Listing of Indications for the use of Calcium Hydroxide... (as of July 2021)
Workspaces & Calcium Hydroxide Ruddle Workspaces Tour & Calcium Hydroxide Q&A
This show opens with a discussion of a recent Dentistry Today news article, “What to Do if You Face Malpractice.” Next, Ruddle and Lisette head out on a field trip to Ruddle’s personal workspaces, where you will receive a rare glimpse into his work environment and what inspires him. Then, Ruddle is back in the studio for a riveting Q&A on calcium hydroxide. Stay tuned for the “What Phyllis Thinks” wrap-up, featuring camping stories and advice from our resident camping expert, Phyllis Ruddle. Say what?
Show Content & Timecodes00:09 - INTRO: Malpractice – How to Proceed 09:09 - SEGMENT 1: Ruddle Workspaces Tour 30:05 - SEGMENT 2: Q&A – Calcium Hydroxide 47:30 - CLOSE: What Does Phyllis Think?
Extra content referenced within show:
Extra movie/video content:
Downloadable PDFs & Related Materials
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...
As one evaluates the current position of clinical endodontics as a healing art, one is struck by the vast differences in how endodontics is understood and practiced from country to country, region to region, city to city, office to office, and from dentist to dentist within each office...
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Ruddle on Retreatment Supply List and Supplier Contact Information Listing
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: Malpractice – How to Proceed
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. How are you doing today?
Well, we have a great show planned for you today, including a field trip. But first, about a month ago, Dentistry Today published an article about what to do if you face malpractice. Although dental malpractice lawsuits are not as common as in other fields, they still happen, and they can be upsetting because it might seem that everything you’ve worked to create is at risk. So, the article outlines four steps to take if you face malpractice, but before we get to those steps, you used to be on the Santa Barbara Ventura County Peer Review Board, so what was the function of that board and tell us about your experience on the board.
Okay. This was in the late 70’s and the early 80’s, so maybe three or four years I was on the Santa Barbara Ventura County Dental Society’s Peer Review Board, and it was comprised of a group of interdisciplinary dentists, and our – so that’s what I got a little bit of experience at. And then our purpose was to remedy a problem. I mean we needed to hear the patient’s complaint.
Then we needed to assess, you know, what was done, what the dentist did and what the patient’s complaint was and assure that there was an actual complaint that could be remedied. And the last thing was the remedy, try to find a solution or a pathway for the doctor and the patient to go forward if they could, or maybe transfer the patient to another doctor.
But that was our role is to basically assess the complaint. And the reason it was interdisciplinary, if it was maxillofacial related or oral surgery, you would have the oral surgeon play a dominant role. If it was endodontics, they wanted to hear what I had to say about it. So, that was kind of our function, and I had a little bit of experience doing that.
Okay, because a lot of patients, when they go into a dental office, they sign an informed consent, and in that, when they sign that, you’re kind of agreeing to go to some mediation if you’re unhappy with the treatment, and so that’s kind of what you were doing there, like mediating?
Yes, conflict resolution, because a lot of times if the patient and the doctor get into a big dispute, there’s a loss of confidence already because probably there was poor communication, so sometimes it’s just a third neutral party can hear it, you can maybe proverbially put your arm around a patient and let them know they might have been rough, they might not have liked their attitude, their spirit was bad, but maybe they did actually pretty good work.
But the patient is upset about something, so you have to see what the doctor did and was it done within the standard of care. And the standard of care can be defined as the – what the preponderance of dentists would do if they were given that similar, same, situation. What would they be doing? And if you’re doing pretty much what everybody else would be doing, then you’re within the standard of care.
Okay, so I guess I – let’s talk about what constitutes malpractice. Because obviously mistakes happen, like maybe you perforate, maybe you break an instrument, but maybe something that a more skilled clinician could avoid, but that still doesn’t constitute malpractice, correct?
You’re right. Let’s be really clear. You don’t want to do any of these things. You can break an instrument, you can perforate chasing a hidden orifice, you can not make the curve at the end of the root and go off the side of the root. Even though those are egregious, if you tell the patient and if you record it and the patient understands what the treatment options are and what the path is going forward, they might – you can be sued, but you’ll never lose a lawsuit.
What we’re talking about is the following four things. Failure to diagnose, that’s serious. I mean you’re going to lose on every one of these if you failed to diagnose something that was right there in front of you and you can show ten other dentists now and go yeah, there it is. So, failure to diagnose.
There is related problems that you’ll probably lose on if you have an anesthesia problem, a difficulty subsequent to the anesthesia or sedation, like a lot of dentists give general anesthesia or light sedation. If you have a patient going to sleep and they don’t wake up or something, those are going to be real problems.
Failure to resolve infection, okay, infection is a big reason for lawsuits. And then finally, the fourth one is known as accidents. And we’re going to talk about calcium hydroxide in a little bit later in this same show, but sodium hypochlorite comes to mind too. So, if you squirt sodium hypochlorite under pressure into their oral vascular bundle, you’re going to probably have a serious lawsuit and you’re going to have a hard time explaining how it’s okay that that happened. And same with the calcium hydroxide.
Okay, well let’s talk a bit about what the article says to do if you face malpractice. And we have a list.
First it says to call your insurance company immediately, and I assume that all dentists have malpractice insurance.
They better have if they’re practicing at least in the United States. You need to have probably about a million per occasion, maybe a three million umbrella, so one million, three million. So yeah.
Okay. The next, gather your records.
Actually, this will happen, but I would suggest you photograph the records as soon as you get the complaint.
Because you’ll probably have to give the originals to somebody down the line, but you want to photocopy exactly at that moment and then don’t anybody in the office change a single word or even add a single comment. It’s been said this. Once you get this photographed and it’s archived, that’s what happened, it’s perfectly fine to get your assistant and sit down and say, you know, Harry is suing us for some reason.
You can tell her why. And could you just write a little flow chart of what you recall happened from memory. It’s your memory now, cause you’re looking back. You might not remember everything. And then I can do the same thing, and that will add some perspective. But that doesn’t change your record.
