For more than 50 years there has been universal agreement that the triad for endodontic success is shaping canals, cleaning in 3 dimensions, and filling root canal systems. Further, it is globally accepted that 3D disinfection is central to success and has traditionally required a well-shaped canal...
International Community & Surgery Breaking Language Barriers & MB Root Considerations
This episode opens with some info regarding the ADA’s published FAQs regarding Covid-19 vaccines in the dental office. Next, Ruddle explores breaking language barriers, whether it be communicating with patients who speak another language or lecturing in a foreign country. Then Ruddle is back at the Board, lecturing on maxillary molar surgical considerations with emphasis on the MB root. And finally, the show closes with another Ruddle Rant, because it has been a while since he has had a chance to vent to the world.
Show Content & Timecodes00:09 - INTRO: ADA FAQs – The COVID Vaccine 05:23 - SEGMENT 1: Breaking Language Barriers 21:30 - SEGMENT 2: Surgical Considerations – MB Root 44:08 - CLOSE: Ruddle Rant
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Downloadable PDFs & Related Materials
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INTRO: ADA FAQs – The COVID Vaccine
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. How are you doing today? Did you enjoy that lightning storm?
That was remarkable.
And it went on for a long time, too. So, we’re going to spend just a few moments talking about the COVID vaccine. A couple months ago, the ADA published a list of FAQs on the COVID-19 vaccine and your staff, and the questions and answers revolved around whether a dentist can mandate vaccinations for employees. So, we’re not going to go over all the questions and answers today, but we mostly just wanted you to be aware that this list exists for if you’re unsure what your responsibilities are as an owner dentist with respect to vaccination and your staff.
So, incidentally, I also want to point out that as of June, about 93 percent of dentists reported being at least partially vaccinated, and around 90 percent were fully vaccinated. So, what did the ADA say about whether a dentist can mandate vaccines for employees?
Oh, well, the ADA has said likely the answer is yes. I’ll add personally it depends on several things. It depends on the state you live in. I think when we were talking, I don’t remember the number exactly, but probably less than half the states would mandate it, another half roughly might just say it’s up to the state governments. So, we have to understand in the states, for the international guests on the show today, is that each state can be different. Each state has its own medical guidelines from their own health officers.
The CDC doesn’t always agree with WHO, and WHO doesn’t always agree with the FDA, and different countries don’t always agree with the United States, so there’s a lot of disagreements, but it’s still probably likely yes. And then, of course, we have to be aware that we might have to make some accommodations. Now, the ADA mentioned the accommodations of pregnancy as an example, but if I was actively practicing and I had a staff, I didn’t have a large staff, but if I had like five or six people, I would want to listen to them carefully.
There could be pregnancies, there could be immunocompromised patients, there could be people on certain medications that are known to be contraindicated to have a vaccine, so you’d want to get an idea if there’s natural immunity, and all those things need to be talked about between the employer and the employee and see if you can get it worked out in a very nice, peaceful way because you are serving the patients.
I do want to add we did use PPE and we didn’t have a vaccine early, and that got a lot of people off the street in a lot of pain and we were able to limp through. Your foods were stocked on the shelves, didn’t have the vaccine, so we can get around it, but it’s getting tighter and tighter now and probably we’re going to have to need to be very careful in the state we’re living in and then we’ll probably have to, like in California, it would be mandatory.
Okay, one question also that stood out to me was who should pay for the vaccine and if you should give your employees some time off a few days after they get vaccinated to recover in case they have any side effects.
Well, here in the United States the vaccine is paid for by the Federal government, so there shouldn’t be any costs there. There could be some costs associated I guess with travel or the actual dispensing, a person that is dispensing the injection. I don’t – I haven’t seen that or heard about that. But yes, all costs should be paid by the employer, and furthermore, there can be side effects. It’s pretty rare on the first injection, but sometimes it’s been reported more on the second injection, so that should be anticipated, so maybe you could do it on a Thursday, if you took Friday off as an example, and then everybody would have like a few days to try to recover and get a little bit better.
So, yeah, you got to pay for it, make it comfortable for them, easy, and then if they need a day or two or more beyond other staff members, they’re all going to be different, that has to – they get paid for that, their time off, and the – we’d be clapping for them to get back quickly.
Okay, well thank you for that information, and be sure to check out that list of FAQs if you have questions. So, now we’ll move on to the rest of the show.
SEGMENT 1: Breaking Language Barriers
Okay, so at the end of August, Dentistry Today News published an article called “Tips for Treating Patients who Speak Another Language.” And we thought this article was very relevant considering advancements in travel and communication have essentially turned the world into one large international community. All clinicians probably on occasion see patients who speak a foreign language, and depending on where you live, you might actually regularly see patients who speak a foreign language. Further, a lot of clinicians lecture internationally, and some even travel to remote regions of the world to help promote dental health.
