Featured graphic from The Ruddle Show: Knowing the Difference - Lightwalker vs. EdgePRO Lasers
Laser Disinfection & Obturation The Lightwalker vs. EdgePRO Lasers and Q&A
This show opens with Ruddle and Lisette talking about the benefits of an office group text chain…Get everyone on the same page! Next is “Knowing the Difference,” where Ruddle discusses some critical distinctions between the Lightwalker and EdgePRO laser disinfection systems. Then, Lisette joins Ruddle at the Board for an informative Q&A on obturation. The show closes with some Philosophical Wisdom from the business and financial realm, very timely in this era of inflation and supply shortages.
Show Content & Timecodes00:54 - INTRO: Group Texting 06:59 - SEGMENT 1: Knowing the Difference – Lightwalker vs. EdgePRO Lasers 23:50 - SEGMENT 2: Q&A - Obturation 42:28 - CLOSE: Philosophical Wisdom – Business/Financial
Extra content referenced within show:
Downloadable PDFs & Related Materials
Clifford J. Ruddle, DDS, examines laser-activated irrigation in endodontic treatment...
Endoactivator Research Addendum. Summary Of Supporting References: Ongoing Clinical Studies & Publications
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...
Many dentists practice with the misconception overfills cause biological harm. Many receive misinformation that overfills cause clinical failure. Others have embraced preparation schemes that intentionally work short of the canal terminus due to the overfill myth...
Ruddle Technique Card on the "Calamus Pack"
Ruddle Technique Card on the Calamus Flow
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.
…What are your options when it comes to obturating a minimally prepared canal?
INTRO: Group Texting
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle.
Hi everybody. How you doing?
So we thought we’d start off today’s show talking about group texting and how your office could benefit from everyone on your team being involved in a group text. So we have a group text for our organization, and it’s often filled with fun and humor, and it’s really good for getting everyone on the same page. It’s also good for camaraderie and it can be really good for your office culture. So when do you turn to the group text?
Well, usually during the day – before I answer your question, I’ll digress. During decades of practicing there was a morning huddle, so it was always five or ten minutes. And during that time when we were a paper office, the receptionist held all the charts and we’d literally go through everybody that was coming in. Of course that didn’t account for the ones that weren’t going to come in, that were going to be emergencies that we didn’t know yet. So we could pretty much rehearse the day, play the game slow-motion in our heads, and then we just went ahead and did the day. So we are now reproducing that.
But when you leave offices – to answer your question – with the iPhone and the different machines everybody’s using, it’s really easy to communicate. So basically you might want to say well, there’s a janitor that’s going to come in. They might all know that, but it’s unusual because you’re having a party and there’s a mess. Janitor might come in, you might have a maintenance person come in, you might have like an IT tech come in for trouble shooting, you might remind somebody to bring the flowers, somebody else is going to bring the cake, there’s a birthday and you’ve got to do all stuff. So it’s really good for those kinds of things.
And then I think it’s good for compliments. Lots of wonderful things happen across the day and a lot of times you get so busy, you don’t really acknowledge people, because it’s during play, during the game. So sometimes you can just step back afterwards when you’re not in the office and just say great job. I would say that’s how we would use it today.
Yeah. I guess I’d let everyone know in the group text that I’m running a bit late. Laurie might let us know that a new show launched. Isaac sometimes lets everyone know that a promo video that he’s been working on is now in Dropbox and anyone can view it who wants to. So I would say that there’s probably something in our group text almost every day.
So we’re maintaining a superb level of communication.
Yeah, okay. So we’re a family business, so don’t really have any set rules. But you might want to develop some guidelines for your group texts, correct?
Well, I was coached to not forget that be sure everybody’s on the text. You don’t want to have like a star or somebody that maybe is just new and they’re not in the group text. So rule one: everybody’s in the group text no matter what.
it’s a great time to lay down some restrictions, though. In other words, I don’t want a group text at 12:00 midnight, nor do I want one at 5:00 AM. So I would say we’re together all day. We don’t need to text each other at the office because we’re a close office and everybody – if you’re a real team, everybody knows what everybody’s doing. That’d be like in the NBA, have a group text to say we’re setting up a play.
