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Avoiding Burnout & Ledge Management Giving New Life to Your Practice & Managing Ledges
This show opens with a book review of Snow Treasure, an inspiring World War II story about ordinary citizens defending their country. Next, Ruddle and Lisette talk about how to avoid burnout by adding new technology and/or new procedures to your practice. Then, it is Ruddle at the Board, this time presenting how to manage Type I & II ledges. The show closes with a special Grandkids segment featuring Ruddle’s eldest grandson, Isaac, who will share some 3D printed creations from a galaxy far, far away.
Show Content & Timecodes01:03 - INTRO: Book Recommendation – Snow Treasure 06:21 - SEGMENT 1: Avoiding Burnout – Incorporating New Technologies & Procedures 23:31 - SEGMENT 2: Ledge Management – Managing Type I & Type II Ledges 49:04 - CLOSE: Grandkids – Isaac’s Clone Helmets
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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.
…I guess when we do this segment we’re going to have these helmets on the whole time.
I can’t see anything… [crosstalk]
I don’t know what…
Isaac… Am I going to run out of oxygen?
Oh it’s caught on your…
Careful… Obviously be careful of yourself…
INTRO: Book Recommendation – Snow Treasure
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle.
Are you happy to be here today?
Yes, I am.
And what have you got for us? I think we’re going to start off with one of my favorite things.
Okay, well it’s been awhile since we’ve done a book review on The Ruddle Show. Season 2 we talked about Into Thin Air by John Krakauer, and that’s a true story of summiting on Mount Everest. So, it’s time for another book review. And this time we thought we would do your favorite childhood book, and we brought this up briefly in a past segment of What Phyllis Thinks.
But here I have Snow Treasure by Marie McSwigan, and this is a 1942 novel, and how were you first introduced to this book?
When I was in grade school – oh, this is really exciting stuff. When I was in grade school we’d have lunch, then we’d have recess, and then we had quiet time. Quiet time was like maybe 20 minutes, and during quiet time, we often shot spit wads and did things that were misbehaving, so the teacher said she was going to start reading a book to us so we would all cooperate, so that’s how that happened. And in fact, this might be the only book yours truly read to my two daughters, Lisette and Lori, many, many years ago.
Okay, well just to give you a brief summary of the book, it takes place during World War II in Nazi occupied Norway, and it tells the story of Norwegian children, and the main characters are Peter, Michael, Helga and Louisa.
And these children use sleds over several weeks to smuggle the country’s gold bullion past German guards to a waiting ship, the Cleng Peerson, owned by Uncle Victor, and the plan is to take the gold to a safe location in America. Now as you can imagine, there are a lot of twists and turns and some close calls, but in the end, the ship is on its way to America. What really fascinated you about this book as a child?
Well, I used to live in Montana, so sledding was normal, long winters, and so all the time, I mean it was normal after school to grab a sled and find a hill or a mountain or an unoccupied ski lift, and we did that a lot. My dad even lashed a rope around his trailer hitch and pulled one, two, three sleds behind his car at different lengths, and that was a thrill. So, you know, I could get into the story because I was a kid and I was sledding a lot, and then these kids were doing extraordinary things.
The other thing that was interesting to me is how – this is just a little detail, but the adults would load the bullion on the sleds, and they’d lay down some burlap, and then they’d put the bricks on it and then they’d lash that down with a tarp and tie it to the frame of the sled, and they’d go down the hill and sometimes right by the Germans. In fact, Peter reports that he even saw the shine on their boots.
Yeah, those were some pretty – there was some moments that were pretty exciting.
Well apparently the author says that the story is based on actual happenings, but there are some historians who dispute it. In 1940, a ship carrying – it was a freighter named the Bomma, and it was carrying approximately $9 million worth of gold bullion. That arrived in Baltimore and the ship’s captain did report that it was gold bullion that had been smuggled past a German by children on their sleds. So, you know, maybe it is a true story. I guess the author said that she got the idea from the newspaper, from the newspaper headlines, but I guess she admitted to changing two things.
Oh, the two things she changed to me were insignificant. It didn’t change the character in the story. The Bomma turned out to be the Cleng Peerson, and there’s a whole way you can discover that. And then the other thing was she had the kids sledding from the village down to the fjord, 12 miles a trip. It was 35 miles a trip. Ask your kids, could they get on a sled and could they sled for 35 miles down to the port?
Well I personally want to believe it is a true story, and the children doing what they did, reminds me a little bit of what the Ukrainians are doing, taking up arms to defend their country. Like it’s just another tale of ordinary people doing extraordinary things. So, maybe this is actually a good book to read to your children nowadays, given the world’s present situation.
Yeah, and I’m left with two things. The amount of trust and confidence that the adults had in their children. And when you think about putting your child in that position, that might cause a pause for some parents. Then the children had enormous courage, and I thought – they made it into a game, but they were taking enormous risk, so I thought back to your Ukraine thing, that’s a really – that’s the way you win things. You dive in and roll up your sleeves.
Okay, well we definitely recommend this book, and we have a great show for you today, so let’s get going on it.
