Featured graphic from The Ruddle Show: Knowing the Difference - Calcium Hydroxide vs MTA
Nonsurgical Retreatment Carrier-Based Obturation Removal & MTA vs. Calcium Hydroxide
This episode opens with Ruddle and Lisette giving a few acknowledgments of excellence for great work in 2021. Next, Ruddle is back at the Board for Nonsurgical Retreatment, this segment focusing on the removal of carrier-based obturators. Then, the season comes full circle with a reprisal of “Knowing the Difference,” closing out with a discussion of MTA vs. Calcium Hydroxide. And finally, the season – and the year – finishes with some exclusive footage, a few deep thoughts, and a special holiday greeting in “Being Cliff.”
Show Content & Timecodes00:09 - INTRO: Ruddle Awards in Excellence 2021 12:14 - SEGMENT 1: Carrier-Based Obturation Removal 41:26 - SEGMENT 2: Knowing the Difference - MTA vs Calcium Hydroxide 49:24 - CLOSE: Being Cliff
Extra content referenced within show:
Downloadable PDFs & Related Materials
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This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: Ruddle Awards in Excellence 2021
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing today?
Very good, and I’m very excited about doing the last show of this year, this season.
Yes. Like you just said, it’s the last show of Season 6 and the last show of 2021. So, we thought it would be fun to close out the year with some awards for excellence for a few clinicians who we believe have gone above and beyond the call of duty. So, we have six awards in six different categories. So, I will say the award, and then you can reveal the winner, I’ll applaud, and then you can say a few words about them, okay?
Is it going to all be the same person?
No, six different people are going to win.
Okay, so the first award is the Ruddle Award for Outstanding Cases.
Well, that would be my friend. I call him my friend, but I’ve never met him, Abbas Mahmoudian.
All right. Well, the reason I chose him is this guy is at the Tabriz University of Medical Sciences, and I was laying in the bed on Sunday morning, as is our custom, and Phyllis said to me one Sunday morning, “Have you ever seen this Dr. Mahmoudian’s cases?” And I said, “No, I don’t know the name.” And anyway, she started showing me. And there might have been literally 30, 40, 50 cases, all kinds of complexities, difficulties, curvatures, retreatments, wow!
I said, “That for a young guy,” because he’s only been out I believe about six years, and that’s a lot of progress in six years. And so, anyway, he’s at the University of Tabriz, University. He’s on the faculty, and if anybody Googles, they’ll see a lot of the faculty guys are more my age, and then you see this really outlier, a young guy, that’s him.
All right. Well congratulations, Dr. Mahmoudian.
Keep it up.
To impress him, that says something. Okay, the next award goes to a clinician for the most intriguing or promising invention that has the potential to change the future of endodontics.
And you know who you are. You can’t hide. Dr. Randy Cross.
Randy’s been on the show, as Lisette said, but the thing I want to say about Randy is he came up to Santa Barbara a few times as a graduate resident student at USC, and I liked how he was thinking as a student. He was thinking about making endodontics better. He wasn’t just accepting, oh I do this, I irrigate, I disinfect. No, he went out to industry, he got the equipment, a little box that he’s modified called the Endocator. It’s chairside. It’s about as big as my fist, and you do some early shaping, mid-root shaping, you do post shaping tests.
You can do tests at any time along the preparation and you can take a sample, put it into a test tube. He inserts the plunger. He mixes in the biomarker, and he gets a digital readout in about 30 seconds chairside to tell you what your residual bacterial load is. This is – I have said it over and over. You don’t even want to hear it. I said this is probably the most thrilling and outstanding innovation I’ve noticed in my professional lifetime.
All right, well, be sure to check out the show where we had Dr. Cross on as a guest.
That was last season, I believe. Okay, the next award, well some clinicians are very eager to keep learning and always improving, and for these humble clinicians, endodontics is a lifetime journey, so the award for the Continuous Student for Life goes to V.K. Karthikeyan. V.K., I’m looking you right in the eye. You make me really proud. Sometimes you get a little bit under my coat, because – okay, I’ll tell the audience. He has a prolific thirst for knowledge, and he is perennially curious. So, he’s running a really nice practice in Chennai, and he’s got his wife in there. I wish I could think of her name, Pavithra, or something like that.
Anyway, they work together as a team. He asks a lot of questions, and he’s always trying to get better. And I really want to acknowledge you. And he caught me in I think – I make lots of mistakes, V.K., but a technical error is not normal out of my mouth, and he caught me on a little mistake, cause I had the wrong cross-section on a previous show for ProGlider, and he corrected me, so we’ll be doing some corrections ourselves, cause I know better. I’m a co-inventor. Thank you, V.K.
Yes, congratulations. All right, the next award is kind of a Lifetime Achievement Award, and it goes to someone who just retired this year and has spent decades doing everything he can to grow endodontics and he’s just done so much. And so, the award for Decades of Service goes to –
Mr. Daniel Nobs. We call him SOS, but that will be between him and me what SOS means. But anyway, Daniel, I’m looking at you. Thank you for all you’ve done around the world. I don’t know any endodontist on the planet, anybody from academics, I don’t know anybody who’s done as much as you. Let me explain for our audience.
