section. What – which discipline are we in, and which shoe do we wear, and all that stuff. But if you put the file in straight, and you’re picking, and you pull it out, you wipe the chelator off the file, Ruddle sees a little curve in the file. That means Ruddle’s tracking. I’m not making. Make the distinction. I’m following an anatomical pathway versus iatrogenically creating a false pathway.
So, you just have to what? Have some time, get comfortable, tell your staff to quit bothering you, because that’s what’s gonna cave you in. That’s gonna be the difference for you between success and failure is probably your staff. And if that happens, that’s your fault, because you gotta tell them, “No distractions. This is not a time to be asking me anything.” And if you have time, and you’re patient – if you’re patient, good things happen. I could almost always [with great emphasis] get through any blocked canal. And remember, that was 90 percent of my practice was non-surgical and surgical retreatment of other people’s failures. And blocked canals were ubiquitous! They were everywhere, on short fills. So, you gotta say, “I’m the guy that’s gonna get through it.” Remember, if you think you can, you can! And if you think you can’t, you’re right.
So, pick, pick, pick, pick! Pick, pick, pick, pick! And you’ll feel that instrument start to engage. It’ll get sticky. Then, you could drop to an 8, because now, you start to have a little pathway. You just need a little smaller instrument. And you could even drop to a 6. But I want you to catheterize the canal. Hey, baby! To and through is magic! And remember, the 10 file – if this is a 10 file, the 10 file is only a 10 file at D0, and at D1, it’s a 12! So we’ve already transitioned to a 12! And now, we’re going from a 12 to a 15! The difference is 3/12ths, 3/12ths. See what we just did? We knocked off the 50-percent change, and we made it a 25-percent change, if we just use a patency file. Again, say “patency!” Spell “patency!” Write “patency!” Okay. So, patency is great.
One last comment. When you get through, don’t take the file out. I can see a lot of you right now. “Oh, great! Whew! We made it!” You leap up to go do a hygiene check in another room. Ha, ha! You’ll probably never get back. When you get there, hang out, and work that file like I’m gonna show you, right here. So, squirt some of this in. Grab your 10 file. This is a case that was referred in, had to take out gutta-percha and had to do a lot of little things to clean up. But now, we’re down to the last two millimeters of the game. The game’s about little things that make the big difference.
So, here’s a slidin’ through passively and some little pecks, some little touches, some little, “Uh, hello! How are you? I’m a file! What are you? Are you mud? Are you putrescent? Are you stinky? Are you a bacterium?” Okay! But you’ll see that little stick, you’ll feel it, and you can slide. Stop doing this! You always wanna turn the screw clockwise to advance it into the wall, if it’s a wooden wall, and it’s a screw. This is endodontics! Sliding is much more effective than screwing! And then, do this. In, out, in, out, in, out – you do this until a file is loose, until you can put your nose on the file and push the file to length. West says, “super loose.”
Now you’re checking your glide path. Take a stroke out, two strokes, three strokes. I like to pull the file back about a stop, about two stops, and then, about three stops. If that file is slipping and sliding, start to say the words “slip,” “slide!” Oh, I love these words! And “glide!” Slip, slide, and glide! Then, you not only have a glide path, you own the glide path. And now, your mechanical files will follow. They need to follow a confirmed, reproducible slide path, a patent canal. All right. So, once you get there, hang out, work it in little strokes. You’ll feel it’ll all start to get easier, looser, and now you’ll start to go, “I can now take it out, because I could find it again and put the next file in.”
So, we’ve worked to the radiographic terminus. I know, if we extract this tooth -- I want you to know that I know, if we extract the tooth, Ruddle’s gonna see two instruments sticking through. That’s patency, baby! You do not wanna work arbitrarily short, in vital or necrotic cases. So, that’s working right to the RT. The reason you wanna work to the RT is because you want your reagents to exchange and then, you can fit a cone. You’re gonna get on this with heat and pressure and carry a wave of thermosoftened gutta-percha and sealer into the apical third.