SEGMENT 1: Avoiding Burnout – Incorporating New Technologies & Procedures
Okay, so on past shows we have talked about how to avoid burnout, but mostly in terms of life balance and getting out of the office. But what happens if you don’t want to go back to the office after you take a break because you don’t like your practice or you find it too stressful? Or maybe you even regret becoming a dentist in the first place and find that treating patients seems like an unrewarding chore. Well –
– toward the end of last year, Dr. Eric Block, who is the author of The Stress-free Dentist; How to Overcome Burnout and Start Loving Dentistry Again. Well, he wrote a five-part article series for Dentistry Today News, and it was about how to overcome burnout in dentistry. And in this series he talked about how adding a new technology or a new procedure could spark excitement.
And so, we’re going to use his ideas as inspiration and build on that, but we’re going to talk about some actions you can take in your practice to start loving dentistry again. But first, let me talk about what Dr. Block says are the main reasons why burnout even happens. What are they?
Well the main reasons are typically enormous debt. I don’t know where you went to school, but I went to the University of Pacific in San Francisco, and that was like the second or third highest, most expensive school in North America. So, you come out of school a lot of times with a lot of debt, and I didn’t even mention if you go on to post-graduate school. And then a lot of times, let’s set that aside, your debt, but now you start practicing and you have staff, a team, and you have overhead, like staff, you have supplies, you have to pay rent or a mortgage payment.
So, there’s a lot of debt. There’s a lot of overhead and this can, over the weeks and months and years, it can start to beat you down. And then, of course, dentistry is strenuous. It’s tough physically and mentally. A lot of patients don’t understand when you’re sitting on your ass all day that it is physically exhausting because of all the things going on. So, there’s that.
And then I think there’s a feeling of insecurity, doubt, a lack of confidence and inadequacy, maybe feeling inadequacy, and here you are in your sixth or seventh year and you got the debt, you’re retiring it, but it’s still there. You’re paying big payments, you’ve got huge overhead, and then you’re exhausted, and then you feel inadequate.
Well it’s pretty easy to see why, you know, a lot of debt, lack of business training, and maybe the dynamics of the office could be very stressful.
But recognizing the problem is obviously the first step in solving it. What did you do in your practice to get some extra business training?
Well, that’s interesting. That takes me right to page 2 on my notes. Well what I did many years ago is I took three courses in no particular order and at different times in my life, but I took one called – from Marc B. Cooper. MBC was the business acronym, and he gave a course on ownership, leadership, management, and marketing. Well, each one of those courses was two days. You’re with about 20 other people that have similar issues, so you’re not all alone.
And during those two days, each segment over eight days everything, you learn a lot about infrastructure. And you learn a lot about business models and, you know, you just said, it, model success, success leaves clues, and you’re with all these people on breaks and they’re having this problem or that problem, and you begin to hear people that have solutions, and so that was very important.
Later in life, we jumped on a plane and took the staff down to see Omer Reed. I wasn’t a general dentist, but I took a course on case presentation, and what they did – there was about 20 people. These are small groups, so it’s nice. They took you, by yourself, and they marched you out of the room, and you were already embarrassed cause you were called out and you had to stand up and leave the room, and you went into a remote room where there was a camera, and there was a patient, a mock patient, laying in the chair, and you had a sheet of paper, and you knew what was going to be recommended for this patient, and you had to do case presentation.
Well when I saw my staff do this, and when I saw me do this, I realized we needed to get a lot better. We needed more confidence. We needed to actually believe what we were saying.
And I guess the last course we took we piled in the car about 6:00, 5:30 in the morning, grabbed all the staff and went down to Los Angeles and watched Tony Robbins. And Tony Robbins being an international motivational speaker. He's worked with Fortune 500 companies, he’s worked with boardrooms of the most elite businesses. You can’t go to that kind of a show, that’s about 1,000 people, and not come away tremendously excited. Sometime I’m going to have to take you on the fire walk.
Well clearly, I think that, you know, increasing your business training and your practice management knowledge, and then maybe getting tips from a motivational speaker seems like a good start to getting a handle on the stress that you have in your practice. You’re going to be better equipped to make a business plan, to reduce your debt, and maybe, you know, manage your overhead better, and maybe get inspired to improve your office culture, but what if you just don’t like the daily routine of practicing dentistry?
Well, Dr. Block suggests that something as simple as adding a new technology could really spark excitement and take your practice to a new level. So, what is an example of a technology that you might recommend adding that would be game changing?
Okay, so I’m really burned out, and I’m really depressed, and I’m now about this tall, and so if you want to like stand up straight and be really tall and have some fun, get your staff involved, and the most important thing I could say, get your team involved, because they’re going to be a big part of helping you achieve, and you don’t even know where the goal is, you just know you want to feel better about yourself.
So, for me, I’ve said this many times on this show, how about a microscope? Okay, I told you this story the other day, but there’s this guy in Texas. You will not be called out. Do not be embarrassed. The guy that sent me my shoes, and the guy that sent the coffee grinder, but that guy in Texas, he was doing pediatric dentistry. He was a general dentist doing a lot of pediatric dentistry. I’m not sure why. He never told me. He just said he did it for 10 years. He was baptized.
But then he moved to relocate his practice, and he started noticing that he was getting a lot of military people off of a large base of about 30,000, 40,000 people. So, he was like the resident guy to do the root canals, and he was completely over his head, he hated it, he didn’t know what he was doing, so he started watching The Ruddle Show. And I’m not plugging me. You could be watching anything to get – capture that inner person that’s great in you.
