Start-To-Finish Endodontics Special Guest Presentation featuring Dr. Gary Glassman

A lot has happened in the sports world over the past few months, so Ruddle and Lisette take a time out to highlight a couple of their favorite moments. Next, we have a special presentation on start-to-finish endodontics by Toronto endodontist and past Ruddle Show guest, Dr. Gary Glassman. After, Ruddle and Lisette have a brief post-presentation discussion, provide some commentary, and “connect the dots.” The show closes with a bit of cynical humor and tough love, courtesy of Demotivators.

Show Content & Timecodes


01:04 - INTRO: Sports Update
06:54 - SEGMENT 1: Start-to-Finish Endodontics – Presentation by Dr. Gary Glassman
27:03 - SEGMENT 2: Post-Presentation Discussion
44:13 - CLOSE: Demotivators

Extra content referenced within show:

  • Special Show Guest: Dr. Gary Glassman
  • Entertainment & Sports Programming Network (ESPN): www.espn.com
  • Ruddle Supply Listing “Shape•Clean•Pack” (see downloadable PDF below)
  • Ruddle Content on "ProTaper Ultimate" and "3D Obturation" (see downloadable PDFs below)
  • Demotivators: Courtesy of https://despair.com

  • Extra movie/video content:

  • Just-In-Time® Videos on "Shape•Clean•Pack": https://www.endoruddle.com/jit/browse/305/shape-clean-pack

  • Select PDF content displayed below. See Ruddle's complete library of downloadable PDF content at www.endoruddle.com/pdfs

    See also Ruddle's complete Just-In-Time® Video Library at www.endoruddle.com/jit

    Downloadable PDFs & Related Materials

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    May 2022

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    "ProTaper Ultimate"
    Mar 2022

    Ruddle Shaping & Finishing Technique Card featuring ProTaper Ultimate

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    "Filling Root Canal Systems"
    Apr 2010

    Virtually all dentists are intrigued when endodontic post-treatment radiographs exhibit filled accessory canals. Filling root canal systems represents the culmination and successful fulfillment of a series of procedural steps that comprise start-to-finish endodontics...

    Ruddle Supply List
    Shape•Clean•Pack
    Apr 2022

    Ruddle on Shape•Clean•Pack Supply List and Supplier Contact Information Listing

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    Disclaimer

    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.

    OPENER

    Glassman

    …The first thing we’re going to do is we’re going to place dental dam, absolutely imperative.

    Cliff

    He used the wrong rubber dam! No, I noticed he used the – it’s called the Young type frame, and I used an Ostby Type frame. So here it looked very different, but we have so much in common…

    [music playing]

    INTRO: Sports Update

    Lisette

    Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle.

    Cliff

    Welcome, and this is The Ruddle Show, and I am Cliff Ruddle. What have you got today?

    Lisette

    Okay, well it’s been awhile since we’ve done a sports update, so I think we should do one.

    Cliff

    Hmm.

    Lisette

    For those of you who watch our show regularly, you know that we are big sports fans of several different sports, much like Greek tragedy is catharsis for the ancient Greeks; well sports is our catharsis. And just in case you don’t know what catharsis means, it means the release or purging of very strong emotions. So, a lot has happened in the sports world since we last talked about sports on the show, so how about I’ll say a sport and maybe you can say a highlight or a recent development or maybe I’ll say something, too, if I can think of something. So, let’s start with baseball.

    Cliff

    Oh baseball, Jackie Robinson, number 42, baseball season started this spring, and we have baseball, and every team, every player, had a number 42 for Jackie Robinson, the first Black player that Branch Rickey for the Los Angeles – whoops, Brooklyn Dodgers, hired him, and the rest is history.

    Lisette

    Okay. I guess like baseball almost had a strike, but then that was like narrowly averted, so –

    Cliff

    Yeah, we have 162 games. The full season is in front of us, and spring training was compressed because of the strike, but now here we are, we’re playing ball.

    Lisette

    Well I saw on the ESPN website with just about 10 games played, the Dodgers are favored to win it all, so that’s exciting.

    Cliff

    No, they were last year too.

    Lisette

    Okay, how about American football?

    Cliff

    Well we have a new Super Bowl champ 100 miles south of us, Los Angeles Rams, otherwise known for me as the Los Angeles Rams, but we almost said lambs, but anyway, that’s not my team, but I’m glad Reid Pullen is watching, cause that is Reid’s team, and Reid was in the stadium.

    Lisette

    Well I know that the Raiders, they got arguably the number one wide receiver, Davante Adams from the Green Bay Packers, so –

    Cliff

    So Gary Carr has somebody to throw to.

    Lisette

    Yes, I have – or Derek Carr.

    Cliff

    Yes, that was said through the mind of an endodontist. Derek Carr, the Raiders’ quarterback.

    Lisette

    Okay.

    Cliff

    Nice catch.

    Lisette

    How about basketball?

    Cliff

    Well, we’re right in the heart of the playoffs, not the heart, we’re at the beginning of the heart. Yes, the playoffs have started, the play-on games are done and now we have the final teams that are playing, and there’s a lot of – maybe Brooklyn, Miami, Milwaukee out east, Phoenix is interesting in the west. We’ll have to let them play.

