This article will briefly review the ProTaper system and technique, and will then focus on the various considerations that will influence predictability and success when finishing the apical one-third.
Rising to the Challenge Working with Family & Managing an Irregular Glide Path
This show opens with a brief mention of which countries rank the highest in dentistry, specifically when it comes to oral health, and why. Next, Ruddle and Lisette explore the pros and cons of working with family members, as this dynamic is not so uncommon in dentistry. Then, Ruddle returns to the Board for an indispensable presentation on managing an irregular glide path. Finally, the show closes with a few Ruddle tips for dental assistants, because behind every successful clinician is probably a talented assistant!
Show Content & Timecodes00:09 - INTRO: Dentistry Rankings 07:37 - SEGMENT 1: Specific Scenario - Working with Family 22:48 - SEGMENT 2: Managing an Irregular Glide Path 44:26 - CLOSE: Tips for Assistants
Extra content referenced within show:
Extra movie/video content:
Downloadable PDFs & Related Materials
It is generally recognized that root canals can be predictably prepared when shaping files have a reproducible and sufficiently-sized pathway to follow. The secret to shaping success is glide path management (GPM)...
Clifford J. Ruddle, DDS, examines why glide path management is the key to successfull endodontics...
Ruddle Glide Path Management Technique Card featuring ProGlider (rotation) & Gold Glider (reciprocation)
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: Dentistry Rankings
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing today?
Okay. Well, we’re gonna start off talking about dentistry rankings around the world. So, maybe you’ve wondered what countries rank the highest or lowest in dentistry, or maybe you think you already know. Well, in May of 2020, a European study was published that looked at 26 European countries in terms of tooth decay, sugar and alcohol consumption, smoking, the number of dentists per 100,000 population, and also the number of dental schools. And this information was obtained from the WHO, from Oxford University, and from the Statistical Office of the European Union. So, maybe you can explain the criteria they looked at, in a little more detail.
Well, what they did is, they wanted to make an index so they could immediately assess from an epidemiological standpoint, what was going on with these populations. So, they looked at decayed, missing, and filled teeth – DMF. And that – this was 12-year-olds, okay? So, not just for the 12th year, but they were looking at 12-year-olds across the first 12 years of their life. And what they found out was some pretty staggering things. They – we’ll talk about them more, but they can rate different countries by these DMF indices, and that told them a lot about what was going on there.
They also looked at number of dental schools, and dental schools will prognosticate how many dentists are graduated and where they go out to practice. So, that would be access to care. So, that was an important factor. And then, of course, to play off you, they did look at dietary things. And when I say “sugar,” I don’t just mean the candy bar, but there’s sugar in a lot of things we eat, even fruits and vegetables. So, they were looking at a lot of this stuff, and they looked at alcohol consumption and smoking, because we know, when we smoke, we get a drier mouth, we change our oral flora, and we get more predisposed to caries. So, those are some of the things they looked at.
And also, if there was fluoridation in their water --
Yes, they looked at that.
-- which they should do.
And that hasn’t always been the case, but it’s growing now in Europe like it has been here in the States.
Okay. So, when all of these factors were taken into consideration, the top spot went to Italy, which has about 77 dentists per 100,000 population. But that’s actually pretty much in line with the other top countries. Italy did have one of the lowest annual sugar, alcohol, and cigarette consumption. So, that might have something to do with it. And the other top spots went to Germany, the UK, and Denmark. And the UK was interesting, because it has a very high sugar consumption, but it has a high ranking in overall dental care, because it has a lot of dental schools, 16, I think, to be exact.
They had a low DMF.
And then, also, 22 percent of their adult population smokes, but compared to a country like France, where 32 percent of adults smoke, that’s actually lower in the UK. And then, also, I guess they’re starting to implement fluoridation measures in the UK. Now, maybe you can explain this to me. Germany and Denmark had the highest annual sugar consumption, but somehow, they still got into the top four. So, how could that be? [laughs]
Well, the DMF for those kids in those two countries, the Danes and the Germans, were like 0.5. That means out of every theoretical 1 child, you would see that was 12 years old, a half a tooth would’ve been decayed, filled, or missing. So, very, very low indices, and it might have to do with a lot of factors. You know, I – we were talking about this. We don’t know a lot about the fluoridation. We don’t know about the national healthcare service. Are they encouraging more dental schools? Are they funding those things, politically? And then, that would mean they’re producing more dentists.
When you go more access to care, maybe the kids, when they’re really little, three and four, they’re starting to get early instructions on how to brush and floss their teeth. So, those things, we don’t know. We don’t know about their diet in general. We don’t know about some of the genetic predisposition that could have a factor in DMF scores.
So, that was interesting. And then, I think you wrote here that Croatia has a very high sugar consumption, like the Germans and like the Danes, but they have a high indices. It’s 4 – 4.2. So, 0.5 versus 4.2. That’s a lot of early caries and things going on in children. And then, Greece has a lot of dentists. We found out they have 125 dentists per 100,000. That was by far the biggest number. And you and I don’t know if they have that many dental schools or if people around the world are getting their training and going to Greece, because that’s the place to be.