And so, he started – he bought a microscope, can you believe it? He’s 64, 65, he bought a microscope, and he is so excited about this opportunity with these military guys. So, he’s doing a lot of endo and he’s learning – he does CBCT, and this is a guy in his 60’s, so you know, it’s possible. So, the other thing is what that microscope, I think you said to me the other day, “Well what if they already have a microscope?” Did you hear about the new adapter?
The adapter, where’s your phone? Your adapter mounts your iPhone to the microscope, just like that, and you can use the microscope’s lenses and lighting to capture incredible movies, and you can play those movies on your phone to your friends, your family, to patients, to – you can organize them, you can get an editor, you can do any or all of it, you can store it, retrieve it, give lectures, start showing staff, you know, presentations like this is a before and after shot, put a bar across the eyes.
You can even take some of this stuff out in your waiting room and just have patient’s befores and afters, and you’re sparking a conversation. And the staff starts to feel energy because they see that what you’re doing internally is manifesting in patients asking for more treatment. So, that’s another idea. What else did I write down here?
Well, even something like the EndoActivator, not a big, pricey item, but it could, you know, invigorate you.
I know laser people and GentleWave people don’t want to hear this, but we have about 80,000 international users and the reason I know that they’re excited, like you say, is they send me their post-operative films, and they’re showing me lateral canals, furcal canals, they’re showing me multiple portals of exit. Do you think that isn’t going to put a spring in their step? Okay, so they’re already feeling a lot more excited about that.
And then, of course, take your staff with you, and maybe go to a study club, a local study club, that might be – we could start one, but maybe there’s one already there. Again, small groups of like-minded people to accomplish unordinary/extraordinary things.
Okay, well one piece of technology that Dr. Block added to his own practice was a 3D printer. Now this kind of intrigued me, because I remember in our second or third show that we ever did we talked about your trip to China and we talked about how the Chinese were 3D printing teeth that they then worked on, so that was interesting to me. I heard 3D printer and dentistry again, and I thought of that.
And then my son, Isaac, who is also our tech guy on The Ruddle Show, he’s going to be with us later on the show today talking about the 3D printer, but he makes these Star Wars Clone helmets, and I’ve seen his process evolve, so when I saw 3D printer, you know, was pretty excited about that.
Did that – we’re off script now, but did that put a spring in his step?
Okay, well back to the China thing, they practiced on the exact tooth they were going to be working on like tomorrow or the next day or the next week, so they did CBCT, they got that, then they used their oral scanner, they had software that converged these two methodologies, and then guess what, they printed out 3D the tooth that they were going to be working on I’ll just say tomorrow. And so, they in this case, they were doing C-shaped molars, so they were actually practicing on the tooth. I still can’t believe it. They’re practicing for tomorrow’s patient. It sounded too good to be true; I love that.
Well I guess Dr. Block with his 3D printer, he prints implant surgical guides, night guards, study models, bleaching trays, dentures, temporary prostheses and even perceived the future where he might be doing clear aligners.
So, he said he has a lot of fun with it, and his staff and his patients think it’s really cool, and it gives him something to talk about and be excited about. But also, besides adding a new technology, Dr. Block, who’s a general practitioner, also suggests maybe incorporating a new procedure, and something that he’s incorporated into his practice are implants, sleep and airway treatment, impression with digital scanners and clear aligners. So, what procedures do you think might be of value to add?
You probably yourself don’t appreciate how many emails I get from dentists, and they’re saying they’re afraid of endo, they might do these, maxillary anteriors, they refer out – they had a bad experience one time or were never taught well in the first place, and now later in life, they’re kind of going, you know, I would like to maybe get back into that, but I’m a little bit afraid, and I’m definitely undertrained.
So, if you just train up a little bit, and don’t start on a third molar. I was going to give a number, but we’re in the US, they wouldn’t work overseas. Don’t even start on molars, just do some maxillary anteriors, maybe venture into a few double-rooted teeth, and do 60 in a row, 70, and all of a sudden, guess what, you start to improve, you start to see things on the post-op film and you’re starting to go, I can do this, and that builds confidence. And when you remove all the doubt, the confidence shows up and the dentist is off and running. So, that’s a good example.
You know, this is a little bit more sophisticated, and you might need to take like a year of two-day courses, but implants. I mean implants are exciting. People come in with spaces and teeth that are not salvageable, so how do you get them back into as bite short of a big, long bridge or maybe a removable denture. So, implants, patients like them, and dentists can learn to work either restoring the implants or they can maybe use 3D imaging, and they can place the implant and restore the implant. So, there’s lots exciting things in that area.
Look, I’m not an orthodontist, and when I left dental school I just knew that you set the plane on the Frankfort plane which is your sideburns. That was the extent of my knowledge I just revealed. But lots of dentists, general dentists, go back and do a little bit of ortho training because they can do interceptive orthodontics, not the big cases, that’s orthodontics. But they would do interceptive and guide teeth, they’re a little bit misaligned, just kind of guide them as they’re coming in to be in great position. I know many, many dentists that have gotten such excitement out of the ortho part of their general dentistry practice. So, venture off in endo, maybe start some implants, get some ortho going, what else?
Oh, of course we’re in a society internationally where it’s the look. People want to have a nice smile, they have more confidence when they’re smiling, they feel like they – well a lot of people just keep their mouths shut; they’re embarrassed. So, if you can do aesthetic dentistry and then post these pictures in a nice book out in the front area where your patients are waiting for you to give them a great smile, maybe they never thought of it.