Our shape confines our reagents to stay in the tooth. Hey, GentleWave, you might think about a little shaping, now and then. And then, at least – at least deep shape, huh? And then, you know, you can pack it down, pack that cone down. Out with the lateral anatomy, boom! There’s the postop. Now, in this postop – you’ve seen this case before. But this is really a hallmark case to show the importance of patency, because you’ll pick up about eight portals of exit, eight POEs, and here you’ve got bifidity, and a third one, three POEs, eight portals of exit. That’s endodontics! Okay? And I saw on the AAE discussion, they’re going, “Oh, gosh, he’s using a laser!”
The results are looking like Hess, Hess type! We’ve been getting lateral canals for the last 35, 40, 50, 60 years. Talk to the guys in the Schilder generation. They were doing it in the ‘50s and the ‘60s. So, filling lateral canals is not a new – a newfound skill. It’s having some ideas – inexpensive ideas. You can do this very, very inexpensively and have lasting results. Lateral blocks! Okay. Well, you know, when you load up that file, and you pull it out, you go, “Oh, I’d better clean the flutes. The file’s really dirty!” Better clean the canal! How about that!?
So, after every single file is removed, what do you think Ruddle does? He uses the EndoActivator. It’s inexpensive. Each Delrin – that’s – like a nylon-type tip. Each Delrin, it’s a polymer, is non-cutting. It works in the pulp chamber. You can see all the bubbles in your mouth mirror. What you can’t see, and what you’d love to see is what’s going on below the orifice. So, we have made simulated canals. You can see the exchange, and that exchange of reagent can go into all corners of the root canal system. And basically, bubbles are formed, because liquids are fractured with the polymer tip. And bubbles form that are unstable because of heat of pressure, and they expand, and boom! They get deep into the tubules. They work into lateral anatomy.
And look at this! Three orifices, all in about the last two millimeters, this is why we don’t wanna work short. Working short arbitrarily means we’re gonna miss a lot of anatomy. Because if you’re working short, this is all gonna be mud. This is all gonna be mud. And you’re gonna basically see something that is very boring and ends right here. So, lateral blocks, you see a lot in retreatment. You see these lesions form laterally. There’s probably a lesion apically. We can all see that. You get a CBCT, yeah. It’d be an overt lesion. But the more overt one that we see in a two-dimensional radiograph is laterally.
You can see that that silver point has broken down. Ions – precipitate ions have leached through a lateral canal or more, and it’s caused osteolytic activity in a LEO. So, get that out. That’s another prescription. Here’s the sinus tract, trace it with a gutta-percha cone. But I wanted you to see the tattoo. The tattoo is not a melanoma. It’s not a cancer. It’s secondary to endodontic failure. So, the prescription on the napkin is, we’ll talk about retreatment in more detail, but we got the shape. We wanna keep the shape as small as we can. The case just needs to really be cleaned, not really shaped.
And then, of course, you can see down-packing and out with that lateral canal, back-packing, postop, and then, about 15 years later, you can see how well the bone has adjusted and adapted to completed endodontics. Remember, endodontics is a regenerative procedure. It’s not a clean-shape-pack procedure. That’s what it is, but it invites the patient to grow bone. So, that’s a lateral block. EndoActivator, have a couple ideas. You can pick up the EndoActivator between every file, you can do it at the close of treatment for disinfection, you can do solvents, MTA, you can vibrate calcium hydroxide in.
Big discussion forum, “Oh, you know, calcium hydroxide can’t be pushed through the foramen.” Quit pushing it! How about vibrating it? We’re just about done, but you know, you just keep seeing this, over and over and over. That’s done by an endodontist in LA. They pride themselves in a 40-minute molar. 40-minute molars that look like that, that guy should be probably put out to pasture, where he can have lots of martinis and really enjoy the short world of his vision. Because there’s ramifications. There’s two separate, distinct, and unrelated problems. We have thermal sensitivity, and we have pressure sensitivity. So, we went after both of them.
But look at what you’re gonna see in the last two millimeters, just in the last two millimeters. Probably missed five millimeters of root canal system. You can see MB1 and -2. They’re spiraling over each other, two separate portals of exit. Look at how corkscrew that DB is. And then, a little anatomy there, and a portal of exit there, and – endodontics should be three dimensional. It should be fun. And I think we can close pretty much on this one is a real strategic tooth. The more strategic and the more critical dentistry you do for your patients, I’m talking about that dentistry that’s gonna be heavily restored, the finances, the time, the investment’s going to be massive, we can’t do endo like that!
