Endodontic performance is enhanced when clinicians thoughtfully view different horizontally-angulated, pre-operative radiographic images, visualize minimally invasive, yet complete, treatment, then use this mental picture to guide each procedural step...
Articles & Preferred Access Writing Projects & Ruddle’s Start-to-Finish Access
The new season opens with Ruddle and Lisette explaining why Season 7 was delayed… They have been busy writing! Next, Ruddle is right back at the Board and back to basics, presenting his preferred start-to-finish access preparation. Then, Ruddle and Lisette discuss his soon-to-be-published paper on the EndoActivator evolution and how this relates to the importance placed on workflow. And finally, the show closes with a riveting Ruddle Flashback… back to Candlestick Park, 1962. Let’s play ball!
Show Content & Timecodes01:01 - INTRO: Off-Season Writing 08:00 - SEGMENT 1: Technique – Start-to-Finish Access 30:30 - SEGMENT 2: Soon-to-be-Published EndoActivator Article 45:31 - CLOSE: Ruddle Flashback – Candlestick Park 1962
Extra content referenced within show:
Extra movie/video content:
Downloadable PDFs & Related Materials
There is an old expression... “Start with the end in mind.” Before initiating the access preparation, think, visualize, and plan to more effectively execute a predictably successful result...
There are enormous differences in opinion regarding the potential to three-dimensionally clean a root canal system. Elimination of pulpal tissue, bacteria when present, and their related breakdown products is directly influenced by a series of procedural steps that comprise start-to-finish endodontics...
In the United States, alone, more than 100,000 dentists perform tens of millions of operative, restorative, and reconstructive procedures on an annual basis. Certainly, these dental procedures are primarily directed toward eliminating carious lesions, esthetically restoring teeth, and functionally moving patients toward optimal oral health...
There was more change in clinical endodontics from about 1985 to 1995 than in perhaps the previous 100 years combined. In these ten years, clinical endodontics changed forever with the emergence of four game-changing technologies...
Ruddle on Shape•Clean•Pack Supply List and Supplier Contact Information Listing
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
…It’s going to be a fabulous day. This is the first tooth in. You’re not even wearing a mask today because you want to smell that dental smoke going up your nose, you want it to go through your hair. It’s a marvelous feeling, that dental smoke in the morning, with a warm beer at 7:00 AM and you’re ready to do good…
INTRO: Off Season Writing
Welcome to Season 7 of The Ruddle Show.
Yes, I’d like to welcome each one of you from all over the world. Welcome back.
I’m Lisette, and this is my dad, Cliff Ruddle, and we’re pretty excited to embark on a new season. So, it’s been awhile since we’ve sat here at the desk filming an episode of The Ruddle Show. I think about four months.
Yeah, it’s been four months.
So, maybe you think we’ve just been resting and doing nothing, but no, we’ve been far from idle. Why don’t you share with our viewers what we’ve been doing.
Well we have been permanently in writing mode, and we wrote, and then we wrote more, and when we thought we were getting close to being done writing, we wrote even more. So, we wrote two papers in this four-month hiatus and one was on ProTaper Ultimate, the launch that was last September. So, we need to now come back and support that with how-to. And then there was the EndoActivator paper that is going to be launching at the AAE meeting which is coming up very shortly.
So, both of those papers are slated to be published in May of this year, one in Dentistry Today and one in Oral Health. And a little later on our show we’re going to talk more about the EndoActivator article. But we’ll get to that later. Right now we wanted to start off our show by talking a little bit about our writing process, because we have a system in place that works pretty well for us.
So, if you think of the final paper as a sculpture molded out of clay, the first step is to put the pile of clay in front of my dad. So, if he’s going to write about the EndoActivator, for example, I go back to other things he has written and I extract pieces that I think will be useful, and I put it together in a very rough draft, which represents the ball of clay, but is far from representative of the final version of the paper. So, once the ball of clay is in front of you, what do you do?
Well that takes me back to college, and my first year of college besides math, chemistry, physics and that, I had to take an elective, and I took clay. So, you know, what you just asked me when I get the ball of clay, I immediately get on the potter’s wheel, and I begin kicking with my foot. We didn’t have electric ones. And I began taking my pen out and I began to cross off, and I see other ways of saying things, and as I grow in my thinking and travel and keep seeing experiences from others I keep adjusting my writing.
So, I might say the same thing 10 different times over 10 years. So, I do a lot of that, and then sometimes I get out the scissors and I see that you’ve given me something and if we’re going to pull the clay up to be more than it is, then we have to cut and paste, and I literally take a scotch tape and put it four pages later.
He literally does it, because he works with a pen, and not at all on the computer. He actually works with a pen and actually with scissors literally cuts out things and rearranges them.
Sometimes a scalpel. Well you know, the pen goes everywhere. It can go in the car, it can go to the beach, it can go up on the side of the hill. A pen is very creative for me. Anyway, a pen. Someday we’ll have to have a special on the pencil, and I’ll talk about the power of the pencil.