Sometimes a problem recognized is a problem half-solved. I mean if I’m going in there with brown stained coffee teeth and tea and I start seeing all these great smiles, I might be asking a question, what do you think about that procedure for me?
I know I’ve sat in the waiting room looking at before and after pictures like in a book, and it’s, you know, I’m like wow, I can’t believe they can do this.
So, another solution to, you know, spice up your practice could be to take your business on the road, like you know several clinicians, and some have even been on this show, who have gone to remote regions of the world to give dental care to people in need.
Yeah, Gary Glassman – well not only was he on a former show, he’s going to be on a future show. Oh my, it’s going to be a clinical procedure start to finish, shhh, tell your friends. Anyway, Gary has gone to Malaysia I believe and helped out with indigenous, but really it was Jamaica.
And in Jamaica the needs were so big in these villages that I don’t want to be out of school, but I think he started a simple clinic, he had to get it staffed, he’s from Canada, Toronto, and anyway, he did a lot of work there, and then we’ve had Rik van Mill and Rik’s been on the show, and Rik and his wife, Wilma, have gone to many places in the Middle East. I can’t remember them all. What was it, Doha and Oman.
Nepal they’ve been to.
Jordan. And they didn’t just go for the weekend. They went for like a few weeks. And so you learn a lot about the people, the culture, what they eat, the architecture. It’s really an enriching experience. And you come home on the plane, and you feel good about yourself because you gave back.
Okay, well I think we’ve pretty much said everything that we wanted to say. Block does state that adding a new technology or a procedure and really embracing it creates what he calls the 3 R’s, and that’s return on investment, reinvigorate your staff, and reinvent yourself.
Yeah, that’s really great, and I – you just said the key word. Take your staff along for the ride, because they need to feel the joy of what you’re all doing together as a team to make sick people well. They’ll get a big kick out of that. And speaking of teamwork, I have a quote for you.
You’ve never heard of this guy. His name is Michael Jordan. And Michael Jordan says, you know, “Talent wins games, but it’s teamwork and it’s intelligence that wins championships.”
We think we need to tell that to the Lakers. Okay, that was –
Good luck with that.
– very informative and I actually thought it was inspiring, so thank you.
SEGMENT 2: Ledge Management – Managing Type I & Type II Ledges
Welcome to another segment of Ruddle at the Board. Here we go. So, when we look at teeth that have been previously treated we oftentimes see posts. They may be misaligned with the long axis of the canal, we can see broken instruments, missed canals, and of course, we can see the ledge. Now what I want to say about the ledge is the ledge usually is formed because we have a blocked canal, and this is failure for colleagues to work to the radiographic terminus with smallest files.
So, we need to carry our instruments right to length so we can keep this debris in solution by passing a file through it and by wiggling that file back and forth in little, short, incremental, vertical strokes, we break this debris up, we move it into solution so it can be liberated. On another show we’re going to have to address blocks, because blocks are ubiquitous. They happen to everybody cause most of us were trained to work short of the radiographic terminus.
So, if we want to start looking then at ledge management, today I’m going to talk just briefly about a Type 1 ledge, but then we’ll focus more on the Type 2, because it’s Type 2 that gives us challenges in clinical endodontics. I mean just right off the bat, how do you slide a cone in there and get it to length if the cone’s going to trip up on the ledge. So, we have to use intelligence. Small ledges, slight ledges, like you’ll see right here, they represent a minor internal movement.
In other words, the block is often times the precursor and the larger files can’t get to length. Those larger files are stiffer, and they’re typically hand instruments or stainless steel, even NiTi as we get to bigger tip sizes, the files even with heat treatment get stiffer, and they begin to follow the outer wall of the curvature. They begin to follow this outer wall of the curvature.
And so, we can see right here a little, tiny Type 1. And a Type 1 ledge is going to be a nuisance. It’s going to – well, I almost said the word you don’t want me to say today, but it will really upset you, because it’s a nuisance. Every time you try to slide a file in there it trips up, you got to jockey it a little bit, get apical to the ledge, and then you slide right to length, and you’re really happy about that, but then you got to look forward to the cone fit and packing and all that, and so it’s just kind of a problem that needs to be rectified. Unfortunately, Type 1 is a minor movement, it’s an internal transportation.
We’ve talked about external transportations. That’s relocating the root to a new manmade opening on the external root surface, and that’s a tear. So, basically, if you have that same tear up here you have the Type 1. You’re going to use stainless steel files, you’re going to get out your viscous chelators, and you’re going to pre-curve the end of your instrument, and you’re going to curve it right towards the tip in the last one, two, three millimeters and maybe about 30 degrees, so a little turn on that file.
You’re going to torque that stop so it’s directed with the unidirectional stop that matches the curvature of the file, and that way when you get down to the impediment, you can begin to go north, east, south, west, you can jockey the file by watching the rubber stop and you can tell where the curve on the file is.
And so, first you’re going to have to break through that debris, and get through that debris so you can smooth it out. Oftentimes as you go through a series of instruments, you can get bigger tapers and those bigger tapers will grab that ledge. They’ll rasp it, they’ll refine it, they’ll smooth it and they’ll eliminate it. So, that’s a quick discussion about Type 1.
