Product Features & Technique Sequence - Safe•Effective•Simple
EndoActivator History & Technique How the EndoActivator Came to Market & How to Use It
This episode opens with a humorous look at astrology and how it relates to dentistry. The majority of the show features the EndoActivator, a safe, effective, and affordable 3D disinfection technology. Ruddle reveals how the idea for the EndoActivator was born, how the product came to market, and how to use this simple, yet very efficient, sonic technology. Stay tuned for some more philosophical wisdom to close the show, this time in the form of quotes from United States presidents.
Show Content & Timecodes00:09 - INTRO: Astrology & Dentistry 06:11 - SEGMENT 1: EndoActivator – Part 1 30:00 - SEGMENT 2: EndoActivator – Part 2 53:06 - CLOSE: Philosophical Wisdom – Quotes from US Presidents
Extra content referenced within show:
Extra movie/video content:
Downloadable PDFs & Related Materials
EndoActivator Warranty Information and Handling Protocol Re: Tip Removal & Battery Replacement
In the United States, alone, more than 100,000 dentists perform tens of millions of operative, restorative, and reconstructive procedures on an annual basis. Certainly, these dental procedures are primarily directed toward eliminating carious lesions, esthetically restoring teeth, and functionally moving patients toward optimal oral health...
There was more change in clinical endodontics from about 1985 to 1995 than in perhaps the previous 100 years combined. In these ten years, clinical endodontics changed forever with the emergence of four game-changing technologies...
For many years, our team has been extensively involved in investigating how to significantly improve existing endodontic disinfection methods. Clinically, disinfection protocols should encourage debridement, the removal of the smear layer, and the disruption of biofilms...
Endoactivator Research Addendum. Summary Of Supporting References: Ongoing Clinical Studies & Publications
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: Astrology & Dentistry
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. How are you doing today? It’s kind of a special day, isn’t it?
Yeah, it’s really great. My [granddaughter] unbeaten champion in tennis in high school, Sophia Ostovany, is having her 18th birthday today, and she’s graduating as a senior from Santa Barbara High School.
Right. I think right now as we’re shooting, she’s doing her graduation practice.
Trying to get that tassel you know, it’s a big deal when you get that tassel moved over.
So we’re going to open our show today talking about astrology, as you can see from the graphic. And living in California, it is not uncommon when you meet people for them to ask you what your astrological sign is. And some people think that this information is quite revealing and really gives clues about who you really are. And then others think it’s complete nonsense. So our approach today is one more of humor and fun. So have you ever had a patient ask you what your astrological sign is?
Yes. It’s typically a female, and they’re usually middle aged, and they think it’s real. And so a lot of times they’d come in and they’d want to know what my sign was. And so you know I’ve always talked on the shows about how you always want to make a connection, a special connection. So yeah, I would play with that; there’s lines I have. Yeah, I’m a Pisces. And then they would start knowingly nodding their head.
Of course, yes; that explains it.
And then they did just that. And then they would make these remarks, and now they understand everything, and now it makes sense, and oh, they’re in the right place. Well then, I even had other patients that would bring in, you know, from their astrological I guess interests, they’d bring in gems, like crystals. And they would lay these stones – they’d get my permission – but they’d lay these stones around, because stones can mean love, it can mean energy, it can be healing, it can be success and all that. And they’d lay these crystals around and my biggest question was, this isn’t going to interfere with the electronic fields that guide my electronic apex locator is it?
Okay, well you just said you’re a Pisces, and apparently Pisces are supposed to be creative, imaginative, are very artistic, and also caring and selfless. That sounds like you, I think, on a good day.
I mean I think Pisces can also be kind of moody too, and that’s probably you on the other days.
Yeah, I was in a phone call yesterday and I was accused of being a little bit moody. But like I don’t like bull___, and I like people to quit talking about it; and just after all is said and done, a lot more is said than done. So yeah, I can be moody, but I think for me it’s just I’m focused.
Well I’m an Aries, and apparently Aries are courageous and strong-willed, and what else? Competitive; I guess I’m a little competitive.
Yeah, you’ve tried to kill me every time we played tennis. It wasn’t good enough just to beat me 6-0.
And then on the flipside, I also have tendencies to be moody, and I guess I have a lack of patience too. And I know that my husband and kids would agree with that.
So looking into a little bit more into this astrology/dentistry connection though; apparently it’s better during a waning moon to have your teeth cleaned. Because I guess it’s easier to remove the plaque during this time?
Waning, and the plaque just comes right off those teeth.
And I actually had a dentist appointment tomorrow to have my teeth cleaned, and it just so happens that the moon was waning. And now they’ve just called me and I need to reschedule.
Not when it’s waxing!
I’m like what?
Those microbes are going to cling to those teeth a lot more when it’s a waxing moon. It makes it more tenacious, more soreness after the visit.
They tried to just give me a new time, and I’m like well no; I have to consult my chart.
Well you know, the good news is just for fun, we’ll have Lori put on the show notes the astrological signs related to what a dentist might be. And then they can better understand – they being you out there, the audience of dentistos – you’ll better understand how your patients might be looking at you.
Yeah. We do have a little something that we could put in our show notes. Also, apparently you should never schedule a dentist appointment when Mercury is in retrograde. So don’t do that, and also don’t try to repair your car during that time either.
You’re way over my pay grade.
So I guess you’re – like Pisces are very intuitive. So what do the planets tell you today about our shooting The Ruddle Show today?
Well they said everything’s in alignment; it’s a perfect day to talk about agitation and all that stuff. And then Phyllis told me that – you know, she’s a Sagittarius and that’s water – no she’s fire.
She’s fire and you’re water.