Close to 30 years, he’s been the Head of Education at Dentsply, now Dentsply Sirona. He has probably 100 people. We’ll use that number as a talking point, a lot of key opinion leaders, and they go – he has them like on a chess board of life and he’s moving them around to the four corners, to the continents of this world. He has sent these people out for 30 years. He’s done thousands of thousands of courses. Of course, he sponsored many of the international meetings, the country meetings. He built up –
Doesn’t he speak six languages?
Yeah, he’s not so smart, but he speaks six languages. He’s brilliant! Anyway, last comment about Daniel, cause I could – we’ve traveled together for so many – tens and tens and hundreds of thousands of miles, that the stories could make a big book. But he built a state-of-the-art teaching center at the factory in Maillefer, in Ballaigues, Switzerland. And when I say he had groups come in, he didn’t have groups from like when we had groups come in and they just came randomly from anywhere in the world. He brought groups from a country.
So, he brought somebody from Japan. It was the most important faculty members of the various schools. It was the movers and shakers. It was the biggest influencers, and he would bring a group of like say 15 or 20 to Belay and it was – I have been told by some of these people it changed their life. When they went to the factory and saw how the instruments are made, then they got a top-level course with a workshop. They went home and spread the knowledge. So, Daniel Nobs, nobody has done it at the level and the intensity you have for that long. So, congratulations, big guy, and I know you got some stuff up your sleeve because although you’re retired now, you aren’t retiring, you’re on to your next journey.
All right. Thank you, Mr. Nobs. Okay, the next award is the Young Dentist Leadership Award, and that goes to –
Well that would be a really nice guy, Moein Seyed Sadrkhani. Now you know Moein cause you met him. He’s a student at UCLA as a resident, and Phyllis ran Ruddle with the Residents. So, he came up a few times in that context, and you would matriculate into the class, and we got to know him. But what he has done, even when he was a resident, he was doing things a lot of endodontists who have been out for years aren’t doing.
As an example, he started – he’s the Chair of the Resident and New Practitioner Committee for the AAE. So, he sets up and plans meetings with his committee to get best speakers to come in to Chicago, and once a year, the AAE sponsors all these residents from all over the United States, they fly in there, and they get these top-level programs that he sets up.
Further, at Texas A&M, he runs the AEGD, that’s Advanced Education for General Dentistry. He runs that program. So, he’s giving back, and he’s in a really – it’s a really unique practice. I have several friends that are in that practice, but it's called Ayik + Berto, not and, it’s plus. So, those two guys are the founders, and he’s in that group and he’s getting it done in Texas.
Well congratulations, Dr. Sadrkhani. Okay, the last award is an all-around award, and it goes to a female endodontist, who just happened to be on our show last week, Dr. Sonia Chopra. Yay!
Okay, Sonia. That was really fun last week, and it’s so much fun, that I’m going to come back and tip my hat one more time. You know, how you communicate is how it is, and sometimes, you know, you’d come up to somebody in the street and in the course of the conversation, you’d say what do you do for a living. I’m a dentist. Well you’ve already put yourself in a four-wall box, and maybe that’s for life. So, I was told years ago that we should think of ourselves as entrepreneurs and one of our enterprises is dentistry.
This defines her perfectly, because she’s not just a dentist. She’s not just a specialist. You heard her story. But then she went on and wanted to get better at her speaking, and it's a very, very steep mountain to climb, but she got on and delivered a TED Talk, and that’s a big deal. You can watch those around the world. They have some of the brightest minds in entertainment and technology and innovation talking about what they love. So, she did TED Talks.
She’s young, out of school. She’s already teaching. But she’s not just teaching. She’s doing E-School, and E-School is a variety of programs based on if you want to phone and talk to her, the human voice in the ear. You can Zoom with her. You can go and take classes, so it’s a whole program of increasing opportunities right down to chairside practice. So, Sonia, you’re going to go as far as you decide.
Okay, well we’re going to make some special certificates and then we’ll mail them out. And we’re going to do this because I’m sure all of our award winners will want to frame their certificates and put them in a prominent place where everyone can see them.
I’m sure I know where Nobs is going to hang his.
And you know what? I think that we had a good time doing this, so I think we’re going to do it again next year and we kind of see it growing, maybe we have more categories, maybe even acceptance speeches. So –
I like the acceptance speeches a lot. That’s a great idea you just ran by me. You know, there’s a lot of people doing cool things around the world, and I want this show to recognize those people.
Okay, well we have a great show for you today, so let’s get going on it.
SEGMENT 1: Carrier-Based Obturation Removal
Well, it’s a big honor and a pleasure to be with you again. This will be my last Ruddle at the Board this year. And so, I’m really excited about bringing a little bit of information, so wherever you are, get comfortable and prepare to learn. Okay, we’ve talked about removing Silver Points. We’ve talked about removing gutta percha, and I didn’t give you all my ideas and tricks, but we went over it pretty thoroughly, and today, we’re going to focus on ta-da, carrier-based removal.