Anyway, I kind of digress. But it’s a great way then to, again, let people know what’s going on. Do it maybe say from the time you leave the office until maybe 8:00 or 8:30, because nothing in life is such a big emergency. But if you’ve got an emergency after hours, you might have to group text and say I’m going in. And then we always have somebody on call that would come with me, an assistant; so things like that. So maybe say 5:00 – 8:30 PM; nothing after that. In the morning I wouldn’t do it early, but maybe just as you’re driving into the office. Don’t do it in the car, but say you forgot something and maybe somebody else can cover you and bring it because you forgot it; things like that. And then keep it really fun, keep it happy. This is not a place where we complain and have bitter discussions. This would not even be the context.
Or like letting everyone know that someone left the bathroom not in tip-top shape.
Yeah, we’d probably want to do that personally.
Okay, well I know that our group texts have a tendency to rapidly descend into crazy GIF humor. How you pronounce that is a whole other segment. You might want to use emojis sometimes, because those are useful if you want to chime in but you don’t really have anything to say. Or even your own Bitmoji; if you don’t know what that is, it’s your own personal emoji. So I have one. So here’s an example of what mine looks like. [Shows pictures]
Oh wow! Yeah, I get those. Those are really cute too, and they’re very expressive, aren’t they?
And I saw you just sent me a text, and so you made one just very recently.
Yeah, well they didn’t have enough choices for this kind of a face.
Well it’s fun. It’s amazing all the things we can do with our phones.
Speaking of phones, I like to take pictures. So one way I use it is I travel a lot. I haven’t the last two years, but before that, I think I told you five million miles by the end of 2019. So if you’re somewhere in another country, it’s a great way to show a friend that the office all knows because maybe they trained in Santa Barbara, or maybe you show architectural splendor or you show something that’s humorous, but it’s a way of staying in touch. And so I like that.
Sometimes I’ll tell people there’s a new book out. There might be a medical alert for something that maybe we all need to know; don’t buy turkey today, in this region it’s flawed. No turkey sandwiches. You can give quick updates in there in your life, or ask questions; anniversaries, birthdays and special occasions can be done on the road.
Yeah, well a group text works really well for our office. And if you don’t – if your office doesn’t have one, we really suggest you get one going, because they’re fun.
So we have a great show for you today, and we’re excited about it, so let’s get going.
SEGMENT 1: Knowing the Difference – Lightwalker vs EdgePRO Lasers
Okay, so it’s time for another segment of Knowing the Difference. We did a couple of these segments last season. So sometimes products or techniques might seem very similar, and you might even think they’re pretty much the same and interchangeable. But often the seemingly similar have some important differences that should not be overlooked.
Now the 18th century French author Madame De Staël said that “Wit consists in knowing the resemblance of things that differ, and the difference of things that are alike.” That’s kind of our foundational concept behind this segment. So today, with that in mind, we’re going to look at two lasers that are used for endodontic disinfection; namely the LightWalker and the EdgePro. And just to start, I think both of these lasers, they use a little bit different technologies, right?
That’s correct. There’s a lot of misunderstandings with lasers, and there’s lots of lasers. But the two we’re talking about are in the erbium family of infrared lasers. The first one is LightWalker, it’s made by Fotona, it’s 2940 nanometers of light on the electro-magnetic spectrum of light. And we have another one, and it’s by EdgePro. It’s called EdgePro by EdgeEndo, and they’ve gone into a collaboration with Biolase, and Biolase is actually the laser company. So they have a laser and it seems close. It’s 2780 nanometers on this electro-magnetic spectrum of light. And you’re saying that’s only 160, not so big. But you’ll see in a little bit, it’s enormous.
So that’s the two lasers. Biolase, just for fun, is about 1984, and Fotona was 1964. But lasers in dentistry came in 1960, so Fotona has been in it for quite a while. These wavelengths are chosen in disinfection because they have a great affinity – the laser light has a great affinity to absorb water. And of course basically everything in the human body, all micro-organisms’ hydroxy appetite is dominantly water. So this precise wavelength targets water; it implodes the water molecule, which means it eliminates micro-organisms.
And I think they call this the Er:YAG, so you might have heard that.
Oh yes. The Biolase laser by EdgeEndo is, in fact, Er.Cr – that’s chromium – and then it’s YSGG. And I’ll let the audience look those up, but they’re atomic elements and they get doped by the erbium molecule and that’s what gets them excited and gets you a laser light.
And the LightWalker one is the Er:YAG.
That one is 2940 nanometers.
2940 is Fotona and that’s LightWalker. And the Biolase combination with Sonendo is 2780.
And they sell for different prices, too.