That’s the palatal root! There’s no buccal roots. This is a big splint! So, I didn’t do any of this endodontics, but the – I sent the patient back to the Beverly Hills dentist to take the splint off, and you’re seeing a little temp on there. But we gotta tap that off, and once we get that tapped off, we have all the fun of getting – not only it was filled to about right here, but we get the bifidity, we get the loop, we get the lateral canal that’s just to the base of the infrabony pocket, and we did the anterior abutment. And I think you would admit, even 25, 30 years ago, that’s conservative endodontics. Look at the amount of remaining cervical dentin. Everybody should be happy in the MI world – the MIE world. Oh, they should be so happy!
So, I wanna close it down with this. Glide path management is the secret to success. He who owns the glide path wins the inner game of endodontics. Best wishes! And as they say in Italy, Ci vediamo all’apice! See you at the apex.
SEGMENT 2: Whose Job Is It? – Focusing on Implants & Patching the Occlusal Surface
Okay. So, we have the new segment to debut for you today, and it’s called “Whose Job Is It?” For the most part, dentistry has some pretty well-defined disciplines, where clinicians focus on procedures specific to that area of knowledge. However, it isn’t always so clear-cut, because general dentists tend to do a little bit of everything. For example, a general dentist might do root canals, or they might even do more complex restorative work. Further, there are some procedures, like implants, that don’t easily fall into a specific discipline. So, in recent years, which discipline has mostly taken charge of implants?
Well, from the inception, many decades ago, everybody kind of started doing them. Primarily, it was first oral surgeons, because it was a little bit intimidating to be putting fixtures in the bone. And then, oral surgeons don’t have a lot of continuity with patient follow-up care. So, sometimes the implants were not placed in alignment for proper restorative. So, periodontists, who see patients forever, they never finish cases, that’s the joke in the profession --
-- they like recalls. They understand restorative dentistry. They work hand in glove with restorative dentists, so they started placing implants. And of course, general dentists, the ones that were well trained, they took classes, and they started doing it. But there isn’t any recognized specialty area of implantology. The ADA doesn’t recognize it as a specialty area. So, to your point, there’s been – I don’t know if it’s been a turf war, but there’s been different groups at different times. Some well-trained endodontists started doing them, and a lot of them stopped. So, right now, I would say in Santa Barbara, it’s the periodontists and the oral surgeons that do the dominant amount. We still have a few cowboys that put them in, everywhere.
Okay. I know that in our first season, way back, in the beginning of 2020, we did a show where we discussed the implants-versus-endodontics option and a little bit of controversy surrounding that issue. And at that time, we also mentioned that the ADA didn’t recognize a specific discipline in charge of implants. So, what has influenced – what is – what I’m trying to ask is, how has it become that oral surgeons have sort of taken it on?
Knowledge, training, experience.
Okay. And do you wanna say --
-- well, maybe the technology you have in your office as well?
-- well, yeah. “Knowledge” means they’ve taken classes. They’ve probably had some failures. They – you learn more – way more from your failures than you ever learn from your successes. So, that would knowledge and experience. And then, when I had my implants placed, in – locally, by an oral surgeon in town, he used X-Nav. And I was very impressed with that, because that was a departure from the old sleeve guides and all of the laboratory work and getting things lined up and fixtures. I mean, he just did it live, and he was watching it on a screen. And then, it controls the depth, the angulation, and it guides you right into proper alignment, so you don’t hit anatomical structures, so that the restorative dentist – and this is all interdisciplinary treatment.
It’s gotta be planned with the general dentist, because they’re the quarterback, and they know the bridge they’re gonna place, the casting they’re gonna place. So, they want that implant in a very optimal position, and they would communicate that. And most of them have a very nice relationship with the oral surgeons or the periodontists.
Okay. So, for implants, since the ADA doesn’t recognize a specialty that is in charge of implants, then, it’s kind of evolved into, like, who has the technology, who’s doing it all the time, so they have experience? So, those – so, it’s kind of fallen to, you said – what did you say, periodontists and oral surgeons?