Carrier-based obturators have come around and been a more important, increasingly growing area in endodontic obturation. So, they’ve changed quite a bit, and what we should probably realize is when we start to look at carriers, we have to think about basically the material, because it depends on the era. So, we have basically, we have the original ones were a fluted file, so those could be very onerous to remove, because the blades or flutes of the file could actually be engaging into dentin.
Then they got a little bit more clever. That was Dentsply, now Dentsply Sirona. And I say “clever” in a good way. They came out with – to eliminate the file. They went with a material called – well it’s a plastic, but it’s a polypropylene material. So, that was really a lot more flexible, it was smooth, it didn’t, you know, engage dentin, and it was easier to remove, but there were other difficulties, still. When you think of these removal ideas that we’re going to talk about, kind of think of a Silverpoint, because removing a carrier is a little bit like a Silverpoint.
And then finally, the new ones are a modified gutta percha. So, we have three ideas. And it’s very useful to look at your films closely, carefully, thoughtfully, and try to determine that you can treatment plan for no surprises, because sometimes these carriers can look remarkably like just gutta percha, and you’re not even thinking there’s a carrier. So, get your different angles, so you can really visualize the task that lies just ahead. All right, off with the writing.
Now don’t worry about writing these down. I’m going to go through each one of these and show examples and what I’m talking about. But I kind of have them organized in the way that Ruddle usually would approach first line of offense. So, NiTi files would be quite quick, and they would be employed and we can sometimes grind up the carrier, sometimes we can get alongside it and auger the whole thing out in one piece.
We’re going to talk about files and solvents. And of course, the solvent of choice is typically a chloroform material, tight material, and most of our sealers and peripheral gutta percha around the carrier itself are miscible in chloroform, or we can actually just write here Xylol. That’s what I use, Xylol. So, files to work periphery around the carrier, get the carrier loose by removing circumferential material, and then maybe you can grab it with a grasping instrument. You can just reach down into the access cavity and get ahold of that carrier and get a good purchase and then get a little fulcrum and then jack it up and out of the canal.
We can talk about heat transfer. You’re probably thinking about the traditional heat transfer units. That could be like an example, Calamus, it could be System B, it could be all these different ways we heat these days. It might even have the old 5004 Touch and Heat. That’s all ideas about heat. Heat I can plunge in. Sometimes you can even plunge into the carrier and freeze, and freeze the carrier if it’s plastic, onto the cooling heat carrier transfer instrument and then let it cool down and pull the whole thing out.
So, you might not have thought about it, but ultrasonics, the byproduct of ultrasonic energy is heat, and heat surged to thermal soften circumferential filling materials. I keep talking about them. But that could be rubber. That is rubber. That’s a C5H11. That’s a modified gutta percha. Those are the heat transfers. Tubes, we’ve talked about tubes in the context of removing broken instruments. That’s another segment. Gosh, we’re covering a lot of clinical endodontics, aren’t we? Just stay tuned to next year. You can’t wait what we’re going to have, quite a platform, a smorgasbord of various ideas, concepts and techniques.
So, we’ll look at tubes in a moment. And finally, once you get your Endo Activator employed into a canal that is now freed of a carrier, you’re still going to notice with your solvent, that as you agitate with your Endo Activator, you can put a polymer tip of the Endo Activator, it’s Delrin, it will not melt, it will not dissolve, it will not soften, it will not stretch, it will not break. You can put it right into a great big bath, a big, big bath of solvent, and you’ll notice the whole chamber becomes colored. The color would be gutta percha, kind of a pinkish tone, and if you’ve got most of your gutta percha out, the color could be the color of the residual cement.
So, you’re getting material out of the eccentricities off the rounder part of the canal and that means you’re getting control so you can start the process of maybe a little modification with the shape, maybe not, but certainly a lot of emphasis on disinfection and then filling root canal systems.
Well, I guess I’m pushing the board pretty vigorously. The Control Room will probably go crazy, won’t they?
All right, so let’s look at the files first. You know, when we launched ProTaper many years ago, I rarely even talk about the retreatment files, but we made special ProTaper retreatment files in the retreatment situation. And these files look different to you, because you can see there’s different lengths. Well, we chose a bigger file that would work in the coronal one-third. It is the only one that has an active tip. Hear me carefully. Let’s check it. It has an active tip.
Why? Because some of the materials in the tooth, not a carrier in this case, but some of the paste which we’ll talk about next season or the season after, but we’ll talk a lot about how to remove those formidable paste fillers, but you need sometimes an active tip to get through a brick-hard material. So, that’s why. So, it’s shorter, because it’s made to work dominantly in the coronal and a little bit in the middle one-third. Why do I say that? Because it’s got 9 percent taper. The idea is not to be cutting dentin.