So, clearly communication can be challenging when different languages are spoken. So, today we wanted to talk about some strategies to optimize understanding. Now we’re going to talk about a few different situations, but we wanted to start off by focusing on what the Dentistry Today article said when you’re actually seeing a patient who speaks another language. So, when you were practicing regularly, did you sometimes see patients who spoke a foreign language?
It was quite common. Maybe I should just tell the audience, in Santa Barbara we’re a pretty small community, but we’re interesting. You might not have thought of this, but the University of California, Santa Barbara, is very diversified with visiting professors. We have quite a think-tank of scientific communities. We have visiting professors that come over. We have an industrial technology center here where we do stuff for outer space and things like that. So, again, those people are fluent in more than one language, but sometimes you’ll get a visiting professor from India or somewhere and it will be over and that can happen.
And then, of course, the one that we’re all thinking of if you live in Santa Barbara, Spanish speaking people. In our community, I think about half or probably more than 50 percent of all Santa Barbarians have some Hispanic origin. So, it’s really important to have a staff member who is bilingual. We always did. There was always somebody that could help Ruddle interface with these patients.
And, of course, when you do use an interpreter, if the patient brings one in, or a friend, it could be an interpreter, it’s important then not to look at that interpreter. Look at the patient because the patient – you need to be building, you know, relationships, like we’ve talked about on other shows, so look right at the patient even though it’s going through a three-way. And then the other thing is try to speak slowly, dumb it down a little bit, speak simply, and pictures are useful.
Yeah, and definitely you don’t need to speak louder because some people do that when they feel like they’re not being understood. They say it again louder, but that’s not maybe the trick. They also suggest that you might want to learn a little bit about their culture or maybe a few simple phrases because this can put them at ease. And it also might make them smile a little bit when they see you trying to speak their language. They might even feel more confident to try to, you know, speak your language a little bit.
But what if then the patient didn’t bring in an interpreter and they overestimated their ability to understand, and then they find they’re a little overwhelmed and they’re not really understanding what you’re saying, and you’re seeing that they’re not understanding, I think you said an option is to draw pictures.
You can draw pictures. One thing I should probably – we should probably discuss. We haven’t discussed this in great detail, but probably it’s picked off on the phone call. I mean in an endodontic office – now I know I’m talking to everybody and there’s GPs and other specialists probably watching the show, so it’s different in different disciplines, but certainly in endodontics, people don’t just walk in off the street unless they’re lost and they want to know how to get to a different office in the complex.
So, when you’re on the phone, that first contact, if there’s a problem with English, right there is the chance for your receptionist to say, you know, maybe it would be good if you brought in, you know, a friend or a colleague who could help you during the consultation so everything will be understood. Now, that’s easy, if in fact it’s a consultation, but you might be referring more to like it’s an emergency and somehow they get to your office. Well now you feel like, you know, you must do something, they’re in a lot of pain, maybe swelling, and so pictures help. I think –
Maybe even if you had like, you know, like this dry erase board, and I mean you often draw pictures of teeth and you can show what you’re going to do and they can always take a picture of it with their phone, too, if they wanted to like remember it.
Yeah. You know, people did take – when the cell phones finally came in many years ago, people would ask respectfully, do you mind if I take a picture of your bracket table because there was always a clean piece of paper with about three instruments because it was an exam tray. It wasn’t like “the tray” and so it was very easy to slide three instruments over and draw.
And then, of course, we got monitors, and once you got monitors you could them, you know, big things, nice, and then they can take pictures of that. They can – well they might even need to go home and think about it and then if they call, we need to have a three-way though, because I can’t talk with them. I would need again to talk with them through a person who can help them understand.
Or also maybe even a Zoom call might be beneficial because, you know, sometimes with gestures and people kind of have a better understanding when they can see your face and the gestures.
Oh sure. Great idea.
And also like I guess if you’re going to give them instructions for like after care, maybe definitely have it written down so that they can –
We always had tear-off pads, you know, we had post-op instructions written down. Even English-speaking people needed that.
Yeah, that’s true.
My sister, you know, not to bring her into this, but she would go into a medical office and anything she heard, and she was twice as smart as I was, okay, very learned, very well educated. She glazed over. When she went into a medical room, if you came out and said, “What did they say?” “I don’t remember.” “Were they hopeful?” “I don’t recall.” So anyway, even – everybody can use written down instructions, and then with a few pictures and written down instructions, that can go a long ways.
Yeah, I mean that’s a good thing you brought up, because I mean a lot of people just have anxiety in general about going to the dentist or the doctor. Then if you add in that, you know, they might not feel like they’re understanding everything because you’re not speaking – you can’t speak their language, then it can even create more anxiety. And I think the more anxiety you have, the less likely you are to understand.
And that’s why maybe knowing a few simple phrases in their language or maybe knowing a little bit about their culture might help put them at ease, and you can kind of make some kind of connection with them. And then they’ll be – maybe calm down a little bit and then maybe even understand better.