They’re doing most of them in Santa Barbara. We have a few general dentists, and probably there’s a closet endodontist that might do them occasionally. But most of it has been given up, because there was a famous endodontist that one time said, in front of 1,200 people at the American Association of Endodontics Annual Meeting, “Come on, you guys! Start puttin’ in implants! Any monkey can drill a hole in a bone!” Well, that didn’t go over very big in the profession, because putting the hole in the bone, to receive the fixture, is the easiest part of it, with all the technology.
So, there’s gotta be a lot of understanding about flap design, sinus lifts, you know, load management, occlusal interference, work balance. All this has to come to the forefront to have success. So – and then, of course, there’s the kind of fixture. Some fixtures are just like endodontic files, some are better, some are worse. So, with time, all this has sorted out over the last three decades. And pretty much in Santa Barbara, to be redundant, it’s periodontists or oral surgeons.
Okay. So, if you were a patient, I would actually want to be the – if I was getting an implant, I would wanna go to somebody who’s doing a lot of implants, who has this X-Nav in their office. And I understand, it’s interdisciplinary. You probably work with other disciplines of dentistry to get this done. But it seems that really, it’s technology and knowledge and experience that determines it.
So, this brings us now to --
Maybe passion, desire. I mean, maybe you’re really busy extracting teeth, and you think, you know, “I’d like to give people more teeth to bite on.” Maybe you decide, “That’s more benevolent.” So, yeah. A lot of it depends on your – your motivations, your inspirations, your desire.
-- okay. So, now, let’s move on to another topic that has come up recently, regarding who should be performing the restorative work following endodontic treatment. And recently, the AAE published their newsletter, and in it, Dr. Richard Schwartz wrote an article, where he suggested that endodontists maybe perform some of the initial restorative work before returning them to the general dentist?
And he says this because the literature seems to suggest that immediate restoration reduces the chances of failure.
Well, after reading that article, the President of the AGD, Dr. Bruce Cassis, was very concerned, after he read the article, and wrote a letter to the AAE. So, why was Dr. Cassis so concerned?
Well, first, we need to investigate Dr. Bruce Cassis, to find out if that’s his opinion, or did so many general dentists in the AGD come to him with such grave concerns that they said, “You know, defend us, protect our profession, protect our discipline. We – these guys are getting out of their lanes, and we gotta make sure, you know, we rebut.” I don’t know if he really would have a problem. But it sounded like, coming from his pen, on paper, on the rebuttal, point, counterpoint, it sounded like he was pretty concerned.
My impression was, he was concerned that he felt like endodontists might be overstepping their – their – the boundaries or not staying in their lane, I think you said, was a good way to put it. It seemed to me that he might have taken it a little personally, because it did seem that Schwartz was suggesting that maybe endodontics was failing because the general dentist wasn’t doing the proper restorative work? I don’t know. I mean, it just might have been suggested.
Well, let me give an example. So, I’ve done endodontics for approaching 50 years, and a lot of times, back in the day, not for decades, but back in the day, it was normal to make it easy for general dentists to get back into the pulp chamber. They are the restorative dentists. Let me make this very clear. There’s a wheel, and in the center of the wheel is the hub. The hub is the general dentist and the patient. The spokes on the wheel are kinda like the graphic, Pedo, Perio, Prosth, Ortho, Endo, and then, of course, the prayer –refer for prayer.
Anyway, there’s these spokes. The wheel rolls true and doesn’t wobble, because the spokes are all intact. So, the general dentist, it’s their call when they want to refer to these other disciplines. Our job, out here around the wheel, is to facilitate patient care, to help the general dentist, to make the patient get well, to help the general dentist have a wonderful, fun time doing the rest of the job. So, when I left cotton pellets in the pulp chamber, and I saw the six-month recall with a radiolucency below the crown, that was the representation of a cotton pellet that was left behind. That’s nothing more than a big sponge or a wick, and everything in life leaks.