But anyway, then I will sometimes sit on it for two or three days in its cluttered’ness, but I’m thinking about it every day, and then I come back with a different color pen so I can re-edit over – oh my goodness, yeah, it looks like that. So anyway, it begins to kind of take shape, and then I want to acknowledge you, because you’re very good at stepping back from 30,000 feet and say where are we going?
Okay, so eventually it comes back to me, and I want to share an example of what it looks like because I really want our viewers to understand what I’m dealing with. So, I then enter all of the editing to the computer. I make grammar corrections. I sometimes ask questions for clarification or maybe I have suggestions. And I’ve never really kept track of how many rounds we do back and forth, but it has to be over 10. Eventually, the edits get less and we come up with a whole new creation. But once a text is written, we’re still not done. What next?
Well about the time I’m thinking we’re all done here, I’m going wait a minute; I made some assertions, I made some comments. We need a lit review. So, we have a master of literature review list that we’ve used over the decades, so it’s – there’s probably a thousand, I don’t know, anyway, but things change and new papers replace old papers, and the lit review has to be current.
So, there’s – actually I dived into a whole section of reading and going to different journals which I’m kind of doing all the time, but now related to the paper I have to get more specific. It’s not just abstract reviews. Okay, you get all that, and so we get the literature review done and the references have to be placed and all that. And then, of course, you think you’re all done, and then my other daughter, Lori, is saying we’re going to need some figures. And I’m going, oh my God, the paper that won’t end!
And so then there’s an image pool, and I have a lot of help from Lori because she kind of knows what images I might have used a year ago, two years ago, and four years ago, so she’s saying you have 10,000 cases in your library, why don’t you use other than your favorite ones. So, we get those and so I’m really thinking I’m home-free now; I got the images in the bag. And then I get something from her, and it’s called you need to do figure descriptions. So, now I have to write something about every figure that is meaningful.
Well it is definitely a process. I think that probably the biggest challenge is the word count, and staying concise and being in the word count, kind of like our opener right now. And then there’s all the Ruddle Rules, you know, it has to be always three things, like A, B, and C, not two or four, but always three, that’s the magic number, 8-line paragraphs always, no one or two-word spillovers on the last line of the paragraph. But it definitely gives you a very distinctive style, but yes, there are a whole lot of Ruddle Rules that aren’t rules for everybody, but that we go by.
Well I guess what I’d say is I don’t get paid to write papers and neither do you, but we hope the papers add meaning to your practice. We hope that you can learn from them. And there will be some insights in there that will spark more desire and more determination to get better. And the I want to thank my family, and even Phyllis got involved in one of the rounds on the weekend, so every – it’s a team effort, so I want to thank the family, and I hope you guys enjoy the papers.
A little later on our show today we’re going to talk about the EndoActivator article and we’re just going to get a look at the show now. We’re pretty excited about it.
SEGMENT 1: Technique – Start-to-Finish Access
Today the topic is access, and when I say access, I mean access the chamber, I mean access the root canal system, access the apical one-third, access the foramen, access results. Okay, so let’s talk a little bit about it, and of course there’s lot of different accesses and we’ve talked about those in previous shows. I’ll just say it real quick. Ninjas, orifice directed, truss accesses. I’m pretty traditional,, known as the teacher that’s come before tens of thousands of dentists all my life. I can tell you everybody wins when they have complete access. There’s no struggling.
So, when our patients come in and start reporting to us their chief complaint, start with the end in mind, you’re already seeing beyond the chief complaint and you’re starting to look at those radiographs. And if you look at them pretty carefully, you begin to start looking at things about orientation. So, this is the direction on your crown, but your roots are kind of going off like this. So, we have some angles in here we have to think about. In fact, access – look at this remnant right here. I think to access that straightline we’d be making it through the pontic. We’d be cutting an access over here so we could get right in there. No, not talking about that.
Sometimes we have to think about should we take the bridge off to help us, but in any event you’re seeing the neurovascular bundle, you’re seeing the proximity of these root ends to the neurovascular bundle. Some of you saw the furcal lesion, so start with the end in mind; it’s the most funereal abutment. Okay, it is the posterior abutment, it’s carrying the bridge. So, you’re going to want to really think this through. There’s an old expression I like to say, measure twice; you can only cut once.
So, when we take our postoperative films, most of us are using two-dimensional imaging and so you’re taking various angles. And we want to move our cone in the horizontal position, we don’t want to come steep, we don’t want to come shallow, we want to use aiming devices like this Rinn kit aiming device. It keeps us pretty much projecting images one to one with the image and the actual film, the tooth itself, the tooth and the image.
So, when you think about that, it’s good to move the cone up to 30 degrees from the mesial. And coming from the mesial or you could come a little bit from the distal, but we throw those roots around to get a better appreciation for the three-dimensional image – to get a three-dimensional image, because we’re really just getting a two-dimensional image, but the three images together give us a better view than a single image alone.
So, you’re planning. You’re taking two or three horizontally different angulated films. Now of course, I need to talk about this. Endodontists, most of them, now have CBCT. It’s a fabulous device. Probably we could have – we’ve had segments on which would you rather have, a CBCT or a microscope? And we’ve debated that back and forth. It’s been debated among endodontists. It’s debated on the endodontic discussion forum. If you could only have one, which would you choose? I’ll take the microscope.