Sure. Well maybe there’s a language called “anxiety that we could mutually speak.
Okay, well let’s look at another situation now. So, you have lectured all over the world, and maybe you can tell us a little bit about what your experience was like speaking to large group of non-English speakers.
Well, it’s changed, as you would expect, over the decades, but if you want to go back to the ‘80s, well just the ‘80s, it was pretty much if you went south in Europe, you were going to get delayed translation, and delayed means I say a sentence, stop. Then the translator says your sentence. And you do that all day long. So, you go over for a six-hour lecture, and you prepare six hours of content, and you realize when you meet everybody, that you really have three hours, because you’ve got to take the lecture and dump it in half.
And then when you south, Latin America, South America, they like to tell me, “But Cliff, Spanish is 30 percent longer than English.” So, now I’m going, “Okay, so my six went to three and now it’s more like two.” So, that’s tough. Now that still is present, but a lot of times big organizations, to your point, you said big meetings, they hire professional interpreters, and there’s different kinds of interpreters. I mean if you were doing a meeting in aviation, there would be a certain interpreter that would show up because they know all about planes and aerodynamics and stuff, and they know the language.
So, dentistry has professional dentist interpreters, and they show up, and oftentimes, the audience might not know this, but you just fly in international, okay, you’re dead tired, you check into your room, and then you get a phone call and it says the interpreters are in the hotel, they’re in the lobby, and they’re waiting to meet with you. They just need two hours. So, we did that routinely. Usually it was planned, but a lot of times, it would be kind of spontaneous.
So, you’d go down there, and I didn’t give them my lecture, but I would try to think of things that might be tricky, like a word I might use here and there. Otherwise, I try to talk, to your point earlier, simple, simple, simple.
Yeah, because you do actually – your style is you do have these little like phrases that you, you know, repeat over and over again.
Can’t use them overseas.
Okay. And then I guess like if they have – if you have like a workshop that you’re going to do too, that kind of maybe cements what you said, like then they can actually see it in practice.
That’s a great point. I’ll answer that and back to the interpreters, we also made little signals. So, I would meet with the interpreters, okay, the day before or two hours the day before my lecture would start. But then we also made signals where we would give them a flashlight from the house and so I told them, cause they’re in a little booth, so people are walking in and they’re in this little nondescript booth, and everybody is picking up their headphones, their headphones, their headphones.
So, I would give them a flashlight, and if I was going too fast, they would use the flashlight. And then sometimes I would just say to the audience, because they’re hearing everything, “Are we doing okay? Are the interpreters still alive in that little room? Do they need a little break?” And there’s usually two of them, because they can only – it’s intense, and they do about an hour and then switch constantly. To the other question, what was it?
Oh, I was talking about how a workshop, if –
The hands-on part.
You know, you were with us in the seminars in Santa Barbara for many, many years. We had people come over, and I won’t pick on the Japanese, but I’m just thinking right now extemporaneously, Japanese group, but it could have been any group, they didn’t speak any English. Maybe there would be ten that would come over and one, the representative doctor, would speak fluently. But you get down two or three docs below him and all of a sudden nothing. I mean not even cursory understanding.
But in workshops, it’s a tooth, it’s a file, and they – you’d see their eyes light up, and they would get it and they would be struggling, you couldn’t say anything, but you’d show them. And then they’re like “ah!” And so, anyway, workshops kind of brought it all home.
And then I guess a lot of dental terms kind of maybe are the same in different languages, so –
Latin is our –
It is kind of like – dentistry is kind of like a language in itself.
Dentistry is a language. And I used to say to a lot of people, even if you can’t understand me, just look at my work. That’s one reason I’ve always spent a lot of time and I’m still married, but a lot of money, to make world-class visuals because I realize from traveling, that’s what they really understand.
So, maybe if you’re lecturing internationally, maybe you also might want to give a few more handouts, maybe a more detailed outline of your lecture. I know you were saying in the old days, you would have to bring over a big stack of outlines or papers to hand out, but now people can just like download stuff from the internet. So –
Oh yeah, I could tell you funny stories, but Phyllis, we used to pack her down like a Sherpa, and I mean I was packed down like a Sherpa. And I mean people, you know, we had to pay extra money to get our baggage through because it was too heavy, but after the first trip, you were doing a tour, so after – you get rid of 25 pounds, next city, 50 pounds, all of a sudden you’re going home and you’re really light.
So, but of course with the internet now, this is all online, colleagues can download it. They actually come into your course with your handout, because they’ve downloaded it themselves. Sometimes the society will download it and hand it out at the venue.
Okay, and I think just as we emphasized the importance of maybe familiarizing yourself just a little bit with your patients’ culture to kind of make them at ease, if you’re lecturing in another country, you might want to know just some basics about their culture, mostly so you don’t inadvertently offend anyone. But you know, I think that people, when they see that you’re interested in them, they’re going to be, you know, more receptive to what you’re saying, too. So, I think that’s important.
