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…My dad is very competitive, so when he knew he was running out of air under water he didn’t – he still did not come up for air...

[music playing]

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

Hi, how are you doing out there? We have a great show today.

Well we wanted to start off today maybe giving you a job idea, and maybe you can tell what I’m going to recommend from the graphic. But maybe some of you are tired of the routine of practicing regular dentistry day after day in your quiet office. Maybe you actually have an interest in dental trauma cases, and maybe you are also a hockey fan, so maybe the perfect job for you is a hockey team dentist, and generally I think they do get season tickets for all of the home games, so that’s a plus. But I think you told me that when you were a resident in grad school that you actually talked to someone there that was a hockey team dentist. You had a story.

Well, we were from the west coast, and I went to dental school in San Francisco, at UOP, but when I went to Boston, it was hockey and basketball and the Red Sox, but yeah, there were some hockey dentists. In fact, what I learned with the faculty is almost everybody had played high school hockey, all the way through, some had played collegiate. A few had played a little bit higher. But what I also noticed a lot of them in their 50s were in older leagues still playing hockey.

But what they told us was they had a lot of stories. They shared with us about the range of injuries. And a lot of you probably think, you know, it’s a dangerous sport. Their puck, you know, is like one-inch thick, and it’s three inches in diameter. It’s about seven ounces, a little less. But it flies at 80, 90 miles an hour. So you see soft tissues injuries, you see lacerations. People spit out three to – stories were routine seven, eight, nine teeth at a time. People can go behind with a stick and gather the teeth on the ice and gather them and take them over to the penalty box of their team so they can be collected and maybe utilized later.

So, anyway, yeah, there was broken bones, broken orbits, skates can go across necks and there was carotid where there was spurting blood. So, it’s pretty exciting if you want to get into that line of work. I mean –

How do you go about getting a job like that?

Well, you don’t just fall into that job. In fact, because you always give me homework to do, I started looking around about how I could become the Los Angeles Lakers or a King’s coach on the dental staff, and I listened to a podcast by Eide Bailly. They’re an accounting firm, but they have a lot of dentists, so they did a podcast with a guy named Jeff Hoy, and Jeff Hoy was the Los Angeles Kings and he was the Los Angeles Lakers team dentist for about 30 years, and that’s when both teams won. The Lakers won more than the Kings. But anyway, he got rings and he had quite a few stories, I’ll just limit to that, but a lot of stories about how that worked.

Because your question was how did he become that? He went to a practice and joined out of – graduated from the University of Southern California Dental School, and he joined a practice where there was two older, senior guys. They had been for 40 some years the team dentists for the Dodgers, the Lakers, the women’s team, Los Angeles Sparks, and some other teams. And so, he loved sports, but he never really was part of that. But then the guy retired, the senior guy, and all of a sudden he was asked to help out a little bit more, and all of a sudden the other guy retired, and pretty soon he was getting contracts from the Lakers and the Kings to be their team dentist.

But what it is, it’s a team, and you’ve got to remember here that there’s a physician, there’s a radiologist, there’s a dentist and there’s trainers. So, if you go to Sports for Dentistry.org, you can go to classes, you can get certified, you can do practical, mock emergencies, and then you get certified. And you can use that to go around to teams. You can start at high school. You can start in college. But it’s very rare to be asked to come in as a professional team. Usually there’s some kind of a chain.

Okay. Well I read an article and I understood from that article that most hockey teams do have a full-time dentist on staff and a dental chair near the locker room.

Yeah.

Usually the dentist for the home team is also in charge of the visiting team’s dental emergencies as well, and these dentists are so vital to the team’s success that usually they have a lot of job security, and even if there’s an ownership change or a coaching change, they still keep their job usually. And in the event that you win the Stanley Cup, then the hockey team dentist also gets a ring, and they also get a day with the trophy. So, I think you talked already about a lot of the different types of injuries, but maybe – did you want to say any more about that, the triage?

Well there’s a difference between an emergency in the NBA and in hockey. In hockey, they’re there to play hockey, so and short of broken bones or incapacitation, the triage is stop the bleeding, smooth off rough edges on teeth, load them up with Xylocaine or Novocain, and get them back on the ice.

Okay, well if you’re looking – if you’re thinking that this is actually the job for you, you should do it sooner rather than later, because the rules are changing and right now, fighting is way less tolerated in hockey. Most players have a helmet or some kind of faceguard or mouthguard.

Even a plastic shield.

Yeah, so there’s starting to be a big dental disparity between the older toothless players and the younger players, many of whom have all their teeth still. So, anyway, it’s, you know, the hockey playoffs are happening right now, so maybe, you know, your job is calling.