Listen, if you hold a lot of teeth in your hands, and you’re doing workshops around the world for almost 50 years, I have a library in my mind of massive variations from tooth to tooth that we see clinically, and I’ve held them in my hand. Oh, there, look at that, and you can see like the extra roots, you can see all kinds of things, and you learn a lot from this growing library of imaging that you have in your mind.
So, basically, many of you would have taken a conventional two-dimensional picture and you would have said, okay, I don’t really see a lot going on here, but some of you, because of your experience would say it looks a little funny right in here. It looks a little moth eaten right in here. But then you come over here and you go aha, what’s that? Looks like a what? Looks like a P-O-E, a portal of exit coming out facial, and then, of course, when you take this view and you get the CBT scan here and you get the slice, you can clearly see the exit of that significant lateral canal that has broken away the cortical plate.
So, I’m not dismissing the importance of CBCT, and I’m not going to get into the discussion today, do we take a CBCT on every patient. That’s another time. But basically, I want you to know that imaging does support access. And then, of course, I like a scope. We just talked about it. I had my first scope in the 80’s, so basically when I could see something, you could probably do it. So, vision is huge when you’re looking for aberrant canal floor anatomy, looking for more calcific orifices, fractures doing down the axial walls, maybe across the floor or between orifices, all these things are really important so we can get big, big looks. You can make it bigger than your fist, okay?
So, CBCT, radiographs, 2D, 3D, we need to have good vision, microscope, or wear a headlamp, maybe some glasses, have the assistant hold the transillumination straight wand, either above the rubber damn or below the rubber damn. You can play more light in from the facial to help you see better. That’s a trick. Well there is some ultrasonic instruments that can be chosen. They have different tip formations and different sizes of balls and footballs. All these are chosen appropriately for whatever the task is that you’re performing.
These very quickly insert tips hook onto your piezoelectric handpiece, and I’m using Dentsply Sirona’s private label from Satelec, so you can see it’s a very, very fine one. Most people around the world are using something in this field from Satelec or Dentsply Sirona. And then you need a few burs. You don’t need every bur in the world and you might only use two burs to get into any given tooth, maybe one bur, but we have them. And you can see the main thing here is length.
So, as we go off to the right you can see the burs get longer. They’re surgical length number 2 round burs, surgical length number 4 carbides. These 2 and 4 carbide round burs are surgical length and that means the longer bur kicks the head of the handpiece further away from the occlusal table so you have a preferable line of sight. So you open up corridors of vision so you can see well. When you used short burs, as you work down deeper you’re looking into the back end of your handpiece and your vision is obstructed and lost.
So, you need a few burs. We have an orifice opener here at the end of it to get that orifice flare. This Stropko, John Stropko invented this quick connect Stropko. It has lower lock threads that can receive a lot of different size cannula, and you can blow air into the access cavity from the side, and you can clear the dust out when you’re doing small, little, precise procedures where vision is very, very important. So, a few tools, but not so many, huh, not so many.
So, a few things to hold in mind. When you cut your access cavities, start with the end in mind. If you say I’m using lasers, your access will probably look a little different, although I’m going to argue regardless of what you’re doing, all the studies are emerging that show when you leave pulpal roof on, you’re restricting fluid dynamics, and that means you’re probably going to have less effect of your high-end technology, lasers, GentleWave and stuff like that.
So, I’m going to say get the roof completely out, eliminate the roof. You want to have great fluid dynamics. So, when you’re doing an access, you’re not just doing access, you’re thinking, what is my disinfectant technology I’m going to be using, what is my obturation method that I’m trained up to do and that I like to do and that I trust. All these will have an effect on how you decide to cut your access cavity. So, right now I’m going to just say de-roof.
What else? What’s the next thing we need to be aware of? Triangles of dentin. There’s now a new age, you know, in the last seven years people have discovered minimally invasive endodontics, so they want you to leave those triangles. That means the head of your file is going to come in over here like this, you’re going to be coming in like that, and all of a sudden, you’re going to be seeing offline accesses, you’re going to be working around extra curvatures that are unnecessary. People talk about this zone right here, this peri-cervical dentin. You can see over here on this side peri-cervical dentin.
Listen, these canals bend abruptly as they enter into the pulp chamber. And because they enter in quite a bit of convergence in the pulp chamber, the canals aren’t centered. They’re not centered evenly between the mesial and furcal side aspect of the root. The canals are always closer to the furcal wall. I bet you the team back there behind would say please use a different color, please use a different color, so closer to the furcal side wall. So, we want to recognize that, and we want to move these canals intentionally away from furcal danger and we want to end up with preparations that are pretty much centered in the roots.
So, triangles of dentin, I think, need to be eliminated. If you’re worried about restorative ability and endodontically strong teeth, and post resistance to fracture, then a lot of people say leave the precious peri-cervical dentin, but let’s look down on the tooth. People know that after you shape and brush that canal away you’re more centered and we have more distance in here that’s just about equal distant and you have stronger roots.