You know, I was – Phyllis and I were in Kota Kinabalu, we were getting ready to go to Japan, and we were having dinner the last night in Kota Kinabalu with a really nice guy, a dentist, and he traveled a lot like I did, and he said, “Oh you’re going to Japan?” I said, “Yeah, we’re going to Japan.” He said, “Well, do you have business cards?” And I said, “Yeah.” And he said, “Do you have business cards?” And Phyllis said, “Well we have probably 50,” because he asked us how many.
He said, “No, no.” He said – he got on his cell phone, he said I’m going to make a call, we’re going to have your business cards. He said, “I have your business card. We’re going to have boxes of these printed.” And I said, “Well why am I doing that?” “Because,” he said, “When you go to” – you’re talking about cultures and knowing and being respectful, “they love to give and exchange cards in Japan.”
And so, we got all these cards. They arrived in our hotel room the next morning, overnight, and we flew off with more weight. But when we got there, everybody wants a card. And they’d all say, “Here’s my card.” “Oh, here’s my card.” No, they hold the card with two thumbs and they present and bow. They present and bow. So, I was doing that, and it felt really comfortable because they liked it. I could tell they really liked that, because I guess most Yankees like me were rude and arrogant. So, that was nice.
And then I went to Spain the first time, and I kissed – this woman went to kiss me and I kissed her on the cheek, and then she turned her cheek, and I thought, okay, France, another kiss. And then it was like back to the third one, and I thought, “I love Spain.” So, Spain was three. France was two. But know your culture, yeah, know your culture.
Okay, well this is all good advice, and I kind of just want to point out to everyone that on our Ruddle Show website in the show notes for each episode we have a complete transcription of each show. So, if you’re a foreign language speaker or English is not your first language and you’re watching us, and maybe you missed something, you can always go look at the transcript to find out what we said, because sometimes when you see it written down, it helps the understanding. You’re like, “Oh, that’s what they were saying.”
It is helpful.
You know, that’s how I am with music lyrics.
Well, I think it’s true. I mean a lot of times – I’ll just give one little example, but just in talking, then Phyllis will bring home a printed email, and I read the email of what we were just talking about, and there’s usually one little thing in there that clarifies it for me or I completely missed. So, the transcripts are great, and we do have them.
And those would actually be very helpful, and at some point, we want to have The Ruddle Show maybe translated into other languages.
That’s one of our goals, isn’t it?
Yeah, so either you could actually have it dubbed or subtitled.
Bringing The Ruddle Show to you in Hebrew tonight.
Okay, well that was a fun segment. Thanks for all that useful information.
SEGMENT 2: Surgical Considerations – MB Root
Today we’re going to have a little lesson on surgery with focus on the MB Root of maxillary molars. Before we go any further, as you keep listening to me – you are listening to me, right? Watch this tooth go around about 10,000 times, and you’ll be thinking as I speak about the maxillary molar is the most widely researched tooth in the mouth. It’s the biggest tooth by volume, and it’s the most misunderstood tooth. And that’s because the MB root is a very broad root, buckle lingual, and that means oftentimes that means almost 90-some times out of 100 it’s going to have an MB2 system.
So, when we talk about the MB root, and when we analyze cases that haven’t worked out well, they’ve already had primary treatment and it’s failing, we have to understand, do we do re-treatment because of the MB2 if it is demonstrated radiographically through different views and angles in your CBCT that there is a missed MB2, then we probably wouldn’t want to put a cork at the end of an empty bottle and hope that our little cork incarcerates bacterium over the life of that patient. It’s always better to clean and shape it through the top of the tooth.
Can’t always do that though, can we? We have patients, and there’s decisions to make. Sometimes these teeth are heavily restored, they’re tied up in splint or reconstructive dentistry. So, sometimes we get pushed to do things at times we would know common sense says probably should go through the top of the tooth, even if you have to take out posts, cores, build-ups, et cetera.
So, I’m really happy to talk to you about MB surgery. We’re going to talk more about surgery as the seasons progress. We’ve talked about flap design, and that’s going to be very useful when we talk about MB surgery, because we are going to talk about those three flaps, the intrasulcular flap, the attached gingival flap or the full thickness intrasulcular flap.
So, now that you’ve seen this tooth rotate behind me for 10,000 cycles, you are locked in that that’s a broad root, it has two systems, and the systems frequently communicate along their length. So, as you think about surgical access, lifting the flap, if you think about osteotomy, if you think about removing granulation tissue, apicoectomy type procedures, the level of the bevel will determine the configuration of your preparation. Right? Because you might bevel down and run into an interconnector, and you can see that the systems do speak and talk to each other through their cross-linkages.
So, now that you’ve seen the MB root, this is just one, but I think it’s pretty representative of MB roots in general, let’s talk a little bit more about surgery. But first, I’m going to come back and do what Ruddle always does. Don’t be a surgeon general and be corking the end of roots when you know you could do a much more infective, a much more definitive job through the top of the tooth. Every time sometimes we try to help patients do what they want us to do, sometimes that blows up in our face.