So Phyllis is Sagittarius, she’s fire, and Pisces is water, and they don’t mix. But she reminded me that we’ve been boiling along for 53 years.
Yeah, I think you can mix. I grew up with fire, so I guess you can sometimes see some of that tension arising on the show.
That explains last week!
I know. Okay, well we have a great show for you today, and let’s get going on it.
SEGMENT 1: EndoActivator – Part 1
The EndoActivator System came to market in about 2005 as a sonically driven system for 3D disinfection, that combines scientific evidence with effectiveness and affordability. Since its launch, it has been validated by over 50 peer-reviewed articles, and is also being used by tens of thousands of dentists internationally. So today we wanted to talk a little bit about the history behind the EndoActivator, and then my dad is going to present to you the EndoActivator Disinfection Technique.
So those of you who already own the EndoActivator and use it will maybe pick up some tips; and those of you who don’t use it will appreciate its simplicity and you may want to try it out. But first, how is it that you came up with the idea for the EndoActivator?
But first, how cool is that graphic behind us? That’s pretty cool.
Yeah, like what is it that happened in the early 1990s that put the seed of the idea into your head?
Notice when you get older and your memory’s not quite as sharp, she’s like setting me up with a fast ball, right down the middle, belt high.
I’ll give you a hint. It’s the early ‘90s and.
Okay. Well I’m in a group practice. I mean each one has their own, respective, independent practice, but there is a conglomeration of dentists in three large buildings and they usually did an annual fishing trip to Alaska. So for years I’d been asked to go fishing, and my standard line was, “guys I really don’t fish; I’m not even a fisherman.” So one year they asked me, and I’d been talking to Phyllis and I said well you know, I want to see Alaska. That’s the reason to go fishing; to Hell with the fish.
So I said I was going to go; they were shocked. And we flew up as a group of about, I don’t know, 15 guys; about half dentists, a few physicians, and the rest were just cowboys. And anyway, we had a wonderful time, albeit really quick. We went salmon fishing on day one – it was a 3-day fishing trip. And I was told to pair off with a periodontist, Phil Smith, and we got on these little boats and we – I’d never fished, neither had Smith – and so they said well, you just troll about 30 meters off the shoreline. And you throw your line out, and there’s a lot of coho so you should be able to get a hit on your line and the limit is 12 for the morning.
Well by the end of the morning, Smith and I had no fish, but everybody else had had their limit hours earlier. And we didn’t know how to fish, and so that night at dinner they told us, when you throw a line out, you guys, you were pulling it in and the fish is very strong, and you need to let them run. So we’d be – you’re supposed to pull them in a little bit and then zzzzzzzzzzz – when you hear that line going out, I mean it’s like meters a second. It’s just like that fish is taking that line out 50 yards, sometimes a football field. And then you start bringing it in. Anyway, long story short: they get tired and you can bring them in.
So on the flight home, they had all their fish and steaks and filets all packed and on ice, and they were feeling very good about it. I was sitting in the plane and was going like you know; I have an idea. And the idea is what if we had a line that was a polymer, and we could activate it, sub-orifice level, in a natural tooth; and we could agitate fluids and get better exchange. So that’s what I learned on the fishing trip. I came – forget about fish, I came home with an idea.
So you saw the strong, flexible line, and the agitation of the water.
Oh, that’s good.
And you started thinking in terms of irrigation, I guess.
I’m a Pisces.
So this is what happens when a master endodontist goes fishing and doesn’t fish. They come up with these ideas. But let’s be clear. You didn’t come back and immediately start working on the EndoActivator project. Because at that time, you were heavily locked in on trying to bring an endo brush to market, and you had been working on this for many years, right?
Are you trying to humiliate me? For ten years I was, as they say in Biblical days, wandering in the wilderness. But I had gone – I had taught people, guys in the industry – taught guys. Looking across Western Europe; we went to Plastic Valley. That’s like Silicon Valley except Plastic Valley is in France. They’re known for miniaturization, nanoparticles. They can throw a half a car at a time in injection molding. It sounds like the end of a world event; I mean they throw a car.
Well, then we went to Mexico. In northern Mexico there’s a fabulous injection molding company and I got turned on to that. Anyway, all these leads failed and I had this – you know, bristles on a toothbrush. I had this idea if we had bristles – they’re called arms – if you had arms down below the orifice and you were reciprocating or spinning, we could really scrub those walls and open up those tubules. But then when I went fishing, I thought you know, my brush, even on its best day – I think there’s a market for it, I think it’ll help dentists – but it’s never going to exchange fluids, really, into the deep, lateral anatomy; or the anastomoses between systems.
So slowly then after that trip I began to kind of let the brush thing go, because I never give up. You know, I have that attitude like all things are possible at all times; just a little effort, thank you. So anyway, started to move away with some critical thinking, and really thinking more about irrigation and breaking the paradigm I had in my head, which was probably incorrect. And I thought, you know what? This agitation device could clean the mother canal, and it could also – through bombardment, it could exchange fluids into the deep, lateral anatomy, and we could probably have a better, clean, root canal system.
So yeah. Okay, so you started filing some patents to protect your IT, and then you began talking with colleagues and friends. And at that point, you were looking for someone that was going to help you manufacture the product, right? And that’s when Dr. Bob Sharp comes into the picture.
Bob Sharp. Okay, yeah. After my brush thing of ten years, I let my ego down and I realized in life you usually have to have help to get things done. Like you building the show every week; you have to have people around you that are really fabulous. So Bob was in my office training with Fred – I think it was Fred Tsustui is his friend – and they came up for training days. We were just all training; I was learning from them and they were learning from me. And I just yelled out one time during the day the way I remember it, and I said you know; “anybody that can help me bring this damn thing to market, they can be a 50% partner.” And Bob didn’t really say anything at that time, but he then contacted me later, within days, and came back to me.