You know, right below the base of the Acropolis. So, I practiced in the Acropolis myself, personally, for several years.
No, that was a joke. So, there’s a lot of variables we don’t know.
And then, what – Netherlands was pretty interesting, though. They only --
Well, they only had 50, but now they only have 49, because Rik van Mill retired. So, they’re really falling!
The Dutch are falling. They’re gonna have to get more training and crank out more people.
Okay. Well, this is a European study, so we’ve been talking about European countries. But how does North America measure up?
Well, we’re declining a little bit. I think we can say, like in a lot of sports leagues around the world, we’re starting to see more quality and equity, and the gap has closed, and the differences are less distinct. So, we have probably the strangest and healthiest teeth in the world, but we have declined a little bit in our ranking. We’re still in the top 10. What else did we have? Canada was doing quite well. They have 1 – an indices of 1, 1 DFM per child that was 12 years old.
And Mexico was kind of interesting, because a lot of tourism goes there to get their dental work done. So, they have some really good education, some great programs. I have many friends in the United States that teach down there [laughs]. So, I can tell you it’s quite good. And people can get really a good, economical result. So, they go there to save money.
Okay. Yeah. Dental tourism, I didn’t really know that was a thing, [laughingly] until more recently.
Yeah. I have a flight booked tomorrow morning to Mexico City to get implants placed.
[laughs] Okay. Well, that’s some interesting information. Obviously, we didn’t cover all the countries in the world. That’s gonna have to be for another show.
But check out the globe. You’ll probably see where you live, anyway.
[laughs] Okay. Well, we have a great show for you today, so let’s get going on it.
SEGMENT 1: Specific Scenario – Working with Family
So, today, we’re gonna talk about working with family. It’s not uncommon for dental practices to also be family businesses. One spouse may be the clinician, while the other spouse might be the office manager, be in charge of the IT, do the bookkeeping, or maybe even assist chairside. Also, different generations might work in the same dental practice. So, working with family can be very rewarding, but it also has its own set of challenges.
So, I know Mom has worked with you in the office. She’s worked with you on the seminars. Your educational company, Advanced Endodontics, is a family business. “The Ruddle Show” is a family business. So, I think we’re in a unique position to talk about the pros and cons of working with family. And we’re gonna get to that in just a moment. But just as an overview, can you give us maybe what you think the secrets to success, to making a family business work – I mean, what would you recommend?
Real easy. Communication. When you don’t know to do, communicate. When you’re not sure, communicate. When there’s doubt, you communicate further. And there’s an old Yiddish expression, “Don’t step over the trash.” Just communicate. So, that would be one of them, and then setting boundaries. I mean, when Phyllis was in the office, she wasn’t really my chairside. That would’ve never worked. She would’ve fired me, and I would’ve fired her. But I also didn’t try to do the books. She didn’t want me really foolin’ around with numbers. So, have boundaries and set it up so both people can flourish. That’s the main thing, is create opportunities where people can grow and learn and feel like they’re contributing. And that’s the big secret.
Well, that is – what you’re talking about right now is actually one of the reasons why I have stayed employed with you for so long is because there is a clear division of duties. And I just wanna say that every person in our family is – has a pretty strong opinion and is pretty smart, and we all have strong personalities. So, it’s very helpful that we have specific duties that are ours, so we’re not overlapping all the time and getting in each other’s way. And also, I do feel like we really have the freedom to be creative, within boundaries, of course. But this encouragement to be creative is what makes it so rewarding and fun, working in the family business.
Yeah. So, you’re gonna probably take us into what, some pros and cons?
Yeah. Let’s bring up the list of the pros and cons. Now --
She did not say there were no cons.
-- [laughs] there’s only a couple cons. But – so, I’m gonna go over the list. I’ll – maybe I’ll read it, and then you can give some commentary, or I might even have some commentary.
So, the first one is, work with – you get to work with people you presumably like.
Well, you know, at this stage in my life, I’ve been married 54 years, and I got 2 daughters, and they won’t let me announce their age, but they’re young ladies, but they’re not, like, babies. So, you presumably know each other pretty well [laughs].
We’ve gone to a lot of movies. There’s been picnics, dinners, fights, screaming, yelling, mix it all into this big cacophony of life, and, you know, out shakes these people. So, I would think it’s excellent, because you know who you’re getting.
Yeah. And I guess if you don’t even get along with your family out of work, then maybe don’t bring them on board. But another one is, you are familiar with their strengths and weaknesses.
Yeah. If you’re hiring a pitcher, don’t try to make him a catcher.
You know, I think that for me, like I was actually – I didn’t lobby to get this job as cohost on “The Ruddle Show”. It was pretty much assigned to me, because my family already knew what my strengths and weaknesses were. I actually felt pretty much like, well, I can’t do that. But you know me my whole life, and you know the things that I’m interested in, and you basically assigned me the job. And it’s actually worked for me. So [laughs] --
Well, that’s because she was creating shows when she was five years old.
Okay. Another pro is there’s instant camaraderie. You have a similar culture.