Okay. And then lastly – oh no, and number three, excuse me, discuss the case only with your lawyer.
Yeah, this is not one you go out to lunch with and tell three other dentists, “I’ve been sued” because anybody you tell anything to, including if you start complaining to your staff that Mildred is suing me, and I couldn’t stand her and she’s a blah, blah. Everything you say, that person can be brought in and deposed.
And also, your staff probably shouldn’t discuss with other offices, the staff that they’re friends with in other offices.
Well, they should schedule a lunch meeting and tell as many people as they can. [laughs]
Okay. And then lastly, be prepared for the long haul. You know, I guess that you need to try to have patience and stay positive cause these things can take time to resolve. But apparently 72 percent of medical malpractice cases, excuse me, are either dismissed, denied, or dropped.
I want to say one thing. We got to ensure that all the audience listening, communicate well with your patients and record keep it. Write stuff down. Like I didn’t write anything down, but my assistants, when I was talking, they were typing or writing everything down that was said to the patient and what the patient said they wanted to do. So, record keeping is critical.
Yeah, and also maybe – I mean you said to discuss the risks and benefits, but you might even want to go a little bit further, really explain, don’t just touch on it. Maybe really explain these things may happen, and they probably won’t, but you know, just be aware.
Yeah, that probably brings me to a final quote from Bernard what’s his name?
George Bernard Shaw.
George Bernard Shaw said that “The greatest problem with communication is the illusion it actually took place.”
Yeah, I think that even happened on our set this morning between our little group so –
Yeah, we have problems with communication around here and we all remember it a little bit differently sometimes, so I have to pull out my tape recorder.
Yes. Yes, you might want to have a tape recorder by chairside that – so by the way, I’m going to go over the risks and benefits and do you mind if I hit record? Okay. Well thank you. And let’s get on with the show.
SEGMENT 1: Ruddle Workspaces Tour
Hello, everyone. You can see that we’re out of the studio today because we’re taking a field trip to see Ruddle workspaces. It is interesting to see where others work, learn what they do there and see what they have around them for inspiration. So, to start, we’re at my dad’s home office, which is about a half a mile from where I live as the bird flies, but it's right next door to the studio. So, Dad, why don’t you describe to us what we’re seeing here.
Well first it feels like Ruddle is being unveiled. Well, you know, it’s like a typical office, but it’s my office, so I love it. So, you know, I have an obvious desk area and a computer where I Zoom a lot, and these are all the shows. I really like this because this is our season. We’re over here now and we’re approaching 50.
And you know, I wonder who this guy is… you know I got this guy, he’s a catcher. Yeah, and that’s my favorite grandson catching. There’s my favorite granddaughter. Actually, I say “favorite,” they’re all my favorite. But she was a catcher too, so there are two catchers along with Yogi Berra and Micky Mantle and the balls. And anyway, just, you know, here’s Lisa and Lori. I guess you’re in Florence at the Duomo. Here we are at a beach in Sicily. There’s Mazy and Lori and Philly and I getting ready to go on our faraway trip, international trip, and there we are at Capri, the island of Capri.
I also see that you have all of the JOE’s organized, and I think they go back to the 70’s. That’s pretty impressive.
I have the very first one, 1976.
And I know you refer to them a lot, so I know you say I have to look it up in the JOE.
There’s all the articles we wrote down there in binders. Of course, we have them on computers these days, but I grab them a lot and look at them.
What about all these books over here?
A lot of these books were given to me by people from all over the world. And so, they’re very interesting. This is kind of the dental part, but this is the non-dental part. Lori probably has a special affection for these. These are Ruddle on Retreatment, the brick we made. We call it a brick, cause there’s four of them. There’s some other ones we did and Tony Robbins’ stuff, and then all the classic books. Where’s Castellucci? See Arnaldo Castellucci… And then, you know, we’re always trying to keep the sailboat going.
Yeah, I actually noticed kind of like the sailing ship and over up here, you have the ship’s wheel on the wall, so there’s kind of a sea theme going on.
I’m at the helm. In the office – in my own office, I’m at the helm.
So, let’s go back over to your desk. And why don’t you describe what you do here?
Well, you know, if I’m working and I’m writing articles or I’m working on R&D or I’m working on show script notes, it would be right here. And I really like looking out, cause I see the ocean, the harbor, Palm Drive. I see the islands on a clear day about 20 miles out, and then there’s the world that I’ve been traveling 5 million miles in, so I like to see the world sitting there.
And then I turn around, Lisette, and we do all of our Zoom shows here for planning The Ruddle Show, and this is where I Zoom with corporate, Zoom with doctors and Zoom for international meetings. And I got special little lights to make it proper. This is where I tune up my lectures just before I hit the road and do stuff, so you know, I got people around me, places, things, sentimental stuff.
Do you work here every day?
Yeah, I start up here about 5:00 in the morning until about 6:00, and then I go on my walk. I go right out up the hill and cut right up the street. There’s about an hour loop I do. It goes up, I don’t know, a few hundred feet in variation in ups and downs and come back, and then shower, eat breakfast and then I’m right back here in my office.
Yeah, we have that photo of you, the mountain lion chasing you that we showed on a previous show.
I was up on the top. Yeah, up on the top of the back area.
I really like your fish tank that you have.
Well, this is my tank that I don’t ever have to cleanse. I don’t have to do anything.
And the fish don’t die in this one either.
They live forever. It’s almost perfect. And then I got a picture of us at the show, and then my granddaughter Eva, you know, she did that little painting for me. She’s quite the artistic one. Then I got Mazy and Lori over here with their son, you see Noah. He’s graduating, so that’s a great picture of them.
What is your favorite part about this workspace?
Well, I got my grandfather’s clock. It’s about 110, 115 years old. It doesn’t work. But a clock is always right twice a day, you know. So, if you look right down here, you have that park down there where we have the basketball hoops, so you know, I like to go down there and shoot a few hoops with the basketball, play catch with the grandkids, get my binoculars out, you know, look out to sea and see what’s sailing in. And then sometimes, I like to just come on out here and be out here and work, you know, this is fine.