    Lisette

    Yeah, the Lakers aren’t playing, and that’s an embarrassing situation, so we’ll skip it.

    Cliff

    I’m really glad they’re not in the playoffs. They really stunk it up this year.

    Lisette

    Okay, how about European soccer or European football, also known as soccer here.

    Cliff

    Well I’m happy to announce, as you know, we talked about it, the US National Squad qualified, so you know, we were playing in CONCACAF and we have Canada was number one I believe. We were two. Mexico was three, and maybe there’s one more that’s going, but they’re going to Qatar or Qatar or Qatar. And so, that’s going to be the first World Cup in an Arab country, so nice; I hope they stay cool.

    Lisette

    Yeah, we actually had a guest staying with us, Leo, from the UK, from Sheffield, and so we’ve had soccer on a lot in our house lately, and I’m learning all about the English Premier League, the Champions League, the various other tournaments and leagues. His favorite team is Tottenham, which I was corrected cause I said Tottenham. But it’s pronounced Tottenham.

    Cliff

    Yeah.

    Lisette

    And just so that there’s no confusion, West Ham is West Ham, not Westham. So, and then I guess we can just like, you know, tennis season just started and the Australian Open’s been played and coming up is the French Open in Wimbledon, so that’s exciting.

    Cliff

    It is, because maybe we’ll have more of the full squad of international players. We lost Djokovic to the Australian Open and I think the US Open, right?

    Lisette

    Oh, the US Open, I don’t know, that happened last year. I don’t remember what happened.

    Cliff

    Last year and then it spilled over to the Australian Open, but they’re all coming together. I guess it’s Roland Garros will be the crowning grand slam and as clay season started and Tsitsipas won the Monaco Open, so here we go.

    Lisette

    Yeah, I guess world events are impacting all sports still. Djokovic didn’t get to play in the Australian Open. So, we’ll see what happens with the French Open in Wimbledon, not only regarding vaccine mandates but there’s also been talk about maybe some restrictions on Russian athletes, so everything is very fluid though right now, so we’ll see what happens. And then we also had the Olympics. Did you watch any of that?

    Cliff

    Well I didn’t watch as many Olympics as I normally do, but I do know there was the usual – probably most viewed would be – you can disagree with me, but I’m just guessing, this is not a – I didn’t look it up. It might be figure skating and then it might be – I know there’s a lot of interest in hockey.

    Lisette

    Snowboarding. Snowboarding is very popular.

    Cliff

    Oh yeah, and the Canadian women beat the US women in the Gold Cup.

    Lisette

    Right.

    Cliff

    Final, got the gold.

    Lisette

    Well a lot of exciting times…

    Cliff

    Half-pipe!

    Lisette

    Yeah, that’s actually really – that’s fun with skiing and snowboarding.

    Cliff

    Biathlon, lots of interesting things. So, there was something for everybody.

    Lisette

    Okay, well I just love it; so much sports, and –

    Cliff

    Soon they’re going to have the endodontics in the Olympics. I’m training for that right now.

    Lisette

    Okay, well we have a great show for you today. Let’s get going on it.

    [music playing]

    SEGMENT 1: Start-to-Finish Endodontics – Presentation by Dr. Gary Glassman

    Lisette

    All right, today we have a guest presentation which you will see momentarily. The presentation is by Dr. Gary Glassman from Toronto, Ontario in Canada, and we actually featured Gary on a show from Season 4, so if you haven’t seen that show, you might want to check out our interview with him to learn what Dr. Glassman is all about. So, what is the topic of the presentation and maybe give us a little context of why we have this presentation that we’re showing today.

    Cliff

    Well it happened in a very serendipitous way. Gary was supposed to give a live patient demo at the Pacific Dental Conference in Vancouver, which is my favorite city on earth. I love lecturing there. It’s just fabulous. Well then they decided, the meeting planners said no live demos because of COVID concerns. So, then they said, Gary, could you do it at home and give us a finished edited copy, and so when I was talking to him about this I said, “What did you get it down to?” And he said, “A minute.” No, he said, “60 minutes.”

    And I said, okay, so you already took maybe an hour and a half procedure cause you’re filming it, maybe an hour and 45, you compressed it down. I said, “If you can compress it down to 20 minutes, I’d like to put it on the show.” And he said, “Done.” So, you know, what a great guy. So, anyway, it’s a little bit about start to finish endo and it is going to focus on Ultimate but there’s so many more things besides the files and the shaping and the glide path management, and you’ll see a lot of other things that we’ll talk about after that segment.

    Lisette

    Okay, well just to tell you a little bit about Dr. Glassman, he is on staff at the University of Toronto and also maintains a private practice. He has published numerous articles. He’s lectured globally on endodontics. He gives seminars, he is the endodontic editor for Oral Health Journal and also on the editorial board for Inside Dentistry. And he’s a Chief Dental Officer for a dental support organization, Dental Corps. And if that’s not enough for you, he’s also done a lot of philanthropic work in the Caribbean, specifically in Jamaica, to raise the level of dental care there. So, we’re very honored to have the opportunity to show this presentation. So, let’s see it.