Well, when you grow up together, you have the same values, same morality, same kinda roles and understandings, and it evolves as people get older and more mature. But it’s always evolving, and you try to grow people, and you want them to go beyond you. So, yeah. I think it’s a great opportunity to continue growing together.
Trust. I mean --
Yeah. I mean --
-- hopefully, you can --
-- if you’re in a family where you gotta hide your money because, you know, when you’re a little girl, and you have a little piggy bank, if you’re afraid I’m gonna get in there and steal your money, it’s not gonna work right off the bat. So, you presumably know you can trust people that have been in your family for a lot of years. That’s not always the case, but in general.
Also, the members of your family may care more about the business being successful. They may feel more invested in it.
Yeah. And I’ve always wanted family and non-family in my business, as I do better, I want them to do better. And if I do worse, they get to at least bank on they get what they were supposed to be getting. So, there should be upside.
And then, the last thing we put on the list is, positive public perception. Now, I actually wanna say something about this first, because I really notice it on my end. When I answer the phone, and I’m talking to a doctor, and – you know, I’m being treated nicely, but as soon as I mention that I’m your daughter, all of a sudden [laughs], I’m treated even way nicer. So, I think that people are just attracted to the idea of families working together. I never have told anybody that it’s a family business, and they go, oh, God, I’m so sorry. But they always are very excited about it. So, it’s a – definitely, the public has a high perception of working with family.
One thing I wanna add is, I live with Isaac, our cameraman and editor and graphic designer. He’s my son. And I do like that we can talk about ideas at home. Like, we don’t have to – I don’t have to wait to get to work to talk about my ideas. We just bounce ideas off each other at home, and it is convenient and fun for us. But maybe – like, that might not work for some people. Maybe some people don’t wanna talk about work when they’re at home. So, how does that work for you and Mom? Do you guys just talk about whatever pops into your head, as far as business goes, at home? Or do you try to keep home and business separate ever?
Well, I’ll play off of you. It’s interesting, over many, many years, you’ll go out to dinner with a dentist and his wife, or the wife is the dentist, and the husband is a dentist, or whatever combination, and there’s usually massive apologies – really a big apology. And then, it’s like, can I ask you a dental question? And Phyllis and I never saw it that way. There’s no apologies. It’s what we do. I mean, we eat, breathe, and sleep this stuff. So, to me, yeah. I need to disengage, and I think after 54 years of marriage, I know when it’s time to have – Phyllis needs her time, Phyllis [with emphasis] time, P-T time!
So, you know that, and you sense that. So, it’s not always talking shop at home. But on the other hand, so many things that we do – you just mentioned the practice. We have a seminar business. We have Ruddle With the Residents. That’s a completely different thing, because Phyllis is dealing with chair people at different schools. We have the – she used to tell me, 20 or 25 percent of her time was setting up tours. So, hotels, flights, transfers to the venues and back, and by the time you start off with an invitation to come speak, you end up with a binder that you take on the plane with you [laughs].
So, we like to talk about that stuff, and what are we gonna do when we get to Bucharest? And what’s going on in Romania these days? And so, it’s fun, and I’ll start Googling where we’re gonna go, so I can maybe say a word or two in their language, to open my lecture. And so, there’s a lot of talking at home about stuff. But we also know when to leave each other alone.
Okay. So, you do – you’ve pretty much perfected a balance, I think, by [laughs] this point in time. [laughs]
We stumbled right into it.
All right. Well, let’s look at some of the cons. So, it’s harder to discipline or fire a family member.
Yeah. I mean, obviously, up front, there should’ve been communication and boundaries, which I just emphasized. But if you don’t have those communication lines, or they were not thorough or clear, and the boundaries weren’t clear, you can have a lot of friction. So, yeah. It’s hard to fire [laughingly] somebody. It’s hard to even discipline a family member. So, these have to be talked about up front, what your expectations are, because when you discipline your kids on the job, they see it as discipline. If you did it to anybody else in the world, they would be thinking, oh, he’s giving me constructive criticism. So, I have to be careful how I say it, and then it needs to be received well, but I think you can work this out.
Okay. And then, the potential for there to be a lack of professionalism.
Yeah. That’s just taking advantage. In other words -- I’ll exaggerate to make a point. But if you have a special dress code, which, for me, was very loose and liberal, okay? It was good hygiene, good presentation, good appearance. You know, I wanted them to look like that. But if they come in with sandals and thongs, or whatever they call them, flip-flops, you know, that’s not appropriate. So, you need to have these discussions up front, and they shouldn’t even become problems down the road. Or if they are, just hand them – what – just hand them the book they signed, because there’s a little thing Phyllis made. It’s like a small, little booklet, and it’s expectations. And when they’re done, they just sign their name, and it means they’re willing to work with those expectations.
Yeah. I know that me and Lori, we’re best friends, but we also are very different people. And I know that when we first started working together, occasionally, it – it would dissolve into a screaming thing from [laughingly] the back – the office to the front of the office. And I think that one of the things about working with your family is, you might try to control yourself a little more, like if it was not your family member. But then, you immediately go right back into that sibling thing, and then, it just escalates. So – but we’ve actually gotten a lot better, though, at --
You guys have gotten better.
-- at not – at that not happening.