Stainless steel files, typically not a 6, not an 8, a 10 is about right. A 10 is stiff, it’s a little stiffer, and you might even want to try like a 10 C pilot file which is even heat hardened to be a little stiffer. Notice I didn’t say a C plus file or a C file, I said a 10 maybe 04, okay, you still have a small tip, but you have a little bit more rigidity behind it. So, now you can slide your cone to length and everything is fine, and that would be a quick discussion on the one that probably you can get through anyway.
Well, the one that I want to talk about now is the one that is more than just a nuisance. And this happens even with rotary instruments. Some rotary instruments are stiffer than others; some colleagues take bigger tip sizes to length. Those bigger files right on the outer wall, and if you have a blocked canal, you’re going to exaggerate the minor transportation, the Type 1 and you’ll turn it into a definite Type 2. It happens absolutely by cutting into the canal. When we cut into the canal, bad things happen. I was always trained to wiggle the file in. When it was snug, pull. I’m cutting on the outstroke. Most dentists, even today, around the world as you watch them in workshop, they’re cutting in towards length. So, don’t cut in, cut out.
So, when you have something like this the question is well can’t we treat it like a Type 1? Can we just, you know, get rid of this whole thing? Go back and look at your CBCT films, if you have that technology. Well definitely look at well angulated, different horizontally angulated films, because you’re going to want to determine root bulk and form. And if you have a little, thin root, you’ll probably mutilate the tooth in trying to remove a Type 2. We always have to then consider the restorative effort and then endodontically strong teeth over years of the patient’s life.
So, I’ve written a lot about this. Ironically, I just noticed right now, I guess it’s about 20 years ago when we wrote that in Pathways of the Pulp. Okay, so that would be kind of the schematic I’d like you to carry around in your brain library of transportations internally, internal transportations or ledges. And so, you can begin to see you can get a really nice shape up here. Why do we shape canals? So, we can irrigate, we can use dynamic irrigation to move our instruments into the un-instrumental aspects of the canal, so we want to get to length, we want to be patent, but it might be impractical to try to remove that ledge because of weakening the root.
So, that’s kind of what I want you to think about. You’re still going to have to deal with the block. It’s more than a Type 1, so this is when you got to roll up your sleeves and you got to have time. In fact, I went back and looked at Pathways of the Pulp yesterday just to see well what did I say about it 20 years ago. And what I basically said is more than anything it requires patience and time. You know, you can’t be in a hurry. They’re not all the same. They’re not all billed to the insurance exactly the same. There are different peculiarities.
And in my case, I’m getting the ledge, the transportation, whatever it is, it’s getting referred into me, okay? So, you can either have it happen to yourself live, and then it’s almost like a retreatment situation, you know, you’re not even done yet, or it could be referred to you and you could be trying to overcome somebody else’s – well, regrettably we’ll just call a deficiency in training. I hate to be rude, but this is all training stuff. Okay.
So, when you have that, you’re going to walk down in here, and first you’re going to pre-curve your files, like a 10. 15 is too big. 10 is stiff enough. I like to use viscous chelators, RC Prep, ProLube or Glide, and that gives you emulsification. It helps to prevent the – this is a cocktail. It’s not just a dentinal block. It’s usually got fragments of tissue in it, so you want to keep those tissues from sticking back to each other. That’s like glue, that’s like collagenous tissue in a cocktail dentinal debris. So, you want to get the canal open and unobstructed.
And the little trick could be if you pass a small file a little bit beyond the foramen, as you move up a 10 file, a 10 file at D1 is a 12. Oh, I don’t know if I can do this. This would be way too hard. We’ll just have to erase it and we’ll start over. But a 10 file is a 10 file at D. At D, it’s a 12. At D, it’s a 14, and it’s a 16, and it’s an 18, and it’s a 20. So, 4 and 5. So, D1, 2, 3, 4, 5, so this is D5, five millimeters up on the file.
So, if that file comes out and it’s a little bit long, you’re catching greater increasing cross-sectional diameters, and that begins to rasp and rasp and refine and smooth. You’re not going to get it out, but you’re going to get it to be the more predictable path, especially if you know it’s on the southeast wall. No, it’s on the northwest side. If you know that with your uni-directional stop, then we can curve our files, and when we get about a millimeter above the impediment, when we get about right in here, we can now redirect the file so that it is curved to go up and off this ledge and feed into the physiologic terminus.
Okay, let’s take a look at how we might do this. So, this is a simulation of a plastic block. It’s the old S block, double curvature, so you don’t know if you’re dealing with a block or a ledge, right? The clinician doesn’t know. Is it just a blocked canal or is it a ledge canal? Is it a block and ledge canal? Well look at your radiographs carefully, because oftentimes if there’s lesions of endodontic origin, the foramen will feed to the LEO, okay, so lesions form adjacent to the portals of exit. Ah, fundamental. So, try to steer your file towards a LEO.
Now when you get the 10 file in here, you’re going to not go to length immediately, but you’re going to do a lot of little mini up/down vertical amplitude strokes to smooth and refine the pathway and get it bigger and progressively bigger and larger so that the next file can go in there. We could basically convert any rotary file with a manual handle, and chairside we can do that in two seconds. And now we have a manual file; no rotary at this point, too dangerous.