    [presentation]

    Glassman

    Today we’re going to be working on tooth number 24, US numbering system, it’s tooth number 12. It’s the maxillary left first pre-molar, and the diagnosis of this tooth is necrotic pulp with symptomatic apical periodontitis. So, the first thing we’re going to do is we’re to place dental dam, absolutely imperative. I’m going to place the dental dam on the tooth, we’re going to disinfect it with full-strength sodium hypochlorite for about one minute, we’re going to take dental floss and make sure that we got a great contact, and we take that dental dam in-between the contents to prevent leakage.

    Then I like to use Cool Dam by Pulpdent. It’s a light-cured rubber dam, and you inject it around the interface between the tooth and the rubber dam clamp, and then we light cure it. It provides a really great seal to prevent percolation of saliva from going into the tooth and also to prevent any of our solutions, either sodium hypochlorite or EDTA from going under the dental dam into the patient’s oral cavity. So, we light cure that for a minute and now we make our access with our 557 crosscut fissure bur.

    Many times when you’ve got a nice, open pulp chamber, you’ll feel that drop right into the pulp chamber. Make a nice outline form into the pulp chamber. Then I like to take an ultrasonic tip and just refine my access preparation. You could see we’re under the cusp tips of the buccal cusp and the palatal cusp. We’re going to take a sharp DG-16 endo explorer, probe the palatal orifice and the buccal orifice.

    Then we’re going to take our slider file, .16 tip size, 2 percent taper, in-between our forefingers and our thumb, very gently let it slide to our estimated working length. This instrument is beautiful. You can actually attach the file clip of the apex locator on it and get a perfect working length. And then you set every file afterwards to that working length. This will create a beautiful glide path. Make sure you fill up your pulp chamber brim-full with sodium hypochlorite. We never want an instrument dry. We want to establish and maintain apical patency with an 08 hand file, .25 to .5 millimeters past the apical terminus in order to prevent the accumulation of dentin debris.

    The next file in sequence is the shaper file, .20 tip size, 4 percent taper, which could create a beautiful shape in the coronal two-thirds of the root canal. And look where the pattern of debris is. It’s in the middle half of that file. Wipe off the debris before we re-enter the canal. Go into the palatal canal and then we brush with it, away from furcal danger, towards the safe bulky area of the tooth. You’re in and you’re out. Again, look at the pattern of debris in the middle third of that file, beautiful shape in the coronal two-thirds.

    Fill up the pulp chamber brimful with sodium hypochlorite, make sure we have good apical patency with an 08 hand file. Remember, .25 to .5 millimeters past the apical terminus to prevent the accumulation of dentin debris. And now we’re ready for our finishing file. The F-1 20-tip size, 7 percent taper. Beautifully designed to shape in the apical one-third with a decreasing taper. Wipe off the debris before we re-enter the canal and we take that instrument while it’s rotating right to working length, and we examine the apical flutes when we come out to see if they’ve been loaded with dentin debris. And we see that they have not been.

    We wipe off the debris, we re-enter that canal until we get right to working length. And we examine the pattern of debris at the apical flutes, and if they’re not loaded, then we move on to the F2. Make sure that we fill up the pulp chamber brim full with hypochlorite, we make sure that we maintain apical patency. The F2 is a 25 tip size, 8 percent taper, we follow the pathway at the apical one-third created by the F1 and we go right to working length and we examine the flutes to see if they’re loaded with debris. You can never have enough sodium hypochlorite in your pulp chamber, and you can never maintain apical patency too many times.

    We go into the palatal canal and we look at the flutes of the – and they’re loaded with debris, and now we can move on to our final irrigation protocol with the EndoVac. Now the macro cannula of the EndoVac is a plastic tube. It’s of zero taper. It’s disposable, single-use, it fits snug into a autoclavable aluminum handle which is attached to tubing, attached to your high volume suction, and we deliver it with the master delivery tip. So, we do this for 30 seconds in each canal to remove the gross debris that’s created during instrumentation. And it’s a beautiful instrument to remove all this debris that’s created.

    And then what we do after that is we switch over to the micro cannula. Now the micro cannula is delicately placed right to working length in canal number one. In this case, it’s the buccal canal, and we deliver the sodium hypochlorite for 10 seconds. And you can see that sodium hypochlorite that’s coming out of the plastic tube has already been to the apex and now leaving the apex.

    Because you create ammonium and carbon dioxide, we want to purge out those gas bubbles created by hydrolysis, and we do that 10 seconds and then purge 10 seconds, purge, and then the next 10 seconds which makes a total of 30 seconds, we keep delivering it, we remove the micro cannula to allow that buccal canal to soak, to charge with hypochlorite for about a minute.

    Now we’re working on the palatal canal. We deliver it for 10 seconds. After 10 seconds, we purge out the gas bubbles and ammonium and carbon dioxide created by hydrolysis, and then at the end of that cycle, we remove it and we allow that to soak into the palatal canal. And while we’re waiting, we’ll take the Endo Activator and we’ll take the tip and we’ll place it about 1 to 2 millimeters short of my working length and we’ll activate that hypochlorite.