And one, the Er:YAG, is doing dentin, enamel; it’s doing disinfection. It does many, many procedures as we’ll see, and that’s $100,000. And then the disinfection unit only that EdgeEndo is selling is about $30,000. And they can both be used in minimally prepared canals, or fully prepared canals. So in this age of minimally invasive endodontics, you can see as the shapes get really small, it's going to be important to have something that can go in there with light and disinfect.
Okay. So the Er:YAG laser, the LightWalker, that uses a technology that’s called SWEEPS; which is Shock Wave Enhanced Emission Photoacoustic Streaming. And you actually have a unique history with the SWEEPS technology, because of its origin from PIPS. So why don’t you just tell us how you even got involved with PIPS in the first place?
Well I’ll try to be short, but basically there was a guy I met. He met me because he was a face in the crowd; he came to my lectures. And this is him telling me the story years later. His name was Enrico DiVito, or just Rico DiVito, and he was from Arizona, from the Laser Institute. And he came to me in my lectures and he was enamored by the EndoActivator, how it would go into the canal and make bubbles, and he knew a lot about bubbles from using the laser. He had lasers; he had more than one laser in his office. And in Arizona, he was doing all kinds of dentistry with lasers. So it was not unfamiliar with him.
So when he saw the bubbles from the EndoActivator, he thought gee; I wonder if I could do something with my laser to do disinfection. The rest is history. He collaborated with engineers and really bright-minded people, and within just a short period of time he came up – he already had lasers, they were everywhere, 2940. But he came up with the fiber wand, the fiber tip that was unique, and it had IP around it, and he was using that to bring light in for disinfection. And then when he got bought out by Sonendo – this is getting complicated – but Sonendo bought out Rico DiVito’s IP, and then they deep sixed the project.
Okay; because they were doing GentleWave.
They were doing GentleWave. So they didn’t want to have two disinfection ideas, but there was room for it.
And you had actually invested in this PIPS technology, which is Photon Induced Photoacoustic Streaming. You had actually invested in it and then just got your money back when it was sold to Sonendo and deep sixed.
That’s correct. Well, I read this book and wrote the preface for it, and before I invest family money, me and several of my friends, my close friends, after we became very familiar with the book, I actually wrote the forward in this book. So I learned enough about lasers that they wanted me – I was very honored – Olivi, De Moor, and DiVito asked me to write the forward. And so I wrote the forward for their book. And then this is a paper that you printed out for me, and it compares – we’re having the whole thing to know the difference – it’s a comparison of Er:YAG with Er.Cr.YSGG and it’s very, very informative.
So essentially, DiVito with his IP; there was something there. It is highly researched, there’s all kind of histology in here and physics and math, and every laser and every one that works on a different wavelength of light; he learned a lot. But basically it was deep sixed, so that was another opportunity for somebody else.
Then how did SWEEPS even come about then? If PIPS was deep sixed, then how did they end up developing SWEEPS; Fotona?
Usually – the laser actually changed a little bit. You and I were talking before the show started; it has to do with pulses and I won’t get into it. But they have a superb pulse; that’s how the power is emitted and gated. It’s actually superior to Er.Cr lasers, and so that was one thing that they could kind of go around. And then they devised their own tip. And these fiber tips – you know they’re quartz and they have – they’re feruled with different elements to shield them – but DiVito stripped away the polyamide sheath on his tip, and then he got a radial and end-firing tip.
So they basically – Fotona found a way to kind of go around the patent so that they could develop SWEEPS.
And end firing might sound dangerous to our audience, but as they’ll see in just a little bit, end firing up in the pulp chamber is desirable.
Okay, well one of the things that you liked about the PIPS technology, I know, was the fact that it used the 2940 nanometer Er.YAG laser. But then one thing about the PIPS technology was that the wand tip just went into the pulp chamber only. And now I see that SWEEPS also retained that by going in the pulp chamber, and then it’s also multi-procedural. So what other types of procedures for example could you do with that laser?
Well with the Er.YAG by Fotona, 2940, you can do bloodless incisions, frenectomies, you can do gingivectomy, gingivoplasties. And if you change the pulse, you can cut dentin and enamel. And before you have a fit out there, it used to take a lot more time to do something with a laser. I remember when Phyllis and I went to Ulm in Germany many years ago to look at lasers; that was 25 years ago. And basically they were holding up a tooth with asbestos gloves because there was so much heat, and it took three times longer to cut something as compared to drills, burrs, dental drills. So now you can cut absolutely as efficiently and safely with a laser as you can with a drill, and so that’s a huge advantage. So it can do all these various kinds of things.