And remember, we do own the case. If we touch it, if we do something and there’s a problem, they come back and see Ruddle, don’t they? Well, I’ve heard from many of you fans around the world, and it’s pretty encouraging for me. I know you’re starting to get these lessons, and here I had a kid just from another country, and he just mentioned that he’s a show junkie. So, to all my friends out there, a big hello, and let’s look at the MB root closer.
All right. So, you can look at Frank Paque, Professor Paque’s work. I’ve shown some of his micro CTs before, and you can see that that MB root can be really complicated just like it can be clinically. So imagine going in here and beveling the root, what would your preps look like? Would there be three preps, would it be a slot prep? Already you’re starting to think about that.
And, of course, surgery would do very little probably to find the portal of exit that’s on the distal aspect of the DB root. And is it facial, is it proximal, is it kind of around towards the palatal? Can you access it? So, those are considerations. This is at a palatal root amp. So the palatal root has been eliminated, and this is just the buccal roots. This is like about a 15, 20-year recall. It’s a long term follow up, because the prosthodontists do to keep the occlusal loads narrow over those buccal roots so there wasn’t a big lever arm with a built-out palatal cusp tip. So, look at that.
Just like you see anastomosing between systems, you see anastomosing between systems, and out of that anastomosing, there is a separate apical portal of exit and there is a separate apical portal of exit, three POEs on that MB root. So, when you’re going to do this kind of reconstructive dentistry, the endodontics needs to be good. It needs to be predictably successful. Then you have confidence.
Okay, well another guy showed me a case yesterday. I’ll talk about that. He showed a whole furcal blowout and it all filled it. He said, “Cliff, this stuff works. I didn’t even have to do periodontal surgery.” Okay, well you see a root that’s really curved. I don’t even know if you can actually read the end of the root. This is where your CBCT would come into play.
You know, I’ve been around the game for about 48 years in endodontics. A lot of these cases were done before CBCT, but maybe you’ll look at Ruddle before CBCT and see the carefulness that we approached the case. We always had three pre-operative views. I was a teacher. I held extracted teeth in my hand all the time. I was getting a lesson on morphology, wasn’t I? So, that carries right back to the clinic when you’re flapping a case and you’ve held a thousand, two thousand, five thousand maxillary first molars in your hands helping colleagues find MB2s. Believe me, that helps you in surgery and non-surgical retreatment.
Well, if we slide it on over, there’s the MB root packed. You can see there’s an outer loop. You can see it re-anastomosis. And then we have a portal of exit. We have a portal of exit. We have a portal of exit. We have another portal of exit. So, cleaning and shaping these followed by some kind of thermal plastic technique where you can move obturation materials into the available vacated anatomy is going to fill root canal systems.
And let’s look at the post-op. Yeah, we did do the DB, we did do the palatal, but we’re looking at the MB root today. So, if we’re going to look at the MB root, after looking at three cases, we could have looked at a thousand cases, you wouldn’t have been any more or less convinced. However, it’s sometimes good to go to human material, and when you do, you can begin to see what we’ve been talking about, a big, broad root.
Broad roots oftentimes hold two channels in here. You can see that these roots are pretty close to the cortical plate. The cortical plate on the maxillary posterior teeth is quite thin. That’s why we like to get our gloved finger up in the fornix of the vestibule and palpate over those imaginary roots, because oftentimes any inflammation at all, little bit of disease apically, will blow out the cortical plate. Now you have communication to the soft tissue and you can palpate those and pick them up.
So, the MB1 terminus would be pretty close to the buccal plate, but getting across that root, all the way across, to the far side, the palatal side, so you can see it and operate and be technically accurate and precise, that’s a little bit harder. That’s a little bit harder. You’re going to make a flap based on thin bone. You don’t know where the roots are exactly, so sometimes it’s an intercellular flap. Like on this case it’s a combination flap. So, you can see I was thinking about leaving the papilla, that would be something to tact to.
Let me say this, before I ever pick up my scalpel, I’m imagining suturing. Start with the end in mind. We’ve said that about a thousand different things a thousand different times. But I already am planning suturing before I pick up my scalpel so when I get to that late-stage game of compression, soft tissue compressions, I’ve already thought it through. So, I have a nice area right here to tack a suture to. I can sling. I can also tack to here. This is all attached gingiva, all attached gingiva, so it’s really awesome. And you can put a little one right in here on the release.
So, we left a collar bone. It’s not real thick, but it’s enough. It has blood supply. And we beveled across the root. And if you look at this root, you can see the configuration of the root. You can see the configuration of the retrograde. All right. So, remember the internal anatomy reflects the external anatomy in every instance. So, think about that when you’re cleaning and shaping. When you see fluted roots, canals, systems, chambers are fluted.