God, it was pure Hell the first year!
And then, I know that --
25 years ago.
-- for me, it – sometimes – because I am the older sister, by about a year and a half. So, when my – when Lori would come to tell me to do something, I’d be kinda – like I feel almost slightly bristled, like my younger sister is telling me to do something. But then, I can immediately get back on track and, you know, this is not – this is not her just trying to up me [laughs] – one-up me.
It’s team sports, everybody. You don’t have to be best friends with your teammates, but you’re trying to win. And when you’re trying to win, you do all the little things you need to do, to be a winner.
Yeah. So, I mean, I guess that – again, if you just have good communication and try to be professional and try to think of it like – try to take a step back, sometime, and – sometimes, and look at yourself and why you might be feeling a certain way, and ask yourself, is it really reasonable. I mean, just self-checks. But you would do that in any job, anyway.
Well, I won’t do it now, but there’s an adage I like to talk about, the five ways to get a result. But the fifth one was – is time and place. So, if you have something that needs to be worked out in the workplace, and it’s live fire, because there’s patients in the office, there’s time and place. So, you might have to just bite your lip a little bit and get through that day and live to fight another day and then, get it all worked out.
Well, I do wanna say that there – we don’t have this on the list of pros, but I mean, it is – this is kind of obvious. It’s, if you like your family a lot, and you get to work with them, then you get to see them every day. So, some families only see each other on, like, holidays or special occasions, but we get to see our family all the time. And then, also, when the kids were off school and stuff, sometimes they would come into the office and help out or just visit. So, that was that kind of informal atmosphere. But then, the kids got to come in and see what you’re doing, and that was always fun, too. I liked that part of it.
It is fun having them hang around. The only problem is none of them stayed --
-- except for my two daughters, and they had to go out in the wilderness, like the – you know, the – what is it called, the Prodigal Son?
And they had to go out and do their worldly things before they came back and found the truth.
Yeah. We did. We both moved away, and then, we moved right back here [laughs]. All right. Well, do you have any closing remarks?
Learn to be a good communicator. I just keep saying that, and we all say that’s so easy, I’ll just do that. But then, you don’t. Think of all the things – right now, think of all the things that really bother you, and you’ll never bring them up. So, it’s nice to compartmentalize and not bring them up, but there should be enough tolerance and forgiveness that you can bring things up and talk about them. It doesn’t mean you’re trying to convince somebody to be somebody that they aren’t, but it’s – it’s the gratitude that they’re there, and the gratefulness is displayed by kindness. So, just try to see people a little bit different than how you see them. Think about standing in their shoes and how it might look to them.
Yeah. One other – I do wanna just add quickly about family businesses, is apparently studies have shown that family businesses tend to last longer and be more successful than a similar type of business that’s not family run. So, that’s due to many factors, but trust, a more unified vision. But also, if you ask the people that work in the family business, it tends to not be so much about the money as sometimes in other businesses. Like they’re not just working there for the money. They’re working there because --
Yeah. I don’t think my family’s working for me for the money. You wanna compensate your staff, like, phenomenally well. But more than that, at some point, that’s all you can afford to pay. But then, they can be part of the growth of the business. So, there’s still ways that they can win. And of course, you can throw in some little things to keep the family’s morale high. Take them to Hawaii every now and then. Don’t drown them when you get – when no one’s looking. You know, stuff like that.
Okay. Well, thanks. That’s some great information, and now I think you’re gonna give us a lecture on how to manage an irregular glide path?
Yeah. That’s like when a family member goes bad, and you have an irregular glide path. Yeah.
Okay. So, let’s go on to that.
SEGMENT 2: Managing an Irregular Glide Path
I’m happy to be with you today, because I’m gonna talk about something we’ve already talked about several times, and then venture into new, uncharted waters. Not uncharted waters, clinically, but when we speak about the glide path, we always aspire to get it. We always hope we get it. We always hope it’ll show up at some point. It doesn’t always show up, does it? So, today, we’ll review very quickly what glide path is, for those of you who are just joining. But many seasons ago and across the shows, it’s come up several times in different ways, Q&A’s and segments itself.
So, glide path management. And I hope the whole time I’ve been talking, you’ve been focusing on that really innocuous mandibular bicuspid. It holds a lot of complicated anatomy, typically, and oftentimes it can be one of the most anatomically challenging teeth we treat. So, when we talk about glide path management, we’re really talking about, can we shape canals mechanically. Because if you didn’t really worry about glide path, if there was a thing called no instrumentation, no filing, then, no glide path’s necessary.
But from what I can see, the trifecta’s still alive. We’re still shaping canals. We just don’t agree on the extent of that shape. We’re still cleaning root canal systems. And we’re filling. So, those are the three things we’re doing, and the hardest thing I think we do is probably getting into the tooth safely. That’s access. And then, of course, the great clinicians can achieve a smooth, reproducible slide path each time, every time, more or less all the time. And we’ll talk about the cases when they can’t.
