Content Courtesy of: Warning Signs You’re at the Wrong Dental Office, Boulder Dental Designs Blog, 16 October 2018, https://boulderdentaldesigns.com/warning-signs-youre-at- the-wrong-dental-office/
Gamechangers New Disinfection Technology and Q&A
This episode opens with a warning…make sure your office does not have these red flags which let patients know they are in the wrong office. Next, Ruddle and Lisette welcome Dr. Randy Cross via Zoom to talk about his new technology idea and what it means for the future of endodontic disinfection. Then, Ruddle does another Q&A, this time focusing on gamechangers that can elevate your practice. Stay tuned for the close of the show for some interesting cast perspectives on shooting The Ruddle Show!
Show Content & Timecodes00:09 - INTRO: Red Flag Warnings 07:19 - SEGMENT 1: Zoom with Dr. Randy Cross 41:37 - SEGMENT 2: Q&A - Gamechangers 52:09 - CLOSE: Behind-the-Scenes – Cast Perspectives
Extra content referenced within show:
Downloadable PDFs & Related Materials
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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: Red Flag Warnings
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. Are you excited about today’s show?
Yeah, the red flags.
So, we found a list called Nine Dental Red Flags, and it’s a list of warning signs to alert the patient that if you see these things in the dental office you have chosen, you might want to rethink your choice. So, it’s also useful, though, for dentists because you will surely want to avoid these red flags so you can offer the best possible dental environment to your patients and be of maximum service to them.
So, here’s the list behind me, and a lot of these things on the list are pretty obvious why they’re red flags, but I’m going to go through the list, and you can – if you want to provide some commentary, go ahead. If you think it’s just self-explanatory, you can say self-explanatory.
Well, I actually had about an hour comment on each one of them.
Okay, well Lori will not be happy about that, but let’s just do the best we can. Okay, so the first thing, your dental records are not requested, your old dental records.
Okay. The office is using old technology.
Wrong office. Well, you know, within common sense, I mean I have family members that changed their dentist because they didn’t go to digital about 500 years ago.
Yeah, and also, you know, you might think well I’m a patient, how would I know how old that technology is? Well, you can kind of get an idea of how the office feels. Does it feel like a high tech office or does it feel like –
– you went back in the past 50 years ago.
Yeah, if you see the dentist back there spinning his legs to make a turbine go so he can grind on your teeth, yes.
Okay, red flag number three, the sterile protocol is broken.
No hands to the mouth, the lips, the hair, the nose or on the floor.
If you can even get through the PPE.
Okay, number four, you have to ask for oral cancer screening.
That’s a red flag. That should be automatic.
Okay. Overzealous about extensive work.
Trying to hit their numbers.
Their reputation is negative.
Why are you in that office?
I do want to add one thing. I go to a dermatologist, and I’ve heard other people around town say that he’s not a nice person. I think he’s a very great dermatologist, but he doesn’t maybe have –
The chairside manner.
Right. So, that is an issue. Okay.
So, at the end of the day, we’d rather be really good than really nice.
I’m going there because of the dermatologist, not because I want him to be my friend.
I really like him.
Okay, number seven, they don’t show their work.
I just noticed over the years that people that show their work are proud of their work.
Right. Number eight, they hard sell caps or crowns.
Well, it could come across as a little greedy. I mean it’s fine to recommend work that needs to be done, but there doesn’t need to be artificial urgency; you just need to be trustworthy.
Right. And the last one, they treat you like an account number.
Well, I think we want to go into an office where we feel energy, we feel excitement, we feel enthusiasm, we want for service or what do you call it, concierge service. We want ultimate experience; we want a premier, premium experience. So, yeah, I don’t want to walk in the office, and they go, “He’ll be right with you, have a seat.” I’d like them to look up, see me, and say how nice it is to see me, even if it’s a pain in the ass.
Yeah, the – when I go into just various offices, usually I find that they actually greet me by name. And I’m surprised that they know my name, but they probably have my chart right there; they know I’m coming in. But I always feel like wow, they know my name.
But that’s neat though, what you just said.
Yeah. So, okay, well is there anything you would add to this list? And I should tell you that this list is from 2018, so it’s pre-COVID, but probably a lot of COVID related issues would fall under the sterile protocol, but is there anything that you would add to this list?
One thing I was actually taught to do in grad school back in the 70’s, is go sit in your own operatory for about one to two minutes once a week, and you’ll see things that you didn’t know were there, even though you’re cleaning all the counters and you’re doing all the usual stuff. It’s just nice to become the patient and have role reversal and see what they’re seeing through their eyes, because, you know, when they’re first seated, they might leave, do this, there’s a lot of busyness and activity, and they’re left alone. So, I don’t like anybody ever left alone. I want conversations always going, even if it’s small talk, making connections. It relaxes people.
Yeah, I think that for me, if I’m going to an office and every time I go to the office I have to wait in the waiting room for a minimum of 30 minutes, you know, I find that to be a little bit annoying.
Try to be on time.
Okay, so just some things to think about, you know, you want your patient to feel comfortable and like they’re in the best possible hands, so if you see areas that your office could improve on, then by all means do it.
You know I don’t know if this is going to work anymore because of COVID and where we are with this infectious control, but we used to give patients office tours, and there was like three tours. One was like there’s the bathroom and there’s where you get coffee and there’s the refrigerator to get some juice. Then there was another tour where we would show them operatories, and then the full tour was sterilization, the whole thing. I mean you’re proud of it; show it to them. It’s kind of like when you’re going to go to an Airbnb, and you go on a virtual tour, and you find out your hotel room.
I guess if part of the tour is viewing the darkroom, then maybe you’re in the wrong office.
That’s pretty good. Be careful about the darkroom experience.
Okay. Well, we have a great show for you today, so let’s get going on it.