What was intriguing about Bob Sharp is he was a fabulous friend, he was a wonderful, gifted clinician, endodontist. And there was a whole – we’ll have to have Bob on the show, because he’s from Alaska but now he’s in Sacramento, but that’s another story. And Bob had all these attributes. He was very curious, and he had done some wonderful research in grad school when he was down at Jim Simon’s Long Beach VA program. So I thought, he is probably the right guy. And what was intriguing is he had a neighbor who – his name is not important – but he was just a couple doors down. This neighbor’s kids played with Bob’s kids, and they grew up together, and this guy is in the import/export business and he particularly brings products to market with Chinese expertise. He spoke Chinese and he had many connections in China, including injection molding.
Okay, so now you’re really getting serious about manufacturing a prototype because you found someone that can make one. So how did this all work?
Well, Bob and I were looking around the landscape, and when you hold the handpiece in your hand it’s got have balance, it’s got to feel ergonomic, it can’t be too small, it can’t be too big, but you need to have nice motor skills on rotation and stuff. So when we looked around the landscape of handpieces, you want to look at a handpiece company. And KaVo at that time had some of the most important and highly and widely used handpieces in the dental market. So we looked at a lot of different KaVo handpieces, but we like their highspeed handpiece because it was relatively short, it was contra angled to get back in the mouth, it had a really nice balance and feel.
So Bob and I had gone to some big shows in Los Angeles and Las Vegas and learned a little bit more about injection molding, so we decided – we’d learned at those shows to get stereo lithography done; SLA. And that is actually a precursor to what your son is using at your home every day, 3D printing. So in those days we were able to have it made almost in 48 or 72 hours. You’d get this thing back, and of course it’s empty inside, but you could feel it, you could see it, you could look at it, you could really begin to understand.
Well, then we had to get some mechanical drawings made, because if you’re going to have it made overseas – and we don’t speak Chinese – Ed needed to know exactly how to communicate, and the best way to communicate is say, “here’s the mechanical drawings and here is the SLA.” And all of a sudden, from a distance and with language barriers, we could get there.
But then there was also you needed to identify the best polymer to use.
Oh yeah. I didn’t know how deep we were going to drill down, but that was the handpiece story. The tip story is I wanted – I was thinking nylon. But as we began to inspect in the medical world; because in dentistry, there was nothing below the orifice that was a polymer in dentistry at that time, except in the field of obturation. Polysulfone was the internal carrier of the carrier-based obturators. So other than that, in another field, another part of the trifecta filling root canal systems, nothing was used below the orifice in endodontics; because it had always been ultrasonics. So we had to identify – we found out in medicine, that the purest grade that can even be implanted it the body was Delrin.
So off to Dupont we went, in Canada – that’s their headquarters – and now we have some Delrin that we have to send over. And you’re going to get into that, but it was my daughter who did all that stuff; get the company identified, then I think she had to go to Amsterdam to get it because that was a subsidiary of their company. But anyway, she had to get all these things into the plant so the company – I’ll say it, TGB – so they could produce it.
So it sounds like you had to find a handpiece, you had to get the Delrin, and then you had to get the motor from somewhere, and I guess you got that from Japan?
Yeah, those little things inside that EndoActivator that they’ll see in just a moment; there’s parts from all over the world. They’re called components. And really our manufacturing source was more of an assembler. So she did produce injection mold, the tips (polymers), and the handpiece body (polymer). But a lot of the stuff inside, the components, had to come and be shipped into the plant so she could produce it and assemble it.
And then there’s the packaging too. You have the packaging as well.
Yeah, Lori gets the double salute. You know, you don’t think about all these things, and I’m just saying this word so simply. It gets so costly; it’s so time consuming. It’s where you are on the bloody edge. They say the leading edge; it’s more like a bloody edge. But it’s called regulatory.
So to go through regulatory so you can launch a product in a country – and first it was North America and Western Europe. You could do those countries as blocks, go through severe, intense regulatory. But then other countries; as you being to get into those countries you have to license, pay fees, they want to see your mechanical drawings. They want to know literally what is the electromagnetic current ten feet from the patient’s head when you’re using this? And you’re going, I don’t know that that applies for this Class 1 product. But anyway, there was a lot of stuff that Lori had to learn to do and get it all there; regulatory. And then of course at some point, you’ve got to get it out to the universities, because I don’t know what the protocol is.
Well, because I guess you took your prototype to Dentsply and you said do you want it; do you want to sell this? And they said not at this time.
Well yeah. You know, I was kind of naïve, but they said where’s your evidence? And to me, so many things I’ve designed in my mind, I’ve thought through in my head; I know it sounds crazy. And I can see them working and I understand it’s a benefit. The papers come along maybe a decade later. But the big company, they don’t just buy stuff to buy stuff. They have to know that they can have exclusivity if they get the product; they have to know there’s patents; they have to know what the DFU, what’s the university research. So all this has to be going kind of concomitantly; you don’t do them linearly or you launch in 50 years. So you have a lot of things going in parallel.
So then you did start reaching out to several international universities for them to develop the protocol.
This is where Professor Pierre Machtou, that you lived in his apartment within his office. Remember that story, as lawyers go? Pierre Machtou, Professor Machtou at Paris 7, was going to help us on the research, because he had residence, he was a chair. He’d been a chair for like 30 years at that time. And so he had some students – I’ll mention his name, Gregory Caron – and they did our first scientific paper, peer reviewed, published in the Journal of Endodontics; and it was thrilling. And so we went back to Dentsply, to finish the story, and they said “Oh, got a paper, huh? Nice! Do you have any corroborating evidence?” Oh, you want another paper? Yes, we need papers, Cliff.