So, people say, well you got to, you know, to got to keep the peri-cervical dentin because it’s a really important aspect for restorative dentists. If you talk to the restorative dentists I talk to and some of the best in the world, I might add, prosthodontists, Frank Spear, John Kois, those kind of guys, Rob Brenners, we’ve had Cheryl Sheets on the show. Those people say when you go into a work imbalance, the loads are buccal-lingual, so the most important part of your circumferential chamfer okay, is the buccal and lingual. There’s not so much loads mesial distal on a tooth, so take out the triangle. All this is to say take out the triangle and go on in.
Now when you go on in, I want you to notice that this is all a shelf. This is all a shelf, and this is a tongue of dentin. And this is a tongue of dentin. That’s where the file gets kicked off axis because it’s being displaced by not having complete access by removing the triangle dentin. So, you start to learn these things as you learn and usually have to go out a little bit this way and a little bit that way towards the greatest bulk of tooth structure because remember under here we have that root, okay? Remember it had a furcal side cavity. So, we’ve got to remember to move the canals away. Oh, the drawings are going quite well today.
So, there’s the example. Say a file goes in easily part way, but won’t go all the way, don’t fight it, don’t drop to an 8. You don’t need to drop to an 06. Just make sure that file is loose at a prescribed depth. You know the depth because you pushed the stop down. Push the stop down on your auxiliary shaper and that auxiliary shaper from the ProTaper family of instruments now will never go apical to where you’ve secured the canal.
So, we can keep the Shaper X in the secured part of the canal, and we can use it to do what? To remove that triangle of dentin, we can move this canal as we’ve shown in the cross-section. We can move it away from furcal danger, and we can end up with more centered preparations in the root. And then you got the inner-connector usually. All right. So, I like the SX. You could use whatever you like. The SX is the number one most sought after instrument to remove coronal interferences, to pre-enlarge the body of the canal to give you deep access.
Hey, we’re talked about coronal access. That’s what we’re talking about. Think about radicular access, deep access. Where are the canals most curved? Where do they usually divide? Where do you usually not like your post-operative films? It’s usually looking at the apical third, the last one or two millimeters. Did you get good access into that region so you could deftly take files to length? All right. And we’ve talked about centered preparations. This is a brand new instrument. It has a different cross-section. It’s quite remarkable. We’ll look at a special report and you’ll learn to appreciate it.
But what you can do with it is you can bring it into a canal that has had a 10 file in it or a slider or a Go Glider or a Pro Glider, anything that has secured part of the canal, and we can use and confine and restrict the SX to that portion of the canal that was previously deemed and verified to be secure. What’s a secured canal? A canal that has a smooth, reproducible slide path over any distance. It could be the whole distance, part of the distance, half the distance.
But with a brushing motion, brushing intentionally away from furcal danger, you can see out here we can move these canals. Look at this. You can see this all the time on your films. You see that little line and you see that line and that is the concavity. The more you can spread those lines apart, the more on radiographic move, straight on, move to the mesial, move to the distal, the more you can separate those lines, the deeper the furcal side concavity. You can have them pretty flat, but the more you can move those lines, then you’re thinking maybe it goes like that, maybe it goes like that. So, you have to really look at those angles before you ever started.
And we’ll just show it again. Use the SX to flare, to remove triangles of dentin, and to intentionally relocate the coronal part of the canal away from furcal danger. I’m just beating this to death, aren’t I? But this is how you have post-treatment endodontically strong roots, and we don’t have to have all those discussions about the fractured teeth, especially when you use the ferrule effect that we were talking about, some of the great master clinicians in restorative dentistry have talked about, the buccal lingual aspect of that ferrule is what’s most important.
All right. So, finally, we get down to this case. I think you might have seen part of it, a glimpse of it, but now we’ll look at it more or less start to finish. Right now you’re looking at this film and you’re going to go through some kind of a casting, okay, you know that. Of course you’ve done a clinical exam so you know exactly what kind of a restorative it is. You immediately start to see the pulp horn going out that way, the roots kind of going that way. This is your triangle. So, if you get this out of here so you can really be more precise, this is the triangle right there.
So, you’re already knowing when you put a file in here, the handle is going to be like coming in like this, and we’re going to want to kick it this way so the handle ends up over here or coming right down into that canal. So, you’re already planning. Seems like there’s a pulp chamber. I can see the roof. I can see the floor. They haven’t completely coalesced, but I know I have a little space to drop in.
Now I want to mention a concept called brushing. You’re not drilling; you’re brushing. So, you look at the isolated tooth. It’s going to be a fabulous day. This is the first tooth in. You’re not even wearing a mask today because you want to smell that dental smoke going up your nose, and you want it to go through your hair. It’s a marvelous feeling; the dental smoke in the morning with a warm beer at 7:00 a.m. and you’re ready to do good.
All right, well I’d like you to visualize in your mind your access cavity, just chart it out mentally. I even say use lipstick on the top of the tooth. Well, then I want you to make your access actually about 80 percent of that. In other words, give yourself some air, a little fudge factor. You don’t know exactly unless you were the restoring dentist, how that restorative is placed on the tooth. It could have been upright for gnathology, for occlusion, work balance, and all that. Or it could be sitting right on the long axis of the root. But we don’t know.