    And it works by virtue of cavitation and acoustic streaming, by way of the hydrodynamic phenomenon and it’s activating the hypochlorite, it’s increasing the temperature of it, it’s breaking up any remaining tissue of it, and it’s just working beautifully to enhance the cleanliness of the root canal. We go into the palatal canal and we go for a full one minute in each canal with the hypochlorite.

    Then we put our micro cannula back into the buccal canal, we deliver our QMix which has 70 percent aqueous EDTA and a chlorohexidine analog, and we do that in the buccal canal, and we do that in the palatal canal. So, this micro cycle of QMix will remove the inorganic component of the smear layer. So, the first micro cycle with the sodium hypochlorite removed the organic component of the smear layer and this one removes the inorganic component of the smear layer.

    I take my Endo Activator and I activate that for a full 30 seconds to a minute in each canal, again, taking advantage of the phenomena of cavitation and acoustic streaming and getting a higher level of clean in that root canal system. That’s the buccal canal and the palatal canal. Understand that this video is edited so you won’t see the full minute in each canal for the sake of brevity.

    So, we do the last micro cycle which is the same as the first where we use sodium hypochlorite, so we delicately place that micro cannula of the EndoVac into that buccal canal and before we do that, we’re going to make sure we’ve got good apical patency and we haven’t blocked ourselves out and there’s no debris that are going to prevent us from doing such. And we take our micro cannula, place it into the buccal canal, and we deliver our sodium hypochlorite.

    So, the first micro cycle of sodium hypochlorite to remove the organic component of the smear layer, the second micro cycle is using QMix to remove the inorganic component of the smear layer, and now that the smear layer has been removed, this last micro cycle will allow us to deliver sodium hypochlorite which will now make intimate contact of the root canal walls, not only clean the root canal walls really well, but also allow us, through osmosis, to get into lateral canals, accessory canals, and all those arborizations that exist in root canal systems.

    So, it’s a 10-second purge, 10-second purge, and after that last 10-seconds, we remove it while we deliver the hypochlorite so we don’t suction it all out, and then we take our Endo Activator and we do one last activation. Here’s the buccal canal for anywhere between 30 and 60 seconds, and then the palatal canal for 30 to 60 seconds. No better way to ensure to prevention of apical debris than to make sure that we ensure good apical patency.

    Now we’re going to dry the canal; we’re going to take our micro cannula, place it in each canal for just a moment, buccal canal and palatal canal, and then take one or two paper points to dry out the remainder of the root canals. ProTaper Ultimate, the F2, paper points. There’s one paper point and then we’re going to go into the other canal, the palatal canal and make sure we got a nice, dry root.

    Now I’m going to just check my working length for one last time before I place my gutta percha cones and fit them, measure that on my ruler. It’s around 21 millimeters, and I do the palatal canal. You can never check your working length too much. And now we’re good to go to measure our gutta percha cones. I’ll take my gutta percha cone into that buccal canal. I want to make sure I’ve got that feeling of tug-back, that feeling of resistance to displacement, and the beauty about the ProTaper Ultimate gutta percha cones is they fit like a glove and correspond to the last ProTaper Ultimate nickel titanium file that we use to working length.

    So, we fit our buccal and we fit our palatal. I always like to take a little bit of sealer. I love the AH Plus Sealer, the ThermaSeal. It has a low small particle size where it really captures the anatomy nicely in those lateral canals and accessory canals. It should actually fill beautifully. It’s nice and radio opaque as well, so it really shows up nice on the radiograph. That’s the buccal canal. And then the palatal canal. And then we’re going to take a radiograph to make sure that our cones are in the exact position that we want them to be. Beautifully done.

    Now we’re ready to do our down pack and our continuous wave of condensation obturation technique. We’ll take our down pack carrier of the Gutta-Smart system. We’ll remove the gutta percha at their respective orifices, and we’ll seat the cone with the large end of a cold stainless steel plugger once we do that, and we seat that cone. We’ll activate the down pack device of the Gutta-Smart in one continuous motion. We’ll go through the mass of gutta percha in each canal, warming that gutta percha as we seal off anatomy on the way down.

    We put pressure on there to prevent cooling shrinkage, and then we do a separation burst, removing the coronal amount of gutta percha from that apical plug, and we repeat that with the buccal canal. We go through the mass of gutta percha, should only take you a couple of seconds, we put pressure on there for 10 seconds to prevent cooling shrinkage, and then we do a separation burst and remove the coronal amount of gutta percha. I like to take some sealer now and paint the coronal part of the root canal coronal to the apical plug, very thinly with some sealer.

    I’m all ready for my back fill now with my back flow device. Now because of the viscosity of the gutta percha coming out of the 23 gauge needle, you’ll actually see that back out automatically. You don’t want to put pressure on that needle, you don’t want to twist it, you don’t want to torque it, you don’t want to use it as a plugger. You just allow it to deliver your gutta percha. Ever so gently let it back yourself out of the canal and take a stainless steel plugger and start condensing that gutta percha.