So Pierre then helped me in Western Europe, and he identified five professors, who we’ll identify them formally in the lecture later. But they had – their life work was in histology and disinfection, so by them using this, they begin to look at the evidence, the histology, the SEMs, and a protocol was born. And that protocol – in other words, how you use it, what’s the disinfection cycle, what are the reagents, when do you switch, all that stuff which we’ll talk about in a little bit – but anyway, that all came from evidence-based research from five universities in Western Europe.
Okay, so then we have the protocol, so then you can write the DFUs, and everything sort of has come together. We decide that we’re just going to go ahead and launch the product ourselves. And so Lori and I – Lori is my sister, by the way – Lori and I began taking orders and shipping out product every day. And I have to say during this time, it was very busy. Because not only were we shipping product every day and being customer service; and then Lori was also still dealing with all the regulation, which is a foreign language to me. But then we also had to be tech support. Because it wasn’t long before some problems started to arise and we had to address these; and mainly the problems were the rocker arm breaking and the battery clip breaking. So why don’t you tell us why these issues were happening and how we solved the problem?
Well, so I don’t lose total credibility; every part inside the EndoActivator was engineered. And what that means; it has to go through stress cycles over hours of time. Your example of the battery clip. If you took the housing off, it was a single AA battery that could be replaced. We had it pushed up tight so that it had good contact with a folded piece of metal. It was probably about .4 of a millimeter, and it was folded so it looked like that. And it would spring.
And it just kind of pinched it.
Well, we ran for hours and we never had – psychic fatigue would be the word – we never had any psychic fatigue failures. But apparently out in the field when somebody is using it, maybe even past 10,000 hours, just that vibration of the agitation of the rocker arm moving the Delrin tip; that was doing a lot of little – countless psychic fatigue cycles, and it was failing. Now when I say failing, it was failing on a very, very small percentage. But again, Dentsply Sirona is the biggest distributor in the world. They have regulatory requirements; they can’t have customers reporting broken battery clips. So we worked with them – we had a team of engineers, but we worked with a mechanical engineer and we formed a spring; and the spring replaced the battery clip. And that could push it up, and that spring could take the load of all those thousands of cycles. And that solved that problem, so then we got a bunch of extra ones and we had a little bag, and if you broke one in the field, rather than having to buy a brand new unit, we could send you out a clip. If I was Apple, I would have said buy a new unit, right?
Maybe, I don’t know.
And then the rocker arm, you know, the tip snaps on and attaches to the handpiece, a snap-on/snap-off. And there’s a little driver that sticks down perhaps a centimeter below the handpiece. Well colleagues would throw it back on the bracket table, and the girls would take it back for sterilization, the staff, and they would clean and disinfect and all that stuff. Well sometimes they were trying to get the tip off and they would take it off like this, so there’s a big lever arm. We wanted them to put their thumb on the back and pull against their thumb to be stable, but nobody read the DVD. And that day we had an introductory DVD in every introductory kit that arrived, it was about a 7-minute movie, it was a beautifully produced movie, we’ll reproduce the whole thing with our multi-media team, it was just like boom, boom, boom, simple, fun and fast. Well nobody needed to read the DVD or watch it, because they said geez, you know. You do this, snap that on, boom, you’re ready to go. How hard is that?
So anyway, we also had drops. People would drop it, send it back; it’s broken. They’d turn it on and they’d say I hear a rattle noise in here. So over time we reverse engineered – well, we didn’t – well, we reverse engineered off of our original drawings another rocker arm, and that was also called a repair kit, and that could be changed in the field. And I told Lori, when you can change it within about three minutes without a lot of practice, then we’ll make this part available so, again, the colleague doesn’t have to buy a brand new handpiece. And so we started having a little repair kit for battery springs, and we had a little repair kit for the rocker arms.
It was not uncommon for me and Lori to be on the phone talking through someone while they were doing the repair.
Well, the funniest thing we were talking about during our walkthroughs for the show is they would dunk these sometimes in cold, sterilizing solutions. You know, can’t do that. And some people even autoclaved them.
Well, what happened is when we were getting reports of them not working, and a lot of times we would ask them to send back their faulty product and we would send out a new handpiece, at no charge usually. And when we got the handpieces back, sometimes they were in quite a shocking condition that you were wondering what they were even using it for. Like you said, some people just tried to autoclave them. And so we realized that there just needed to be more product education about the barrier sleeves and how to remove the tips and all of that, and not just count on the DVD teaching people how to use it.
Eventually we took on a fulfillment center so we didn’t have to ship the product. And then by 2008, like about three years later from the launch, then Dentsply started distribution of the product, and that helped our workload a lot.
We had about ten papers by then.
And now they’ve actually acquired the business, and that was only just finalized this year. So it’s been a long process.
I just want to acknowledge Bob Sharp, a wonderful friend, and his wife, Susan, and their family in Sacramento. And he worked hours and hours that Ruddle didn’t have to work with some Sacramento based engineers. There were two groups of engineers that were in two different big factories and companies. And I just want to acknowledge you, Bobby, for helping me get this thing to market and helping us have a little bit of fun.
Yeah, we hope to have Dr. Sharp on our show in the future to give us the history from his perspective, and also maybe fill in the blanks a little bit. And also, I just want to say that you are working still with Dentsply on an EndoActivator II, which will be coming to market soon. Right?