So, look at how I’m holding the file. Take progressively longer and longer strokes. And if that file can slip, slide, and glide over the apical one third, you have a smooth, reproducible glide path, and mechanical instruments will follow. So, if you start to look at all the work -- and you’ve seen a lot of these cases before – but it’s just to say it again, what these cases all hold in common is, they were all negotiated. They were all catheterized. The canals all got a working length. We verified that there was patency. And then, we checked to say that there was a glide path. We verified the glide path. And then, there was some effort at shaping and three-dimensional cleaning and filling root canal systems.
So, I – in a recent show, I talked about Ultimate. It was a special segment, and I launched -- basically, through the product that launched on September 1, we talked about Ultimate. Ultimate has a different, dedicated glide path file specifically for the system. It’s not Go Glider. It’s not ProGlider. It has a different cross section. It has a different design. It has different metallurgy. And even that won’t, in every instance, get to length. I had some of you email me, and you triumphantly told me, it’s working! It’s working very, very well, but not every time!
Let’s not forget. We identified some numbers. We said that about 63 percent of the time, the key opinion leaders internationally – did a lot of teeth on the bench, extracted teeth, filled out reports, sent them back in – and they said, without any hand files, they could achieve length 63 percent of the time. That means there’s a reciprocal 37 percent where you’re going to have to have another idea. So, that’s what I wanted to show. So, it is – the three rings means it’s different than the ProGlider. That’s your visual identification. But understand, even with this new design, it’s not going to go each time, every time, all the time.
There will be certain kinds of cases where you’re still gonna need to break out your trusty hand files. And that would be more like the .06, the .08, and the size .10. So, when your glider doesn’t go, and we talked about how to hold it. We’re not up here pushing and pecking, just let it run, let it advance, let it go smoothly. As long as it’s moving, fine. But in this case, when it hit the bifidity, then that lets you know that if you’re gonna introduce more shaping files, they’re gonna do the same thing. And as you get bigger in your D0 diameters, you’re gonna start to make the old classic shelf, and then you’re gonna have a ledge and probably drive debris into vacated space and have a ledge and a block.
So, that’s what we have to think about. So, we immediately break out the .10 file. And when you get the .10 file in there, I like a viscous chelator. Remember, a viscous chelator gives you lubrication, it emulsifies vital collagenous tissue, and it keeps debris more effectively in suspension, so it doesn’t settle back down into the narrowing cross-sectional geometries, and we invite a block or promote a ledge, something like that. So, you can get the .10 going, and the .10 file, you’ll move it down through a bath of a viscous chelator. That will give you emulsification. It’ll give you flotation and lubrication, and it’ll stay with the flutes better than an aqueous solution. There’s almost nothing aqueous down here.
You can put a little pre-curve on it, and as you get down to the impediment, you can begin to understand it’s not slipping easily. It’s not going. So, here’s what I wanna say. You know that – we’re just making this up – the diagnostic working length, let’s just say that it’s about 20 millimeters. So, when you see your rubber stop is parked way up in here, and you know you’re short by this much, you know that you’re short by this much, and you know that the impediment might be at 17 millimeters.
So, you know that you can look at your unidirectional stop, you pre-curve the file so it’s oriented with the little unidirectional line, so when you get down to about 16 or 17, you can try to walk that tip into different possibilities. There might be a bifidity. There could be an – a sharp turn in the canal. All those things could help promote the block and could promote the ledge. So, just lightly with the .10, and feel it. If the .10 won’t go, the biggest trick I’ve discovered over all the decades of practice, and I’ve taught to thousands of dentists, is pre-enlarge. Immediately pre-enlarge.
So, you can take the SX from the Ultimate family, and you can know that it’s 19 millimeters long, and you can get into the canal easily, because you’ve already had the slider down to the bifidity, and it wouldn’t go, and you can start to brush. And you just do a little, light, lateral brushing. Improve your shape. By pre-enlarging, you remove canyons of restrictive dentin. Now, this will allow you to pre-curve your file, and you can pass a pre-curved file through a pre-enlarged canal. That’s the trick. So that when the file arrives deep and gets down in towards this area, you’ll have some curvature to help you path find towards the terminus. We could even say termini. But now, you’d have to be pretty clever.
So, here you come back in. Again, viscous chelators, RC Prep, ProLube or Glyde, again, lubrication, emulsification, flotation. The debris is more effectively held up. You know from looking at your stop, you should be going a little bit deeper, if you’re gonna get to working length, so you know you’re short. And you know where you’re short. You know by how much you’re short. And now, you can begin to put different angulations on the tip of that file and try to direct it east, west, north, south. Okay? Try to get to length. When you get to length, of course, this is when you use your apex locator, take a working film, and confirm the patency. So, working length and patency are part of this.
So, you have a pilot hole, right? You know the length, you’re patent, you know you’ve got that part done. The question left is, I have working length, I have patency, do I have a slide path? Check it out! How we do that is, pull the file up about – but first wiggle it a little bit, make sure it’s nice and loose. Then, pull it up about one stop, and slide back down. Now, pull the file up about two stops, and see if you can slip and slide back to the radiographic terminus, the working length. Now, pull it back like three stops. If you can slip, slide, and glide over that apical part, you have a glide path. If you keep hanging up a little bit, but you can jockey the handle, redirect the file, and extend it to length, you have a pilot hole, but you do not have a glide path!