Oh, it is nice out here.
You know, you can sit here and look out and if you look at our city, you know, we have the Arlington Theater and the Granada and downtown. The kids, you guys went to junior high right there, and then that’s Santa Barbara Junior High and then over there, those big yellow low buildings, that’s Santa Barbara High School. That’s where you guys also went.
And there’s the wharf out there where we opened our season.
Oh, yes, in fact you can see the wharf, Stern’s Wharf. We went right out there. We heard those planks, boom, boom, boom, boom, boom, boom, and yeah, and then our studio is over there, so that’s nice. We just walk over to the studio. So, yeah, it’s a small, little piece of property, but it has big vistas.
Okay, great. I really like this workspace. I can see why you would feel inspired working here. So, why don’t we head out to the office now and take a look out there. And incidentally, that’s eight miles away, so I’ll see you there.
See you there.
Okay, so now we’ve arrived at the office, and this is the same office that you started your practice in over 40 years ago. And it’s been remodeled a few times and the setup has changed to reflect how advanced endodontics has evolved. So, right now, I’m seeing this beautiful marble floor. How has this area evolved?
Well, it’s had a lot of uses. Back when I had a partner and there was a two-man office with several ladies working, this was partially an operatory and a lounge, all in this space. We made the first simulation endodontic laboratory in the world, and it was pretty awesome. It was 10 stations. Every station had its own monitor, and I could walk along, and I could see what every person was doing.
Your sister was working in here with Philly and I and we were pretty much the team, and we had 10 doctors at a time, and it evolved into a patient chair. That’s what this patch is here, and we did a lot of patient shoots. In fact, we had like tracks that went around the outside. We had a high camera and a low camera that could wheel smoothly around. We had our X-ray machine and digital and all that stuff, so we did a lot of patient shoots here, and then we tore that out and now you’re looking at a mysterious space whose future is yet unknown.
Yes, we’re going to see what you make of it.
It’s going to evolve again.
Okay, so you work two places here fairly regularly, the Histo Lab and the conference room. So, where do you want to start?
Let’s go to the conference room.
Okay. Here is your conference room. So, tell us about some of the features of this room.
Well, before we built the simulation lab next door, this was a little teaching center. In fact, many people that are watching this on the show will have said, I was there, because hundreds and hundreds of people came through here. And, you know, this was a conference table for lectures. The multi-media was back behind there, and then I had a screen here that I could push a button and the screen would come down and so on and so forth, screen up.
But this was something we made so we could have a workshop in here, and the center comes up with the push of a button, and when it comes up, it evolved into an eight-station lab. There was water, there was air, and we had quick disconnect pedals underneath. They could be plugged in so the doctor could run the rheostat and run his hand pieces high and low, all without electric motors. But we soon overwhelmed this area, because there was cords and wires and then microscopes came, so we had to go to the simulation lab so we could have microscopy. And we were doing that in the early 90’s.
So, then, you know, when I’m here working, I’m either in the Histo Lab. That’s why I’m usually out here, to be in the Histo Lab, but a lot of times, I’d have to come over here and sit down, and this is like my little desk, so I sit here. So, if I’m talking to you out there, anywhere in the world, and I’m at the office, I’m probably sitting right here.
In fact, it’s not unusual to walk by and hear you on the phone in here.
Oh, well now I’ll have to be careful.
In recent years, you’ve had groups of students come here, residents from some southern California universities, come in here and this is where you lecture to them, when we didn’t do it at the Doubletree, but when we had the smaller groups in here.
Yeah, well when it all started, Ruddle with the Residents, it started right here, and it was just the three schools. We had – well I guess four schools. There was Long Beach VA, UCLA, USC, and Loma Linda. And those residents would come here, and we’d pack them in, put some extra chairs around, and we had some really great fun. But then when more resident programs were involved, we went to the Doubletree and the hotel where we could get 50 or 60 maybe at a time with faculty on top of that.
I see you have some work in progress here, so what is this I’m seeing? What is that about?
Well, this is the Endo Activator tip that snaps on, and what we were looking at is right now currently, it would be like if this is the hub, so there’s like a little square down here, and if this is the hub, the active tip emanated right out of the center. So, we started doing prototypes where it wasn’t centered and we had the hub like it is, but the tip was inserted off center, off mast, and we saw that we got a lot bigger two alpha.
What is this over here, this 30-minute show, which – which never got achieved yet?
Well, you know, I think this started – we’d have to ask Lori and you and Isaac. But I think it was around 2019, pre-COVID, and we were all out here in the conference room brainstorming The Ruddle Show and we were kind of saying we needed an opener, we needed a couple meat and potatoes and a kiss off and a close. So, yeah, that was kind of a rough scaffold of how it evolved.
It’s now a 50-minute show pretty regularly. Or an hour, yes.
And I had a patient, you know, she was a grand lady, she’s passed away. And her and her husband were remarkable people. He was at the Bauhaus back in Germany in the original days when art was evolving in its renaissance, and so some of these paintings in here came from Herbert Bayer’s triangular thing and that’s triangular squares and stuff. So, it gives me a lot of energy. I see those colors and I see the geometry, and I used to be a math major, so I love all of the precision of these paintings.
Now I’ve come in here before and I’ve seen a little cup of almonds and a hard-boiled egg, but it’s not here now, but do you ever eat here while you work or is that just for show usually?
Well, when I’m here, I usually have lunch with the team, so whoever is here on that day we’ll have lunch back here and yeah, I’ve been known to have a hard-boiled egg with a little dash of salt.
So, I’m also noticing that I don’t really see any clutter around, which is very different from how like say Mom and I work, because we have stacks and piles around us. So, are you opposed to clutter?
I hate clutter. Clutter destroys my mind. It ruins my focus. It actually does. And I’m not nearly as creative when I have a lot of stuff around, because it’s like I don’t have control of my life. So, it’s important I think for all of us to maybe clean our rooms and get a certain level of organization so we can focus, be creative and more productive.