Did everybody hear that? The idea is if you’re disassembling, we’re focusing on removing the obturation material, period. Any shaping would be done subsequent, in a bath of sodium hypochlorite. So, that’s the short tip and that would be the one you would use first if this was your idea. Obviously, this is longer, so we come over here. It’s a little bit longer. It goes deeper. It will go to the bottom of the middle one-third.
So, if we draw a tooth over here, just for fun, you know, we have our thirds, coronal, middle and apical, so you can use the second one, the two-striper, a 25 tip with the 8 percent taper, and that 8 percent taper, again, these tapers are just combined to the apical third of the instrument. They have regressive tapers behind that. Why? So, we don’t cut dentin. We’re trying to do retreatment, like I just said. So, you can have one that goes, you know, if you have a canal in here and you’re trying to work, you can take your number 1 right into here and you can take your 2 into here, maybe a little bit deeper, but you’re not in the apical one-third. That’s the whole point here.
So, then you have a smaller one to go around curves theoretically and work in the apical one-third. I’m always reticent and I’m cautioning you, when you start to think about using rotary against an obturator, again, it could be plastic or a modified gutta percha, like in Gutta Core, Gutta Core. Well then you need to maybe think more of hand files and solvents, so we don’t entertain a broken instrument. Okay, so that’s a little bit about the files.
First line of offense, it’s easy, chuck it up. The rpm is going to be a little higher, so normally we say work at 300 or 400. Ultimate we said was 400. ProTaper Gold was 300. You’re going to work at 500 or 600. You’re going to turn up your rpm a little bit, because extra rotational speed generates friction. Friction causes thermal softening. Thermal softening allows materials to begin to be removed. So, that’s a little bit about the files.
Now I talked about chloroform. I also brought in the word Xylol. They’re more or less equivalent. I get Xylol just because it comes with Kerr Pulp Canal Sealer. How about that? So, anyway, those are the two solvents, and you need some small hand files. Remember, CBOs, carrier-based obturators, are inserted and cemented in cement. The cements are usually miscible in a solvent, so if you think of the solvent that is going to be – get you in there with your little hand files, you might not want to start with this one. Maybe you’re going to start with a 15 or a 20.
You want something a little stiffer. You’re up coronally. You’re not going to carry that instrument to length. You’re just going to work in the coronal one-third a little bit with maybe a 20. So, it’s like pick, pick, pick, and not much seems to be happening. And it’s pick, pick, pick, straight file, stiff file, brand-new file, not a curved file. And all of a sudden you’ll see in the movie, you’ll see some gutta percha come back up into a slurry in the pulp chamber. You’ll see it in your mouth mirror, and you know you’re starting to dissolve the material. That’s good news.
So, you can keep working. You can go, you know, 10, 15, 20, 25, 10, 15, and back and forth, back and forth, and all of a sudden, you’ll see the head of that carrier start to free up and get loose. Well, I’m having a lot of fun here, but I’m sure burning through time, aren’t I? You really can’t use the back row of instruments, because you’re trying to get between a dentinal restrictive wall and the carrier. You’re trying to work on gutta percha and sealer. You’re trying to undermine the carrier itself.
I said grasping tools. I mean everybody has pliers of some sort in their office. I like to talk about the Stieglitz Plier, because it is pretty stout and pretty strong. You can really, you know, grip down on something and get that powerful purchase we talked about. However, it’s a little big. And a lot of times if you’re trying to put this in an access opening, okay, so let’s just say we have an access opening here. Well, you want to get over something, so there’s an obstruction down here, and you want to open up those beaks and get over this so you can grab it. But you hit the dentin or the access chamber, so we must modify it.
So, I just go to a lab next door in the general dentist office. I work in a complex, a medical dental complex where we have many, many dentists. So, I can go next door to a friend and I can use his lab and I can take a grinding wheel and I’m really, you know, thinning the instrument out up in here. I use a burrow wheel to get it nice and smooth so it can be disinfected and go through sterilization, and it comes back like this. But I’m not really doing too much right in here. So, that’s called the modified Stieglitz. Please do not email me and ask me where you buy the modified Stieglitz, because I just told you it’s made custom. Ooh, lot of work here getting this explained.
Heat, this happens to be the Calamus unit. There’s even another generation past this one. Don’t worry what I’m showing. It’s just to provoke a thought that you’ll put in your bag of tricks, and when you show up chairside and you’re looking at CBR removal exercises, you’ll grab your bag and say what the Hell is in here, I need tools. I need tricks, I need ideas. So, it could be anything that generates heat.
And we would – this is the heating side, so we would use a – I would say use like a small taper tip, something like, you know, I think it’s an 05 or something. I’m going to put a question mark there, but I know there’s basically a small, a medium, and a large tip.
Well, you’re not using this one and you’re certainly not using this one, so it would be the small one. It might be 05 or it might be 03, but the point is, it’s narrow and it can plunge between a wall and it can get between the carrier and that wall.