So, you can see that configuration. You can see everything is clean. Listen, in the mid-80s is when this all blew up. And it went from like really crude surgeries done with quite a bit of skill by some to really, you know, Gary Carr came along with the retrograde preparation technique with ultrasonics. I really started enlightening things on crypt control. We started to get different armamentarium for reflection. Our blades became smaller. I mean there was a whole emphasis on miniaturization, and we’ve been doing that then since that period of time. And of course, the decades have rolled by and all you kids grow up today, and this is what’s normal for you. But it wasn’t always this way.
So, let’s look at flaps up and talk about curettage. So, you can see your big breach in the cortical plate. You can see you got good bone in here, good bone, but I want you to see that breach. You can see your crown. And again, this is a different case, but again, we left the papilla to suture to. We left so we could suture. And if we just slide that over, you could see we’ve done the curettage, we’ve left the collar of bone. The roots are quite broad, quite broad, buccal to lingual, and you can see how that retrograde preparation and the retrograde fill itself is perfectly paralleling external anatomy.
You can take methylene blue, Chinese red, and you can dob it on a – pledge it, hit the end of that beveled root, let it run into the PDL, flush it out, and you can matt perfectly your PDL space and you can wash it all the way around. You can see it perfectly, so you know you got down on that root, you’ve beveled it to solid bone. To bevel a root to solid bone is to propitiate the relationship between root canal system anatomy and portals of exit and lesions of endodontic origin. Think about that. You’ll be driving home tonight and you’ll be thinking about that.
So, let’s look at our first X-ray of a case we’re going to treat. You know, some of these roots, buccal roots, are pretty clumped together. They’re pretty close in proximity. Others are very divergent. You can look at this gutta percha. This is an example of overextension and internally underfilled. Ruddle, why don’t you go back in? Why don’t you get back in the chamber? Look, you might even see – hey, let me get that out of there so you can see. You probably see what? You see this. You see that? You see that.
That probably means there’s an MB2, but you know, there’s patients behind this, and this patient would not allow me to go back through her casting. She would not allow me to go back in and was kind of like if you can do it surgically and it works fine; if it doesn’t, I’m having it out. She was not a very happy patient. So, sometimes you have to talk to a general dentist, you have to tell the patient, you know, I didn’t really say “sign right here,” but I do not like approaching empty canals from the surgical field.
So, you can begin to see our gutta percha that you saw on the pre-op film zooming through the end of the root and traveling up higher. You can see some gutta percha right in here, but this is a little opening through the osseous crypt. Here’s a second crypt I’m developing, and I’ve just uncovered the buccal roots, and they’re sitting right there in front of me, right in proximity to the buccal cortical plate. So, you might think well, then I’m going to start doing a lot of surgery, this is easy.
Listen, I’ve got to come back and talk more about incisions, elevations, undermining incisions. These are all details. Okay, how you raise the flap, retraction. We haven’t gotten into that. You say, “Well who cares about retraction?” Those cause a lot of soft tissue injuries if you don’t know what you’re doing. Then there’s the osteotomy, crypt control, AB section, retrograde prep, retrograde fill, all these things we’ll be covering.
But right now, we’re starting this surgery and you can see we’re going to have to now get across that root. And that root turned out to be pretty wide buccal to lingual. Once again, not to be redundant, but the distance from the cavo surface to the MB2 portal of exit, the distance from the buccal surface over to the MB1 portal of exit, the interconnector, notice how there’s fluting, notice how there’s fluting and notice how our prep looks just like the external anatomy.
We can run that out with ultrasonic instruments. They’re much, much smaller. We can go up the long axis of the canal three, four and five millimeters, depending on the tip you choose. We want rough and diamond tips because they chew up that gutta percha much, much more effectively than just a smooth, slick instrument that’s thermal soft and you gutta percha and streaking it around. So, lots of ideas.
How about a failure? I showed this at a world conference recently, and it was a broken instrument. And to me. it’s not even trapped in the canal. Let’s look very carefully. I’m pretty close to the screen, but let’s look carefully. That’s what I see. Rolls of symmetry would suggest a path more like that. So, I think we’re either deviating and false path finding and shaping out in no-man’s land, maybe we’re drifting off into the other system, I don’t know, but something doesn’t look right, isn’t right. So, we’re going to go in and look at that.
How are you going to handle this? You’ve got to go back in and try to remove it. All these things have to be discussed with your patient. Slide it on over, and if we make like a real careful, early osteotomy and just start, you know, getting in there to the bone, moving a little bit medial with our access, you can see we’re uncovering the root. You can see the halo of gutta percha right about this level. But you can see – I’m showing you the broken instrument; the broken instrument normally would be inside the root, but if you beveled your root carefully, you can just come right in on it and it makes for a nice education.
You’re loving this stuff, aren’t you? You’ve loving the MB root, because it’s a surgical challenge. You know, dentists like challenges, don’t they? They get bored with ho-hum work. So, if you keep this case rolling, we’ve got to get in here, we’ve got to bevel those roots down. Often times, you’ll be doing the DB. Sometimes you’ll be working through one osseous crypt, sometimes two osseous crypts based on divergence of roots, just reviewing a little bit.