So, the room had many different purposes, and I would say if you’re watching this, maybe every office should have some kind of a room like this where you can be creative, discuss problems, brainstorm the future together, get those goals written down, get them up on the wall, nail them to the wall, so you know, you see them every day and you’re confronted with them.
I know you’ve also had meetings with Dentsply people and other reps.
Well has been a big R&D room, you’re right. We’ve had engineers in here. We’ve had salespeople in here, marketing people. This has been a great room for so many things, so any office that’s watching this, this would be a great place for you to blow the lid off, take it to the next level. Just having a room like this you’ll do things you didn’t even think you were going to do in the future.
Now I don’t want people to think we’re leaving these blinds down because we don’t want the sun to come in to ruin our shoot. You actually keep these blinds down all the time, correct?
I do, and you know, like I think you said, you could hear my voice. Well, I can also see out, so it’s kind of like a one-way mirror. I can’t see perfectly, but I can see the blue sky, I can see lots of green which gives me more of that outdoor stuff cause we’re four-wallers a lot of times, but yet people can’t see in. If you went out there and looked in, you would just see your reflection in that glass window. So, lots of light and have it clean and organized and see what happens.
Okay, let’s go on over to the Histo Lab now, okay?
Okay, I’ll show you the Histo Lab.
Okay, so here we are in the Histo Lab. Why don’t you tell us what you do here and also maybe give us some background on this interesting ceiling I’m looking at?
Well, this used to be an operatory. It was a four-operatory office, and anyway, when I sacrificed the operatory and it became more of an educational center cause of our downtown office, the real nerve center, I wanted a little Histo Lab, a little sanctuary, so a place to work. So, the first thing we did is we wanted to have an interesting ceiling. I want to vault the ceilings up. I like height in a room, because it opens up my thinking, but this is inspired by the Duomo in Florence.
Like the design on the windows, right?
Yeah. And so, a woman made a scaffold and laid down and for about a week and a half she was like, you know, doing the ceiling. And I said, “Well can we have a bird fly?” So, we even have a – cause patients used to be in here. So yeah, I said, “The patients will be looking up and they want to see sky and they want to increase their vistas, so you got to have a bird as long as it doesn’t poop on them.” So, anyway, we got the ceiling, that’s kind of nice.
But in terms of the working environment, this has been a really great place. This is what I call my Histo Lab. We had a lot of doctors come over and train. Like if you’re training with me, it’s one-on-one. I can see what you’re doing on the monitor; you can see what I’m doing. Sometimes two doctors would come and then I’m standing up and I’m looking at what both of them are doing.
The scopes have been built in. They can go up and down and pull out, and then I have this bar we engineered in the 70’s, late 70’s. This slides in like a patient headrest. I can mount a tooth, and this is completely three-dimensional, so I can go up and down with my chair, I can go up and down with the scope and I can go up and down with this. So, anybody from a little lady that might be 4’6” to a 6’8” person can work at this simulation lab.
We have one pedal on the floor, we have access to high speed, low speed. Well, this is your station. This is the high speed and low speed. This is ultrasonics and then we have a Stropko. Look at that Stropko. John would be proud, and we can use air and water. We have a high speed vacuum over here, and then I have a prototype motor. My motors are all built in, but this is a prototype motor, cause we’re working on the endurance limit concept.
I have a lot of experimental things going on here. These are all prototypes. Nothing is in the market. So, we have manual files, and we have the ultimate project. We have the various instruments there. So, I do a lot of work here, and then I have to go over next door, sit at this granite table, and fill out my questionnaires and make observations, and that’s what tweaks the product and helps guide it towards conclusion.
How many days a week, on average, would you say you work in this office, in the Histo Lab?
Well, it goes in cycles. I may not be here for two or three weeks, and then all of a sudden I might be here every day, even weekends, cause it’s just fun for me. It’s not really work; it’s play. So, I might be here Thursday, Friday, Saturday, Sunday. So, it goes in streaks based on what we’re developing at that time.
And I know that a lot of times I come in here and you’re listening to music. So, you like to listen to music while you work?
Yeah, it’s quite inspiring.
When that door is closed you can’t actually hear anything out there, right? It’s like a soundproof room?
It’s pretty much soundproof, yeah.
Because I know Mom always has her country music going out there, but then you don’t have the country music in here.
I don’t ever hear it in here. And then I really like, you know, I’m looking north, and the trees got pretty big, but there’s San Ynez Mountains up there, so you know, sun, the light patterns change during the day, and you’ve got your plants going and it feels quite inspirational.
So, if you’re a doctor and you sign up for a one-on-one course with you, you’d be working in this room, and you’d also be working in the conference room together, right?
Yeah, we’d go over there and do a lot of didactic stuff, maybe show a few cases and zoom around to different things of their interest, cause when we do these classes, it’s not my curriculum; they design their own curriculum. So, every doctor needs to write down very carefully and then we have some phone time together or we Zoom, and we actually make a course specific for their needs. So, just in time.
Wow, that’s pretty cool. What do you like best about this workspace?
Well, I like the endo activators. They’re quite nice. Yes, I love working with the polymer tip, you know. I can do my eyelashes and stuff like that. It gets everything flaked off and gone so I look quite young and impressive looking.
So, what do you actually like best about these spaces?
Well, I like everything. I like the granite floor cause it’s easy to clean. I like that I can sit here, and I have an elbow rest, and with a one pivot move, I can grab anything I want.
These chairs are very adjustable.
Lumbar, up, down, seat tilt, everything, so I like that so I can be comfortable. Cause once you get in here and you start working, you might be here for four or five hours working through the scope. And then, of course, I can document and film and record what I’m doing. A lot of times I’ll send this to engineers, and I’ll say, you know what, you need to change this a little bit because look, that’s what happens when we are currently working like we are. So, I use this lab a lot to understand better what I’m doing clinically.
Okay, well just to kind of close out on the workspace, like what are the – do you think are the most important qualities for you to be able to be creative and inspired in your workspace because I know a lot of us are working from home now or maybe in other areas that – from than they worked in before. So, what would you recommend to people about their workspace?