The coefficient of expansion between build-ups, metal cores, amalgams, gold, the casting itself, they’re all different. So, things move, and they’re moving on a microscopic, micron level. So, we’re just trying to slow things down, disease, from a gallop to a trot. And so, if we see cotton pellets left behind, and we know everything leaks a little bit -- people drink cold fluids. They drink a hot coffee. Things are expanding and contracting. Movement, thousands of cycles, 1,200 pounds per square inch, work balance, things move, they begin to leak.
So, back in the ‘70s, general dentists liked that convenience, but endodontists started knowing this trend. And because of that, there was a trend in endodontics to manage the pulp chamber. So now you’re getting into a little issue, because maybe the dentist wants to put a post. Maybe the endodontist doesn’t think it needs a post. That’s where we need to communicate. So, we always – when we started not leaving cotton behind, I would ask general dentists, “Do you want” – in that day, “Do you want Cavit from the floor all the way up?” And a lot of them didn’t care. But they didn’t want all the work of drilling out the Cavit, so they still wanted that cotton pellet.
And then, we kinda got into conversations with the general dentist, “Well, what if we protected Ruddle’s orifices, and placed something sub-orifice level, one or two millimeters?” So, we would stub, in that area, a little bit of amalgam, one or two millimeters. I didn’t say three or four. I said, “one or two,” below the orifice, and bring the core all the way up the occlusal surface, and that was considered a definitive repair. The assumption is, the crown fits well, it’s aesthetically pleasing, it has proper biological width, and there’s a great soft-tissue response to the margins of the crown, if they’re subgingival, and of course, supragingival would be – even be better.
So, that was a – a little trend back in the ‘70s. I’m just – we’ll get to the other stuff. But that was where we started taking more responsibility for the chamber, because leakage is the fatal flaw in endodontics. And 100 percent of all failures are bacterial in etiology. So, if we worry about leakage -- I’ve said this on other shows. Mahmoud Torabinejad said that if you tag gutta-percha – or tag bacteria, occlusally, in a saliva environment, you can pick those bacteria up, I think he said 60 or 90 days – because I get confused. Then, the lady, Lisa Wilcox, also did a study, same thing, and one of them said 30 days, one said 90 days.
I got the memo. The memo was, gutta-percha can be entombed in a root for the life of the patient. The key word is “entombed” or “incarcerated.” But if it gets exposed to salivary leakage, it breaks down rapidly, over the entire length of the shape. So, that was a big wake-up call. Those were monumental studies that evolved in the ‘70s and 80s, and all of a sudden, you start thinking, “We gotta manage leakage.” And as my friend, Denny Southard, an endodontist in Tulsa, Oklahoma, said, “And manage the rest of the seal.”
So, endodontists were really concerned and [laughs] really focused on sealing the root canal system. But then, we saw little breakdowns in communication with the referral, and then, in the middle was, was it the cotton pellet, still? Or was it something leaky, restoring the cement to be there for 30, 60, 90 days, and now we’re trying to get a lifetime out of it? So, endodontists began taking more charge of the pulp chamber. I didn’t get to any of the other stuff yet, but just the pulp chamber.
Yeah. I think also, Richard Schwartz was saying that not putting a restoration on immediately also predisposes to fractures, too. So, that was an issue, where he was saying, “You need to at least do something initial to get it going.” And I don’t think, actually, Dr. Cassis had a problem with some initial restorative work. I think it was more that he thought maybe Richard Schwartz was suggesting more than just the initial --
And he – and he was.
-- and – and maybe this is, like, somehow eroding the trust that exists between general dentists and endodontists. And I think that that’s kind of what the – the main problem he thought was happening with the article.
Then, Dr. Al Gluskin, the President of the AAE, wrote a response letter. And he was saying that Dr. Schwartz’s article wasn’t meant to be like an AAE policy statement, but rather, just to spur discussion, like what’s happening with us, right now. And I just wanted to read one little, short paragraph that he wrote in his response, Dr. Gluskin.
He wrote, “The AGD letter goes to the heart of what referral relationships are all about. Who performs certain procedures is determined by consensus between the referring doctor and specialist, with clear communication” – which I’ve heard you say, many times now – “and mutual respect. Our common goal is to provide the best possible care for patients, putting patients first. As specialists, we also want to make life easier for the doctors who refer patients.”