So, there’s a lot of things to uncover here. But notice we’re not having gushers. There’s a lot we could talk about, ferrate sulfate, special Ultradent brushes to paint the bleeder. You can crush Collacote into those nuisance bleeders. You got to really flush out that ferrate sulfate stuff and you got a curette telling you – you stimulate fresh bleeding upon closing the flap, so you don’t leave a big culture medium for bacteria. So, crypt control is perfect because there’s that old expression, if you can see it, you can probably do it.
So, if you can see it, you can probably do it. And again, the challenge of this maxillary surgery is to get all the way across right to solid bone, flatten that root down. If the lesion keeps moving up around the root, you’re wondering if there is an exit. Is there a portal of exit that we’re missing? So, to bevel the root to solid bone is to appreciate there’s no pathology apparently coronal to the surgical apical intervention.
Okay, erase-o. You know, it’s a nice cold day in Santa Barbara. It looks like it’s going to rain. We had a lightning storm. I mean this is a day to teach. If you ever had a day to teach, this is it. Bring it, bring it! So, the preps look different. We’re able to go up along axis at least three millimeters so we can get a better corkage. And of course, slot preparations and again, you can see that hourglass configuration. You can pick it up a little bit on the radiograph. So, that’s that.
I think we have one more case. I could show you, you know, in the old days, we talked about carousels. We used to show up with slide carousels. They had 80 slots for slides or they had 160, so we’d – I was almost going to say, but nobody would have understood me, I have carousels and carousels of MB2s, but then you would know he’s 500 years old.
So, on the last case, yes, we do do surgery a lot on previously surgerized teeth that are failing. And I want to acknowledge Shimon Friedman at this time. I could acknowledge – I already mentioned Gary Carr as the father, not of the microscope, everybody says that. He was the father of surgical ultrasonic instruments. That was a breakthrough.
The first micro-surgical course in the world was in Santa Barbara in my office. Steve Buchanan was the surgeon. Gary Carr was up to show his new tips. They were not even to market yet. And we did – Steve did a surgery on a lower molar. So, that all happened with a group of eight endodontists, and that’s changed everything, and the rest is history.
So, we showed in that course way back then, and I believe that was 1991 or 1992, we showed that many, many cases that are failing surgically are failure to find all the apical anatomy, including the what? The isthmus. The interconnector. The one that connects the MB2 with the MB1. So, this is done by an endodontist, a very good endodontist. And you know, he did the root canal, then he did the surgery and now this is my pre-op.
So, when we went in here, this is what we saw. I’d just gone in, and again, you can just keep seeing how thin this cortical bone is, you know, here’s the nick of the tooth right here, and you can begin to – and, you know, a little bit more of it. And you can begin to see the bones and here’s the root. But when I beveled that down, this might have been amalgam in that day, but what do you see? You see a giant isthmus with Avogadro’s number of microbes undoubtedly dancing around inside the isthmus having a field day. There’s so much substrate, it’s so much fun to live and thrive until Ruddle comes along and I’m going to change the biology.
So, what I’m going to do is show you a trick. I first taught this, I don’t know, in ’87 or ’88, because people were saying in that era, you know, when I run my ultrasonic instruments, just as the ultrasonic instruments came in about 19 – close to 1998, say 2000, we started to see these surgical instruments. They would jump around, bah, bah, bah, bah, bah. You’d be brrrrrrr, and they’d be jumping around, and all of a sudden, you’d get preparations that were out here. They got really big, because of dancing, getting off the track.
So, Ruddle remembered his days at the University of Pacific in San Francisco. We were an operating school, and we could cut those gold foil preps and we had special hand instruments that could do that. So, what we did is I introduced a hoe, a chisel, a hatchet. Those can just like chunk, chunk, chunk, about three passes, MB2 to MB1 and you have a tracking groove, and it can be quite deep. Every time you do that, be you’re making about a half a millimeter, millimeter, millimeter and a half, that tracking groove you can put your diamond coated tapered ultrasonic tip right in that tracking groove, and you can run that out, and you can run that all the way out and have a very predictable result.
Okay, so now that you’re starting to appreciate the advantages of a sharp hand tool to make a tracking groove, you can now see we’ve done that, and notice we’re down there already about two millimeters, and then I can come in and put that tip – I can put the tip of that instrument right in that MB2 and start dragging it right across and right across and back and forth until you get the depth you want and sometimes the isthmus is as deep as the MB1 and 2. Sometimes it's a little shallower. It depends on what you find once you get in that tracking groove. Sometimes it disappears because you’re just in a little anastomosing area and once you get below that you could meet a solid dentin again.