Well, try to get it as organized as you can. Like for me right now this is very organized because of the world Shape-Clean-Pack. We do a lot of retreatment and even we can put microsurgical models in here. So, if you’re organized, you can see things really clearly in your mind, at least I can. And a lot of times I can conceptualize how something is going to work before the machinist even turns the machine on.
And that’s maybe a talent I have. I don’t know, but I can see things mechanically in my mind. So, I’d say be organized so you can stay focused. And if you’re focused and organized, you’ll be more creative and you’ll be more productive.
Well, thank you for sharing your personal space with us. I think our viewers will be inspired, so thanks.
Well, that was Ruddle uncensored.
SEGMENT 2: Q&A – Calcium Hydroxide
Okay, so here we are back in the studio and now we’re going to do a Q&A, and this time it’s going to be around – all the questions are going to revolve around calcium hydroxide. So, are you ready?
Okay. Here’s the first question. “I routinely place calcium hydroxide in the instance when I can’t do one visit endo and need to schedule another visit. Besides using it as an interim intracanal medicament, what are some other ways calcium hydroxide is used?
Okay, that’s a great question, because there’s probably more than ten, and because I’m getting old, I won’t remember all ten, but I’ll give you the ones that come to mind as probably the most important.
If you think about a tooth just for a minute, you know, there’s a pulp in here, and there’s deep decay and it invaginates, and sometimes as we clean out the decay, we go right into the pulp. So, we can use it as a pulp cap material. And you can put a little calcium hydroxide in here and then you can put your restorative, being careful not to plunge your calcium hydroxide into the pulp chamber. You got to just lay the calcium hydroxide over the exposure and make sure when you pack your restorative, you’re wiping it in, flowing it in, versus packing it in. So, pulp capping.
Another reason we’d like to use it is in trauma. So, a lot of times these teeth can get avulsed and knocked out of the mouth, and when we put them back in and replant them, if we can have a short intra-oral time where it’s not out of the mouth too long, ideally less than five minutes, then what we can do is when we initiate treatment, assuming we do do treatment, we can clean this space out and we can place some calcium hydroxide in here, because calcium hydroxide dissociates, and when it dissociates, you get your hydroxylians, those hydroxylians are very basic and people have thought that it can get out of the tubules and off the main body of the canal.
And what it can do then is stop clastic activity, like dentinal clastic activity, and abort internal resorption. So, we use it when there’s already resorptions, that’s another one, and we use it then in trauma cases. So, in resorption cases, where – let’s see if I can remember how to do this now. Yeah, well I should have just hit this. In trauma cases, we talked about doing the root canal, placing the calcium hydroxide, and then just letting it sit there. Sometimes I wanted to emphasize, for two, three months, don’t be in a hurry to get it out.
So, pulp capping, trauma, internal resorption where there’s blood, that means it’s a hemostatic, so the hydroxide ion can help cauterize tissue, if you will, but not through cautery, but it can arrest the bleeding so you can then get control of decay. So, it’s really good in the internal resorption. Less for external resorption, but sometimes when we have seen replacement resorption, the PDL, we’ve actually opened up the tooth, put the calcium hydroxide in, hoping that the hydroxylian can work, and the calcium ion can work all the way through the tubules to the cavo surface to arrest, maybe, or slow down external or replacement resorption.
Sometimes you’ll see a tooth and you see a tooth and it will have a really, let’s say a large, large lesion. And so, sometimes in necrotic teeth when you have these big lesions –
We need an “r.” Necrotic needs an “r.”
Oh, necrotic needs an “r,” yeah.
That’s why I’m here.
So, you have a pulp chamber, you shape the canal, and you put the calcium hydroxide in here again, and the idea is these big lesions oftentimes you can get some healing going because they’re basic. This is more acidic, and acidic byproducts of bacteria are neutralized by the hydroxylian itself. Another idea would be in cases where you have drainage. So, you might have a serous exudate coming up through the canal, a serous exudate, and so we can use it in those instances.
Obviously, she mentioned at the top of the show in retreatment cases, what she mentioned as an interappointment medicament, but in retreatment cases, a lot of times disassembly is one visit, knocking post out, taking cores out, getting out the old filler material, silver points, gutta percha, you know, those kind of paste fillers. And then you can use that space, once you’ve eliminated obturation materials, to place the calcium hydroxide. So, I don’t know how many I’ve given.
I think – I have in my notes “induce root formation.” Did you talk about that?
Yes, I haven’t, but that’s a good one. In fact, that’s another one. You can have these teeth that have these blunderbuss apices, and what you’ll do is if you, obviously, if you have a vital pulp up in here, you might just do – we already talked about a pulpotomy, open this up, and then what we could do is just get rid of this and this and this, and I guess I have to do something a little different. Well, I thought I had a lesson. There we go, there we go, there we go. And we lost the tooth.
But anyway, you can place the calcium hydroxide, you can make your access – if it’s just – if it’s vital, but you can get control of the bleeding we can just place calcium hydroxide here, and the idea is to get Hertwig’s epithelial root sheath to deposit dentin and get formation so we can get the tooth to finally start looking like what we’re more accustomed to seeing. It might be a big pulp, but getting the growth and the formation so we can do a future root canal or just leave it. It might just heal. So, you might have this opened up and this and you have your restorative, a lot of times, those go on for a long time.
If you did a deep pulpotomy, you might go a little bit deeper, and sometimes we would go here. I would keep the calcium hydroxide out of this area, because these are viable cells, and those are the viable cells that are going to stimulate root sheath formation. So, if you – the hydroxylian, when it hydrolyzes, it kills the membrane of the cell, and that means that you destroyed DNA and mitochondria. So, that means you might not get the cells that are here working in the way you want them to work. So, keep the calcium hydroxide back in the tooth a bit. Remember, it’s an environment. The calcium hydroxide doesn’t have to go everywhere.