Well, we can use the bird beak orthodontic plier, the bird beak’s orthodontic plier, and we have something I can show you, I believe, is a way to curve that. And you can just roll that handle. So, pinch it, pinch it, take the handle and pull the handle through a radius, and you have to do that like at least 180 to 270 degrees. You have to over curve it. It’s NiTi. It has shape memory. It will spring back and try to be straight, was made straight, always tries to get straight. So, you have to over curve NiTi. Now heat treatment’s easier, but in this case, I don’t know if I want to really highly heat-treated instrument because it’s too soft, so I prefer just straight NiTi.
So, you can put the curve on it. You notice the little orientational, unidirectional stop, the file then is curved to simulate where that marker is so you know where you are, and now we can take that, and I’m going to actually pause. This is what’s so cool about greater tapered files. Hey, lock in, greater taper. I just showed you the 10 file, and I said that was at D1. It was a 10, I said at D5, guess what, I said it was a 20, equivalent to a 20 file. But an S1 at D5 is almost a 40, almost equivalent to a 40 file.
So, you can see you have twice the taper. Twice the taper back here means you have a greater chance to start to engage that shelf, that ledge, that impediment. Oh yes, I saw thousands of these in my life. I’m getting chills down my back right now. All right. So, you want to be sure to use a greater tapered file. In fact, Steve Buchanan, back in the 90’s, had a file that was 6 percent, 8 percent, 10 percent 12 percent, and they had a maximum flute diameter of 1 millimeter.
Those might have been almost the perfect instruments for ledge management because they had big taper, but the files were basically all 20 at the tip. They just got 20 and then it got 6, 8, 10, 12, so those were great instruments, especially when you’re in the apical one-third which is about 3, 4, 5 millimeters. All right. So, we’ll come off pause and we’ll let this file work.
So, we just said a D5. The S1 is about twice as big as a 10 file. And then we said even a greater tapered file than an S1 could be used. In fact, if you could get an F3, 30/09 and if you just got it a little bit past the ledge, you could restrict your work to right in through here, right in through here, and that way you’re not going to length, but you’re progressively smoothing and refining.
So, here I am with the S2. It’s about two and a half times bigger than a 10. I don’t want you to put a 15 file in here, a 10 is enough. A 10 gives you plenty of spatial glide path for instruments to follow, and so you can use these instruments intelligently, thoughtfully, and be thinking about where’s the impediment, how far down is it from my reference point, what’s my working length? You’ve got all that discovered now. And here we going with a 20/07, a 20/07, so you can see 7 percent, you know, 27, 34, 41, 49, something like that, 48, 49. Anyway, you can see you’re getting pretty big up there about 5 millimeters away from length.
And that gives you an opportunity to throw a 20/02 in. A 20/02 is passive through it’s whole length. You’re just checking to see – you’re gauging the foramen to see if you used a 20/07, then what about the 20/02, and you can see the 20/02 is very much more parallel, but they have agreement, so you take a cone and you hold it next to the last file that was snug at length, your 20/02, and you snip it. Use a gutta gauge; those are great.
Maillefer makes a gutta gauge, and you can just stick a pointed cone through the 20 hole and take a scalpel and cut it off and you’ll have a perfect machined out 2/10the of a millimeter cone. The idea is the cone should go and be trimmed accordingly to the last file that was at length because that would capture the cross-sectional diameter of the terminus. All right. Okay. Are you having fun yet, are you getting some ideas? Cause I think I’m getting some ideas.
I’m ready to go handle an internal ledge. So, you got a cone. Trick. Take a dappen dish, fill it up with isopropyl alcohol. Why don’t we just say about 70 percent. About 70 percent. Bend your cone between your gloved fingers, just bend the cone so that your cone has a, you know, here’s your cone. You just sit it in here. If you dip that cone in an isopropyl bath for five seconds, that cone is rigid and stiff. Now notch your cone, notch your cone, not only for working length, but notch your cone for orientation, orientation.
So, when you get to like – let’s just pretend that we’re working at 21 millimeters, we know the impediment is about oh, let’s just say 17 millimeters, and let me get some of this stuff out of here. So, you know that this is a 20 and 20 is the working length, and your impediment, let’s just say for fun is at about 16 millimeters. So, when you get down in the canal and you’re coming – sliding that cone in at about 15, maybe 14 millimeters, torque the cone with your fingers, you’re not putting it in with a plier, and roll that cone around and orientate it so the curve is going uphill, uphill, and you’ll be away from the ledge, you’ll steer it past and then seat it. That’s a really good trick.
I’ve been teaching that little trick for probably about 35 years, and I’ve noticed that a lot of people were like wow, that thing is almost as hard as a silverpoint. Another trick, I threw this in last night at 10:00 in the cans. I put it in late. You know, the M4 handpiece comes to mind because it’s readily available. Sybron Endo has the M4 reciprocating handpiece. Let’s remember, it’s clockwise, 30 degrees, counterclockwise 30 degrees, chu, chu, chu, chu, equal bidirectional angles, M4.
What’s great about the M4 is you can work a hand file apical to the impediment. Then you can come over with your M4 and it will chuck up the handle of your ISO file. How about that? So, once you get the file in there and past the impediment, you can now latch onto a handpiece and work that, and that’s much more efficient than your fingers, and you can begin to rasp out a lot of Type 1’s. Now this is not an M4, this is not to market yet. It will be to market in 2023. Whoa, 2023, yeah.