SEGMENT 1: Zoom with Dr. Randy Cross
So, today we’ll be joined by a guest endodontist, Dr. Randy Cross, who is first going to give a presentation about an endodontic invention he is working on, and then he is going to join us via Zoom to answer some questions. So, we are very enthusiastic about today’s show.
And I know you especially are very excited about his invention. I think he’s told me, I don’t know, a few times now that it’s one of the most exciting things that he’s seen as far as endodontic inventions go in all of your years of practicing. So, why don’t you tell us a little bit about Dr. Cross, how you met him, and maybe tell us a little bit about what he’s working on.
Sure. Well for those who don’t know Dr. Randy Cross, he’s married and has two kids, lives in Santa Cruz, went to UC Davis, University of California, Davis, and got his biochemistry degree. Then he went on to the University of California, San Francisco, where you were born, got his dental degree, and then he worked for 10 years in the field as a general practitioner and he was a director of two clinics for that 10-year period, and then he went to the University of Southern California, USC, we say. He’s a Trojan man. So anyway –
To become an endodontist, right?
Yeah, he’s – well I think we learned that he’s going to graduate this Friday and he’ll have finished his post-graduate work as an endodontist. So, that’s cool. I met him, to answer that question, I met him at Ruddle with the Residence program that Phyllis set up years ago, and he was one of the kids out there in the audience, and we connected. And then what we connected on was his new innovation, his idea – at that time it was just a concept about a chair-side method to determine the level of remaining bacterial load with a biomarker. So, that was very impressive.
And that actually brings us to the topic of his presentation. So, we’re going to watch that first, and it’s about I think about 12, 13 minutes. We’ll watch that and then he’s going to join us via Zoom, and we’ll ask him some questions. So, here’s the movie.
Hey, everybody, this is Randolph Cross, and we’re talking about biomarkers and endodontics. Before I do, I just want to say it’s a huge honor to be on the Dr. Ruddle Show. He’s a legend in the endodontic community. He’s given so much. So, thank you, Dr. Ruddle, for having me on. You know, in the past we used to do cell culturing. It was – fell out of fashion for many reasons, and I think what the future will be is a biomarker, just a quick, easy way to find out is my root canal clean to have a good prognosis before I close up the case.
I do want to put a word of warning out there. This is very cutting edge. This needs to be backed by clinical research. This is my findings in a small subset of patients, so, you know, just take everything I say with a grain of salt, but I think it’s super exciting. I’m very passionate about it and I’m just real excited to be talking to y’all today.
Everybody, so the general outline today I’m going to talk about, you know, what seems to be important when you’re doing a root canal. We’re going to look at some past research to show how effective biomarkers are in cell culturing is to see when a root canal is clean and what that actually means. And then we’re going to go ahead and look at some of my findings to see where some general trends in biomarkers and what you can expect from using a biomarker for your root canals.
In this picture, there’s Cliff in the middle, there’s me at the back right, and this is the Ruddle at the residence – at the start of my residency. I just thought it was so cool that during his presentation he was talking about being able to determine when a root canal is clean and here we are, a year and a half later and I’m presenting what I use to determine when my root canals are clean. So, it’s pretty neat.
When you look at what’s important in a root canal, a lot of things are beyond your control as an endodontist, you know, you can’t control the health of the patient before they sit in your chair, the size of the lesion, is it necrotic or vital, and a lot of times you don’t even have restoration to even know when you’re going to go to the dentist to get it crowned. And it was interesting when you looked at the research because you would think that are you short or long at the apex, what filling technique are you using, how’s your filling quality look, those are huge factors in determining root canal success, but the research shows that it’s probably important, but just not as important as you would think.
What always seemed to be important is did you find all the anatomy, did you get down the canals, you’re not missing a canal, and also were the canals clean when you sealed the case? It seems like those are the two biggest factors to making sure that your root canal is successful. Did you find everything, and did you clean everything? So, in the past, they used to culture bacteria from the root canals before closing the case, and some studies would show very different outcomes if there’s bacteria in there. If it didn’t have bacteria, it would have an 80 to 94 percent success rate. If it did have bacteria when you sealed up the root canal, it could have a 44 to 68 percent success rate.
More recently, they’ve been using a biomarker calcime [sounds like] to show whether the root canal is clean or not. If there’s high levels of that biomarker it’s rated 20 percent. If there’s low levels of that biomarker, it has a 90 percent success. So, you know, there is significance to is the root canal clean or not before you fill it. But the problem is both of these are time consuming, and nobody really does it anymore. If you did have a quick easy biomarker, I think it kind of opens up a whole world of endodontics. It means that you could just test your root canal to make sure it’s clean before you filled it. If it’s not clean just clean it some more. Maybe you could go ahead and, you know, you can be conservative for the cleaner root canals and take it up to a larger file size for the dirty ones.
You know, maybe you don’t have to do 2-visit endo. You just let the bleach soak a little bit longer. Or you hit it with the Endo activator, ultrasonic, whatever you choose to do to clean it out. Maybe you don’t have to do as many 2-visit endos. And also, it kind of brings up an interesting dynamic of okay, you have an old root canal, looks great, but then the filling leaked. There’s the cotton roll that got infected, whatever happens to your old root canal. But now as opposed to just arbitrarily deciding to retreat or not, you know, if you had a biomarker, you could just look and see if there’s bacteria by the tooth. So, I think there’s a lot of really cool practical applications to it.
And when you look at a perfect biomarker, it would be easy to use, easy enough for residents to use, it would be cheap, it would be reliable, it would give you very reliable data, versatile. These are necrotic, vital retreat cases. It would be sensitive. It would detect less than one living bacteria in the cell and also be portable. I mean it shouldn’t be a CBCT, it shouldn’t be a centrifuge, it should be easy and then when I looked at some biomarkers, I found a great one.
In the graph on the right, I got some teeth, extracted teeth and cleaned it out and you can see as you go to a bigger file size in these extracted teeth, this biomarker goes down and down and down. And the other kind of interesting thing you can see is that different teeth get cleaner at different rates. So, maybe not everything is a 2504. Maybe not everything is an F5. Maybe you can go ahead and gauge this – the size of your file to how dirty the root canal is.