Let’s see, so we talked about root formation. Another thing you could do is in fractures. Sometimes in fractured teeth that are incomplete fractures and not hopeless fractures, it’s good to use the calcium hydroxide again, for a period of time. We talked about exudates, serous exudates, large lesions, necrotic teeth, when we don’t have the time to finish. We talked about the inter-appointment dressing, the pulp capping. I think that’s a pretty good start on a list.
Okay. We also – you saw a list drop in, so if we missed something, it’s on the list. At least you know that’s another way it can be used. The next question. “How do you recommend placing and adapting calcium hydroxide?”
Well, we can learn a lot from the article, The Double-Edged Sword of Calcium Hydroxide in Endodontics, by Gluskin, et all. That was JADA 2020, I think it was May, May issue, but the double-edged sword. Well, there’s all these advantages, okay, I just listed maybe seven or eight, and there’s probably 10 or 11 or 12, but the double-edged sword was if you have a tooth, as an example, and we got our molars sitting in here, when we got the neurovascular bundle coming up and then we have a mental foramen. And this is our neurovascular bundle.
So, the thing is you need to take films. You need to know what the relationship is of the root tips and root ends to that neurovascular bundle. And surprisingly, in this paper, in second molars, maybe I should draw this down a little bit longer, but in second molars, it’s about 1.42 mm. Those roots are just a little bit away from a major structure. So, assess your films carefully. CVCT is nice to get another perspective, three-dimensional. And then use it carefully.
The problem in this paper, they identified, is people syringing it into canals. So, here you have a tooth that’s going to have root canal, and let’s just say there’s a lesion down here, and they get it opened up, and then they can put a canula down the canal. But if you wedge the canula in the canal and you start syringing – these are usually syringe type devices or there’s threads and it screws, it’s a screw plunger. So, you either have a physical plunger or a screw plunger, and if you wedge the needle, you’ll make the canal an extension of the needle and you can inadvertently syringe calcium hydroxide into a major structure.
That can cause major problems. I mean permanent problems for life. Those are going to be big lawsuits, okay, so the idea is for me, I’ve never tried to get my canula this deep. I have no problem, if this is your orifice and this is your canal, I’ll put a canula in here and just loosely squirt a little bit in, just loosely squirt it. Take the canula out, take the endo activator, put a polymer tip on it, go down into this mix, this medicament, this medicinal, and brrrrr and you’ll sputter coat, and you’ll throw it on the walls, and you’ll change the pH. You don’t have to pack it, that’s the whole thing. Stop packing the calcium hydroxide.
In this paper, they show six cases and every one of them was a lawsuit, and there was terrible damage from paresthesia to dyslexia (sounds like) to all kinds of various burning pains that patients reported, and you need to get on this. If you have an accident, you need to get on in 24 to 48 hours. That means get help. If you don’t know what to do, the quicker you get this calcium hydroxide out of this neurovascular sheath, that means microsurgery and a surgeon, either an endodontist or maxillofacial oral surgeon, you can head off a lot of those symptoms. But if it sits in there longer than about 48 to 72 hours, look out, you could have permanent problems.
So, getting calcium hydroxide into this nerve area, that would constitute malpractice?
You’re going to really have a problem beating that in court.
Since we talked about it earlier.
Yeah, well that would be a classic example because – well that’s one of the four things is accidents related to sodium hydrochloride and calcium hydroxide, and that causes neural damage.
So, one other question now. “The literature states that clinicians do not always completely remove calcium hydroxide from the root canal space. How do you remove it and what are the ramifications of not completely removing it?”
Okay. Calcium hydroxides are resorbable material and you carry it away. So, when you put it into a tooth, it might lay there for a week, a month. I’ve had cases where I’ve changed it every six months for two or three years, just to give you a sense that we’re not in a hurry, especially if these would be trauma cases, teeth that were avulsed and replanted, and I’m not in a hurry. I don’t have any problem letting it sit there.
But when I do want to remove it, it’s been said it’s almost impossible to remove, short of using something like ultrasound. That’s the endo activator all over again, because that polymer tip is slapping those walls. It fractures liquids, bubbles form at the liquid interface, and they expand because they’re unstable due to heat and pressure and it bombards the calcium hydroxide, puts it back into solution so it can be flushed out of the tube. So, to repeat again, we put it in passively, and only in the coronal one-third. Then the endo activator comes in and go up and down, little, short strokes. That has no vertical component. That has a lateral component, okay?
And then removing it, do the same thing. Because if the calcium hydroxide is left in, if you have, you know, like a – let’s say you have a resorption defect, and then it comes on up like that, the resorptive defect, you’re going to have calcium hydroxide in here and you’re going to have it in here. And so, you can use your files and you can cleanse out most of this, but the problem is if you leave it out in here it can wash out and if it washes out, there’s dead space, and dead space, if we didn’t get all the bacteria out, can induce growth and proliferation and reinfection.
Well, when, if you had that extra space, wouldn’t that, if you were packing with like warm vertical condensation, wouldn’t it fill into that space?
It probably would if – that’s a great question. It’s probably more like okay, that’s a great question, because you get about 2,000 pounds per square inch of sealer hydraulic, so the question was through hydraulics, wouldn’t you push cement in there, and then that reminds me of Newton’s Laws of Physics. Only one mass can occupy the same space at the same time. So, it’s soft and you’ll squish it and move it around, but you won’t eliminate it with warm gutta percha.
Maybe this is a little better example. Say you had a torn apex, so you make your access, and you have reverse – you have reverse apical architecture. You want positive architecture. You want decreasing cross-sectional geometry, so you’re packing into resistance form. So, if you squirt in your calcium hydroxide in here, and you’re getting most of it out, well when you pack, you might be able to do this, you might be able to get, if you have enough root thickness, you might be able to get positive architecture.
But if you left calcium hydroxide on the walls, and then you pack, and most dentists are using a single cone unheeded. That calcium hydroxide is going to wash out, and what you’re going to see in another view is if this is the canal – I need another color. If this is your cone, it’s not going to be touching the walls. If this is calcium hydroxide in here, oh good, this will be a green color. If this is our calcium hydroxide in here, that’s all going to wash out, and as that washes out, then you’re going to have a tooth, and here’s your cone, and your cone, to exaggerate, will be a floater. It will be a complete floater, and this will be space now from the washed out.