And so, that’s those ideas. What’s another idea that can make heat? We talked about earlier, ultrasonics. So, these are the Pro-Ultra Endo instruments, and you have a generator. This is Dentsply Sirona equipment. In Europe, you might have slightly different boxes, generators. You might have slightly – I think they have little different tips over at Dentsply Sirona, but certainly in North America, you can buy the Endo 1, 2, 3, 4. These are – you wouldn’t get this one for carrier removal. This is a good chamber tip, so this is really good to use in the pulp chamber to blast out circumferential materials, composites, cements, amalgams.
So, that would be a stout little instrument that wouldn’t break and it’s a chamber instrument, chamber instrument. And then your 3 – this is a 3, your 3 and your 4 and your 5 are the most commonly used ones, because they have smaller profiles and they can get in-between the dentin and the carrier. Okay, so that brings us to another idea that generates heat. Heat again thermal softens gutta percha.
Now a lot of times when we think of tube delivery, tube mechanics, there’s lots of tubes. I mean you can just go to a medical catalog and just buy tubes, okay? Anything that can stick down through an access cavity and can jump over, so you got a tube, so it can jump over the head of a carrier is appropriate. But you might not have thought of the post removal system, SybronEndo, you might not have thought about them, because it says it’s a post removal system. Well, Ruddle never actually intended for the 1 and the 2 to be used for a post. They’re too small. The post would have to be so small, that I would ask you why are you even using a post? It looks like a silverpoint. That’s a joke.
Anyway, if you look at the inside diameter, anything that’s sticking up out of the orifice into the pulp chamber that is bigger than 6/10 or 85/100, you can take a tap. The only thing to really emphasize it’s counter-clockwise. You’re going to engage by turning it backwards. There was a reason for that. That’s because if you’re talking about taking out a screw post, you need it to go counter-clockwise, not clockwise, or you’ll tighten it up, drive it deep in the tooth and split the root. So, there’s a reason why the kit is all the taps are operating at a counter-clockwise rotational direction.
So, the 1 and the 2 are very appropriate, not sub-orifice level. Their outside diameter would be a problem in that case, but it’s not a problem in the pulp chamber, so file that one away. A lot of you already have it, because you sent me cases where you’ve taken out the post. You sent me cases where you’ve used it for different things, a carrier as I just said, a silverpoint. We’ve talked about this, but now think again. It’s always about – it’s not this or that; it’s not either/or. Always think in terms of and/both.
Now we’ve talked about these, too, the file removal system. I heard that some colleagues have told me they have had trouble getting it or acquiring it. I don’t want to hear any whining. Just get the idea. We made this kit. It was sold through Dentsply Sirona for years. In fact, anybody out there who is listening, go ahead and make it. I don’t need any royalty or anything. It was my intellectual property, but what you notice is we have one-millimeter, that’s OD. So, that works perfectly in the pulp chamber or you could use the post removal system. It can actually work in central incisors, maxillaries, palatal roots, distil roots with some lower molars.
It can actually work into the canal a little bit in the coronal one-third. It’s appropriate. And we’ll look at this screw wedge. There’s a screw wedge that goes down, passes through that entire lumen of that tube, and you see the tube at the end is beveled and you see in a blowup that’s there’s also a cutout window. So, we can take the screw wedge, run it down through the lumen and we can capture the obstruction. We can capture the obstruction, and if we seek this even further, then we can get it up into the window and our screw wedge will drive this out. That way we get a mechanical purchase, and I’ve taken out a lot of stuff with the file removal system.
So, silverpoints, carriers, things like that. So, now you have some ideas. And then we have one that will go in the middle one-third easy, eight-tenths of a millimeter. Think of your shaping files and kind of like get some confidence going. When you kind of compare these instruments to the kinds of shapes that are being prepared around the world in teeth pretty much every day. So, they’re appropriate.
So, if you can’t get the file removal system, you can just start by getting a tube that has an outside diameter. I’m stressing OD versus ID, inside diameter, outside. It makes a big, big difference. So, here I’ve disengaged the screw wedge. You can see the screw wedge then would pass down through the lumen and you can see just a little bit of it right in there, and then the end is beveled to scoop up and shepherd the head of the obstruction into the lumen of the microtube, so now we can use the screw wedge. It’s a left-handed turn, everybody. Oh, Ruddle’s world is counter-clockwise. If you agreed with me, we’d both be wrong.
Wait a minute. That sounds like one of those paraprosdokians. All right. Well, erase-o, please. So, there’s your tubes. Ands then finally, finally, when you have removed the encumbrance, it’s out, and you’re thinking, gee, should I switch to sodium hypochlorite? Should I start doing a little shaping or just disinfection? Wait a minute. Use your Endo Activator in solvent. In this case, we said Xylol or chloroform. Either one of those is fine. And you’ll provoke a whole slurry of color up into the pulp chamber which means that represents residual tissue that wouldn’t have been removed with sodium hypochlorite.
So, the solvent gets it out off the eccentricities around the rounder part of the canal where the carrier occupied. And now when you switch to sodium hypochlorite and EDTA and you start your disinfection protocol, wow, that’s when you have the opportunity to fill root canal systems.