And I think we all want this picture on the right. We all want a tooth with a lesion to heal, and I think that’s why this biomarker could be so good. It basically takes a lot of the guesswork out of your root canals. You know when it’s clean and you know you can fill it and be sure that the bacteria is removed. So, I don’t think it’s only a benefit to the patient. It’s also a benefit to the dentist, you know, when the canal is clean. It takes a lot of the guesswork out.
If you want to finish in smaller files, great, you now have a tool to use to know when that canal is clean without removal of that tooth structure. You know, we can always look for outliers too. We all know there’s bacteria in fractures and cracks and perforations and things like that, and now you have a test to see is this tooth abnormally high in biomarker.
And I mentioned the ideal biomarker would be real easy to use, and that’s what this is. It takes about a minute. Once you want to stop and check for cellular debris, you go ahead, and you rinse the tooth with sterile saline. You put a hand file in there just to agitate the walls for about five seconds. You put in the paper point. You throw in the tester. You squirt it in the chemical and then you put it in your reader and then 10 seconds later you get a result.
Now the really cool part about this presentation is looking at some of the data from me using this biomarker, and some of it is surprising, some of it is what you expect. So, on here, we can see that, you know, at the beginning of the root canal, the hand files, they have a lot of biomarker present. When you’re done instrumenting, you still have a lot. But less. And then right before you finish the root canal after all you’re irrigation, you know, it’s not zero, but you have a lot cleaner, but it’s still there. I think that was the most surprising part with these root canals is that looking at bacterial levels goes from a million to one, a million to zero.
When you look at this biomarker for cellular debris, it’s still there, there’s still bacteria remnants, biofilm, on these canals, it’s just a lot less. When you look at the findings as a whole, the results are pretty interesting. Like some of them I already expect. A vital case was easier to clean than a necrotic case, which is easier than a re-treat case. Some of these are kind of things we didn’t expect and that was that there’s the findings between molar, premolar and anterior and biomarker are pretty similar. I thought the molar would have had more and that could just be from my small sample size.
And the other kind of interesting thing was that if you do a 2-visit endo, it doesn’t remove all the bacteria, it doesn’t remove all the biomarker, so in my cases here is that my 1-visit endos were a lot cleaner than my 2-visits. That being said, because I have been testing with biomarker, I would usually do just 2-visit the ones that were a little more dirty, so I don’t think that putting medication in makes a tooth more dirty, but that by having a biomarker I know which teeth that I need to, you know, throw the kitchen sink at to get clean.
The really interesting piece is that when you look at the individual results, it's extremely variable and it seems like there would be these outliers and what was interesting is those outliers tend to be the ones that failed, they tended to be the ones that had perforations, that had a vertical root fracture, that had an open margin. It was really neat that you can get same day one-minute feedback on just something that just seems peculiar about the case.
This next graph I just removed those top 15 percent. So, okay, let’s ignore those ones that are really high. I mean what do the other ones look like? And you just get the same answer. It’s just extremely variable. So, even if we remove those top findings that just something is going on with the tooth, you know, you still get these levels that are very high and very low. What’s kind of neat is if you get a level that’s high it’s not the end of the world. You go ahead and you put more bleach in, you do ultrasonic, you leave the room for 20 minutes, whatever you preferred method of cleaning the tooth is by doing that, you bring down that biomarker level.
And we’ll see, but it seems like that would make the canal more successful. At least for me what it also does is if I have a case of the sinus track, I have a case that’s percussion sensitive, I had a case in the past you’d think you’d have to two-visit this, well this biomarker, you know you’ve done everything inside of that root to get it clean, so why not just finish it the same day. It lets – it takes a lot of the guesswork out. So the findings are pretty neat. It’s that each tooth is extremely variable. You know, some teeth are going to be dirty when you measure for biomarker, and some may be clean.
If they’re high, then you can go ahead and just further activate, further irrigate and my findings suggest that if you do a five-minute activation, irrigation round, you reduce those levels by 32 percent. So, it doesn’t completely disappear, but you know, it takes a lot of the guess work out of how much you have to clean it. When I get those really, really high numbers that are off the wall, it’s usually something is weird. It’s a tooth that’s going to fail, it has a vertical root fracture, it has an open margin, just something is weird about the tooth and it’s neat to know that before you finish the root canal, before the patient pays, before the patient gets a crown, before this awkward moment comes in after the patient is already gone.
It also – if there’s an old root canal that got exposed to saliva without, you know, using the Schmidt [sounds like] Decision Tree and these arbitrary guidelines of how long was the saliva there, how does the root canal look, how does the filling look. It’s just an individual patient’s tooth findings of there’s bacteria on the root canal and there’s not. So, I think for me it’s – it helps me gauge do I redo the root canal with an actual individual finding for that patient. You know, if there’s saliva on the root canal, it may not be a big deal, or it might be, but at least this gives you another tool to find out what to do for those cases.
And the other really interesting thing is, you know, we’ve always judged root canals in the past on how does the white line look in the radiograph, you know, does it look good? You know, is the root canal short or long or long apex. Maybe what’s more important than that is how much biomarker or how much cellular debris, how much viable bacteria is in the root canal.
Here are some of the sources that I pulled from to put this document together. Thank you, Dr. Ruddle, you know, for the wealth of knowledge, being so inspirational, and just kind of guided me and really helping me along the way cause, you know, you had faith in this kind of project from the very beginning and I don’t think people know how much you really helped me out. I also want to thank my wife, Audrey. For the last two years, Monday through Friday, she’s been watching the kids as I finish my residency, so I’m just so in debt to you.