So, after reading that response – his response, it doesn’t really seem like he is trying to say that endodontists should take up all the restorative work. He’s just wanting to say, there needs to be – I – the main thing there needs to be is communication.
Well, I’ll go one more scenario. This is normal. When general dentists are in a more mature practice, and they’re busy, emergencies are an intrusion into an otherwise busily scheduled day. So, the problem is, is the general dentist sees a patient who was up last night, and they immediately take a bitewing or something, and they diagnose that it needs a root canal. “It’s gonna really disrupt my day, and let’s get him out of here, get him to Ruddle.” So, that’s going to be sent to me. When I see the patient – I’m just making this up. It's all psychodrama roleplaying, but you’re all dentists, so you can imagine.
It could be a little bit of decay under the crown, it could be blow-out decay, it could be some marginal decay, and it could be crestal, to the crest of bone, or sub-crestal decay. That’s in my office now, as an emergency, and I’ve probably backed off a little bit on a regular scheduled patient to take care of this patient. But how do I do the palliative treatment with all this stuff going on? So, I’m obligated to remove the casting, if one’s there, because it’s defective, clean out the decay.
The general dentist could’ve done all this, right? They could’ve said, “Well, hey, I’m gonna send you to Ruddle. But first, let me invest about 40 minutes, taking the crown off, clean out the decay! Electrosurgery!” So, bring in the electrosurgery, use your laser, cauterize that tissue. “Oh, my God, it’s clear to the crest of bone! Maybe I should do a little bone ramping!” No! They wanted it out of their office. So, in Richard Schwartz’s favor, he was a general dentist for 20 years. That doesn’t make it good or bad, it just means he has experience doing this. The general dentist is entrusting me to take care of their patient, get them out of pain.
So, part of endodontic treatment is pretreatment. And pretreatment is caries’ control. What if the tooth’s not even restorable? What if Ruddle keeps cleaning and grinding out all the caries, the soft dentin, and I feel like, you know, short of a periodontal miracle – crown lengthening – we’re gonna – I – this tooth’s non-restorable. Well, then, why am I even doing palliative treatment? It should be extraction instead of the – so, I think both sides in here, I think both sides were completely crazy.
Because I think what Cassis’s should’ve done – Bruce, you’re my pal, and I don’t even know you! You should’ve called up Al Gluskin, and you guys should’ve had a coffee, a coffee with Al, a coffee with Bruce! And they should’ve talked about this, because I’m not looking. I have never met an endodontist that is a specialist who has isolated their treatment to this discipline. “I wanna do more restorative! Bring it on! I’m a little under-booked! I need more procedures to do!” That’s not how it works at all. We’re there to do endodontics.
And if we have to chase decay, then, guess what? Ruddle’s gonna do a core build-up, because I need to isolate the tooth. And how do I isolate a tooth that’s subgingival? So, Bruce, I think you would agree with me. I don’t think we even have any differences. If you refer me a patient, like I just described, I do caries’ control, I can’t even clamp the damn thing. So, yeah. I’m gonna do a Tofflemire. I’m gonna do a build-up with one of those bonding materials. In the old days, it was amalgam, and then an ortho band. But I’m gonna do all that. Then, I’m gonna make my access. Now I have total control.
I can do world-class endodontics, and I can refer back a case where all you gotta do is land the margin. Sometimes – it came up in this article that I love --
-- it came up that Schwartz said, “Well, you know what? Sometimes those margins are sub-G, and I have a microscope, and I’ll put the margin on for the colleague.” I never met a general dentist that didn’t say, “Thanks a lot! Rick, thanks a lot! Cliff, thanks a lot!” Because we’re making their life easier, and we’re – we’re – we’re charging a small build-up fee. Please! It’s not about who gets paid, because it – there were several inferences, “gettin’ out of your lane,” “you’re lookin’ to expand your income,” “you’re takin’ away our work.” There’s no turf war. There’s no turf war, at all.