So, in closing, let’s bring this case in by just seeing the end result. So, there it is. You can see we’ve gone up the long axis of the DB, you can see we have a very narrow isthmus in here, and then we have a little bigger diameters cause we’re in the MB2 and the MB1, and you can see it right there. So, listen, I hope you’ve enjoyed this surgical presentation. I hope you get out your scalpels and try to do a few little things. May your reach exceed your grasp.
CLOSE: Ruddle Rant
We’re going to close our show today with another Ruddle Rant, and just to remind you how this works, I’m going to say a topic and then my dad is going to have one minute, and we’re going to turn this little sand, one-minute sand timer over, and while it’s going, he has one minute to tell us how he really feels about that topic. And if he’s still talking when the sand runs out, I’m going to stop him. I might let him finish his sentence; it depends on where it’s going, and then if you finish before the sand runs out you can either just say, “I’m done,” or we can just sit here like in silence for emphasis.
Well, if you – if I finish early, it’s because I’m not saying the things that you would later edit it out anyway.
Okay. All right.
And I’m looking at some of this stuff here. I think you’re going to edit out a lot of it.
Okay, so we’re going to – the first topic is clinicians who believe that the endodontic triad is dead.
Okay, I only have a minute. The American Association of Endodontists, the AAE, has an ongoing discussion forum where people weigh in, post cases, make comments and act crazy. Okay, so recently a non-serious person that cannot be taken possibly with any seriousness, said that shaping is now de-coupled from the triad. The triad was, remember, shaping, 3D cleaning and filling root canal system. This same colleague who said it’s decoupled is using files, he’s shaping his canals, and he’s using his – should I say the company’s name?
No, I won’t say –
Speak to the camera. Speak right to that clinician.
Okay, so this clinician, if I was meeting with them seriously, I’d say, “You made white lines on your X-ray; how did you get that canal opened up? Did you do it with your fingers? Are you can endodontic whisperer? And how do we get irrigants down and catheterize the canal that’s blocked and if we don’t catheterize the canal how do you get re-agent flow into the lateral anatomy and clean root canal systems which you worship?
Please, get serious.
That was starting to get going. Okay.
I was only warming up.
The next topic is endodontic specialists who are not up-to-date on certain techniques.
Listen, I don’t care what you do know, what you learned and forgot, or what you still hope to learn. We’re all learners, hopefully, in the profession. There’s no experts, just serious learners. But when I see on the form again young endodontists, I’m wondering what they’re learning in their programs, because one colleague said, you know, “I have a root defect around the curve, and how do I get MTA around the curve; I only have my stainless steel pluggers?” Oh, s!!! I got to get going!
Well, myself probably 25 years ago, NDDD in multiple lectures and articles, in textbooks, chapters, around the world, and I’m just one guy, have written about trimming a gutta percha master cone to have sufficient cross-sectional diameter apically, but you have a flexible plugger. Can you imagine that? And you can put a little aliquot of MTA in the coronal one-third, and take your trimmed gutta percha and you can shepherd the material, pass it around. And did you ever hear of the EndoActivator? Did you ever hear of the EndoActivator? That’s one of its hero ideas is to move mud into root defects.
And your time’s up.
But I love that colleague.
And stay on top of it. Okay. The last one if going to be non-dentistry related.
And it has to do with the baseball playoff format, because the baseball playoffs are just starting, and I know we’ve had a lot of just separate discussions, me and you, about it, and I know that there’s some issues that bother both of us, so I’ll let you now talk about the baseball playoff format.
This is for David Landwehr. Anyway, a dear friend, an exquisite endodontist, I’m wasting time, okay. In American baseball, you play for six months and you play 162 games. So, there’s many teams that make the playoffs, and I won’t get into the complication, but there’s several teams that make the playoffs. But the format that really gets me going is when the second-best record in baseball, a team that won 106 games, tied a franchise record, got beat by San Francisco who won 107 games, they won one more game, why would those two teams ever be placed in the first round of playoffs?
Well, they’re not. The Dodgers get to play a team that’s won about 20 to 25 less ballgames in a one-game playoff, winner take all. That’s bulls!!!. Oh, I have more time. So, they said rearrange the division leaders and in your wild cards, and seed them, just like the do in tennis and football and all the other mainline sports. So, right now we have a crazy rule and major league baseball needs to take care of it.
Okay, well thank you. Yes, the Dodgers will be playing in their one-game –
One-game playoff game tonight against the Cardinals and they’ll see who gets to go up against the Giants. So, anyway.
If you know baseball, anything can happen in one single game. The rest of the playoffs move to five games. That’s more fair. And then finally, the traditional seven game playoff, where you have to be the first one to win four games. So, one game for the whole season, six months, 160 games, all decided by one game.
Yeah, that does seem a bit unfair. But anyway, that’s our show for today. We hope you enjoyed it and hope you have a great evening watching the Dodgers. Well hopefully by the time you see this show the Dodgers are still in it. So –
They’ve alive and playing.
Anyway, that’s our show for today and 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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