Oh, I love the music of that. We play that clinically, too, so, you know, the patient knows that something didn’t go well, and we’re working on it. Remember, the difficult we do immediately, and the impossible takes just a little bit longer. So, now that you know you don’t have it, we gotta go to work. Now, you could grab your .15. That’s the next bigger file. What you’re trying to do is, by differentiation, you already can see that this branch right here is a little bit bigger than this branch right here. So, by making this a little bit bigger and progressively bigger and incrementally more big, what you’re doing is giving yourself the opportunity to slip and slide into that branch each time, every time. And the predisposition for the file is always along the path of least resistance, and that will go into the bigger hole.
So, if you have that going on, you’d normally go the .15, but in my world now, with Ultimate, we have Slider. Slider’s purple handle, the .10 – ISO file’s .10. But the thing is, the Slider has a bigger taper. So, if you can get the tip, which is about the same as a .15 -- it’s about the same as a .15, on the Slider – if you can get it a little bit pre-curved, it’s manual – remember, it’s manual, because we don’t have a slide path yet. So, no mechanical. And you can return that instrument kinda like the motor would drive the mechanical version.
So, a motor drives the file clockwise in its cutting action. So, the clinician is kinda just spinning the handle clockwise, and that’ll draw it down in. If it gets a little too tight, a little quarter turn to unwind, and then do some little refinements, some little, short-amplitude strokes. Each stroke serves to smooth, blend, and expand the slide path. So, now, we’re almost twice as big in this branch as we are in that branch, and of course, you can’t see any of this, but you can be – you’re figuring it out mentally. You’re mentally conceptualizing what your instrument’s doing, because you can see it in your mind.
So, as you work that file, you’ll find that at some point, you can come up above the impediment. You can slide right past it. And now, it becomes a world where we can do it mechanically. So, 63 percent of the time, you’re going to be able to take a dedicated mechanical, like an Ultimate Slider, to length, with no hand files. But there will be a 37 percent reciprocal number, and I mentioned for Professor Machtou and myself, we got that mechanical number up to almost 80 percent by just having a way to hold the handpiece, that idea, and then we talked about the cross section being superior to a ProGlider or a Go Glider or any other dedicated glide path file.
So, now, you can see you have something you can work with. So, now that you have the concept, and you’ve visualized it, because you’ve all encountered this, many, many times. This is not something I’m telling you that’s new. But we’ve never really looked at why. So, when we have an irregular glide path, there’s actually several kinds of categories. There are anatomical reasons we don’t have it. There are retreatment reasons we don’t have it. And then, of course, we have pathological reasons, like resorptive areas, where there’s a big defect.
You know, you have some of these big defects, and sometimes, you’ll have a canal go up, and it’ll be really moth-eaten. And then, there’ll be this little branch. Well, your file can easily travel through the coronal two thirds, up into this area, but the trick is to pick up the segment that’s more apical to the resorptive defect and to negotiate that. So, you can have an irregular glide path and resorptive defects. How about broken instruments, blocked canals, ledges, Lentulos, and all the stuff that blocks canals, amalgam dust that falls down. Sometimes we drive a stone deep, and now we can’t get around it.
So, those are more like iatrogenic problems, but I’m today gonna just focus on anatomical. And it could be primarily the division. We just looked at it. It could’ve been a trifidity. I showed you a bifidity. It could also be a sudden change in direction, where the canal makes a sharp decreasing-radius turn. And those oftentimes present clinically as no way to actually make a smooth, reproducible glide path, at least on the early instruments. As you enlarge a little bit, just like we saw in the animation, you’ll begin to then think about rotary, if you can go from no glide path to a secured canal.
All right. Let’s look at a few. When you see threatening teeth on your pre-op, take pause. Thoughtfully look at everything. Begin to analyze the length of this tooth. This is a long one. This is like 23-, 24-millimeter tooth, from the top of the cusp tip to the terminus of the canals, far below. You can see systems traveling through that mesial canal, all the way to the end. I think you can see that. So, you’re not thinking, this is more than a little bit of desire and effort. But if you look over here on the distal, you see a canal that goes down, and it just kinda stops.
And when you see canals that kinda play out and stop somewhere short, those canals are either dividing, making sudden changes in direction, and you should expect – you should anticipate – your mechanical file probably will just float down to about here. And then, pull it out, and you’ve already opened this up, augured a lot of debris out, and you’re gonna have a more successful opportunity to catheterize the terminus. So, that’s what we did. And you can begin to see why it was a very, very complicated apical one third. That distal system has multiple apical portals of shape excellence. And you can see there was even some blow-out resorption! How about that? And then, off the resorptive defect down in here -- off that resorptive defect, you can see multiple branches, each going in their own, separate way. They’re all important.
So, there was an example. When you look at this maxillary bicuspid, you’re probably thinking, wow! It’s not so hard. I see it’s heavily restored. I see a discernible canal. But again, the canal kinda stops about right there. And then, you kinda have this big bulbous root, don’t you? It’s kind of out of proportion to the other teeth. So, you should expect divisions. And when we treat the tooth, of course, there’s divisions. So, these are examples where you won’t initially have a glide path. You might work these trifid areas until finally, you may get a file to slide every time you want, but there’ll probably be one of them or two of them that you won’t be able to easily get into.