So, be sure you use some kind of agitation for a period of time to get out all the calcium hydroxide. It's probably one of the hardest things to do is to remove it. But it’s easy to remove if you have the technology.
Okay. And the last question. “So, to summarize, what are the main benefits and drawbacks of using calcium hydroxide?”
Well, it’s a great summary, because we all have about 10 things on our list of ideas. Maybe we’ll even go back another show and break down every 10 and have like a segment on this and that, because these are just talking points to get you, as clinicians, excited about different ways you can have something in your bag of tricks to overcome a difficulty. So, we’ll go through the – we’ve done the advantages. The disadvantages we’ve also just reviewed.
Just keep it in the tooth. And that means don’t lock a needle into a canal, and either mechanically or use a screw thread, inject it out through the end of the root, be aware of your neurovascular bundles, the schneiderian membrane, the sinus upstairs, and downstairs, the mental foramen and the neurovascular bundle. So, it’s like anything else. You can die in your car, but you probably won’t. I think we did the statistics.
Bad things won’t happen to you.
So, just be careful how you put it in and then we’ve told you a few tricks on how to get it out.
Okay, well thank you. I think that was very informative and like you said, we might do a segment on it in the future.
CLOSE: What Does Phyllis Think?
Okay, so while the world is more and more getting back to normal, not everyone is ready to jump on a plane and head to a summer vacation destination. In fact, it so happens that more and more people are thinking that a camping trip sounds like an appealing adventure. So, maybe a lot of you didn’t know this, but my mom, Phyllis Ruddle, is a camping expert, and has camping experience that ranges from survival camping to snow camping to more luxurious camping. So, this segment of What Phyllis Thinks is going to revolve around camping. So, are you ready for some questions?
Welcome. I’m glad to have you back on the show.
It’s fun. This is a fun subject.
Okay, so let’s start with the survival camping. Can you give us some context of why you were even participating in this activity?
I know. But I’m from Michigan. Does that say anything? My dad was extremely involved in the response to a disaster. At that time, it was the Cold War, late 50’s, early 60’s, Cold War with the Soviet Union, and depending on where you were in life, I think some people, looking back, I think some people were more afraid than others. And he was very involved in practicing all the survival things.
And so, he developed what was called a Three-Day Survival Kit, the size of a lunchbox, and all you got to take was a little knapsack with a few things in it. I think we had a sleeping bag, but I was pretty young – we must have had a sleeping bag, a hatchet, a knife, and then you had enough food in your little survival kit, powdered stuff, that you could add with the things you found in nature, hopefully no poison mushrooms. He was an expert on everything edible in Michigan. And you’d get your water from the creek. We had water purification tablets. So, we would go out for three days and survive off the land and just had a few minimal things that we were able to use that were from real life.
So – okay, so this little survival kit that’s the size of a lunchbox, you said you had some powdered food in there.
And what else was in there? Just because this is actually maybe good for someone to have on a camping trip, even if they weren’t doing the survival camping, in case of an emergency.
Or just in your house if you ever –
Did you have matches?
No, well I think he had some matches. But we did have to – we had to start fires without matches. That was part of it, just in case you didn’t –
Or if it rained on your matches, you had to learn how to start your own fire. So, the thing I remember the most was the candy bar. Nobody was allowed to eat the candy bar until the hike out on the last day, and that kept us going. I remember being hungry the whole time. I mean the food tasted absolutely wonderful. We were eating weeds and sticks and stuff from the forest, so we were hungry, but it was fun, it was an adventure, and any time you heard a plane go over you knew that was it, you now thank God you were out here in the woods, and you were going to be safe so –
Because you thought it was the Soviets coming.
Okay. Oh gosh.
A great way to grow up.
They were also on practice missions.
I mean I assume you had some first aid stuff in there like –
I assumed that the adults carried the first aid stuff. I’m not aware of anybody getting injured.
Okay. So, what was the best part about survival camping, and what did you like least or what was the most challenging part of it? I know you said a few things, hungry, being hungry the whole time.
The best part was being in nature and just feeling comfortable that you could potentially survive, and I always joke with people nowadays, cause I’ve lived in California for, I don’t know, 50 years now, and I always say if I have to flee into the wilderness, I’m fine if I’m in Michigan. If I’m in California, I have no idea what to eat.
Is there a season you recommend for camping, because I know you’ve also camped in the snow. Would you even recommend this?
Maybe once. I found it pure survival. I don’t like to be cold, and I get asthma from cold air, and it was very challenging and an adventure, but and it has stuck in my head forever, but I definitely prefer summer – summer camping. That’s more fun.
I guess there’s ample snow around for water.
Oh, water wasn’t a problem, and it wasn’t polluted snow in those days.
Did you make an igloo?
We made lean-tos. No igloos. We didn’t have enough snow in Michigan to make igloos. But we would make – lash together logs to make a lean-to on four sides of the fire and then it reflected into where you slept. So, we slept pretty warm, amazingly. It was harder functioning, cooking, all those kinds of things, you know.
It seems the smoke from the fire would give your – make your asthma worse though, too.
You don’t remember?
No, I survived; that was the key.
So, I know you camped in all kinds of campgrounds, beaches, grass, rivers, lakes, some with bathrooms and showers and some without. So, what type of campground do you prefer today?
Before I moved to California and went –
The Four Seasons. Before I went camping with him, I assumed all campgrounds were toilet-free. I just assumed growing up. We had no campgrounds that I remember having any showers or the things that they have in California. And the first time we went camping together and there’s a shower and there’s running water.
Hot water and it was quite shocking to me to discover that California – now they didn’t have the grassy campsites which I loved in Michigan. Everywhere we camped, either at lakes or rivers, it was always like a grassy place to put your tent, and it was a very clean feeling. And California was hard for me with the dirt campsites. I – that was hard.
Very dry, and summer, of course, very brown.