What? Yeah, we’re doing – we’ve been working for two years on it. Well, didn’t you say about 15-year-old technology? I mean, we wanted to change it significantly about seven years in, because after you’re in the market – and I was going all of the world lecturing, writing articles – the market is the place where you hear how happy people are and how disappointed people are. So you always – I’m always listening incessantly to how to make things better. So finally corporate agreed that the market was really growing; disinfection is really central, it’s a hot button right now. 3D disinfection. And so they’re all in. And guess what? You’re going to have – for about $1200 you’re going to be competing with about $70,000 technology for just about the same result. Oh my goodness; it’s going to upset the market. It’s one of those things that’s called a disruptor.
Okay, so exciting times to come ahead. But we just wanted to give you a little glimpse today about the 25-year journey of the EndoActivator. It’s been a lot of work, and if I asked you if you wanted to do it all again, I don’t know if you would just immediately say yes, let’s do it all again. Because there were quite a lot of challenges, and we omitted several legal disputes regarding patents, that probably ended up costing a few hundred thousand dollars. So it wasn’t all just fun and games, and it took a lot of perseverance and dedication. It did turn out well, though.
Is this the time I get to acknowledge my family? I mean, I’m looking right at the camera. Without Phyllis writing the checks – which I don’t know why she did. She should have said you’re all finished; move out before we go bankrupt. You spend a lot of money when you do private development; we’ve talked about that in other shows, private versus corporate. I want to thank Lori; a soldier and general behind the scenes that really learned out of nowhere how to run a business like this, separate from the educational business she was in. And then of course, thank you.
You’re welcome. Okay, so now you’re going to actually show us how to use the EndoActivator, and point out some more of the product features. So let’s get on with that.
SEGMENT 2: EndoActivator – Part 2
Well, you just saw when we were on the other set how a fishing trip can lead to a lot of danger; and over 25 years that danger turned out to be an opportunity. So let’s get back to the EndoActivator.
Well, the reason we were thinking about agitation in an EndoActivator from the fishing trip was because I perfectly had in my head from the time I was in residency school – and that was like in the ‘70s, mid-‘70s – we knew Hess’ work and he talked about root canal system anatomy. And I’m not going to talk about how he cleared the teeth and how each specimen was prepared, but just there’s 10,000 teeth in this book and here just look at six images you begin to wonder, don’t you? How am I going to ever clean that thing? Well let’s keep going.
So in the modern era we’ll turn to Frank Paque, a wonderful friend and endodontist, and he did a lot of micro-CT work. And you can see in these beautiful images on human teeth, there’s root canal systems. So this was done; micro-CT is non-invasive, but again, it’s showing clinicians what the task is that lies ahead when you’re doing and scheduling clinical endodontics.
So this is a palatal root amp over on the molar, but you can see it has a lot of similarity. These are not the same images, but they’re similar. Because you can see right here, there’s anastomosing between the MB 1 and 2. And clinically we see the same anastomosing, and the origination of another whole portal of exit that has its own, separate, apical portal of exit. So anatomy matters, especially when you’re restoring just the buccal roots in splint dentistry.
And of course you’re seen some of these micro CTs before. You should see them really every day. It’s just like another tennis lesson. If you’re going to be a pro tennis player, you’ve got to be hitting the ball every day. So you’ve got to the looking at the anatomy because it always refreshes your mind – hit the refresh button – so when you sit down with a patient, you’re thinking systems and not canals. So one system trifurcating, and I already did this once before. We have one, and we have three and we have two. So 1,3,2.
And we can look at another case. This was the first one we ever did with the WaveOne, single file technique. But if you look at Frank’s work, you have a mid-mesial coming of an anastomosing deep. We have a mid-mesial coming off of the system. We have multiple portals of exit, and that’s why we’re having this little session today; so we can talk about how can you do this? A lot of you are doing it. You send me cases and I’m thrilled. Others of you are now inquiring how you do it, because the hot button – the hot button in clinical endodontics today is 3D disinfection. And you could to a really good job at an affordable price.
So if we just kind of close out with a little collage, you can see every one of these little pictures, 9 of them, they’re systems. Say “systems”; I can’t hear you. Say “root canal systems”. How you communicate is how it is.
So if we pull your last file to length, your last shaping file that went to length; if you pull it out, if you pull it out of that tooth, you can see on the way out there’s lateral canals, there’s anastomosing between systems, there’s a smear layer on the internal walls, the dentinal tubules are blocked and occluded with mud. The mud could be dentin, of course; it could be remnants of vital pulp tissue, if it’s infected it could be even bacteria. So it’s a cocktail, typically. And if you’ll start to look then at what’s left, a lot of you would say I’m ready to fill. I’ve got my final file to length, I fit a cone, I confirmed it radiographically and I’m ready to pack.
You’ve just gotten started. In fact, one of my pet peeves is all the literature that’s comparing; does this system clean better than this file system? Come on everybody! Files don’t clean canals. They just make a shape. They make a smooth, tapered shape to length eye-view. And if you can do that, now you can get started on the last little phase of this, and that’s the disinfect so you can fill root canal systems.
So, this is what we’re trying to do, and I want you to start thinking about access cavities; that’s a category within bread-and-butter endodontics. Then there’s glide path management, preparing canals, 3D disinfection, and then there’s filling root canal systems. So clean out all the pulp, all the remnants. Get rid of the smear layer, that’s the byproduct of our instruments cutting across dentinal tubules; we’re blocking and occluding those tubules. And then the biofilms – and I won’t get into the sophistication of populations of bacteria that can speak to each other through quark communication – but we’re talking microbes and bugs. So that’s your job in 3D disinfection. Many of you, you’re so close to being able to fill systems. You’re getting those great shapes, but you’re just not thinking; well I’ve been irrigating along the journey and you’re thinking that’s probably enough. You should have a little time set aside at the end where you just focus on 3D disinfection and watch the anatomy show up on post-operative films.