    Then I like to clean it out, get it all ready for my referring dentist, place a cotton pellet or some plumbers tape in there to act as a spacer, and then I like to use a Dual Cure blue Core Paste as a temporary filling. I use blue Core Paste because it’s – you can differentiate it between tooth structure and restoration, and the dentist knows that there’s a temporary filling in there. Check the occlusion and take a radiograph. Very happy with the result. Nice tapering preparation, good homogeneous seal, patient is given their post-operative instructions, and a follow-up call, and all is good in root canal land. Thank you very much.

    SEGMENT 2: Post-Presentation Discussion

    Lisette

    Well that was an excellent presentation. I just want to emphasize how easy it is to work with Gary. He is so professional, friendly and kind and it just really showed. And I love how it ended with him just walking off like that. What was your impression of the presentation?

    Cliff

    Well it was very professional. It was very clear. And I love the organization. So, just to, in no particular order, when I just sort of did a once-over around his operatory, it reminded me of how we worked all those decades, and there was a high level of organization, but even the tray setups, I was looking at the tray setups. Two assistants. We had two assistants many times because endodontics grew up and got harder with microscopes and stuff. We needed another person there.

    So he was – he had the whole operatory on the same page, and I thought they were delivering excellent care, and the communication a lot of times was unsaid, but they had a little banter going and he was mumbling along about what he was doing, and he just seemed totally relaxed. He seemed like the pro he is.

    Lisette

    So, did you notice that anything was different than the way you perform the procedures?

    Cliff

    Yes, he did it in 18 minutes. That would have been six hours for Cliff Ruddle.

    Lisette

    Okay. Well we want to actually talk about some of the similarities and differences, because both you and Gary are very successful clinicians who routinely achieve predictably successful results, but the way you arrive at the successful outcome is just a little bit different. And we don’t want to say one way is right or wrong, because you’re both individuals with different preferences, opportunities and life experiences, so things are going to be a little bit different.

    But let’s take a look at some of the differences and the similarities in the way that you both perform start to finish endodontics. So, when he started working, what did you first notice besides how quick he was?

    Cliff

    He used the wrong rubber dam. No, I noticed he used the – it’s called the Young type frame. It’s a horseshoe. And I use an Ostby type frame. So, Gary, we’re very different, but we have so much in common. No, that’s – they’re both plastic frames is the point. The reason I like the Ostby is because there’s two points and you can unleash the whole left side in this case, my example, and you can make it like a hinge door, open it up and put the film in for working films and stuff like that. And I think for me it was just a little bit more practical for taking intraoral films, but they’re both plastic frames, which means we don’t see metal on a radiological film.

    Lisette

    Uh-huh.

    Cliff

    Okay, the next thing I noticed is he used a Transmetal Bur or no, he used a 557 fissure bur to make his access, perfectly fine. I normally use a diamond. Once he got in, we’re both the same. He did ultrasonic refinements. I do, too. I even invented the sign tips which for refinements of access cavities, so he is very detailed. I saw him step by step by step. He used the slider. He got to length a couple passes in each canal. It was a bicuspid. It was number – well 12 won’t work around the world. It was a maxillary left first bicuspid, two-rooted.

    And then he went right into a shaper, a few passes he was to length, very, very quick. And then he went through the finishers, F1, 20/.07. He didn’t see enough debris in the apical flute, so it was a prompt to him to move up to the F2 and that’s a 25/.08, and he got debris on the end of his file, signal, shape’s done, it’s time to clean. Ah, the cleaning regiment was quite different.

    Lisette

    Yeah, I want to interrupt, because I noticed that he used the Endo Activator, but he did mention two other products that I haven’t really heard you speak of when you talk about your technique, and the first one was QMix, which I understand is an irrigating solution to remove the smear layer?

    Cliff

    Yes.

    Lisette

    And so what do you think about QMix?

    Cliff

    I never have used it. If you use QMix, what I tell people around the world is you’re a better clinician than Cliff Ruddle. You’re going to a little higher level of maybe redundancy in the hope of killing a little bit more of the bacterial load. QMix was invented by Haapasalo. It’s a final rinse solution. It doesn’t replace sodium hypochlorite. Sodium hypochlorite is still the only reagent we have that digests tissue, so I then follow that with EDTA to get the smear layer off the lateral walls, and then I come back with sodium hypochlorite because now it can penetrate, circulate and digest into the uninstrumental anatomy.

    So QMix to me is not necessarily because – listen carefully, sodium hypochlorite, if it can reach there and make contact, then everything is killed in 10 seconds, all spores, all viruses, all microorganisms. So, QMix came along to kill more microorganisms. I thought they were already killed. And it has EDTA in it, so I use EDTA. So, I thought it was an unnecessary step for Ruddle, but if you want to use it, fine.

    There’s a caution. And as you’d expect with anything that’s like that, you’re using chemicals and the reagents are sodium hypochlorite, 70 percent EDTA, and there could be other things you’re using. That’s what I use. But when you mix CHX, okay, chlorhexidine, 2 percent, when you mix that and it gets mixed in with those other chemicals, and I’m talking about sweeping and suctioning them off, so I’m not saying mix them like two bottles into the same container. I mean sodium hypochlorite, then you aspirate it out, you got to aspirate it all out.