What I really want to mention before I go is please, if anyone is out there and just did research on this topic, I mean I think there’s just huge potential, send me an email. So, if you’re a resident, faculty, you know, whatever, if you’re looking to get some research and try to figure out, you know, your new system or, you know, kind of you want to test out something and have a quick, cheap, easy way of doing it, that’s what this biomarker does. My email is firstname.lastname@example.org. So, please feel free to shoot me an email in case you guys want to, you know, help out some research in this area.
Okay, so now we have Dr. Randolph Cross here joining us by Zoom. So, thank you for joining us, and that was a really excellent presentation. Thanks for putting that together.
No worries. Thank you.
Yeah, Randy, I’ve really been telling my family a lot about you, because when I first heard this idea from you, this concept of yours, it – I have said this and maybe I’m getting tired of saying it or you’re getting tired of hearing it, but I think it’s the most important method or invention that has happened in my almost 50 years of being involved in clinical dentistry. So, it’s just a delight to have you here. And we probably have a few questions. Is that okay?
That would be fantastic, yeah, I’d love that. I’d love to try to answer those for you guys.
Okay, well the first question I had from watching your presentation, well you’re calling the product the Endocator [phonetic] on the presentation, but that’s probably like not a permanent name yet, but what does it actually consist of? Is it a tester device and a solution? And can you tell us what the solution is or is that information proprietary?
Yeah, we’re kind of still working out some of the details, but kind of a general overview, so you know, in endodontics you dry up the canal with paper point, you just throw it in the trash, and you pull a canal. So, with my device, you put in the paper point. As opposed to throwing it away you put it in the full tester and the re-agents are premeasured so there’s no science or anything like that involved. You just kind of squirt in the enzyme and you’re not going to be able to see it with the naked eye, but it’s creating a little signal.
And so after putting the paper point after putting it in the tester, you put it in my device to read that signal. So, the whole process takes about a minute, and it will kind of give you feedback on how much cellular debris is present in that root canal. Yeah.
You know, Randy, this seems like a huge advancement. I don’t want to date myself, but back in the 70’s we were doing culturing with paper points, and we used to laugh and say well did we really think that the bug would jump out of the lateral canal and leap onto my paper point so I could get a negative culture? And it seems like since then, over the last like 50 years, this is really sophisticated as bringing us into biomedicine.
Yeah, it’s individualized care, too. It’s no longer this broad necrotic outcome and vital outcome. Like this specific tooth, how much cellular debris is present? And the other thing I like about this is I’ve done some culturing. It’s really hard. Like I’ll get positive results in things I shouldn’t get positive results on and negative results when, you know, for almost every case, and it’s black and white. My device is quantitative. It’s, you know, 10,000 shades of grey where you can see exactly how dirty it is and you get feedback in a minute. So, it’s not like you sealed the case and you can’t do anything else about it. You can go ahead and hit it with the EndoActivator, you can let the bleach soak longer, you can close it up, you can, if you’re working on two teeth, finish one tooth and let the bleach soak in the other one and then come back and finish the other one and kind of time it so that, you know, you’re providing individualized care for this patient. So, it’s pretty neat, it’s pretty cool, and it’s super easy. It’s not like culturing. It’s just three buttons and a result and then you can act on it. And yes, it seems really high – much more accurate than culturing, at least in my experience.
Well, I was wondering how you came up with this idea and maybe how others haven’t come up with it before you now, because apparently you have a background in biochemistry, and this probably influenced your interest in using biomarkers to trap endodontic infection. But like what sparked the idea for you?
Yeah, it was kind of based on my background in biochem and I actually worked in a biochem lab for a year, so you know, culturing and things like that wasn’t really scary and, you know, I ended up with a background in live acid and things like that. But what got me is just that finals week of first year, winter, I’m like there’s got to be a better way. We’re learning about Schrogen and “sponge fest” [sounds like] and the importance of it being a clean canal as opposed to dirty and bacteria positives/negatives. And I’m like there’s all this information that’s showing how important a clean canal is, but there’s nothing to actually kind of figure that out. Like there’s got to be a way to figure this out.
So, I went ahead and found a biomarker that I think will be perfect for it. It can detect vital teeth. It can detect necrotic teeth. And it is very fragile. So, after a couple days DNA is not going to be present. So, it’s detecting like, you know, PCR which, you know, old traces of DNA. This has to be live fairly recently for it to be able to detect it. I’m just like this is going to be crazy; I know we’re broke; I know I’m in residency but for my Christmas present can you go ahead and buy me this lab device.
And she went ahead and got it. And I’m expecting it not to work, I’m expecting it not to be sensitive enough cause it’s only a minute. It shouldn’t be able to get goods results in a minute. And sure enough, I get an extracted tooth. I clean it. I think it’s cleaner, cleaner, cleaner, cleaner. And what blows my mind is just that it’s not even like it’s barely detecting it. It’s like a very detectable signal as you clean the canal. It’s just real easy to use and it worked out really well. So, yeah, it’s been quite a ride, quite a journey.
Well, have you figured out how clean is clean enough yet or is that still evolving?
I think that’s still evolving. I think that I have my dialed way of cleaning the tooth, irrigating it and testing it, and I know when I kind of test it with other people or maybe the pre-doc clinics that don’t have the EndoActivator, don’t have advanced irrigating system that we do, you get different results. I think we need to get not just how I use it in my levels. I think you have to get more people using this to really find out what levels are safe to close a tooth.
But that being said, if I get high levels, you know, for the most part you just clean it up and get it lower, but if I get high levels and I can’t really clean it that much, it starts to put red flags in my treatment and then, you know, it can suggest if the tooth is going to fail or not. So, I have my results, but I have to get other people using it to make that how I use it is similar to their results as well.
Well Randy, what would be some of the outliers that you might – if you get like a crazy reading that’s completely not consistent with your experience, what are some of the things you’re looking for?
Yeah, so that’s the interesting part too. So, for the most part if I get a little bit higher reading, then I just clean it some more and it gets cleaner. The outliers are the ones that I clean it and it doesn’t really get clean. It only gets clean a little bit more. So, kind of some of the examples I’ve had are like a perforation, vertical root fractures and also just teeth that I know that just don’t seem to work.