I remember – well, we went camping a lot when I was a kid, and I do remember only one time being on a grassy campground, and I only remember one time.
And I remember thinking that this wasn’t real camping, cause it wasn’t on dirt. Okay, so like I just said, we camped a lot growing up, and I remember you always made great meals for us. So, can you describe how you cooked and planned the meals?
I had list upon list upon list and they’re somewhere in my stuff, I’m sure. It was before computers, so I don’t – I actually did a search to see if I had anything in the computer, and I don’t. And I just made detailed – that’s what my dad would do, make detailed lists of every single detail that you were going to need for the number of days you were going to be gone. And I did the same, and you just focus on one pot meals or maybe two. And maybe some things over the fire like the bread we would make on sticks and things like that. So –
Oh, I remember that. I forgot about that. That was so good.
Yeah, the best, that is the best, yeah. And that was allowed on our survival camping too and you would wrap it around the stick.
Yes, I do remember that. I had forgotten until you just mentioned it.
So, one pot meals, very big. One big pot and everything goes in it.
And then you had like a Coleman Stove, right, or with the – it had two burners.
Two burners, and those were the days where you pumped it up and it was also the days of the lanterns. You had to pump up and get the little wick going and the whole thing. Now it’s all these battery things you can use. So, it’s very different nowadays.
So, what kinds of activities do you like to do while you’re camping?
Swimming, reading, relaxing, lots of fire time, and you go to bed early, so just relaxing.
That’s because you get up at the crack of dawn.
And if you’re doing all the cooking, you’re tired, I know.
I’m even wondering if you could even make a fire at any campground in California.
I don’t know. Maybe if you had a stone pit. I don’t know. I wonder if that might be true.
Okay. So, have you ever had any issues with wildlife while camping?
We had one big issue on an early camping trip with you, and we decided last minute –
You were the problem.
Memorial Day weekend, I think it might have been the weekend before Memorial weekend, go to Yosemite and camp. We knew they had great campsites. They were awful. You were only about two and a half, maybe. We left Lori with some relatives. And all the campsites are full, so we had to go to the backpackers’ campground, which was – they were laughing at us bringing in our huge ice chest, our tent. They had – they didn’t have tents, you know, it was so funny, but that was the only spot available in Yosemite Valley.
So, we had all this stuff to transfer from the parking lot, hiking back into where it was, and so we left you sitting with all of our stuff, and we came back, and you were gone. And of course, we weren’t very good parents in those days. We thought you would just stay there and wait for us, and you had taken off straight in a direction. We started running and yelling your name and we found you, thank God. I was just telling him it would have been a total disaster if you had left.
Well maybe you got sidetracked cause I asked if you had issues with wildlife, and you talked about me getting lost.
Well then, that night – that night –
This is all the same trip now.
I didn’t grow up around bears. We didn’t have bears in Michigan that would harass you camping, so I had no clue about food in the tent, things like that, I really had no experience with that. So, we go to bed, I put all the leftovers in the corner of the tent, right by your little bed, and in the middle of the night, we hear this big – you can probably make the noise, big heavy bear breathing noises. I was like –
It was terrifying. And we kind of hear all the campers around us saying, you know, there’s a bear, there’s a bear. And I’m going, “Oh my God” and finally, Dad says, “Did you put food in the tent?” I mean we can hear it right outside our door.
It’s banging against the tent.
And I’m going, “Yes.”
So, the bear went away momentarily. I put – set everything outside the tent, and we laid back down. and I think we had you between us at that point, and it came back, and it took the big ice chest, and, in the morning, it was all dented. It never got it open, but it took our peanut butter, I remember that disappeared. And it was quite terrifying.
Okay, well you have five grandchildren. They all went to Montessori. And every year, each class had two campouts a year, and so you’ve gone on a lot of one-night campouts with school groups.
So, how was this camping different for you?
Well, I took my blowup bed, so that was very different. Back in the day, we never had any comfort sleeping. It was every bone was sore in the morning. So that was exciting. We had – I’ll share a picture when we do the show and – of the rugs and the – the quilts and all the, you know, we – it was very luxurious compared – we call that “glamping.”
No other – I remember other class members, classmates, coming up and just being like, “Wow, look at your setup here.”
And we had everything. We had the little dustpan and broom hanging on the tent, because from my experience I have all the stuff you need, but I didn’t really have to use a whole lot of it, but –
She was good at making lists, and so we would even be camping, and she’d have her list, you know, tucked away, and if I’d say, “Well where’s the whisk broom to clean out the entry to the tent?” Oh, put it on the list. So, as years went by, we became very effective campers.
It was in my head, yes.
Yeah, I remember I think pretty much like when my kids had to go on a camping trip, of course, you had to come. Like I wasn’t just going to take them by myself. All right, so what is your tent advice for people?
I would say go a little bigger than – if it says six person, I would buy a little bigger. It’s so nice to have a little bit more room for your clothes, for your rugs, to sit in the evening or whatever. That’s kind of where I lean to these days.
So, like if you have four people going, maybe get a six-person tent.
It makes life much more fun.
Yeah, we now have a three-pole tent that sleeps 500 people.
Well, you don’t want all your belongings outside.
Barnum and Bailey.
Back in Michigan, it was the old canvas tents with no floors. I mean, I can remember my dad pitching that thing. It was terrifying.
I think – I remember one campout we saw a tent that got blown away by the wind. So, maybe staking it down is –
– something that’s necessary?
Absolutely, with the guy lines and everything, yeah. Don’t cut corners.
Trench if you’re in a rainy – we don’t ever have to trench around here.
All right, so just to close, what do you think is the most rewarding part of camping in general?
Just being in nature and being with friends and family, and the food tastes so good when you’re camping.
When you’re really hungry.
When you’re really hungry, yeah, there’s not as much going to the refrigerator snacking stuff, so but just being out in nature is fun.
Well thanks for coming on the show, Mom, I really like this topic. I’m actually thinking about a camping trip myself.
Big Sur for you.
It seems overwhelming, so anyway, that’s our show for today. Hope you enjoyed it, and 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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