And so at least the endodontist doesn’t know, because the endodontist didn’t do the crown. So, make your access about 80 percent of what it will ultimately expand and become. That’s a little trick. Once you get in, and you know where the orifices are, you can jockey your access a little bit north, south, east, west, to accommodate the pulpal floor anatomy. Okay, so make it 80 percent.
So, I like to use a transmetal bur, high speed handpiece, of course. And you’re moving in – we’ve already picked it up. We’ve just done a lot of drilling to get through a fairly thick casting, but I’m coming on around, and now I wanted to show this surgical length round bur, and notice where my head and my handpieces are; it’s almost off screen. I have a perfect line of vision. I can always watch everything I’m doing. There’s none of this cutting blind. A lot of you are still cutting blind and hoping to fall in and then 20 minutes later, you have your access done.
Just brush your way in, mesial distal, buccal lingual, about a half a millimeter, half a millimeter, half a millimeter as you advance down towards the pulpal root. And sometimes you’ll uncover some big denticles, stones. Think about doing this case with an orifice, directed access, a truss access, a ninja access, good luck. That’s a big stone. That’s a radicular stone in the pulp chamber and it had to be dissected out. Look at those projections that are extending down into the orifices, and look at how we chip out more. Can you imagine doing this through a truss? Some people are clever and they can do it, but I’m not teaching clever people; I’m teaching tens of thousands of dentists to do predictably better endodontics.
So, you can come in here with your high speed and your suction and your ultrasonics, blow out that dust. That’s what the Stropko does, blows out the dust. Track – track the interconnector from MB to ML, back and forth along the groove, and often times you will find a little orifice, and you can get a file started. Isn’t that exciting? You can come back and open it up with a GG 1 or 2 just to put a little mouth on it so you can see it. You can use your ultrasonics wet or dry to refine and blend in everything into your axial walls.
So, if you look at any cross-section through the root, any cross-section, if you imagine that root and its cross-section, obviously you’re like this and you’re like this, and you got your inner-connector. This canal is going to be always a little bit smaller than these bigger ones, right? Because why? That’s the furcal side concavity, so our mid-mesial is a little bit smaller than its counterparts MB and ML. All right. We’re just about done. And we can look at one more case, just one more case.
So, you’re going through crowns all day long. Access, maybe I can change your thinking. You’re not just accessing the pulp chamber, you’re accessing the foramen. So, when I’m making my access, I’m thinking like you are, but I’m also thinking about the canal’s multiplanar curvature, where it is positioned in the root relative to the external walls. I’m thinking about the terminus and is it quite curved. Is it abruptly curved? Is it a gentle sweeping curve? Is it relatively straight? I want you to think about what’s my irrigation technique? Will my access cavity support my 3D disinfection?
And then you’re probably standing in that triad and how do I feel root canal systems today? Oh, I’m doing vertical. I’m doing carrier-based obturation. I’m doing single cone. All these things will adjust your access accordingly. So, your access now in today’s world is based on technology, based on your philosophy and based on your willing to treat root canal systems. So, access your endodontics.
Okay, I even placed the post myself. I machined the post in chairside. It takes me three to five minutes. I use a transmittal bur, and I keep putting the post in until it drops down and is radiographically confirmed to sit on my gutta percha during the down pack. That way I’m not making an optimal shape even bigger to accommodate a post. And the thrill of the fill, furcal canals to furcal lesions, complete endodontics is what you’re trying to access. Thank you very much.
SEGMENT 2: Soon-to-be Published EndoActivator Article
Okay, so we mentioned in the opener that we’ve been busily working on two papers the last several months, and in this segment, we’re going to talk about the soon to be published EndoActivator article. And this article is called, Endodontic Disinfection 2022 Balancing Predictability, Possibility and Practicality. And you’ll notice there’s three things there.
Okay, got it.
And this is going to be published in the May issue of Dentistry Today. So, we’ve written a lot of papers on the EndoActivator and we’ve reported on it on this show. You might remember the fishing trip to Alaska where you got the idea for the EndoActivator. So, maybe you’re wondering what else we have to say about it. Well the EndoActivator has evolved and it has a whole new look, and why don’t you just tell us about the new technology and what’s the motivating factor for it to even change in the first place?
Well as you ask that question it’s so loaded cause I’m thinking of three years of R&D and all the little trips to Europe and – okay, really excited about it, because what we have is a new platform, and the platform is going to really improve your workflow. There’s three attachments. If you see to the far right, you have a transilluminator. That’s good for diagnostics for fractured teeth. If you look just to its left, you’ll see that we have a curing light. Some of you might be surprised to know, but this is one of the best rated curing lights in the world. It’s won awards. But what you probably don’t know is that 50 percent of all modern dentistry uses a curing light.