So Pierre Fouchard talked about flushing the toilet of a cavity. Herb Schiller talked about flushing root canal systems. So I think we should have an honorary flush. So when you’re flushing root canal systems, good things happen as you begin to liberate debris, organic material, for a very complicated internal space.
So this is what I’ve been talking about. This was the journey from the fishing trip; this is the final product. So after many, many years, and having to change my thinking, and going from a brush – well maybe we should put bristles. I should talk to Lisette; maybe we should put bristles on these guys and now we can have the brush too. Well, don’t think we haven’t thought about that. Anyway, this is cordless; it has a single battery right back in here, AA; and you have the choice of three tips. And they just snap on the driver. We talked about the driver sometimes breaks; the driver is what attaches the tip, the hub, to the handpiece itself. And of course – I won’t go through all that stuff. Just watch the instructional CD that comes with it; DVD or whatever.
So this is a polymer. This is not metal. This is Delrin. It’s soft, it’s flexible, it does not cut, it cannot cut dentin. So, like the pendulum, maximum diversion out one way, you get the angle alpha, equal and opposite, that’s alpha; so we can say that our tip moves through two alpha. And there is no dampening; remember we said dampening. With ultrasonics you touch a you might get a real small pattern of back-and-forth movement; and that’s not nearly as effective. You want a lot of energy in there. You want big wave formation. Hey, I live on the West Coast; I’m in Santa Barbara. So there are slow waves; remember, it’s really slow. When there are slow waves, they can build in their amplitude. And that amplitude means bigger waves, generate more power, and that means more agitation, more exchange of solution into the un-instrumentable portions of the root canal space. So kind of fun stuff. It’s safe, it’s easy. Every tip – every tip costs, in the United States, two US dollars. Okay, $2.
There’s a lot of stuff going on here, so let’s break this down in a quadrant. Let’s look here. I’m directly – so you can really get this, I’m superimposing the two graphs of the wave going down through the device, whether it’s metal or a polymer. Yellow: really, really fast. We said it’s 40,000 hertz (cycles per second). We said the sonics is really slow. It’s about 10,000 – listen – cycles per minute. So we’re not even comparing cycles, seconds to seconds, or minutes to minutes. We’re comparing seconds to minutes. But you get huge displacements off the X axis, and that is what we’re looking for is those big amplitudes. So that’s that graph; sonics versus ultrasonics.
We said that sonics, when it goes around a curvature – I’m just making this up. In an MD system on a lower, mandibular molar with about 30° curvature, about mid-root, your tip will continue to move, even when the polymer is riding the wall; riding that wall of the shape preparation. Ultrasonic dampens; you lose your two alpha, you lose the benefit of the disinfection effort. This has been really talked about a lot with a series of papers. You’ve seen two or three skins already. It’s not the same paper, though; go back and look carefully at the show. They’re different papers, a series of papers talking about nodes, antinodes. Sonics only has one single node and one antinode, whereas ultrasonics has multiple nodes and multiple antinodes. That is the explanation, if you want to drill down and get into it more, why we don’t have any dampening with sonic technology.
So to just bring that home; if you see a tip in mid-air, you can look at the silhouette pattern, and we can grid that out on a metric ruler and it’s about 5mm. You’re like Ruddle, wait a minute! You can’t stick a 5mm two alpha into a 1mm orifice. Yeah, you can. And it just dampens it all down a little bit, but that thing’s thrashing. So it works on two principles. One; just the slapping of the polymer against the walls is mechanical energy like the bristle of a toothbrush brushing your teeth. Okay? Then the second thing that happens is when you go around curvatures, notice the tip. The tip is still working wildly through its two alpha, even when you’re making almost – with the long axis you’re making almost a 90° angle. So tremendous deflection still gives you agitation. Of course, the other thing besides mechanically slapping the walls is we’re fracturing liquids; and we’ll look at that in just a moment.
So protocol; anybody want to hear the protocol? It’s very simple. You shape the whole canal. So you’re shaping along, a few instruments or one instruments over a little bit of time. And you will have the tooth brim full, your access cavity, with sodium hypochlorite; 5 or 6%. So you’re shaping in the presence. When you’re all done shaping, you fit your cone. When can you shape, when can you evac? When you can fit your cone. When you can fit your cone, you’ve got the shape. How do you know you’ve got the shape? When the apical flutes of the last file to length are visibly loaded with mud, you know that file just cut its shape. So don’t keep over-instrumenting; you’re now ready to fit your cone. Confirm that, and then what? Select the tip.
The tip you select should be really loose at 2mm short. So if working length is – let’s say just 22, make it up, cycle down to role playing; if working length is 22, you’re going to fit your tip to 20; 2mm short, and the other requirement is loose. 2mm short and loose so the tip has a chance to move. The tip is not frozen or locked up because it’s wedged in the canal.
Okay, aspirate. Aspirate out all of your sodium hypochlorite. Aspirate it out, and fill the tooth with 17% EDTA, and go to work. Bring your EndoActivator in with the tip you chose – for me it’s usually a red tip. I’m infrequently using yellow; sometimes blue. But those are like on a bell curve; those are for fringe types of cases. Small ones, long ones, narrow ones; these are big ones, fat ones, straighter ones. But typically it’s a red tip, 2mm short and loose, and then fill the tooth up with EDTA and go in there an agitate for one minute. When you’re done with one minute, aspirate again, fill it up with sodium hypochlorite, and agitate for 30 more seconds. So it’s a minute and a half of agitation using different reagents. One takes off the smear layer and opens up the lateral anatomy; so when you come back with sodium hypochlorite, now it can go into available space, and it can begin to bombard into the tubules and anastomoses, and all the ramifications that comprise a root canal system.