Well, I’m at 21 minutes it appears. I’m at the very end. I want you to notice the concept wicking I talked about in the 70’s. I’m about 480 years old today. My face has worn out two bodies as you can see. But I talked about some of these things a long, long time ago, but we get so many questions cause I didn’t expect you to buy anything, but if you would have investigated the articles, watched the tapes, the DVDs, the videos, you would have seen this.
But fill up your pulp chamber and then pull it off so there’s just solvent below the orifice. Put a paper point in it. Watch. Watch the paper point. Oh, we got to see that again. Wicking. Wicking. Wicking is pulling cements, because they’re miscible in the solvent, and it’s pulling them peripheral to central and your paper point will come out pink, and that represents even more material that you couldn’t get out just with agitation. So, now you’re kind of mopping up. You’ve heard of mop-up exercises. This is like, you know, they come in, we’re mopping up now before we do something important like fill a root canal system. So, don’t forget wicking.
So, I’m going to show you like maybe if you’re nice, I’ll show two cases. I’ve put in three, but I’m thinking one is enough because I don’t have time to show you every single example clinically that I just went through, so it’s more important to give you the knowledge. Teach a man to fish and he’ll eat for a lifetime. Give him a fish and he’ll eat for a day. So, we’re trying to teach a little bit about fishing.
Okay, so in this pre-op, you can see some really overzealous enlargement in the body of these canals. They’re really over-prepared. It looks like they were gates’ed, like a Gates Glidden, like sink a big GG, no feathering, no blending, no awareness of peripheral dentin. But anyway, that’s what you get. So, when you’re doing retreatment and we attracted a lot of it, you’re going to get a lot of cases that have been badly managed.
And then you can see just parallel preps, you know, you look here and you look here and you look here and you look here. That looks like it’s parallel to me. This looks like it’s basically parallel. Parallel canals are hard to think of the thermal dynamics, the vortex that you need with your reagents to get them agitated and active and working off the body of the canal into the un-instrumental portions. That’s when you’ve got to have a little bit of appropriate taper, appropriate for the root that holds the canal.
So you can see we have three carriers, and the tooth I’m going to show, the photographs, are something similar to this tooth, but not exactly the same. So, in the isolated tooth, you can see we’re going to go with the one-striper. That’s the 30/09 with the active tip, and you can just watch it go in there. In this instance, because of the overzealous pre-enlargement in the body, I could get lateral to that carrier and I’m auguring out gutta percha and I’m cutting up and pulverizing that polysulfone carrier. And so now I can go well, more can be done. I can go deeper now. I can go more into the middle and the top of the apical one-third.
So, we fly in the 25/08. It’s a little longer and will reach deeper. And just a pass or two and boom, I got a lot of irrigation to do and clean out residual tags of GP and get sealer complex out of there. But I have control of that canal, and that is just how fast it is. And when you chew them up, the next one will chew up a little easier. So, as you go down deeper and deeper in the canal, appreciate that you have smaller instruments, the three striper, the two striper, the one striper, that are appropriate in that area of the canal.
All right, so we’ll tackle the MB. Now you could do this different ways. This is a teaching setup here, so I want you to see that I’m using a small size file, the 6, the 8 are not appropriate. Probably even a 15 could have been better. But notice how when I pick, pick, pick, I’m breaking a slurry. Notice the rubber stop is getting pretty close to the reference point. That means I’m getting pretty deep, aren’t I? And I’m starting to free up that polysulfone carrier. So don’t – see how pink that is? Look at how you’re provoking and bringing a lot of that complex into solution where it can be cycled off the occlusal table.
So, now you could probably use a grasping instrument. You might want to use a plier. You might say gee, I could get a Hedstrom. Hedstrom displacement is phenomenal. I mean we talked about Hedstrom displacement with silver points. I said files and solvents today, but files could be a reamer, a file, a Hedstrom. A Hedstrom has a positive rake angle. It will dig into that soft polysulfone. That’s another idea. I have many videos showing this. Some of you have gotten those videos and you can see even much more than we’re talking about today.
I wanted to show you the file removal system, because many of you don’t know much about it. So, we’ll come in here with that. Remember, it’s got an OD of 8/10ths so it can easily go in the coronal one-third, especially when they were opened up with GG 4 and 5 and maybe a 6. So, you can see – look right in this area. You can see as I turn the screw wedge and advance it down, cause there’s threads up here that get caught in the handle, so as I catch those threads, I’m driving that screw wedge plunger, and you know what, it was going out the side of the canal window.
So, I just turned the window a little bit, then I turned the screw wedge in a little bit deeper, and now you can see I have physically taken this carrier – here’s the carrier. I have intentionally pushed the head out through the cut-out window, and my screw edge has gone past it, and I’m wedging, and I get it all out in one big piece. So, that’s pretty exciting for a clinician. So, you got your palatal out, you got your MB out.
We won’t waste a lot of time. I did the yellow carrier here, because I broke off the coronal part, got the coronal part out, maybe you’ve seen this before, but most of you haven’t. And then I used the yellow one with the OD of 6/10th of a millimeter, to reach really deep and got out that last little apical plug of that polysulfone carrier. So, we can work a file in there and break up cements, move a little more GP into solution, irrigate vigorously, get everything cleaned out, and then you’re pretty much ready to modify the shape a little bit, not coronally, no more shaping coronally, but a little bit of deep work to blend.