So the LightWalker then can do all of these things; but the EdgePro, that’s just for disinfection only?
The Biolase Er.Cr.YSGG is for disinfection only.
Okay. Well it definitely seems like a plus that the LightWalker can do all of those other procedures on top of disinfection; especially considering the higher price tag. But what would you say is the biggest distinction between the two lasers?
Well the biggest clinical distinction – get off the technology where I’m more familiar, clinical – is back to the Fotona laser, the LightWalker. You hold the wand in the pulp chamber only. You do not go down canals. That means all the canals are disinfected simultaneously, and the whole cycle is about 2½ or 3 minutes. There’s some different chemicals you’re flushing through the root canal, there’s some water rinses between, but more or less it’s about a 2½-3 minute protocol doing all the canals that have been cleaned and shaped; whatever your desired shape is, and you can disinfect simultaneously.
So that’s huge because well do I go into the other one right now? If you do the EdgePro, you’re going to take a wand, that fiber tip, and you’re going to go into the canals. And you’re going to go within 2mm of the working length. So you’re doing one canal at a time; that’s a huge distinction. And it’s pretty technique sensitive. You must withdraw the wand, the fiber, at about 1mm a second. And you’re doing three passes per canal, and there’s two phases – it gets worse. Okay, Phase I: three passes per canal. That gets out your smear layer and your gross debris. For disinfection, it’s another whole cycle, and it’s three passes per canal again if you do it according to the articles I’ve been reading.
What if you don’t pull it out? What’s happening?
Well, what this paper has clearly shown is anything from dentinal melting. There could be hot spots that turn brown, and they’re very noticeable with the naked eye, but you can look at them even closer with SEM. The thing is, when you put a wand in a canal – okay, let’s say you have a fully shaped canal, so you have a pretty good reservoir counting the pulp chamber above it. So when you put the wand in the canal down within 2mm, presumably there’s going to be reagent that you can activate, because it’s the reagent that you’re activating that’s causing the disinfection.
So the problem is, as your shapes get smaller, the same wand – you have radial firing tips, so they’re going sideways and not so much in – they like to talk about that. This is the EdgePro laser, goes pretty much a lateral firing to get into the tubules and lateral anatomy. But the thing is, those wands and fiber tips can start to touch the dentinal walls in really minimally shaped canals, and that’s when you get the burns. And you’re displacing the little bit of fluid that’s below the orifice. How much fluid is below the orifice in a shape of 20:04 as an example? Probably a few drops. So when the wand goes in, there’s probably not very much liquid in it.
And then if the canal’s very curved, then what do you do?
Well, you’re going to touch the walls. I wrote down here, they have seen – I said melting, burns, cracking and ledging. Ledging the finished preparation.
Okay. Well, that is some really useful information. Let’s bring up the graphic that kind of just summarizes some of the things that we’ve gone over.
Oh, summation, yeah.
So we’ve identified that they’re called – one is the Er.YAG, one is Er.Cr.YSGG, with different wavelengths. The biggest clinical difference is that the wand is confined in the pulp chamber for the LightWalker, but then into the canal which we just talked about why that’s problematic, and then also becomes technique sensitive and potentially dangerous, all because of the wand going into the canal.
I just want to make a point. I don’t know if you nailed it. But on the Yttrium-Scandium-Gallium-Garnet Laser over there on the right, it absorbs into water three times less – that’s about 300% less than the Yttrium, Aluminum, and the Garnet. So they seem close knowing the differences, but there is a big, enormous absorption rate difference.
Okay. And then of course there’s the cost difference, but it sounds like there’s maybe a reason why.
Well for the cost, if you’re just an endodontist and you’re going to say I’m not doing – you might be interested in bloodless incisions for surgery, but you’re probably not thinking you’re going to be doing other kinds of procedures like a general dentist. But if you start thinking about two phases of cleaning, each phase is three cycles per canal. And if you start adding that up and you’re doing endo all day, do you have to get to June or July and you’ve already paid the extra $70 grand of the calendar year where you bought it? That’s a question, but I would think you’d come pretty close to paying it off.
Well, it seems EdgePro is pretty new in the marketplace. So it would be interesting to see as research is published, if the issue of the risk of dentinal burns becomes – turns into a bigger issue. And maybe even there might be some evaluation about how effectively it cleans considering that it requires so much more time, absorbs less, maybe there’s less fluid in the canal because the canals are minimally prepared and the liquid is displaced when you put the wand in. So at least interesting to see what the research shows in the next year.