It’s – I never had – in 45 years of practice, I never had one general dentist call me up and scold me for doing anything. Well, all’s I got – they never even saw the endo. Half the time, they didn’t even see the x-ray. They just said, “Thanks a lot. That was heroics. Thanks for puttin’ that – geez, you even landed a margin for me!” Yeah. Just take an impression, pal, and off to the lab, and get the casting, put it on, and everybody wins.
Well, you know, I have to say, I read the letters that you – because you gave me these letters. I read those two letters before I actually read Dr. Schwartz’s article. And so, after I read the letters, then, I’m like, “Well, geez! What did he say in his article?” So, then, I found the article and read the article. And I can actually kinda see both people’s sides. I think the – the problem just kinda comes down to just the tone of the article, honestly. It just – I can kinda understand why Dr. Cassis might’ve been a little offended, and I can also understand where Dr. Gluskin is coming in, saying that “You know what? We just all need to work together and be a team and communicate and have respect for each other.” So, I – I could kinda see both sides.
Maybe we should have Bruce on the show.
Yeah [laughs]. I --
Because I know Bruce. I mean, I know that old Bruce – I know Alan Gluskin. He was at University of the Pacific when I was there, and we both went to endo. He was a general dentist, and I was a kid finishing up. We both went to endo school in more or less the same, exact period of time. And I know Rick. I’ve referred family members in San Antonio to his office, because we had a dark tooth in the family from trauma. And although he didn’t turn out to bleach it, he’s a very ethical and honest guy, and he referred it on to a general dentist that he works with. So, I think endodontists are here to please.
I hate to say that. I mean, look. Available, affable, and affordable, right? And we’re there to please the patient, please the general dentist, and we’re part of the team. And I – I really think that what’s missing here, before this big statement, where it really sounds like two big organizations, one’s about 60,000, one’s about 8,000, are doing this, come on, guys! Pick up the phone and talk it through, and then, write a – write a nice article together about where the boundaries are, where the gray areas are. Where’s the commonality? And is it okay if we play in that area of commonality a little bit?
And if not, we could always refer the patient back to you, Bruce, and you can do the cleanout. You can do the electrosurgery, crown lengthening. And you know what? Most dentists would say, “Well, Cliff, if I’m gonna do all that, I might as well do the root canal!” [laughs] Yeah. You might as well do the root canal.
I actually – okay. We have a graphic now to show you that answers our question, “Whose job is it?” So, why don’t we see that graphic. Together, Everyone Achieves More – Teamwork. [laughs]
So, what is the whole preface, the whole foundation of interdisciplinary treatment? It’s teamwork.
Yeah. And I think you said it before. This was never an issue for you, because there was always communication and mutual respect. And I think that you just need to be communicating with – if you’re an endodontist, you need to be communicating with the general dentist, and vice versa.
Well, I said this to my daughter, when we were planning this segment. And I mean, when it makes a magazine, and you have two big organizations, I tipped my hat to her and said, “Okay. We’ll do it.” My inside conversation was, “Why would we ever do a segment on this? This has never been a problem, in 45 years! I don’t even know that it’s a problem for anybody!” But apparently, it was a problem, so we’ve talked about it.
Okay. Well, thank you for all of the useful information and your insight.
From now on, I’m – I’m gonna refer caries’ control back to the general dentist.
If they promise not to do the MB1.
CLOSE: Ruddle Flashback – Gambling Jackpot!
So, we’re gonna close our show today with another Ruddle Flashback. So, you ready?
Okay. Let’s go back in time to 1976, Las Vegas. Why don’t you tell us what happened there.
I got it! I can remember. Yes, I remember perfectly. Gambling pays off.
Well, I had just finished the program at Harvard School of Dental Medicine and graduated, and we had taken the famous ride home that we will have to tell in another story, that you remember. And I got back in Santa Barbara, got my practice started, and it was time to go to the AAE meeting, the first one since I had graduated. And of course, it was in Las Vegas. So, in this particular instance, because you guys were young, Phyllis didn’t come with me. So, I went by myself, and the first day was a glorious gourmet meal of many speakers, you know, relevant topics, fun stuff. And that night, I was with my pals, and there were a few drinks, and nobody wanted to gamble, but I thought I should, because I was there.
And that’s what you do in Vegas, right? You don’t go to dental meetings in Vegas, you gamble in Vegas. And what you do in Vegas stays in Vegas, right?