    Because when you come in with CHX, it forms unsoluable or insoluble precipitates called para chloramines, and that’s a group of chemicals that looks kind of orange-brownish. It’s widely been reported in the literature, but those can be carcinogenic. So, those are insoluble salts. So, then they drill down, they say well, if you can rinse even more, then you can get more of your sodium hypochlorite out so you don’t have that reaction.

    But the reaction’s been reported, so I just thought why would I be using that when I already kill everything in 10 seconds with sodium hypochlorite. I already have 70 percent EDTA, and then I don’t have to worry about this chemistry going on and dentinal tubules, lateral canals, anastomoses, things like that.

    Lisette

    So, the QMix is kind of a mix of the chlorhexidine and the EDTA?

    Cliff

    Exactly.

    Lisette

    And they added the chlorhexidine so that it could have that antimicrobial effect?

    Cliff

    Yes, the chlorhexidine is none other than CHX, that’s it’s chemistry acronym, and then it’s 2 percent, and then it’s got EDTA in it. It’s a cocktail.

    Lisette

    Okay, yeah, so just so I’m understanding properly, it’s everything is already dead, but the sodium hypochlorite and then –

    Cliff

    That’s what I assert.

    Lisette

    Okay. All right. And then another thing he used in the disinfection process was the EndoVac, and I hadn’t really ever heard you speak of that. What’s your opinion of that?

    Cliff

    Well, the EndoVacs had quite a bit of popularity, but I would say if you took, you know, if you’re looking at international endodontics and an amount of users, it’s a very, very, small insignificant number, but for a lot of North American endodontists, they did get the EndoVac. And the EndoVac, I think I can just say here there’s a master delivery tip, MDT, and that is what is going into the pulp chamber and it’s putting your reagent in the access cavity.

    But then there are two tips. There’s a macro tip and a micro tip, and the macro tip is a polymer, and it goes to length. So, as the assistant is putting in fresh reagent up in the access cavity, the cannula is going down the canal to within working length and its suctioning, and so you get a circuit going, fresh irrigant, the suction is pulling it down through the canal and taking it back up in the lumen of the cannula. So, when you’re doing a lot of gross work, a lot of shaping, you’ll use the macro cannula.

    But it will block quite easily, so we don’t want to use the micro cannula until you’re just doing a little bit of finishing work. Like maybe Gary would want to use it more between the F1 and the F2, because he’s not doing a big job, he’s doing a little job. And the micro tube has laser cut pores. It’s a much smaller cannula, and they can go around curves, get to length, and it suctions. My concern with this – it’s not a concern. You are getting ccs of circulation through the root canal system perfect. Everybody would go that is ideal, but it doesn’t give it a chance to go laterally.

    That’s my – that’s always been my thought. So, that’s one reason I like the Endo Activator because it can exchange kind of like this and then it can move reagents laterally into the uninstrumentable portion. So, I’ve always thought if you use it, you’re just doing a step beyond what I might think is appropriate, and I think if you use it, there’s no problem. I was fascinated with it though, and you could see the bubbles going through the lines and you could see it’s getting a lot of circulation. And he’s a consummate clinician and I think he’s taking that extra step to make sure he’s getting everything.

    Lisette

    Okay. I think that – I think you were telling me too, that the EndoVac is very safe, too, because of how it uses negative pressure or something so it can help maybe not have – get irrigant through the foramen, is that correct?

    Cliff

    Yeah, negative pressure irrigation is what made it so popular, because normally colleagues are – they got a syringe here, I don’t have a pen, but anyway, they have a syringe, and they push on a plunger and that’s positive, okay, positive irrigation. Negative is what you’re describing, and negative means it’s being pulled like you would suck through a straw and take Coca Cola out of a cup. You got a straw clear to length so you got to have the canal opened up enough to get the straw in, and then you can’t, it’s impossible to irrigate through the foramen and have an accident.

    Lisette

    Okay. And so, if he’s using both, maybe he is thinking that he’s getting the vertical exchange and in using the Endo Activator getting like the lateral agitation too?

    Cliff

    I have never –

    Lisette

    So, is he covering all bases or something?

    Cliff

    I’ve never talked to him about it, but I would think you’re exactly right. He knows he’s getting that loop, but confined to the shaped part of the canal. I think he’s using the Endo Activator to get the lateral circulation.

    Lisette

    Okay, excellent. So, now moving on to obturation, I – when I was watching it, I thought it was very similar to the warm gutta percha with vertical condensation technique that you use, but it seemed a little bit different, and then also I know you’re a big advocate of Kerr Pulp Canal Sealer. I noticed he used a different sealer. So, what are your comments on the obturation section?