So, when we say workflow, we can do diagnostics, we’re doing 50 percent of the general dentist work is curing, build-ups, repairing, blah, blah, blah, blah. And then finally, if you see attached, the black attachment on the handpiece, that is the new EndoActivator. So, it’s pretty exciting. There’s a battery there. There’s two batteries. One’s up inside the distil end of the handpiece and then one’s just a backup. A battery usually would last an entire day of doing procedures. So, that’s pretty neat.
If you look at it side-by-side, it’s gotten a lot more sleek, the neck is thinner, it’s got a smaller head, smaller profile, so it keeps our lines of sight really quite nice. So, that’s just a comparison old and new. And then, of course, you can look a little bit more and you put this tip on and you go down into your reservoir of sodium hypochlorite and you’re agitating solution everywhere, so that’s exciting. But you’re going what the heck’s going on below the orifice?
Well, I’m not going to get into this now cause we’re just launching the article, we’re talking about new technology, but bubbles expand, implode and send out shockwaves and, of course, if you do that, that gets us to why we made some of the improvements. You wanted to know about the cross-section. The cross-section is a parallelogram, so that means it’s going to displace more liquid, so we’re just showing bubbles. We’re going to get more bubbles. We’re going to get better exchange, more penetration, circulation, digestion.
And then finally, we have a new movement. It used to be the old, linear motion. Now we’re moving elliptically. We’re making circles. So, all those things together are higher speed, better tip cross-section, better movement, we’re getting better exchange.
And I also heard you mention a very important word, workflow. And this makes me think of – and by the way, I really do like the new sleek design. But thinking about workflow, it makes me think of start to finish endodontics and how the EndoActivator fits into the whole procedure. So, what kind of canal shape needs to happen or what kind of canal preparation to maximize disinfection with the EndoActivator?
That’s a great question, because I kind of said that in another segment we’re doing here on access cavities. When you start doing your access cavity you got to start with the end in mind. Well what are the procedural flows that you use, your workflows, to get through start to finish. So, one thing I’d like to talk about then would be shaping facilitates clean, everybody. It always has. And well-shaped canals become well-filled canals.
So, we talk about appropriate shapes and I guess I want to guess show you a slide that shows, if we’re talking about Ultimate, it has a one millimeter diameter wire which means the part that actually goes below the orifice isn’t one millimeter, so we’re getting bodies on the order of 7,500th, 8,500th of a millimeter, depending on the length of the root, and that respects perfectly the concept of minimally invasive endodontics and strong teeth. And then, of course, we get the deep shape, and with Ultimate, as you know, the finishers are 7, 8 and 9 percent, just restricted to the first three millimeters.
So, when we get deep shape, guess what everybody, we can clean, and we have a lot of scientific evidence from multiple schools around the world showing that if you follow protocol, we can clean and we can fill because well-cleaned canals become well-filled canals and it’s quite easy for dentists all over the world to push thermal-softened materials and get a complete seal.
So, basically we need a root appropriate shape to use the EndoActivator in, and we do talk in our paper about some higher end disinfection technology.
That can clean very minimally prepared canals.
But we discussed a little bit what their value is and how their used and how they compare with the EndoActivator. Maybe – what are the higher end technologies we discussed?
Well you want me to talk about two, and I’ll talk about two, and then I’ll go A and B on one. Is that okay?
Permission? All right. so, we have lasers and GentleWave. They purport to like a shape on the order of about a 20/02 or a 15/04, somewhere in that neighborhood, which means the EndoActivator probably wouldn’t be able to go through its back and forth two-alpha pendular swing because it would be limited and restricted by the confines of the dental walls. But these new technologies, let’s take lasers, photon. Fotona makes Er:YAG laser. I really, really like it. It’s $100,000, and the thing that’s so cool is it can – the wand just sits up in the access only. It does not go below the orifice, so it’s very exciting. It’s $100,000 and it can do several kinds of procedures beyond disinfection.
There’s a new one that’s launched. It’s in the laser family. It’s the B part, and it requires the wand to go sub-orifice level, which I do not like because the thermal pressures, thermal burns, injuries to dentin and things like that, but a lot of people are thinking about that. So, we have lasers. That’s about $30,000, so $100,000, $30,000, lasers. Set those aside and go to GentleWave. GentleWave, you have to build a platform on the tooth, you got to put the handpiece, this is $100, roughly, $80 to $100 disposable handpiece. You got to throw it away after every single patient, but you have a closed system, and you cycle fluids through, and that’s about $70,000, and it’s a one-horse pony. It does disinfection. Stop.
Okay, well I do see that those might be a little bit harder, those technologies might be a little harder to just seamlessly fit into a workflow that you already have in place. Like you might have to make some adjustments. Also, a lot of GentleWave users –
Stop. You have to make a lot of adjustments. Just ask the users about they have to adjust their access cavities, they have to adjust their shaping schemes, they have to adjust how they fill a root, they’re adjusting everything, and we don’t really know scientifically, there’s a few sporadic papers here and there. Lasers have a great body of – listen, when I say lasers, I’m talking about Fotona Lasers; it’s a good one. A lot of the other lasers are not so good. They’re very, very expensive and they don’t have evidence behind them.