So, most recently I finished a case, you know, we end up testing for the results afterwards and it was a sky high number, the patient is coming back, and I think the tooth is going to be extracted. So, I have one-off cases where it just seems high levels and it just – for the most part if you seal it in those high levels it doesn’t seem to work out. So, I have my results filed in and I’m hoping other people have similar findings as well.
That was one thing that I thought was very interesting in your presentation, that if you keep getting high levels, then maybe you need to be looking for something else before continuing on with the case. Maybe there’s a vertical fracture or, you know, an open margin or something. So, that was very intriguing to me.
Yeah, and it’s great to figure that out beforehand, before you seal up the root canal, before you put a crown on it, and before you then have to go ahead and open everything up again. So, it’s great. And the other interesting thing too is like sometimes these levels will get low and it’s not like you’re expect them to be low, so maybe the patient has a sinus track and in the past like well I can’t close this up because of the sinus track. But if my results are telling me it’s clean inside the tooth, at least for me I’m confident it’s clean inside the tooth and just close it up. Why bring him back for a second appointment if you’ve done everything inside the tooth to clean it out?
Did you want to add anything, Dad, about that?
Well, I’m just so impressed because, you know, Randy, for a lot of decades of my practice I was known for nonsurgical retreatment or surgical retreatment but revision, revisional treatment, and there’s a lot of missed canals, so it would be pretty interesting if this could pick out maybe the elusive missed canal.
That is fairly interesting. And I think it just depends. If there’s a lot of fins into one of the canals you’re testing I can see how that would have higher levels. If it’s a totally separate canal, you know, it would be interesting. And I think that’s where we need more research. Just a lot of these questions it would be great to have answered. And I think this is a great answer for if you’re in the canal, making sure it’s clean enough. But there’s those other questions like well what happens if there’s a missed canal, you know, can this start detecting that? I have no idea. It would be really interesting to find out though.
So, Randy, was it even possible to keep this device, you know, in your own territory? I imagine there was tremendous infighting on campus for every student in the post-grad program and you have big classes. They must have been trying to get that out of your locker and steal it.
It’s been pretty exciting. I mean I think the best story I have with, you know, other people using it is, you know, I think it’s a Seltzer and Bender cognitive dissonance, like why did the great looking root canal fail? So, I used it. So, like we’re overseeing some – we both have our patients. We then go ahead, and we test our patient and the root canal where I was helping out a student with, it looked pretty good, but there’s a little, tiny void in the apical third. So, you know, I could see a lot of people critiquing that and saying oh that’s not good, that’s not good, and you know, maybe – but my other friend, he finished his root canal -- beautiful. It looked perfect, filled all the way to the apical, great. It was a fantastic root canal.
But then we compared test levels, and my root canal had 10 percent the biomarker that his did. So, we really wonder like why did this root canal fail? It looks great. Well, if you’re sealing 10 times the amount of food for the reinfection, then mine which has 10 percent less, I mean, you know, it’s obvious. I mean I think we put so much emphasis on these white lines in the root canal when the biggest or are you happy when you’re short, you’re happy when you’re long, I think a bigger, you know, kind of curve ball is how much food did you leave for reinfection? How – what is the likelihood that you’ve left live bacteria in there based upon a biomarker present. So, I think that’s been a bigger question.
I like that a lot more in your presentation, Randy, where you said, you know, like fill to the terminus, you know, dense pack, maybe, and you gave all these things, but it was really neat how you identified just like one example was restoration of the endodontically treated tooth, that was a big deal.
Yeah, and I think all those things are important, but I think when you try to look at it from like a completely dirty tooth to a completely clean tooth, I think you got to make those even. So, I think you can have a tooth that’s clean the same and you have one that’s short of the apex or one with the restoration or without, I mean I think you got to equal those out in order to get those findings. So, I’m not trying to say that those other things aren’t important, but I think what’s way more important did you clean the tooth before you sealed it? So, to me that’s the most important thing.
Okay, well right now why don’t we show a video? We have a one-minute demo video of you using the product. So, let’s watch that now.
I’m going to go ahead and demonstrate what the cellular debris testing looks like. Here I have a cleaned-up tooth. First, I rinse it with water to remove all of the disinfectants. Next, we need to hand-file to scrape the walls and get a better sample. Next use a paper point to go ahead and transfer that sample from the tooth to the tester. I’m going to go ahead and squirt in the reagents, and then load that tester into my device to go ahead and get a measurement. You can see it’s pretty easy and it takes about a minute.
The neat thing about it is it’s so quick and if you get a high rating, you just let the bleach soak longer. You can hit it with another round of EndoActivator. You can go ahead and bring them back for 2-visits really high. In this case, that tooth was clean, so we go ahead and close up the case.
So, it seems really simple to use and that you could easily integrate it into pretty much every case.
Yeah, and since I’ve kind of come up with that concept that’s basically what I do. And then the neat thing is I usually just use if once. I do my normal routine. I clean it out and then I test it at the end, and if it’s clean, I seal it. If it’s not quite clean, I put the sodium hypochlorite in and activate it one more time, and if there’s really high numbers, that’s when I have to do, you know, maybe a second test or even a third test just to make sure it’s clean. But for the most part, you do like a final check before I finish the case.
So, where does the project stand right now? I mean, I know that you filed some patents, and some have been granted, some are patent pending still, but are you working with a company, are you getting more research done on it? Where does it stand now?
Yeah, so it’s just moving along. So, it’s kind of, you know, we’re getting the formula down, like the generic formula worked okay, but we’re going to add more buffers for the higher disinfectants. So, right now I’m just going to work with a couple of companies to make sure that when it gets released, it’s the perfect version and just really works out well for the endodontic community.
You know, Randy, I noticed that – cause we’ve talked about this for, I don’t know, is it fair to say well over a year, maybe almost two?