This one is called – we won’t disclose the angles today, but we’ll just say it is a micro-reciprocation idea. And it’s very, very micro angles compared to 30/30, and they’re not equal. And we can use that idea to get through blocks, Type 1 ledges, and Type 2 ledges. And you can see some of these canals with no hand instruments. I particularly thought this was interesting. Those are nasty curves and very, very thin roots. And this is deceptively tricky, so you’ve got three systems. So, basically, you’re going to see a big change going forward in how we negotiate and create glide paths.
All right, so let’s look at a few cases, and then we’ll be done. And I’m looking over at my time, and I’m just on time because I got to go really fast now. All right. You get a lot of cases like this. This is just poor training, a lack of understanding. The terminus should be up into this region right here. You can already map it, and if you try to draw a little line, you can see we have a definite shelf, definite shelf.
So, you are thinking, you know, this is an anterior, it’s not going to be a big deal, I can find that apical part. Remember, a lot of ledge canals were previously – blocked, blocked. So, with a little bit of effort, viscous chelators, a size 10 file, this took me two one-hour visits. What did I say about patience and time? What did I say about being your word to the canal? Keeping your promise, okay, be your best. Yeah, you can go in and do surgery and whack off the end of root, do an apicoectomy, but a lot of patients don’t like that. I refer to this case fondly as my “anchors away case,” anchors away, we’re going to sail right to the end.
A lot of these training is the major thing, in college we’re trained to work short. College we’re trained to grind 35 stainless steel hand files to length. Remember you’re seeing a lot of retreatments years after the initial treatment was completed. It takes time for things to fail and leak, and over time, this is a problem. Not only is it an apical problem, but it’s an asymmetrical problem. This is where our LEO is.
You must talk to your patients. Listen, tell them, I might have to do a little surgery.
Let’s try our best to do it non-surgically, but show them with pictures what you’re challenge is and what you’re going to try to do, and then if you fail, you can still wait a little time, but if you watch it on recalls and it’s not responding or they’re in pain, you have to do surgery.
So, remember how we can curve, even rotary handle files. We can convert them into manual files, and then we can spend some time, we can go around the physiologic canal, we can fill the false pathway, so we have a false pathway from the previous dentist. Ruddle is finally able to pick up the 90, almost 90, guess it’s about 80, and there is a lateral canal to a lateral root lesion. This makes a clinician feel very pleased, because you’re now filling root canal systems, and it explains the pathological outline pattern.
Molars can come in. So, I showed you an anterior, I showed you a bi. Here’s the molar. If you look at this distance, if you look at this distance, it’s not symmetrical. That’s not following the canal. From different angles you can already see it’s probably a ledge. Is it Type 1 or 2, we don’t know. Is it blocked apically? Could be. So, those are all chairside discussions you have. The block is worse than the ledge sometimes, okay, the block is worse than the ledge.
Broken instrument and the distal buckle, yeah, I saw it. But we’re only trying to make this patient asymptomatic. This is a physician. He’s very busy. He’s in the OR all day long. He has no time to come in for multiple visits. So, we were going to do the least amount of work to get the biggest possible result, asymptomatic and healing. So, you can see in the post-op film there was two apical portals of exit. We were able to get back in an apical to the shelf and get two systems. We did not do the DB and the palatal.
And then finally, the last case, I told you about all these iatrogenic things, but let’s just reveal there are pathological problems, and these pathological problems, sometimes they create shelves and ledges internally that are tricky. So, you can see it’s going to be a long access pattern; we’re going to make our access pattern and cavity, extend it clear up to the gutta percha, we have to realize it’s already a pretty big hole up here, so we don’t have a lot of wall thickness. We have a big punched out internal resorption area, and we have a lesion and a larger lesion.
So, that’s how I see the case through my eyes, and of course, there’s all the discussion, surgery, bleaching discolored tooth, et cetera, and we can start working. Of course, we talked about internal resorption. They can be perforating. You can have vascular issues then to manage. That’s another lecture. You can see with the cone out, we basically have blood coming from the palatal side, or I’m sorry, the facial side. You can see the defect right in through here.
And so, finally, we can get all that cleaned out, we can get hemostasis, and then we can fit our cone and we can get on that with heat and pressure once it’s got sealer on it. Kerr Pulp Canal Sealer is still my sealer, and we can carry a heat wave right up through this master cone. We can move gutta percha and complex laterally and vertically, and we can get a really tight seal.
Now this is a good friend of mine, he’s an endodontist, and we’re about 30 years later, and I won’t mention his name from the San Francisco Bay Area. He still has his central incisor. I hope today you learned a little bit about resorptions that can cause ledges, but we’re talking primarily about the internal ledge, Type 1’s and 2’s. I hope you’ve learned a little bit, and I hope you will buff out your ledges. And more importantly, I hope you will prevent getting ledges.
CLOSE: Grandkids – Isaac’s Clone Helmets
All right, so my mom and dad have five grandchildren, two from me and three from Lori, and you have seen them on past seasons of The Ruddle Show, they’ve made some appearances, and also you are probably aware that Isaac, my oldest, who’s 23 years old, is also The Ruddle Show cameraman, editor, graphics designer and is actually challenging now to have him also on the show, but we’re doing it.
And we thought it would be really cool to have a segment called Grandkids over the next seasons where we feature one of the grandchildren in the close, in our close to the show, and explain what they’re up to, and you know, it’s just kind of interesting. So, do you know what they say about grandchildren? I found an anonymous quote, and I think it kind of sums it up.