So that’s the protocol, and it was made by some really important guys. I talked about this earlier when we were at the other set. But Professor Pierre Machtou has some friends that he knew that had been involved in disinfection over decades of their lives; each one of them. Each one of these people – Kishor Gulabivala, Paul Lambrecht; Gulabivala, the Eastman, London; Paul Lambrecht, the Catholic University of Leuven, Belgium; Phil Lumley, Birmingham, UK; Pierre Machtou, Paris 7, Paris; and George Sirtes, Geneva. So those people and their residents and their students begin to look at SEM, and begin to look at histology, and this was the protocol that was born. Ruddle wasn’t smart enough to make the protocol. I knew I had something; I can think conceptually and I could see all this happening, but I didn’t know if it was two minutes, one minute, 30 seconds, bla-bla-bla.
So there’s your simple to use protocol. And then if we employ it into a fluid-filled pulp chamber and a mandibular molar – it’s kind of exciting to see all the agitation – but you want to know what’s going on below the orifice. Below the orifice in simulated canals, you can begin to see the activity. Listen carefully. I talked about, as that instrument goes through two alpha and slaps the walls, it’s cleaning. It’s cleaned mechanically the prepared walls.
The other thing I told you is it fractures liquids. So when you fracture a liquid, at the liquid interface where it was fractured, bubbles form; and those bubbles form because they’re unstable because of heat and pressure. When they expand and implode, they send out 40,000 shock waves per every one, single bubble. So this isn’t cavitation; this is not acoustic streaming. This is bombardment. And it's like taking a power hose and blasting paint off of masonry. So you can see how we are getting biofilms and rods and cocci. Just like you take a carpet and you go like this and you get a wave going through the carpet. That bombardment strips that stuff off of walls and out of the branches, and you can have a really clean system in about a minute and a half. Is that too much time to shortchange your patients, when maybe you’re just doing handheld irrigation? I want you to come along; you’re going to enjoy it. When you start to see post-operative anatomy on those films, you get excited; and you want more of that, and you can have it.
Clean root canal systems can be filled in all their dimensions. For decades, generations of dentists, even if they developed hydraulics, they could never move filling materials into this anatomy because the anatomy was still obstructed. And if it’s obstructed, you can’t ask your materials to displace that debris, so you need to clean it out. Sometimes – let’s be honest – you might have a little debris left; little pieces or fragments. During the 2000 pounds per square inch hydraulics – that’s the Bernoulli Principle – you can blow debris out into the attachment apparatus, the periodontal ligament. And you have an immune system out here, you have round cells, histocytes, polymorphonuclear leukocytes. OK? These can engulf the debris that we were short on getting out – deficiencies with Cliff Ruddle – but if I get it out here, the body can take care of it. What the body has a really hard time doing is handling necrotic tissue products in the avascular root canal systems after pulp death. So that’s the jolt; get it out, get it out.
So if we keep going now – we’re almost done – you can see all of these beautiful openings. The tubules are open, the bifidities apically. You can look at this; you’ve seen it before. We have thousands of SEMs. Just look at the literature; they’ve been published, a lot of that has anyway. We have now 50 papers, peer reviewed in the international literature; 50. I like these; these are some of my favorites. There’s the Machtou Study right there. This was the first paper that Dentsply Sirona wanted to see; and they said well, that’s a nice start Ruddle, but you need a little bit more evidence. So the evidence came. It took some time, but over the years we now have statistical, significant evidence show the EndoActivator cleans root canal systems. And some of this was compared to lasers; some of it was compared to some pretty sophisticated stuff. But the little, old EndoActivator did a pretty damn good job.
So in closing – and I’ll show three cases and we’ll be done. We have a lot of literature, so you have evidence – remember evidence – ease and affordability. Now it’s not just a 3D disinfection device. It also what? Can adapt calcium hydroxide. If you’re doing the second visit for bloody canals, drainage, not done yet, not right. So that we can not only replace it with a tube, but then we sputter coat it, agitate it, throw it up on the walls, change the pH – the pH is about 12 – that neutralizes acidic reaction, so use it for MTA. This is mud, like concrete; we move it into root defects. You know you vibrated stone in dental school to fill your impression models; you can vibrate stone, if you will, MTA mud, into root defects. We can also activate solvents in the retreatment situation. So when we’re taking out gutta percha, even when we take out a silver point, what’s left is residual cements that were used in that era, and we can use an appropriate solvent, and we can agitate that solvent to better remove residues in the retreatment situation.
Some people sputter coat their sealer. And they place their sealer on the tip of the EndoActivator, put it down the orifice and sputter coat up and down a little bit, move it in amplitude strokes. Another idea. So there’s a multi-use – unlike Gentle Wave where you have to made a platform, you commit, you’re all done shaping; and you put the platform on, you run through a cycle, anywhere from about 6,7,8,9 minutes. Guess what? You have one chance. Nobody’s going to do that twice on the same patient. The EndoActivator, every time I take out a shaping file, brrrrr – I agitate my solution! So we’re using the EndoActivator entire – the whole procedure. It’s like this little device right here. It’s really small; put it right here; and you can run from room to room; you can even take it home. I don’t know, you can use it in the pool maybe. I don’t know.
In the US it’s about – it’s less than 600 US dollars. Each tip is about – less than or equal to two US dollars. It’s readily affordable. Nobody’s ever had to take a class on how to use it, okay? It’s pretty intuitive. The things I’ve always tried to invent are always with three words: simple, simple and more simple.