Get a little taper going after your disinfection and then re-filling the root canal system. I use vertical condensation. So, there we are. This is just money in the bank, you know. You see stuff like this and stuff like this. That’s an accident waiting to happen. But anyway, you can see we found an extra system, an MB2. We still have the coke bottle preps, because we can’t grow dentin, at least today, but we can certainly improve our deep shapes and get all four systems.
That would be probably what I would want to say in closing then. I won’t show the other case. But I want you to look at your pre-operative films carefully. How many cases have I gotten in just the last few weeks from colleagues around the world and they got fooled because they didn’t see a zirconium post or a titanium post that looked like gutta percha and radial opacity. So, they got fooled. And then they got on the case and it’s like, whoa, this is really tough. Measure twice, cause you can only cut once.
SEGMENT 2: Knowing the Difference – MTA vs. Calcium Hydroxide
All right, so today we have another segment of Knowing the Difference. And when we did this segment earlier in the season, I explained that often products or techniques might be seemingly similar, but often have important differences which in turn make them more suited to certain procedures. So, the 18th Century French author, Madame de Stael, said, “Wit consists of knowing the resemblance of things that differ, and the difference of things that are alike.” So, the last time we did this segment, we talked about chelator versus sodium hypochlorite. This time today, we’re going to talk about calcium hydroxide versus MTA.
Okay. First of all, I’m saying MTA to honor my friend, Mahmoud Torabinejad. And he was chairman for decades of the graduate program at Loma Linda University. He used to bring his students up to Santa Barbara and he invented in about – it was released in 1997, I believe, MTA, mineral trioxide aggregate. But that is just an example of the tricalcium silicate fillers, we can say, not sealers. There’s – you got to get that – this is a tricalcium silicate, like putty filler. So, that’s the family, and MTA is underneath that. Brasseler has a BC putty, bio-dentine, those are all tricalcium silicate putty fillers. So, I’m going to say MTA from now on, but when I say MTA, it could be any one of those.
Okay. Well at the end of last season, I believe, we did a Q&A on calcium hydroxide. And in the Show Notes for that show is a detailed list of all the traditional indications for the use of calcium hydroxide.
Now, however, we’ve taken that list and modified it a little bit, because with the advent of tricalcium silicates, now MTA is better suited to certain situations than calcium hydroxide. So, here’s the list. Let’s bring it up. And why don’t you briefly go over it. But mostly focusing on why MTA is a better option than calcium hydroxide in some situations.
Let me make it real easy. Let’s think of calcium hydroxide as a provisional or a temporary dressing. If the dentists out there just grasp that, then you already know the difference. So, think of the column on the right. That’s your tricalcium silicate putties or fillers. They are definitive. They’re meant to go in something and be archival. So, that’s a quick difference.
Calcium hydroxide, people come in, they have pain or swelling and maybe you do a little work, but you need an interim appointment, you put in some calcium hydroxide. If you see some internal root resorption, you put it in, you might leave it a month, you might change it, you might put in another month. You’ve got to be careful about how long we keep it in there, so we don’t weaken the dentin. Symptomatic teeth, they don’t calm down, calcium hydroxide is used again as a dressing. And we talked about how to place the roots last time. You’re going to follow all that perfectly, aren’t they? All right.
Immature root, you can use it to get Hertzwig’s epithelial root sheath induced, secondary again and form root end closure. You can use it in almost any retreatment case. In other words, you disassemble, take out the gutta percha, silver points, carriers, pace fillers and maybe put in calcium hydroxide as an inner appointment dressing and then have them back. Persistent symptoms, draining, sinus tracts, things like that, it exudates, that’s where you use a dressing.
Now when we go to the other side, bio-dentine really is pretty interesting, because bio-dentine has superb mechanical and handling properties. So, it comes in a capsule. You intrude the two together, put it in an attrituator and do the cycle, but when it comes out I mean it’s like putty, and you can form it into a ball, you can put it on the end of an instrument and carry it into the surgical crypt or whatever. So, it’s really easy to handle. It’s pretty inexpensive as compared to MTA, so handling, physical characteristics.
And of course, all these materials, what they do is they release hydroxide and calcium ions. It leeches out of the material in a controlled way and what it does is it reacts with peri-radicular tissues and it can form, guess what? Hydroxyappetite. That’s the foundational building block, if you will, for bone and teeth. So, it’s really, really good in that context. So, pulp capping used to be calcium hydroxide. Now pretty much because it can wash out so easy, we’re using one of the tri-calcium silicates. You can see root perforation, either repaired ortho grade or retro grade. You can mix up your mix and put it in there and it’s going to stay there and it’s more archival again.