Well back to GentleWave, a lot of GentleWave users are claiming that they can so efficiently clean canals, that when it comes to obturation, they are filling root canal systems, like in other words, they’re seeing lateral canals filled on post-op radiographs. So, is this type of result unique to someone using a $70,000 technology or can these results be obtained with the EndoActivator as well?
Well, many of these cases were done before the EndoActivator. The EndoActivator is about $2 per patient. People all over the world have trained with me and have made their own discoveries on their own, have been filling root canal systems for as long as endodontics has been alive. I sent you a little thing on my phone the other day. It was 1948.
Oh yeah, I know, I saw that.
And that guy was filling root canal systems. So, if you have an appropriate shape and you have some ideas and using voluminous amounts of irrigant, you don’t have to go out and buy $100,000, $70,000, $30,000 of something to do it; you can do it just like that. So, filling root canal systems is novel for them, but not novel for me.
Okay, well the EndoActivator uses sonic energy, and we talk a lot in our paper about the sonic advantage, and we’ve actually talked about it a little bit on The Ruddle Show, too, comparing ultrasonics and sonics. But let’s go over it again. Why is it desirable to use sonic energy when you’re agitating an intracanal irrigant?
Well maybe I’ll just bring up a slide. It might, you know, remind us. But anyway, blue is sonics and gold is ultrasonics. You can see the blue line is going very slow through its sinusoidal wave curve on the X axis, but what you do see is enormous amplitude. There’s huge displacements. That’s very interesting when you want to move an intracanal irrigant. If you and I went to Padaro Lane and we wanted to do some body surfing, would we be looking for a pretty good wave to catch or would we want to see a little chop come along?
Well if there’s a little chop like with ultrasonics, you’re not going to catch the wave because there are no waves. Ultrasonics uses metal insert tips, so metal insert tips break, they dig into the walls of canals, especially if they’re curved, they ledge, they can transport if you carry them to length. But the most important thing is on the right. Sonic energy can go through huge two alphas. You can see about 5 millimeters out over the block unrestricted.
When you put that 5 millimeter back and forth and shove it into a shaped canal, a well prepared canal, it dampens the 2 alpha, but it’s still going to vigorously be striking the internal walls and if you bend it around a curve, notice how the tip continues to display full movement. When you do that with ultrasound, the tip stops moving.
With ultrasonics. So, with the ultrasonics you can see it dampens 2 alpha, you lose it largely, and now you’re not doing what you want to do. I might say one last thing. A metal instrument moving in a root is going to touch walls; it’s going to be generating the very smear layer you’re trying to remove.
Okay. Well in the paper we talk about the clinical protocol, which is very similar to the existing protocol for the EndoActivator.
And we talked about our show. We’re not going to go into it too much right now. It is available on our website. We do also mention, though, some adjunctive uses for the EndoActivator besides disinfection. What are those?
Well that’s kind of one thing I’m pretty proud about. We talked about GentleWave being a one-horse pony, and okay, so it can clean out a root canal system. I didn’t even mention bloody canals today, did I? Oh, I guess I didn’t mention the post-op pain, and I guess I didn’t mention you can only use it in selective cases, so you’re not even using it all the time. The EndoActivator, you can bring it at any time in a ballgame, so if there’s nine innings, you can bring it out on second inning, the fourth inning, the ninth inning, and if you have to adjust your prep, you don’t have to put the platform back on. With GentleWave, you can come back and use the EndoActivator again. Okay, just stick it any time you want to.
But probably what she wants me to tell you about is for years, decades, we’ve been using vibration with a polymer tip; it’s flexible and doesn’t cut, just said that for the first time, congratulations over here. You can move MTA, so we can use a mix of MTA, sub-orifice level, and we can move it and adapt it into a root defect, into a blunderbuss or an open apices. We can use it in the retreatment situation with a solvent, and we can agitate our solvent to remove remnants of obturation materials.
And finally, most of the profession is still using calcium hydroxide. So we can adapt on the first visit, the calcium hydroxide to whatever internally in the intaglia of the root, or second visit you got to get it out and most papers say you can’t get it all the way out unless you use some kind of ultrasound. So, we use it for those three things beyond disinfection.
Okay, I guess you can lower the speed setting; I guess there’s different settings?
Oh, thanks, on that first product shot there’s that on/off switch on the new EndoActivator, first bump is 18,000 cycles per minute, bump, bump, two bumps with close staccato, you go to 3,000 cycles per minute, and we would – thank you – we would use for those injunctive procedures, we would use it at 3,000.
So MTA doesn’t fly all over the place.
Well yeah, we’re not trying to sputter coat the wall of the office.
Okay, well I’m excited for the article to be published. Do you have any closing comments like I think we have a list of some main criteria to look for in a disinfection device.
Well okay, so you want to have an evidence-based idea. You know, we talk about this a lot and some of you out there I probably offend you. Listen, I don’t want to offend anybody that has GentleWave or laser, okay, you’re trying to do a better job. My point is there’s about one million dentists that are never going to have that technology and they need a way, too, so it has to have evidence, it needs to be easy to use, slide right into your workflow, and then, of course, it should be readily affordable. Well of course, it should be safe, it should be effective, and I would think it should have – contribute to the workflow when you’re doing a multi-procedural task with this tool.