Yeah, right about, yeah.
And it seems like – I’ve learned a lot from you, so I want to acknowledge that to the audience. I’m the student and I’m learning from Randy Cross. But anyway, we have these numbers that you recite, and I was – you and I had discussions, maybe when we come to market, we’ll have it in some kind of an easy scale of zero to 10 or zero to 100 because cowboys like me, when you started to say this much load is left, I’m going like whoa, is that going to be okay? But then you tell me it’s relative to a much bigger number.
Yeah, so that’s definitely true. Right now, we’re trying to interpret these numbers, and I know what those numbers are, but I want to make this easy for everybody. So, yeah, the goal is to go ahead and get these scales in the thousands and, you know, things like that and get to a simple 1 to 10, 1 to 100 scale. So, yeah, we’re working on making it easier to interpret at this point.
It seems that this could just change the whole standard of care, because if you can assign a level of cleanliness that becomes a new standard, then it seems to me that it would be unethical to finish and pack a case if it hasn’t met that benchmark. So, that’s just pretty amazing to me.
Yeah, I mean it does bring up that consideration, especially if you’re going to put like, you know, a $5,000 bridge on top of the tooth and you’re in a debate, do I retreat it, do I not retreat it. Well with these results, you know, quantitatively now, okay, I cleaned into the canal as best I can, maybe I have to do something else. Maybe it’s time for a surgery and it just kind of gets rid of all that questions in your head.
So, I’ve had cases where it still hurts the patient afterwards of something happens, and I didn’t test it, and in the back of my mind I’m just wondering – like there’s a thousand things going through my mind. With this device, I know that I cleaned everything I possibly could inside the canal and I don’t ever – when I do that, it seems like there’s bone healing or signs of healing. So, it just makes it really easy. And I think that’s a good point is that, you know, you might as well make sure you clean the canal enough before you seal the case.
If I purchase one of these things and started using it, I guess I’d have to categorize my caseload as pre-Randy and post-Randy.
The other hard part is you get competitive. You’re like no, I can’t do it off of this, like, you know, I can do a little bit more, I can do this. I mean you almost get competitive on yourself to try and make it as clean as possible. Yeah, and the other thing is like some teeth are going to be clean, some are going to be dirty, and you can’t, you know, you can’t feel bad about that. You can’t feel bad that that’s a necrotic tooth, that bacteria has been in for 10 years. And levels are going to be higher than vital cases.
You know, you can’t feel bad the re-treat case wasn’t really that dirty compared to one that was, so some teeth have different levels and at a certain point you have to explain to the patient, hey we did everything we possibly could. Your tooth is just a little bit more infected than the average tooth, but fingers crossed, we got it clean enough to go ahead and do a good job.
And have it work out for you.
You – we did everything we could. You just have very dirty teeth.
And that’s kind of true. When you have patients that have had bacteria in there for 10 years going in every odontoblastic tubule and just living in there, you’re going to get higher numbers and you can’t take offense, you know, you can’t be like you’re not as good a provider because level is higher or lower. It’s just what the tooth and what you’re trying to do for the tooth. And that’s why I like this. It’s just a great tool to know how much to clean the tooth and what you have to do. Maybe some patients are 25/04. Maybe some finished at 25/04 file. Maybe some patients you used 1 percent bleach, but some patients, maybe you have to use the full 8 percent bleach. Maybe some patients you have to get to an F5 so it just kind of lets you give individualized care on all these patients based on the amount of bacteria you’re bringing out of the tooth.
So, Randy, I’ll tell a little story for my close, but and I’ll look up here at the camera, but anyway, Phyllis started many years ago this program called “Ruddle with the Residents,” so we were really excited and enthusiastic to receive like west coast residents from a lot of different programs. And I think I must have said to I don’t know how many classes that came before me because I’ve been saying it since the late 1970’s, Randy. Why can’t we just go out to the pool with a little piece of paper and dip a little indicator into the water and look at the ph and know do we add chemicals today or are we still good?
And apparently, you’ve got us to a place where we can check the pool. So, that I’m really grateful for, and I want to tell you, I mean you’re doing something that’s going to change the way we practice and approach endodontic treatment internationally, so for that, we’ll definitely want you back in the future and stay in touch with me, big guy, because you know how much I think this is going to change the future of endodontics.
Thank you so much for joining us today, and we really do want to follow you on this journey, so we will have you back again.
Thank you guys for having me on and again, if any of your guests have any questions or want to do research themselves and, you know, just feel free to reach out to me at email@example.com and we’ll get you kind of, you know, to help out with this new step in the endodontic career, so thank you guys so much for having me on.
SEGMENT 2: Q&A – Gamechangers
So, we have a short Q&A for you, and since the theme of our show today is game changers, these questions revolve around that idea. So, I’ll ask the question and you answer?
Okay, here’s the first question. I used to routinely do 2-visit endo, but have now started to schedule the majority of my cases for 1-visit only. What is your opinion regarding one versus 2-visit endo?
Well, you know, it’s a loaded question. It depends on a lot of things. First of all, do you have the time scheduled to be definitive and to be complete and do quality care? The other thing is how does our patient present? Are they coming in with swelling? Maybe they have a lot of pain. Maybe the tooth is necrotic. So, maybe we can start to talk already about vital versus necrotic cases. So, I do 1-visit on necrotic and vital cases. Mainly it’s just chair time. I won’t do 1-visit if there’s acute symptoms. And that could be just a lot of pain with no swelling or it could be pain with swelling.
Now if it’s necrotic, sometimes you got to get them on antibiotics, you got to get the bacterial load, serum levels up on that antibiotic so that when you do go to work, you have serum levels, blood levels, protection. So, other considerations are the case difficulty. And we’ve talked about that on previous shows, that AA assessment form, but if you see something that’s really long, really curved or recurved and, you know, very calcified mineralized canals, that’s probably – their joint might not be able to withstand – their TMJ might not be able to stand a long, long session. So, I mentioned joint vital versus necrotic, symptoms versus no symptoms, case difficulty, and I think that’s the big ones I can think of right off the top of my head. I’m sure there’s others.