And to be fair, it has a 99% kill factor, so your EdgePro laser has claimed. And they have a lot of research, because Biolase has been around, as I said, since 1984, so they have a lot of patents. I mean it’s stunning how much technology these two companies that we’re talking about have. But it does kill bacteria, and when it’s used correctly with the right shape, it can be a good disinfection unit. It just takes a lot more time.
Okay, yeah. I guess it just depends on what your priorities are and how much time you have to learn the technique.
Pulp chamber only? Or do you want to go into each canal six times?
Okay. Well do you have any closing remarks?
Well, I think both these lasers have been shown to be efficacious in the world of clinical endodontics and disinfection. However, if you’re a little intimidated by the price; I admit, many times – I’ll be commercial now – I’ve talked about the SmartLite Pro EndoActivator and the market version existing EndoActivator. And for an entry fee of about – the market version is about, let’s just say under $600 US dollars and every procedure is $2 or less per patient. The new one, the SmartLite Pro, it’s going to be about $2200, and again about $2 per patient. So certainly the colleague who wants to climb a little higher on their journey towards better disinfection, there are alternatives. And there’s over 50 university-based papers behind the little old EndoActivator.
Okay. Well thank you for clarifying the difference. I thought that was a great segment. We’ll do another one soon.
SEGMENT 2: Q&A – Obturation
All right. Well we have a Q&A to do today; we haven’t done one for a while.
This time the questions about going to be about obturation. So are you ready for the first hard-hitting question?
Let’s do it!
What is the different between seeing a sealer puff on a radiograph vs. and overextension?
Can we look at a few cases as an example?
All right. So we’re not going to go into diagnosis and the techniques and the files and the method. But anyway, got a great big lateral lesion – that’s a lesion of endodontic origin. It’s traced by a gutta-percha point through the sinus tract. And we have fit the cone and we have down packed, and a lot of you are going, that’s just a little bit too big. So the question is what’s the difference? Well Schiller always talked about 100% filled with surplus after filling. So this system is 100% filled. We can control our puffs apically more than we can laterally because we fit a cone down here. But there’s no cone fit in and look at the size. The size of this more apical lateral branch is bigger than where I put my files. And it’s got reverse apical architecture; it actually gets bigger as it goes out to the cable surface. Some of you think that would probably influence healing. But if you look here at about a 30-some year recall, you can see the inevitability of the bone to grow back in. So this is an example of 100% filled with surplus. And surplus is irrelevant to the outcome of the case. So that’s that example.
So your body can easily handle any surplus like this that would come in?
The sealers are biocompatible. And we did research when I was a resident at Harvard University; we did block sections on prisoners. Went in and took out this and looking at it histologically, and you could see osteoid, the scaffolding for bone, growing right up and into your curved pulp canal sealer, and it’s very archival that puff, that sealer puff is there decades later. I like that. So we shouldn’t fret about filling a root canal system, and the surplus is not really a big issue.
All right, so another case real quick. We’ve got to do this quickly. So this is a whole thing, I’ll show this case later. This is a great example of moth-eaten external resorption. In fact, we’re going to have a show, what? With Terry Pannkuk coming up here on external cervical invasive resorption. So this is not that, but it’s another resorption. Look at how moth-eaten this root is; part of it’s gone.
So you pack down into it, and some of you might go, that’s pretty big, Cliff! But I think if I get rid of my circle, you can see again at about 20 years; notice the trabecular bone is tight around the puff, little, tiny puffs apically, very tough case to treat. But let’s not linger. Surplus after filling, keep hearing it. Well filled with surplus.
Now this case is an example of it’s under extended and it’s under filled; it’s both. So normally you would go through the splint dentistry. It’s a roundhouse, so it’s a very sophisticated crown bridge. And if you go through this – Dennis took me out to lunch, brought a little bag, showed me the study models because he had the stone dies from the cast. There’s almost no tooth structure up in here that is called patient; that might be hard to see. Then the idea of the roots kind of going this way and the crown’s going this way, so the idea was could we do surgery and I thought that was a joke. But we did surgery. And that means we have to come in at an apical approach and come up, because we don’t want to shorten the root.