So, you could work the file manually, get it apical to the defect. You could hook up your handpiece. Or if you got a manual handle on it, just walk that file. You can use, in this case Ultimate, just like a mechanical file, turning it with a manual motion, clockwise, and in a very safe way, you can do that, and you can do it very quickly. You can walk a catheterized canal from here to here, and that’s probably like 15, 20, 30 seconds.
Well, look at the anomaly! Who, in their mouth, has this bicuspid? And you notice they have two bicuspids, and you notice the one is an outlier. It’s, like, huge! I mean, look at the dimensions on this thing, compared to this. Look at its length, compared to this guy. And you realize, wow! There’s a lot going on! And it’s got a big system. I’ll fall right in. Access should be pretty straightforward. And I think I can get a mechanical file that’ll just float through that large system. But you gotta be careful, because most of our complexities are in the apical one third. That happens to be anatomically the last three, four, or five millimeters of most systems.
So, that’s where – you know, I had a friend once say to me, “I don’t look for trouble, but trouble often looks for me.” So, when you’re a chairside clinician, trouble might be lurking. Well, we got in here, and after about an hour and a half, I could fit two cones. The case was actually pretty easy, except there was that deep division. And that septum is quite formidable. So, you can get your rotary file to easily take this path. Ironically, you might ask yourself, why? Well, that’s just the way it fell. The rotary files could always come in here. This had to be done with manuals.
And so, as we did it with manuals, we were able to get it to where we could fit two cones. We still kept plenty of dentin, circumferential, peri-cervical dentin. I didn’t say open it so wide – you might have to have one cone that’s the normal cone you would fit that’s based for the system of the file. Last file to length, choose that master cone. But you might need to make a different cone, completely, to fit on the other branch, because it’s gotta be skinny through the body, so they don’t bind, so you can direct that during the path. So, here’s where I fit my cone, almost no puff. And where I didn’t, of course, there’s not quite the control, and hydraulically, it becomes filled, and everything after is surplus after filling. How about that?
So, there’s a deep bifidity. And here we are, many, many years later. You can see it’s been restored. You can see the bone is grown in. Did you – if we go back, you can just see, you know, this thing was like a massive lesion. See how it crawled up the root? Some people might even inadvertently think that was a fracture, a vertical fracture.
All right. And I think we’re off to the last case. And again, it’s a key tooth. It’s strategic. It’s the anterior abutment of three in a bridge. And again, you see that LEO, that lesion of endodontic origin, and it’s apical, and it is what? Does anybody see it?! Is it apically and laterally?! When you start to look at your films more, you’re gonna start seeing more, especially if you use aiming devices and have really good protocols. So, we took the anterior abutment off. Here’s the files actually in both branches. Obviously, if you put a file in one branch, it blocks that pathway, and it’s easier then to insert the second file. And since the other branch is blocked, it tends to take the path of least resistance.
So, sometimes you have to hang out with one file that’s kind of in your way clinically. Sometimes I’ll have the assistant put a little floss through the handle and pull the handle away, so I have room to operate, and I can get to that pretty quickly. And then, I can get to that! Now, notice this lateral branch is about as big as the ones I put files into. So, you can see, we got both branches, and we got a third portal of exit. And then, of course, getting it restored, having the patient come back, and reviewing your work. So, irregular glide path is when you don’t have a smooth, reproducible slide path over the length of the canal, to the terminus.
If you could get your head in the patient’s mouth, you’d take your nose, and if you just push the handle passively, push that file right to length. That’s a smooth glide path. I really want you to lock into what you can have. And when you have that, then rotary instruments can follow. Or don’t forget, you can have the manual versions to help you through the case. Okay!
So, I think in closing, there’s a Ruddle’s Rule! And it was based off the famous -- now late -- late Yogi Berra, a famous catcher, Hall of Famer, played for the New York Yankees. And one of his favorite expressions was, “When you get to the ‘Y’ in the road, take it.” Ruddle’s Rule says, “When you get to the ‘Y’ in the canal, take it.” Good luck on navigating the systems!
CLOSE: Tips for Assistants
Okay. So, tips for assistants.
So, I just found a regular old Mason jar and then just wrote “Tips” on a piece of paper and taped it to the jar, and then, if you just place it in a conspicuous place in your office --
Like at the front desk [laughs].
-- yes, and you might even put a little note on it that said, “If you liked what happened here today, show your appreciation”, or --
We have one in every bathroom, too.
[laughs] Okay. Well, just kidding. This isn’t the kind of tips we’re talking about. We’re gonna close [laughingly] the show today with some Ruddle Tips for Assistants that might turn a pretty good assistant into an excellent assistant. So, obviously, different offices do things differently, and doctors have different preferences. So, these are Ruddle tips, to be clear. And maybe if you think back to some of your best assistants, what about them made them so great?