I can think of a couple.
Well, I know that on a previous show, we talked about the redundant time of scheduling – the redundancy time, when you schedule for a second visit when you could have probably finished out in about 15 more minutes.
We did that show. We found out that according to my mentors’ five partners, 15,000 patients, there’s about 30 minutes of nonproductive time, redundant time, every time you reschedule the same patient.
And the other thing that I thought of was from Dr. Cross’ presentation where he pointed out that and when he tested the biomarker levels after 2-visits, it was higher than 1-visit, and maybe it’s because saliva might get in there and there’s more bacteria, I don’t know.
Well, you’re bringing up another question/answer that we won’t do today, but it would be one versus 2-visit endodontics. And in preparation for this show, I was looking at some of the Scandinavian literature and there’s always about the same five, six, seven guys, really well known, respected around the world, but they basically said that after 1-visit, you could never assure in necrotic cases for sure, even in some vital cases, depending on the level of breakdown, that you could produce a clean canal or system in 1-visit. That led to a lot of Scandinavian emphasis over decades of two-visit endodontics, and oftentimes calcium hydroxide as the temporary medicinal properties we put into the canals between visits.
And then, of course, my classmate, Richard Pekruhn in 1981 started changing that whole conversation with his seminal paper in the Journal of the American Dental Association on one-visit endodontics. Five years later in the JOE, he then went on to talk about the failure rates associated with 1-visit versus 2-visits, and it was only a very small uptick in more failures, and he had some reasons why. But anyway, yes, Randy showed us that if we had the confidence to be knowing that we’re clean or bacterial loads are below a value that is deemed appropriate, then there’s no more guess work.
Right. And he says if it’s not clean, just clean it a little bit more.
That’s right. If you run out of time, just provisionalize it, calcium hydroxide, bye-bye.
Okay. So, the next question. It’s been a long time since I raised my fees and I really should, but I don’t want to alienate my patients. What do you recommend?
Well, we talked about the reciprocal part of this problem on a recent show. We talked about discounts. So, you know, you can Google the Kodak study, the Eastman Kodak study. I learned about this study in the late 70’s. It seems like there’s quite a few people talking about it, so maybe it’s not so innovative, but the Eastman Kodak study said for every thousand dollars that you produce per unit of time, you know, the Kodak study said 75/25. Just for ease today I’m going to say about 80 percent is going to be your overhead and that means that it will be about 20 percent would be your margin to take home, your profitability.
And so that would be, you know, $800, and that would be $200, and so the question we talked about last time was what happens if you discount it? And it’s way more than the magnitude of the number you’re quoting, like five or ten percent. So, what if you raised your fees, was your question, as something as little as 10 percent, well 10 percent of 1,000 is $100 and that $100 goes right over here because your overhead is not more tomorrow morning. The rent is not more tomorrow morning. The staff is still paid the same. The supplies are still the same.
They will all elevate with time, we recognize that, but an immediate impact, you raise your fees 10 percent, crank out an extra 100, you go from 200 to 300, the difference is 100, 100 over 200 is 50 percent. So just by doing something pretty small, you can make an enormous difference.
Right. Cause I think we talked about on the show that if you’re offering a patient a 10 percent discount, to a lot of patients, 10 percent seems like a pretty small discount, like it’s nothing to get super excited about.
I think likewise, a 10 percent raise, like if the fee is 10 percent higher, that’s also very – seems like a negligible amount and nothing to flip out over, so yeah, I think, but it really makes a big impact here, so that’s –
You know, the Kodak study also looked at something that you’re hinting about. I want the market to hear it. You might say, well if I raise my fees 10 percent, I’m going to lose patients. All of sudden I’m sitting around reading magazines. No, they did that work too cause they studied all businesses, small businesses, in the United States that operate at about 75/25 or 80/20. Dentistry fits right in here.
They found out that when you raise your fees 10 percent, you lose zero percent of your patients. When you raise your fees 20 percent you lose about 7 percent, and the 7 percent you lose are the moaners, the whiners, the gripers, and the complainers. It’s the ones that your receptionist spends about 80 percent of her time on. Maybe you ought to clean house and raise your fees 20 percent and say bye-bye to all you people who are miserable in my practice.
Okay, well I think we have time for one more question if the answer is a little bit shorter.
Okay, I heard that.
If I was going to invest in one high-end technology and one more affordable technology, what technology would you recommend that would make a big difference in my practice?
First comment, dentist specific, because if I interview you and 10 other people, you’re going to be at different levels of your career and what’s important for you might not be so important for somebody else. In other words, you might already say, I have a microscope, I got a microscope, I was in the early, you know, that middle-80’s thing. I was in that ground base movement. But then I would say, well how about CVCT for you? Do you have that? And if you said, “I don’t,” I’m going to say you’re going to be a much better diagnostician. You’re going to discover more pathology. And of course, that means you can take care of people in a more profound way.
So, I would say CVCT and microscopes are great. And then if you said I need something just kind of low end that will be a difference changer, well, I would ask do you use stainless steel hand files or do you use NITI? Do you use a big series of files or if you really want to get simple have you ever thought about Wave1? Pretty much 80 percent of the time single file technique. What is you said, you know, we don’t have digital, and my assistant is developing films and she’s gone sometimes for so long I fall asleep. I mean me and the patient are sleeping.
Well, if you got digital, that could really, you know, in five seconds, one-thousand and one, boom, boom, boom, it’s on your screen and you’re able to make an assessment and continue working. Apex locators, I mean how about an electronic Apex locator? You can get into those for less than a thousand bucks and it’s going to give you more accuracy, it’s going to keep that procedure flowing towards success. So, those are a few things I can think of.