So this is under extended and it’s underfilled, and I saw those, thousands of them over 25-30-40 years of practice. People working short as per their training. So it does make a difference not to get to length. Not every time, but sometimes.
You’re asking, well how did that look at 5 years? That’s how it looked at 5 years. Notice how the bone’s grown up really tight; it’s butting up against the root and the retro material itself, and you can see we’ve been able to overcome an under extended and under filled tooth.
Next. Are we ready for the next? This is the last one. This is an example of over extended and under filled. So this silver point is to and through the foramen, but internally, it’s open and leaking. So Schuler made a big point about the so-called over extended ones are actually oftentimes internally under filled. So the idea then is to go in and get the careful access, get the silver wire out, pack it. Notice you’ve got the big Leo over here again; here it is, big Leo. You’re not surprised that there are portals of exit adjacent to the lesions; that’s pretty much anatomy. But if you keep following the case, 25-30-35 years, you can see again how good the bone has grown in and how tight that bone is on the lateral aspect of the root.
So it’s really important when you look at cases, not to say well gee, it’s a little short; or it’s a little bit long and that’s why it’s failing. Be thinking laterally as well as vertically.
I actually have a little question before you take that away.
Is it common for – when it’s over extended and under filled, is it common for there to not be as much of a taper in the canal?
Because this looks more like a straight line to me, and I notice that these look more tapered.
It’s looking more like the preps of today. You know, back in the ‘50s and the ‘60s we’d say oh gee; it’s one of those old silver point cases. Jasper introduced silver points in the ‘30s; they were taught in every dental school in North America, virtually every one. Thousands of doctors were trained, millions of patients received them. But what they were is they were – as to your point – they were a much more conservative preparation. And Schuler said that these so-called instrument canals were neither clean nor shaped. So now today we’re making really small shapes again, can’t all buy lasers maybe, you maybe can’t buy other sophisticated stuff, so can you really – do you really need to emphasize a little bit more taper, still leave plenty of residual lateral dentin, and you can see over time, properly restored. It’s a bridge abutment, 3-unit bridge, it’s inevitable to heal.
So more taper means what? Better shaping facilitates cleaning, cleaning facilitates filling root canal systems.
Okay. Next question.
I’m ready! Q&A is up there.
Okay. What is the difference between the continuous wave technique, and Schilder’s technique, or warm gutta-percha with vertical condensation?
Okay, we have two critical distinctions. [Laughter] Boy, I heard laughter in the control room. Check! Okay, we’re good. So we have a distinction. I’ll just say vertical condensation and I’ll say continuous wave. The first is going to be technical, and then the second is going to be clinical.
Technically, this is a wire that comes down like this, and this is your heat carrier. So as you turn on the unit, heat is coming this way. And as we let go and deactivate, the tip is cooling, but this is a heat sink; it’s called a heat sink. So it’s a bigger mass of material, we’re drawing energy from that mass down here, so we’re heating and we’re going to get a 5 mm heat wave apical to wherever we place it.
Over here you have a little different device. It has a copper wire in here, and it heats in this direction; it heats apical coronal, just the opposite. This is heating coronal to apical; this is heating from the tip. You get a 1 mm heat wave. Here we had a 5 mm heat wave. So this is heating the other way. There is no heat sink because it’s heating from the tip with this copper wire.
So that’s the technical difference between the units. I like a longer heat wave because I usually down pack to about 5 or 6 mm, and I know that wherever I end, I have thermal softened the gutta-percha apical to my plugger, which means I can take a pre-fit plugger and I can mold and adapt that gutta-percha into the cross-sectional dimensions of the root at that level. So I like that. That’s the technical.
The clinical distinctions -- we just said the 5 mm mark, so we’ll just say this is 5 mm. But in classic Schilder, you’re going to – you’ve got a cone in here like this. You’re going to sear off the cone, cut off the cone, and then you’re going to get waves of condensation. And you’ll usually get 2-3-4 as you down pack. So you plunge in, you heat the mass, you get a wave in here, and then you can bring your pre-fit plugger in here and you can step it and push, and you can work your way down.
In continuous wave, you’re going to have the same kind of a tooth we’ll pretend. And we still down pack to about 5 mm. Except when you have your shape and you sear off the cone, you’re going to activate and you’re going to plunge and go down in one continuous motion. I went too deep. It should take you about two seconds to plunge. Then you deactivate and you remove all the gutta-percha up in here, you take your plugger and you step it around. Remember, you only soften your cone for 1 mm. In continuous wave, the apical 4 mm of the cone is body temperature, 37° C at most, and that means you’re relying on a single cone technique in the apex, which is the most complicated aspect of root canal system anatomy.