So real quick then in closing; anterior abutment of a long bridge, branch, bifidity of that lateral canal, more branches. Look at that, another little bifidity over on that branch. There’s maybe six portals of exit. You’d see a really long tooth; one edge is up here on the edge of the film, the other – roots are down here on the bottom. It’s a long one. Here it is five years later. Got the furcal canal, and the distal root, for me, is thrilling. So thrilling anatomy, furcal canal, multiple apical portals of exit, bifidity of lateral canals. You can do this. Ruddle didn’t even know this anatomy was there. Sometimes you use that EndoActivator, and you’re thinking it makes you more than you are and closer toward all you can be. So that would be really a fun case for you to do too, and experience the thrill to fill.
Last case. Big lesion, big old lesion on the lateral; almost nothing apically. And get in there and boom; out with the two lateral portals of exit. Some of you think that puff of cement’s a little big. You’ll get used to it. The body adapts nicely to osteo – I mean osteogenically, bone can grow right up. We have the science and the research on that, at least for certain sealers that are non-agitated, non-aggravating to the periodontal ligament. So we want them to be dimensionally stable, biologically inert, and we want bone to grow back over time.
So in closing, activate your endodontics, and have the thrill of the fill.
CLOSE: Philosophical Wisdom – Quotes from US Presidents
So we’re going to close our show today with some philosophical wisdom. And you might remember, we’ve done this in the past. We’ve talked about Chinese proverbs, we’ve done Murphy’s Laws, and also sports coaches. So today our philosophical wisdom is going to take the form of quotes from US presidents. So I’m going to read a couple quotes, and then you’re going to tell me what it means to you. And these are quotes you’ve chosen that you like. You liked the quote. You didn’t choose the president; you chose the quote.
Yeah, that’s true.
So the first quote is this. And it’s by John F. Kennedy. And it is: “Those who dare to fail miserably can achieve greatly.”
Well, that’s pretty inspiring to me. I used to play a lot of sports, so what it means to me is – they always talk about the lines; you’ve got to step over the line to be on the field of play. And when you go play different teams and different competitions, you don’t always have a guarantee you’re going to win. You have expectations; you know you’re training well; you’re playing well as a team. But if you don’t get out on that field, you have no chance to win. So I always took that quote when I heard it several years ago as like if you don’t get out on the field and try, you have no chance. But if you get out and dare, you can be awesome. And even when you lose, you’re more than you were. You learned a lot and you’ll be better next game.
In a way you should almost expect to lose if you’re in sports. Because only one person, for example, can win a tennis tournament. But you don’t even have a chance to be that one person if you don’t even enter the tournament.
Right. So dare to play.
Okay. And then the other quote you picked was by Dwight D. Eisenhower, and it is: “Accomplishment will prove to be a journey, not a destination.”
Well, when were young – and when you were young and when I was young is separated by decades – didn’t you always have aspirations and goals and stuff? So back to that quote. You know, I used think about the end; like the goal, the attainment of that goal. And then when you’ve got the goal it’s like yeah; well, I’ve been working on it for 10 years, 5 years, 3 years. And what I’ve learned as I’ve gotten older over the last decades is have a lot of fun, because it’s the journey that makes you more than you were. The destination is kind of expected; you’ve been working on a serious goal. Well of course you’re going to have a success. And even if you thought you were going here, a lot of times if you keep on the path, you might end up over here or here, or somewhere else. But you’re on the field, you have a chance to win, and enjoy that journey. And during the journey – like your daughter’s going to go to this school this year – who knows where that’ll take her? She’ll discover stuff and boom; she might go a little bit different, but stay on the path.
If you just think of the EndoActivator journey that was 25 years long and still ongoing. If you were just thinking about only the destination the whole time, you would have basically let 25 years go by and missed it.
So act on your dreams.
I picked a quote, and this one actually kind of gives me chills, and you’ll see why.
Let’s hear it.
It’s by Abraham Lincoln. “I don’t like that man. I must get to know him better.”
Wow! In this day and age, this society, the way the world is right now. Say that again.
“I don’t like that man. I must get to know him better.”
I love that.
I do too. I mean I think that we’re always seeing so many differences between us and others. And maybe if we just dig a little deeper, look for the commonality. There are people that I have in my life that my first impression of them was I didn’t like them at all. And now I really like them a lot. So it can go both ways.
You can also really like someone at first and then it can go the other way.
So maybe we shouldn’t be so judgmental on that first chance to make that first impression. Maybe we should visit a little bit, drill down a little bit and maybe emerging will be a new relationship and commonality that’ll take us to the future.
Probably everybody has something in them that can inspire us. So we need to keep searching.
Nice. I like that a lot Lise.
And then I’ll just close with this quote, because it just reminded me of the whole EndoActivator story we told today. And this one is by Herbert Hoover: “Be patient and calm. No one can catch a fish with anger.”
That’s probably why you didn’t catch a fish the first day. Probably you were fighting in the boat.
Well, we were a little upset that the other boats had their whole catch done in two hours, and our boat was – I looked at the floor and it was like pretty empty; I didn’t see fish.
Not even worth calling it a vacation.
I screamed at the fish, but they didn’t bite.
Well that’s our show for today. I hope you liked it. We’ll see you next time on The Ruddle Show.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
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Moving with the Cheese & Delving Deeper
A Better Understanding of Change & File Brushing
The Dark Side & Post Removal
Industry Payments to Academics & Removing a Screw Post
Special Guest Presentation by Dr. Don Tyndall
Controversies & Iatrogenic Events
Sharing Knowledge Pros/Cons & Type II Transportations
To Be Determined
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