“Grandchildren restore our zest for life and our faith in humanity.” And since today we talked about overcoming burnout and also at the beginning ordinary citizens doing extraordinary things, this is like the perfect show to debut our Grandkids segment. So, today we are welcoming you, Isaac Clifford Kershner, to The Ruddle Show. Welcome.
Welcome, Isaac Clifford. It’s just great to have you on the show, and you know what, as we’re sitting here I’m wondering who’s running the controls?
That’s Lori, so I’m wishing her the best.
All right, Isaac, why don’t you tell us what we have here, and how a 3D printer relates to all of this.
Okay, so I make with my friend, Drake, clone helmets from the movie Star Wars, and each of these is a different helmet. And these two, this one and this one, are 3D printed entirely, and then these two are molds from this, which – should I just go into the whole –
Tell us your process, yes.
Okay, so what we do, what we used to do is we used to 3D print a whole helmet and they look like this. And so the same with that one over there. And that was a really fun, but it took a long time, because 3D printed objects are – they have to be printed and then you have to sand them down a lot, and then they are painted, unlike those two.
But we realized that to make things more efficient for like producing them for selling and stuff, it would be better to make one master helmet and then make a mold and a cast from them, which is how these two right here were made. I don’t know if both of these can be seen simultaneously. There they are.
Nice, very nice.
So, that’s how these two are made. This one is actually a Ukrainian helmet. We made it based off of the flag. You can’t really see the symbol here, but it is made – inspired by the Ukraine conflict.
Okay, well when you – I know you – last year you purchased two 3D printers. Were you thinking this is what you were going to do with it or did you not really know at that point when you purchased the 3D printers?
When I first started printing we – I got a printer like beginning of last year. And I started playing around with it, and I started making like little things, and then I started realizing maybe I could print things I made like this right here. I don’t know. That helmet, and I tried that and it took a really long time, like three weeks, to print. And then I got – I started talking to my friend, Drake, I’m like hey, we could actually make helmets, like fully, and we kind of worked it out. I went through a lot of trial and error and we started printing helmets a little faster and a little faster until we got to the point where we now have a house full of helmets, which we haven’t sold any yet, but that is the goal.
Well you kind of told me then what the goal was. I was asking was this a means to an end of is this newfound knowledge really a springboard to something else?
I don’t really like to think of that far ahead. The goal is to sell helmets, because they’re really fun to make –
He’s going to make a good businessman.
They’re really fun to make. They’re just – it’s hard to get every single aspect at making one helmet down. I mean you can see this one, for example, has – and it’s falling apart almost. Oh, one thing I’m planning on printing soon is attachments for this. Yeah, to like you can slide the thing on. So, the 3D printers are so very much in this process, but I don’t really have any huge plans other than we want to sell them, me and Drake, and we have yet to do so, so we’re pushing to do that. It just seems like we constantly run into new problems, and have to solve those.
Well what advice would you give to someone who purchased a 3D printer? I mean is it hard to get started? Cause I know that you have a very mechanical mind and I know that you’ve had to do a lot of tweaking and stuff. Would you say that anyone can do it, or maybe it takes a certain type of person?
Yeah, I think now especially with the internet, it’s possible for anybody to get involved. I will say you have to be willing to like run into a lot of problems and kind of constantly have struggles and be able to solve problems is a good I’d say thing to have, because I mean I print – this mold is like a master helmet now and it – I mean we’ve printed maybe – I’ve printed – we have like 20 helmets or so. I’ve printed maybe like 40, and it’s evolving over time. I mean in our basement there’s just a pile of helmets and they’re all failures. But yeah, so I would say you have to just –
Or they’re stepping stones to success.
Yes, exactly. So, I would say that you definitely need to – you definitely want to be able to solve problems and then you also have to be very willing to completely fail a lot, and that’s horrible sometimes, but me and my friend get through it and we are now here, so that’s kind of cool.
One thing I noticed in our Zoom meetings, we have Zoom meetings like in preparation for the show, and so it’s very convenient. But Isaac is running the Zoom meeting and Lisa and I are there interfacing. And Isaac started showing Lisa and I just recently some coding. You want to speak about coding? That threw a little curve ball at me. I thought, wow, that’s going to help catapult you to another level.
Yeah, so I mean speaking of problem-solving, the other thing I try to do is make games, and I am – I’d say I don’t know anything and I look up everything I need to know, and I spend a lot of time just messing around until I get the results. And recently I started actually trying to do Rossi Plus Plus code, and it was very hard, but I’m getting farther than ever with it, so kind of neat. Maybe I’ll show that sometime on this show. I don’t know.
Well very exciting, Isaac. I know that it’s fun to watch you because you’re always so busy with your different projects, but you’re also always so excited about everything you’re working on, and so it’s just kind of a joy to see just someone working with so much excitement.
Well I guess I’ll close my part by saying, you remind me a little bit of me. And that makes me very happy because the inventor’s journey requires what? Imagination and curiosity and critical thinking. So, great job, pal.
Thank you. And also thank you, Drake, who helps with sanding, painting, and gluing and all that.
All right, well thanks for sharing these, and next time, we’ll feature another one of the grandkids. We’re still deciding who, but stay tuned for that, and I hope you enjoyed our show. That’s it for today. See you next time on The Ruddle Show.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.