So to summarize. Continuous wave - you heat from the distal proximal. Classic Schilder - different technology, different unit, different everything. You heat proximal apical, get a 5 mm heat wave versus 1. And then finally continuous wave: you get one shot, two seconds, as you plunge through the body of the canal – coronal 1/3, middle 1/3 – you get two seconds to get everything, and sometimes I think you can blow right past significant portals of exit that exit laterally, and you might have plunged through it and not had enough time to deliver it. So in Schilder, you get multiple waves of condensation, multiple forgiving opportunities to adjust and adapt, and thermal soften your gutta-percha in every single section of the canal.
Okay, I have an extra question, and this is kind of related to something you told me before. You told me that the Calamus can do both continuous wave and the Schilder technique, correct? But then you also were talking about the different technologies and how it works differently. So I guess the Calamus can work both ways?
Yes. Phyllis, your mom, discovered this probably I’m going to guess 25 years ago, and maybe it’s 30. But I was just talking by the DFU, the Directions for Use, continuous wave, classic Schilder. And then we have a technology to support that. If you change the settings on your Calamus box – so you have Calamus, this is what I’m using. And it’s a box. And you have a heater side and then you have a squirt side where you can – you have a hand piece that hangs in here and you have a hand piece that hangs in here. One side is to thermal soften gutta-percha; one is to squirt thermal softened gutta-percha. But anyway, there’s a readout up here, and you’re supposed to be about 200° C for continuous wave. If you do Schilder with this device, you want to put it at about 350°, and that way you can do interrupted.
So again, we’re not doing a continuous plunge through the canal; we’re plunging in 3 or 4 mm, taking out a little bite of gutta-percha. Two things have happened. By taking out a bite of gutta-percha, we’ve got another heat wave deeper. And the second thing is, by taking out a bite of gutta-percha, you can take a pre-fit plugger and work deeper in the canal, and generate another wave of condensation, albeit closer and closer as you progress towards length.
So you can change the settings, and you’re actually using a device that can be used either way. But that’s a great question, because a lot of people think they can’t use their existing box to do Schilder.
Okay. All right. The next question is, what are your options when it comes to obturating a minimally prepared canal?
Prayer! Well listen. Most people now are trying to operate at about a 15/02, or maybe a 20/04. Now listen. This isn’t the masses. This is a small group of people, and if you go to the endodontic discussion forum, it’s kind of like how big – no – how small can I make my prep versus how small is your prep. Everybody’s trying to get smaller and smaller. So as the question said, as you get smaller and smaller with your tapered shapes, can you actually get the armamentarium in? And the answer is no. And in fact, a lot of people right now are emailing or texting or calling me, and they’re saying, instead of getting down to the 5 mm level, maybe I can only – we’ll just make it up, but we’ll call this our final shape. And you’d like to get to the 5 mm level. Well a lot of people are saying yeah; but I can get to mid-root.
So we would need different gutta-percha, because you’re going to get a maximum 5 mm heat wave with Schilder. If you use continuous wave, you’re only going to get a heat wave of about 1 mm with continuous wave, but will your instrument? Like I just told you about the copper wire and how it heats distal proximal. So the trouble is getting the armamentarium in, so that means people are compromising the technique. They’re only getting maybe warm gutta-percha to here and all the way up, but what about here? We know from the literature that the preponderance of anatomy is basically in the apical 1/3. So that’s where you have most of your branches and options, deltas, spins, trifidities and bifidities. So probably it’s led to a lot of the single cone technique with BC Sealer, because you can still fit a cone in what I would call a pretty small prep. Schilder would have called it an under prepared canal.
So it’s led to a single cone technique, and that’s led to a new sealer method.
And this is all we have time for, but this is problematic you think; this BC Sealer and single cone?
We’ve talked about it before, but it is problematic. Because first of all, I think you’re compromising obturation. Now I love the forum; they’ll show a case where somebody gets a little lateral branch and everybody’s oh, you’ve to a lateral canal and look how small this prep is. These are anecdotal evidences; these are case reports. We’re going to need to look at a lot of data, big end samples from around the world, university based generated stuff, and it’ll probably take us 5-7 years to find the edges of the truth. But it’s led to the single cone technique.