Root resorption, internal, not so much external, but internal. Terry Pannkuk is going to be on the show next season, just did a fabulous case, you’ll see it. Dental traumatology, well you know, there’s lots of different kinds of fractures and cracks and propagations, but it’s a good material in that situation. Induces, so it’s inductive bone. It’s osteogenic. I mentioned that with the calcium and the hydroxide ions, forming hydroxyappetite.
And then we can use it much more effectively in the open apex case if you’re going to do it definitively. In other words, you’re not going to get the apex to close. You’re just going to do a one visit and do it. I didn’t mention bio-dentine sets on the order of minutes whereas, MTA sets on the order of about four hours.
And those calcium hydroxide ever set or does it set kind of –
It sets, but it’s not durable. I mean if you put a drop of it here and let it set up I could just go like that and flick it off. So, I mean, and then if there’s any leakage at all it coddles and turns to mush, so a lot of times when we’ve gone back into teeth that were pulp capped with calcium hydroxide, we’ll find a zone that used to be calcium hydroxide, but now it’s just like liquefaction necrosis. It stinks even.
So, your tri-calcium silicates are really a complete step up and they’re so bio compatible that they’re really on the map, and I just – I think it’s worth talking about this briefly. And we could spend – we could have a show on every one of those. Maybe we will. I mean, I’m serious. It could be very interesting. But it’s just to introduce it to get them out there that we’re kind of moving away from calcium hydroxide in definitive work, but calcium hydroxide is still on the radar, and it’s very important as a provisional dressing.
Well, I was just going to say, you know, we’ve talked about this a lot, but when you opened starting to talk about it, you said so clearly one is more definitive and permanent and one is more temporary. And I think that that really kind of – when you said it, that clearly for me it’s like amazing how long we talked about it and we talked about that aspect. You just made it so clear, so quickly.
Yeah, you know, I was, you know, we have these lists and stuff and I was on the website and I can tell you all these different things. And really, I was laying in bed one night and I thought well, knowing the difference is one’s a provisional and one’s archival.
All right. Well thank you for that information, and we’ll do another segment on Knowing the Difference, and we kind of already have an idea in the works, so stay tuned.
CLOSE: Being Cliff
All right, so that’s a wrap on Season 6. We’re going to close out with another segment of Being Cliff, so enjoy that, and thanks for watching.
Really enjoyed bringing these shows to you over this year with Lisette. It’s been a big joy and we’re looking forward to seeing you next year.
[various talks with music]
So, some weeks ago, Phyllis gave me a long, long list, several pages, of this thing called paraprosdokians, and I didn’t even know what it was, but apparently it’s a figure of speech where they end a sentence or a phrase with some kind of a surprise ending or unexpected anyway.
Like what’s an example?
Well, which one do you want? They begin the evening news with “good evening” and then proceed to tell you why it isn’t. Another one is you do not need a parachute to skydive; you only need a parachute to skydive twice. Going to grad school does not make you an endodontist any more than standing by this garage makes me a car.
Welcome to the Ruddle Show. I’m Lisette and of course, this is my dad, Cliff Ruddle. How are you doing today?
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. How are you doing?
How are you doing?
I’m doing pretty good. How about you? You didn’t answer.
Oh, I’m doing excellent.
Okay. Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing?
How are you doing?
Pretty good. What about you, though?
Oh, I’m doing excellent.
Okay, so we’re both good.
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. How are you doing today?
Just to conserve time, I’m doing excellent.
Okay, well we’re going to get right to it.
I didn’t say it was your fault. I said I’m blaming you.
Nostalgia isn’t what it used to be.
It’s all right. That’s fine.
And then India and went on down here to Malaysia. Right here is a little city – I’m practicing, please. Now I’ll have to pick it up a little bit. It’s right here in New Guinea, and there’s a little city here called Le, and there it – You guys see it?
Oh, there it is, Le, L-e. And then if you kind of – then I’ll go over here and see here’s Hawaii and so she must be right out in here. I found all kinds of islands they talked about… and so she was making her route to come back to the states… It’s only about what, five or six football fields? Actually right on the belly of the Equator. I mean if you take this Le leaving New Guinea and you’re coming on the route to Hawaii, it was almost – you can see Gilbert. Remember we read about Gilbert Island?
I used to be pretty indecisive, and now I’m not so sure.
OK, one time facing the board.
Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, over the cooking, cracking of the big coffee beans.
Sorry, one more facing me.
Saturday, Sunday, Monday, Tuesday, Wednesday, Thursday, Friday.
Oh yeah, you again. Well since light travels faster than the speed of sound, some people appear quite bright until you hear them speak.
Okay, so for more than –
Oh, stop a second. When you’re talking, if I look at you, does that make you feel you need to look at me and then does that throw you off because you’re focused on your opening and you have a paragraph, so should I not look over?
No. You can look at me. That’s fine.
Listen, I want to tell everybody that joins The Ruddle Show and everybody that doesn’t, I want to wish you all a very, very fine holiday. And so, I know you’re from continents all over the world, different cities, different customs, different cultures, different everything, but wherever you are, have a really wonderful holiday and enjoy your family, and I will see you next year.
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.