So, anyway, I went to my room and got, I don’t know, ten bucks, because we were on a shoestring, having finished up Harvard and the University of the Pacific, in San Francisco. At that time, I think it was like the second or third most expensive school in the nation. So, we were into a lot of debt, and I went down there with a limited amount of money so Phyllis wouldn’t beat the Hell out of me later. And – well, I should tell this now. My uncle was a big gambler, and we shouldn’t even go into his life. He was a troop – gunner on a troop ship in World War II. He was a wild man, but he did love to gamble. And he said, “Whenever you gamble, Cliff” – he thought I was a big gambler. I wasn’t.
He said, “Always get the attention of a big crowd.” And I said, “What do you mean?” He said, “Well, choose a machine that is close to a line where people are going into a show,” because they’ll start queueing up about a half hour early. And he said, “About ten minutes before the show, there’ll be hundreds of people ready to go in. So, try to get a machine right by those people.” So, I waited for one to come clear, and it was a bicentennial machine. Our country was founded in 1776, and this was 1976. And so, it was a four-line deal. You gotta line up four things.
And I was pulling on the handle, putting in three quarters, pulling on the handle. And I was gettin’ a few feeds, a little bit of trickling. So, now I was playing with their money. My money was gone, but I had a little house money. And I put in four quarters, pulled the handle, and boom! [Sound of slot machine] One, seven, seven, six, and bells went off, and everything – the people in line went crazy. They started cheering. And all of a sudden, this little lady with a hat on – she was with the hotel – the casino – she came running up to me and whisked me away by my arm and [laughs] – and right to this cashier area, where they paid me $1,776 in cash.
Well, I had not seen that kinda money in virtually all my life. So, that – that was like, you know – well, I was gonna say, you remember Duane, but we won’t go into that story, either.
But I thought I’d probably become a billionaire. And so --
-- I immediately went to my room, but it was like 1:00 or something in the morning, and of course, there was a full program the next day. So, all the endodontists were sleeping. So, I went to knock on Mike Scianamblo’s door, because I wanted to tell somebody the good news. And Mike, when he came to the door, I threw all the money at him. And it went all over the bed and everywhere, and he said some very tough words, but it was like --
-- “Get out of my room! I’m trying to sleep!” Well, I was very happy, still. I wasn’t too discouraged. So, I called Phyllis and told her the good news and went to the rest of the show. So, yeah. We lined up one, seven, seven, six.
I remember Mom telling us at home that – that you won money on a slot machine in Las Vegas, and me and Lori were really excited. Do you remember what we used the money for?
We bought a hot tub [laughs].
Oh, right! So, where we used to live, in Santa Barbara, we had this really nice backyard. A little creek was running through. It was very idyllic, and we had a redwood deck. So, yeah. We put in a hot tub, didn’t we?
I do remember a future chore that was to come was draining the hot tub [laughs] and cleaning it [laughs].
Yeah. So, anyway, that’s an example of gambling pays off. I’m actually – so, you’ll just hear it from me, I am not a big gambler. I work too hard to gamble. But I always do like to play like – you know, take 20 bucks down and see what happens.
Okay. Now, I wasn’t gonna say this, but you’ve actually won another time in Las Vegas, about the same amount of money, at a later date. So, what tips do you have for our viewers about how to win in Las Vegas? [laughs]
Heed the words of my uncle. I mean, they – they want you to see winning. They want everybody that’s gonna lose, like their shorts, they want you to see winning does occur. So, don’t go to the back of a – you know, deep bowels of a bunker in a hotel and find a corner that’s quiet. Get out to where the traffic is [laughs].
So, develop a strategy to win, kinda like in endodontics, right? [laughs]
Yeah. Endodontics, if you are where I sit, I would say, when some people perform it, it’s a complete gamble.
So, I hope they hit the slots and line them all up, you know? Shape, clean, pack, and resto, R2C, restoration to crown! Pull that handle! Win!
Okay. Well, thanks for sharing that story. I liked it a lot. Thanks. See you next time on The Ruddle Show.
[Video playing again as the family heads back home after the taping]
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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.