The other thing is BC Sealers, the tricalcium silicate sealers, as we’re repeatedly said on this show, are immiscible in any reagent in the marketplace. So in the retreatment situation, which I made a living doing, you’re taking out silver points, carriers, gutta-percha and paste fillers. And when you get all that out, there’s residual stuff. If you can’t the sealer out, which is sealing the root canal system, it’s going to compromise your ability to do good, standard retreatment where you can address more of the root canal system anatomy than surgical; and it will lead to unnecessary surgical interventions.
Because it’s very hard to remove?
Because it’s impossible to remove.
I mean you can – they always show little skits where they go, well Cliff; there’s gutta-percha going down through the BC Sealer. Don’t you know how to take out gutta-percha? Use a solvent; use chloroform; use Xylol. The thing is, they’re not talking about lateral. Sure, I can make a pilot hole through gutta-percha and get to length maybe. But what if they’re filled short? Now I have an immiscible sealer blockage apically. In other words, always practice for no surprises. Always come from “what if.” What if this breaks? What if the seal breaks down? What if they break their tooth and need a post face? What if I have to get back in? Always play for outs. Always have an out in your bag of tricks so you’re not irreversibly blocked.
Okay, well thank you. We just got through a few of the questions. Part of that’s my fault because I added a few questions.
I’ve always been accused of saying way too few words, too.
All right, well we’ll do another Q&A soon; thank you for that information.
CLOSE: Philosophical Wisdom – Business/Financial
So we’re going to close our show today with some philosophical wisdom. And this time it’s going to take the form of some quotes about business, finances, or money. Because in this era of inflation and supply shortages, probably a lot of people are struggling with their finances right now. So we each picked a couple quotes. One is a little more serious and one is a little more funny, related to money and finances. So why don’t you read your quote and tell us why you chose it?
Well, we’ve done a little work with our team here, with Tony Robbins. He’s a motivational coach and I liked one of his quotes, so here it is. It’s about money: “The secret to wealth is simple. Find a way to do more for others than anyone else does. Become more valuable. Do more. Give more. Be more and serve more.”
Okay. Why did you pick that one?
Well, I think as a professional – and we are all professionals that are watching the show, or maybe some of your family is. But basically, we’re always serving patients, and I always was trained to exceed expectations. So if you just try to do more than other people, and then you give a little bit more, be a little bit more, serve a little bit more, give a little bit more; I think that’s kind of the essence of being a professional person. And when you do that, I think the patients are alike.
Okay. A lot of times when you give your money freely and your time, you don’t seem to have to worry. Somehow it comes back to you.
Well if you want to get biblical in a good way, it says right out of the Bible, the more you give, the more you get. So you don’t give to get, but it turns out that way.
Okay. I chose a quote by Benjamin Franklin, and it’s this: “Beware of little expenses. A small leak will sink a great ship.”
Oh, that’s true.
Yeah, I kind of feel that way sometimes when I get my credit card statements. I’m like wait. I only spent a little bit there and a little bit there, and how does this add up? I even ask – sometimes I’ve gotten out my calculator and tried to check the credit card charges to make sure that they actually are correct.
So yeah, sometimes it’s maybe helpful to pay cash, so you don’t have to have that issue, like when the credit card statement arrives. But that is something that little things, they kind of tend to add up, all those cents.
Well it also helps you spend exactly no more than you’ve earned if you pay cash.
And that kind of takes me to the funny one.
Okay, yeah. Read your funny quote.
“Too many people spend money they earn to buy things they don’t want to impress people they don’t like.”
That is funny.
And I remember when I was young; sometimes somebody would get a new car in high school or something. They couldn’t afford it; it was on a shoestring. And they were driving around to impress everybody and they didn’t even need it.
Okay. Well I chose a quote, my funny one. I just thought this was hilarious and everyone’s going to get it. It’s by Yogi Berra, the baseball player. And then I read it to my house guest who’s from the UK, and it completely fell flat. Because you don’t see – the quote is this: “A nickel ain’t worth a dime anymore.”
Well, you kind of have to have knowledge of our currency. Then you also have to know the expression “not worth a dime”. So maybe that was only funny to our American viewers, our English speakers, but not to everyone.
Well, I have been told starting about 45 years ago; never tell jokes to international audiences.
It may not always work.
I had to spend a lot of time explaining the quote. If you have to explain your jokes that long, maybe it’s not funny.
Okay, well that’s our show for today. Thanks for watching and we’ll see you next time on The Ruddle Show.
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