That is a bonus that it’s multi-procedural,
So, that’s a big bonus for the EndoActivator.
Yeah, so what I was going to say that with all this activation stuff, maybe you could just activate your practice and activate your life and maybe activate your greatness.
Yes, well watch for the article. It’s going to be in Dentistry Today, but eventually we’ll have it on our website as well. So, yeah, thank you. Thank you for that information.
Thanks for the paper that will help support everything we’re saying.
CLOSE: Ruddle Flashback – Candlestick Park 1962
Okay, we’re going to close our show today with another Ruddle Flashback, and I think we’ve done a Ruddle Flashback every season, so this would be our seventh one. And right before we started the segment, I was thinking about some other Ruddle Flashbacks we’ve done, and I’ve jotted them down. There was the skill saw accident where you almost cut off your thumb. There was the Christmas tree in the fireplace.
Oh, don’t bring them all up.
Where the house almost burned down. There was winning on the slot machine in Las Vegas.
Visiting the Demilitarized Zone in South Korea, and the dentures flying out of your patient’s mouth during your board exams. So, yeah, definitely go back and check out some of the Ruddle Flashbacks because they’re interesting. It’s when my dad tells a little story about his past. So, today, you’re going to take us way, way back before I was even born, back to 1962 Candlestick Park.
Well okay, for you baseball people and maybe overseas, it’s a little less except in Japan and Latin America where a lot of our players come from, anyway, it’s Major League Baseball and as she said, it’s the year 1962. I’m 14 years old and it’s Candlestick Park. And for those of you who don’t know Candlestick Park is a baseball park, was a baseball park, it’s been leveled, but it was quite a grand park in its day, and it was just south of the city of San Francisco a few minutes by car. And I’ll take you back just a week earlier. A week earlier on October 16, it was game seven. So, the Yankees –
Of the World Series?
Of the World Series. So, two leagues play, the best teams go through a ladder and they face each other off in a World Series game. It’s seven games and it’s played alternately between the cities, four and three, so it was a home game for San Francisco. It was at Candlestick Park and it was game seven, and it was three games apiece. And I know these players so well, but Manny Alou was on first base, Willie Mays came up, hit a double, and he ended up at second and Manny was pushed over to third, so there’s runners on second and third and two outs.
And Willie McCovey comes up, big 6’7” guy. He hit a rope to Bobby Richardson at second base, and that ended the ball game, and that was the third out, and the Yankees won it 1-0. Okay, so, you know, I was watching all this on TV with my brother-in-law Carl Rosich, a retired dentist from Lodi, California, now but this was way back when he wasn’t even a dentisto yet.
He was like 18 or 19 and you were 14.
Yep. And I don’t know exactly how it came up. We didn’t have cell phones. But somehow we communicated by horse or by runner, and we decided that we should go to Candlestick Park. It would be absolutely fitting cause we’re such ball-crazed nuts that we just had to go back and experience the joy – cause I was a Yankee fan, remember. So, anyway, we decided to go over to the park, and so we get in his car, he’s driving, and we arrive at Candlestick Park and there’s huge concrete for cars. There’s no cars, nothing. The whole parking lot is empty. And we go, well, good and bad. Good because we’ll probably be able to investigate a little about the park, but –
You brought your gloves and your ball and your bat, right?
Well we had hoped to get on the field. So, anyway, people don’t believe the story now because they don’t remember this is 1962, for the third time. So, back then the season was over, there was apparently no players working out or stretching. The season was over. There was no front office people. There was no stadium people cleaning up or anything, and we arrived in center field and it was a high chain-link fence because at that day they hadn’t finished the park and closed it in with that new, modern scoreboard. So, we saw the 12-foot chain-link fence and I looked at Carl and he looked at me, and he said we can easily get over the fence.
So, we threw our glove over, threw the ball over, threw the bat over and all of a sudden we’re climbing up the fence. And then we dropped to the other side, and all of a sudden now we’re scared. We’re going, my God, what is there’s police or what if we get arrested. We got to get back over the fence. But there was nobody there. And finally we started yelling and you could hear sea gulls coming in off the bay, sweeping around over the stadium, and we began to play catch, and then we began to see if we could hit the ball. And you know, throw it up. It wasn’t like pitching.
And Carl, he disagrees with me, but he actually hit one out from home plate, and to left field, and I could not reach the outfield. I could only reach the warning track. So, I had to move out to past the pitcher’s mound close to second base and then at that age I was able to hit a whopper right out of the park.
So, anyway, that’s a flashback. It’s always been good memories. In fact, I was reminded of it because Carl and my sister, Pat, just drove through Santa Barbara and stopped, and guess what, this story came up, and then Lisa and I were thinking maybe this is flashback material. So, I’ll just leave you with this. Every ending has a new beginning, so that season ended but now there’s the eternal hope that spring training is here and we can play ball.
And it looks like it’s going to happen.
They made the agreements on the contracts and everything.
So, play ball.
Okay, well that was our show for today. Hope you enjoyed it and see you next time on The Ruddle Show.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
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