    Cliff

    No problem. Well, you know, I think what you’re trying to do today is highlight that I don’t want to put myself in a category I don’t belong in, but if you’re talking about good clinicians around the world, everybody is aspiring to do the best they can. There’s lots of ways to get to Rome, many ways to Rome. So, I think what you saw him do is he uses different sealer. He uses AH Plus, very good sealer, thousands of users, has good history, good research, has great flow, great particle size, it’s radiopaque. It’s histologically good. It doesn’t wash out. It’s inert. It’s dimensionally stable. These are all good things, so you know, I have no problem.

    ` I’m just going with the Schilder cement. Schilder, in the late 50s and early 60s worked with the Kerr company and made Kerr Pulp Canal Sealer. To me, there is no better sealer on this earth. It’s a paste/liquid and you have to mix it, but if you want to talk about particle size, it’s smaller than that. If you want to talk about radiopacity, it’s more radiopaque. If you want to look at 30 and 35-year recalls, it’s still there. They don’t have enough recalls yet to say it can go 30 or 40 years. But I want a really good sealer because sealers are what seal the root canal system.

    In terms of continuous wave versus vertical, I went to Boston, so I learned vertical, the old-fashioned way, where we plunge in, get a heat wave, hesitate, take the fingers off the heat source, let the tip cool, take out a bite of gutta percha, bring in a room temperature plugger, step, step, step, step, step, scrape all the gutta percha off the walls and press. And during that 10-second press, you can move thermal softened gutta percha laterally and vertically.

    So, he’s doing the vertical condensation, he’s getting the lateral components, but he’s doing it all in a two-second down pack, where we’re doing probably about a 12-second down pack cause we plunge, take out a bite, plug, plug, plug, take another bite, go deeper, go deeper. Two or three cycles you’re usually within five millimeters of the working length, and then you can cork, you can deliver thermal soft and gutta percha laterally and vertically into the apical one-third cross-sectional dimensions, and out with the lateral canals.

    So, he’s doing it in one continuous, continuous wave. I’m doing it interrupted, and then backpacking, I like to put in small increments, 3, 4, 5 millimeters at a time, three or four climb deep and then the next squirt can be maybe 4 or 5, but don’t put in more than 5 millimeters at one single squirt, because you can only move gutta percha maximum 5 millimeters. So, if you put in 7 or 8 millimeters and you’re up here pushing like a wild man, or a wild woman, well, you’re getting good adaptation more coronally, but you’re not getting adaptation deep.

    Lisette

    Okay, well what are your thoughts on how he finished the treatment by placing the cotton pallet and then sealing up or closing up the tooth with the temporary blue cement? And knowing Gary, I’m sure he’s in communication with the clinician who’s going to be doing the restorative work, and there’s probably almost 100 percent a clear plan in place. I’m asking you though this because I know that recently we talked about some controversy in dentistry about who is in charge of the restorative responsibilities. And –

    Cliff

    Whose job is it?

    Lisette

    Yeah, and how much involvement should endodontists have in making sure that the work they perform is protected. So, what are your thoughts on this?

    Cliff

    Well you know, Gary only had 18 minutes, so Gary didn’t tell us a fraction. He gave us a glimpse of a procedure that was beautiful. If he had more time, he would probably say this case is referred from this referral, I know who they are, we have great office/office communication between the ladies at the front, and this doctor wanted a cotton pellet so he didn’t have to overly drill deep into the access cavity. It’s a convenience. The only thing you’ve heard me say is I was doing that back in the 70s and then we would notice on a recall, sometimes that cotton pellet was still in there.

    So, that’s like a sponge that’s wicking and everything in life leaks. Everything moves. The coefficient expansion between metals, dentin, composites, your alluding cements, they’re all different. Everything is moving in different rates. So, Gary would want to take responsibility for the rest of the seal and because that’s a lot of times why endodontics fails over time is it’s coronally leaking. But probably in this case he knew his referral perfectly, as you pointed out, and he know that was exactly how that doctor wanted the case to come back.

    Lisette

    Okay. Well a very big thank you to Dr. Glassman for that wonderful presentation. It’s inspiring to see the differences and similarities in how clinicians practice, especially when it’s very influential and well respected clinicians like both you and Gary, and this is actually kind of one of our main themes on The Ruddle Show, because we’re never trying to say that Ruddle’s way is the only way.

    We just want to tell you what – tell our viewers what you think, what your preferences are, what you recommend and why, but then it’s up to our viewers to use critical thinking and figure out what’s best for them. So, thank you again, Dr. Glassman, for that great presentation.

    Cliff

    Yes, and one last thing to the audience, you saw a wonderful procedure, you saw it in a step by step manner and even though there were a few differences, this is most important, everything Gary did was consistent with Ruddle endodontics.

    CLOSE: Demotivators

    Lisette

    Okay, well we’re going to close our show today with some cynical humor and tough love, also known as Demotivators. So, there are these cards and they have a little saying and I’m going to read it, you’ll see how it works. It’s interesting that – I looked back in Season 4 to Gary’s show that he was on because I was just wanting to make sure it was on Season 4 because all the seasons become a blur. But I did notice on that show that Gary was featured, we also closed with Demotivators.

    Cliff

    Did we?

    Lisette

    Yes. And so, from now on, Demotivators I’ll always associate them with Gary so –

    Cliff

    And that’s a good thing, pal.