Well, you know, this is a little bit touchy for a guy to be saying this, but when I meet people, I look a lot regarding their appearance. So, that doesn’t mean they’re gonna be good or bad, but I want them to be neat, clean, good hygiene, and have a great presentation, because they’re gonna be meeting your patients. How about that? So, that was important. But then, that’s just outwardly. So, there’s a person inside that you gotta dig in there and find out who’s in there, and can they bring that to the game.
And I really think it’s important that they have social skills. It was really important for me to have assistants that could talk to people, authentically. Like be authentic and not just this little chirping chatter. But you know, when people come in, and they’re upset, and they’re angry, and they were up all night, and they’ve had a toothache, they need compassion, and they need somebody to understand that we are gonna take care of you. We’re gonna – we can stand in your shoes.
So, I think you really want people that can communicate, they can relate to other people, and they can maintain a conversation. I really looked for that, because if you can’t really talk to somebody – it doesn’t mean you’re not a good person, it just means, maybe we’ll put you out in the garage, and you can clean files or something. But if you’re gonna be with people, you gotta be able to react with people and be the best you can be. I think it's --
Well, let me say one thing about that.
Because if I was a doctor, I – like, often, the assistant goes in, seats the patient and talks – does some chitchat before the doctor comes in. If I was a doctor, I would challenge my assistant to at least identify one thing that you’re talking about with the patient, before I come in the – into the operatory, and when I come in, say, “Oh, so, Janet’s daughter’s getting married in Cabo next weekend. And you were just in Cabo, right?” I mean, something to make some kinda connection from what they were just saying, or their kid plays tennis. Maybe your grandkids play tennis, you know? Like something – make some connection.
Yeah. On that special segment we did, I think it was “Ruddle’s Tips for Success”, where Phyllis interviewed me, I said in there to ask an unscripted question. That’s exactly what she just said. You’ve got to ask questions. If you must speak, ask a question. Questions are the answers. Questions, you got kids, I got kids. You play soccer, I play soccer. You love to downhill ski, good. You like to travel, I like to travel. You like good wine – the more of these bonds you can make, as it is in life, as it is in business, it’s about relationships.
So, I want my assistants to immediately get into relationships. And if they’re – through all walks of society. There’s all kinds of people that we see, but there’s always an unscripted question that can bring that person to life. And then, they can also introduce them to me and say, “Did you know he likes to’ blah, blah, blah?” Or she does. And now, I’m off on it, and all of a sudden, they’re feeling like they’re at home. So, I like that. They need to have energy. You know, you can’t have assistants--
-- that just drain the room. They drain the operatory. They’ve got to be plucky. They’ve got to be high energy, happy, and they’ve gotta be compassionate, and all these things start to build the kind of person you want. What else do I have on my list? They need to have peripheral vision. So, you’re an assistant. We talked about boundaries, but that doesn’t mean if you see a whole roll of toilet paper on the floor, you just --
-- walk by it all day long, because it’s not your job! It’s somebody else’s job! So, we need to have peripheral vision. We need to see what needs to be done. And great players cross train, and they help each other out, and we want the office to always be good. So, what else did I have here? They gotta be willing to adjust. Life is full of changes. Your schedule is only as good as when you walk in, in the morning, and you know the phone’s gonna ring, and within moments, the whole day can seem like it’s in turmoil. People have to adjust and adapt.
So, you don’t wanna hear all day long, “I didn’t sign up for this!” [laughs]
No whining! Whining is dispiriting.
Okay. What about any behaviors to avoid?
Well, I think we won’t go into the big hitters, you know, like – big character traits, like honesty, integrity, and accountability. But just in general, being on time, and leave your problems at home, and show up and be ready to work.
Okay. I also know that you don’t really like whispering. [laughs]
Oh [laughs], whispering! [Whispering gibberish] Don’t you like how [lapses into whispering again]. You know, that – whispering, go public. In fact, I’ll even – when I hear whispering, I’ll even yell from the back. I’ll go, “Come on! We wanna hear the joke, too, you know! Don’t leave us out!” So, whispering, you don’t know what the whispering is. Are they talking about the patient? Are they talking about you? Are they talking about a fun time they had? So, yeah. No whispering. Just – if it’s so good to be talked about, let’s talk about it publicly.
When I hear whispering, I know they’re talking about me [laughs].
That’s what I assumed. [laughs]
And then, I guess – I had heard you mention, try not to just drop things. Obviously, it happens, but try to hang on tight to the dental tools [laughs].
Yeah. Well, we teach early on, because things will – you know, there’s a lot of four-handed stuff we do in endo. That might surprise general dentists, but if you’re really – general dentists out there, if you’re really doing a lot of endo, you’ll learn, that assistant can make you way more than you currently are. They can make you more money. They can make you have more free time. They can make you have a more joyful day. They can help you do better work. So, you want all that, so --
Okay. Well, thank you for those tips. And we will do this again on The Ruddle Show. We already have an idea how to change it up a little bit. [Rattling coins in a jar] So, we’re excited.
Yeah. We have these around the office and --
-- throw coins in if they think the assistants did a good job. Looks like there’s a lot of pennies in there.
[Music coming up] Okay. Well, thank you, 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.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.