Okay, well thank you. You know, I think that we had a great show today. I really was very impressed by Dr. Cross’ presentation and him too, and we got to see a major game changer there. And now we’ve just talked about some more game changers.
And as a follow-up, sorry, but I didn’t talk about it when Randy was here, but he said – I know he said a minute, but he didn’t say the fee. It’s only going to be a couple bucks a patient, so there’s a cheap, ineffective – a very powerful effective way to know with certainty, with a low amount of investment.
Yeah, that’s actually – if you think of everything we talked about today, the cost of that, and then the result you will have, that’s definitely a game changer.
I’m really excited about that.
Okay, well that’s it. And we’ll close after this.
CLOSE: Behind-the-Scenes – Cast Perspectives
I’m going to close today with a segment we call Cast Perspectives, and it’s going to be a little video where all five of us who work to create The Ruddle Show will give you a little insight into how we think about shooting The Ruddle Show or maybe issues that are important to us. So, we’re going to watch that video now and we hope you enjoy it.
I hope you learn something from the Cast Perspective.
So, see you next time on The Ruddle Show.
So, we just finished filming our game changing episode and saw some exciting new technology. But it’s not just this episode. We are always locked in on trying to find new ways to make a difference, whether it be talking about AI, new technology, technique tips, maybe trying to give you a fresh perspective or even strategies on how to have a winning attitude. So, keep watching, because we promise you at some point, we’re going to say something that might just make a major difference in your life or practice. It’s basically us challenging ourselves to be the best we can for all of you.
I love having a guest on the show. I have all these people in my mind from all over the world that I got to get on the show. I have a big queue of them waiting patiently to come on the show, but what I get to learn is from the experts, and when we have somebody on, a guest, they’re usually bringing something that Ruddle can’t do, is deficient in, and there’s somebody much better than me to do that. So, having a guest on I learn from the guest and each one is different in their own way, and it takes me right out to the cutting edge of what they’re thinking about.
You may ask what is the major job I do on the set. I come in; I try to be quiet. I’ve been critiqued for that, but my main job is keeping everything stocked and running smooth. Toilet paper, paper towels, water, do you need to buy something? Oh, it’s a write-off, great, let me know. Thanks.
What would I say is a personal challenge working on The Ruddle Show? That’s definitely balancing all of the emotions and the temperaments that we have. Working in a family business is the best and but it also can be extremely – what’s the right word – dynamic and stressful because you want to maintain relationships while at the same time foster creativity.
So, one thing I do every – about two or three seasons as I create a new opener for The Ruddle Show, and my mom helps me brainstorm, and this time I actually tried to involve pretty much everybody in it, and I pretty much every single time, I learn a ton about how to build like a composition and put audio with music and visuals together nicely and stuff, so very good learning process for me.
How does it work in the family? It’s the best and the scariest. I tend to be the peacemaker in most situations, try to talk it through quietly, but if it escalates and there’s yelling, then I have to go hide somewhere, and I need to work on that.
So, I find it very challenging to figure out what to wear for the shoots, because I want to be professional but not boring, so Isaac and I joke that I aim for Capitol attire from The Hunger Games. So, those of you who know me personally know my style is a little bit eclectic, so I try to choose something that is interesting, but hopefully not distracting.
Well, you’re probably thinking what critique would Ruddle get from his family, cause I’m surrounded by all these family people and all the dynamics, differences in ages, personalities, oh, oh, oh, they said to surrender, because they said being an endodontist and probably Type A, I had to be my hands and fingers on all the levers and dials. They said to surrender, shut up, and do exactly what they tell me to do.
I know the clinical footage is relevant and we’ve built a whole Just in Time library about that and we do that all the time on The Ruddle Show, but I’m always encouraging the group here to get out of the studio, outside, somewhere in Santa Barbara, the wharf or really anywhere for that matter outside of the desk sometimes so that you can see Ruddle and Lisette in a place that they’re not usually seen, and it also makes it very interesting and you get to learn a little bit about how they operate outside of the studio set. Maybe seeing Cliff and Lisette doing some sort of sporting event together, that would be fun.
You ask what are the anxiety issues for me on The Ruddle Show, because I’m pretty laid back. Getting Cliff’s computer set up and the pre-launch day when Lori and I are at the office getting everything uploaded. Lori does most of the work, but I’m there too, and I’m so happy when it’s all done.
So, people think that a lot of times because I’m an endodontist, I can just get on the show and give a few lectures and he’s been giving lectures for about 45 years, so that’s got to be a piece of cake. Even that’s not easy. In fact, one of the things I like the most is the learning part, so when we do all those little segments a lot of times like on artificial intelligence or alternate reality, I’m learning.
What’s one of the hardest segments I had a hand in shooting? Definitely this one.
So, one of the biggest problems I’ve had on The Ruddle Show is audio. At first, we were using Lavalier mics which had great audio, but were really hard to set up and had a lot of static issues, so we switched to boom mics which pretty much have the same audio, but maybe not as good but they’re way easier to set up and completely out of the way.
What are my favorite parts of The Ruddle Show? Well, I have to say my favorites are the outtakes that we do, the silly things that we capture here and there. I still think we should capture a good old family fight; those are my favorites.
Timekeeper, that’s my job on the set, so my perspective on being a timekeeper, you have to have a really loud voice so people will listen to you, but I find that there’s a lot of loud voices on the set, so I just have to always try to be the loudest.
So, my dad, or shall I call him the GOAT, he’s always the first to arrive and the last to leave, every time.
What’s the very first thing Ruddle does when he enters the studio? I get the Hoover. I’m a permanent vacuum man. Everything has to be pristine cause the staff is arriving, and we have to set the decorum. It has to be excellent.
So, there was that one time where we thought we lost shows 1 through 4, but I was able to recover it from the corrupt drive, thankfully. I should probably mention it was a whole week later, very stressful.
So apparently, the plumbing at the studio runs maybe slightly up hill so the toilets never flush very well.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.