    Lisette

    Yes, and we actually love them. All right, so let’s see what we have today. All right, the first one is tradition. It looks like this. It looks like it’s showing the Running of the Bulls in Pamplona. Okay, it says, “Just because you’ve always done it that way doesn’t mean it’s not incredibly stupid.”

    Cliff

    I’m going to get in trouble on this one, but I don’t know how many staff members I’ve had over the years that came from other places and they wanted to do things like they’ve always done things because how you’ve always done things there’s the very best way you could ever do it. So, sometimes you have to detrain and get rid of your hard fought for proficiencies, surrender, get a little bit worse, then take the big step and go beyond where you were.

    Lisette

    Right. Maybe kind of like how people do spring cleaning on their house. Maybe you should do it on your own self sometimes, because maybe – I – it’s amazing to me how often you – I’ll even point something out to my kids, like why are you doing that that way, that’s not right, and they’ll go well, I’ve always done it that way. That means like somehow that that justifies it.

    Cliff

    Well if I had more time, I’d tell you a lot of stories that came along with doctors who came from around the world and took seminars and they’d always say – they’d always start out, and I won’t tell the whole thing. They always say, “I want to tell you how I do it.” Of course they’re coming because they get blocked all the time, right? So, the reason they travel great distances and pay a lot of tuition is they get blocked a lot. I don’t want to hear how they do it. I might start doing it like they do it. So, but they’ve always done it this way, but they want to get it through the block, okay.

    Lisette

    Yeah, you might need an update.

    Cliff

    Patency, patency.

    Lisette

    The next one is called Challenges. And it looks like this. It says, “I expected times like this, but never thought they’d be so bad, so long, and so frequent.”

    Cliff

    Well yeah, you know, duh, okay, I talk to a lot of people from around the world. It just happens in an educational position like I’m in, so lots of daily emails, phone calls from everywhere. And I’m always amazed at the young dentists that are oftentimes in these DSO type clinics. DSOs can be really, really good, but there’s some notoriously really, really bad ones. So, they’re in there and they feel like they’re cracking the whip, go faster, go faster, and they’re making mistakes, and they sometimes get burnout. And I think we’ve done shows on burnout. And burnout is – you just read it. Read it again.

    Lisette

    I expected times like this, but never thought they’d be so bad, so long, and so frequent.

    Cliff

    Well change things up, right? Go back and look at our burnout show and shake up that paradigm so you can get up that mountain. Please! Climb!

    Lisette

    I mean I don’t want to get negative but this just reminds me back in April in 2020 when we went into lockdown and we thought it was going to be a couple weeks.

    Cliff

    Couple weeks, yeah, couple weeks. Yeah, oh, that’s perfect, a lockdown became two years. Oh, that’s very good.

    Lisette

    Okay, so then the last one we’re going to do today is called Achievement, and it shows the pyramids. And it says, “You can do anything you set your mind to when you have vision, determination and an endless supply of expendable labor.”

    Cliff

    Well, I was telling Lisette just before the show started that this reminds me of post-graduate instructors, chair people, chairwomen and chairmen. So, they’re at this program. The students, the postgraduate students, matriculate, and then they leave and there’s always a new wave coming and a wave leaving. And they crank out a lot of research. And the students are doing the research. They’re like slaves.

    So, the slaves are doing all the research, the mentor is guiding, he’s got his finger on the levers and dials, and papers are coming out, but long after the students are going, pretty soon this instructor, this chairperson has countless papers in the literature. I can name a few name, I won’t, they would be embarrassed. They should be, because it’s the same old same old, and they build monuments like – hold that up again, monuments that are universally recognized as great wonders of the world. So, yeah, it’s nice to have a lot of endless labor support all around you.

    Lisette

    Yeah, cause I do think that I have the vision and the determination, but maybe I need like a team of 20 following me around.

    Cliff

    That’s right. Start a grad program.

    Lisette

    Okay, well that’s our show for today. Hope you enjoyed it and we’ll see you next time on The Ruddle Show.

    [music playing]

    END

    Disclaimer

    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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    03.03.2022 Update

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    Happy New Year

    2020

    01:52

    Behind-the-Scenes Studio Construction

    Timelapse

    The Ruddle Show
    Season 8

    Release Date Show Get Notified
    10/12/22
    Endo/Perio & Recent Article
    Crestal/Furcal Defects & ProTaper Ultimate
    10/19/22
    WaveOne Gold
    Special Guest Presentation by Dr. Julian Webber
    10/26/22
    Microscope Tips & Perforation Management
    Q&A and Furcal & Crestal Perf Repair
    11/02/22
    Knowing the Difference & Calcification
    Esthetic vs. Cosmetic Dentistry & Managing Calcified Canals
    11/09/22
    Sealer-Based Obturation Techniques
    Dr. Josette Camilleri Discusses this Current Trend
    11/16/22
    AAE Discussion Forum & Endo Errors
    Trending Topics & Common Endo/Restorative Mishaps
    11/23/22
    To be determined - Check back soon!
    11/30/22
    To be determined - Check back soon!
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