And remember, it’s never too late to become what you always wanted to be.

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

All right, well, we debuted a new segment earlier this season and it was called Every Patient? And just to be clear, that’s with a question mark, Every Patient? So, the point of the segment is to discuss patient protocol and ask if every patient should receive the exact same treatment or if patient care should be more individually tailored to the patient’s specific needs. And of course, there are other factors, external to the patient that also might influence patient care.

So, last time we talked about CBCT, a higher end technology, and if that should be used on every patient. Well today we’re going to discuss another higher end technology, GentleWave, so my question for you is should GentleWave be used on every patient?

Well by golly, if you buy a unit for $70,000 you’re going to want to use it on the barber. Okay, every patient. I think what happens, and this is just from following people that actually have it, cause there’s quite a few users, as you know. I don’t know how many there are. I’m going to guess there might be 800, 900. I think I said two seasons ago 700. Anyway, let’s just say for fun less than a thousand, could be wrong. But when you pay that kind of money, you do want to use it on every patient, but you probably only had one machine.

So, what I’m hearing on the forum is I’m in Room 4 but the unit is over in Room 1, do we detach it and drag it over? Well wait, a minute, is it a posterior tooth or an anterior tooth? That would have a consideration. They now have two handpieces, an anterior and a posterior handpiece. But there’s reports of it being somewhat complicated. So, you got to build a platform, and then you got to go through the disinfection cycle, and then you probably had to alter your shaping because you don’t want sodium hypochlorite pouring out the end of the root.

And then, of course, you probably also need to alter or be thinking about how you might obturate this root canal system because you probably have a more minimally invasive preparation. But let’s go from the top. Sonendo, the company that sells GentleWave, if you go to their website, you can find right on the website that you shouldn’t use it on wide-open apices. And let’s clarify that. They are basically wanting you to be a 20-02 or a 20-04, so anything over a 20, which is quite normal, they’re recommending you not use it. And then they also talk about root proximity, the neurovascular bundle, the metal foramen, the maxillary sinus.

So, those include a lot of teeth, and we should push the unit back and not use it. And then perforations, resorptions and fractures. So, those five categories basically are contraindications for using it. But it does clean well. We said that many, many times. So, you want to use it all the time, but there’s probably a lot of restrictions.

I just want to clarify that Sonendo didn’t always have these contraindications on their website, correct? Isn’t that more recently added, like it’s ever evolving?

As the market discovers some of the accidents and proclivities for certain things to happen, the protocol is continuously changing.

Okay, well I have an email here from a practicing endodontist and I want to read a portion of it because it’s interesting. He raises some important concerns that he takes into consideration when deciding whether or not to use GentleWave on a patient. So, here’s what he says. “I am using GentleWave on about 5 percent of my patients. I use it for C-shape canals and similar situations. My reasoning for not using it on 100 percent are for several reasons. I do about five cases a day and it costs me $500 a day.” And here he’s referring to the hundred dollar disposable handpiece.

Very good.

“I have not been successful in making that up. Does it make it a $500 difference? I don’t know. Neither does anybody else. GentleWave advertises you can now do cases in one appointment. I have been doing that for 20 plus years and have had regular recalls and have had incredible success. Cleaning and shaping with ProTaper gives me lateral canals everywhere. A well fit cone fills canal space very effectively. If you judge GentleWave by lateral canal, I get them without it. If GentleWave cleaned all the tubules better than my current techniques, I would expect to see more lateral canals than I do now. I don’t see that. For necrotic cases, I do consider using it.”

“So some days I use it for several cases a day, and most not at all. I have a doctor that refers me everything and a lot of it. He doesn’t want GentleWave used on his patients until there are 10 years non-biased, well-designed studies that say it works without having a negative effect.” So, 5 percent of his patients is what he uses it on.

Well, I think what you just said in a clean sentence is he was achieving what GentleWave promises without GentleWave.

Right.

So, yeah, the 5 percent thing is probably true. I know some people use it quite a bit more than that, but it seems like the longer I keep following the endodontic discussion forum, more and more people, I don’t use it here, and I don’t use it there, root proximity we already talked about. So, it turns out that there’s quite a few places where people aren’t using it. So, yeah, it’s the do you want to throw away a $100 handpiece each time? And when I say $100, it could be $75, it could be $125, but somewhere around in there, so that gets to be kind of costly if you’re thinking you’re taking maybe more risk, you’re not really achieving greater success rates.

And one of the things that I wanted to point out is Sonendo’s own advertising is, you know, healing so much quicker. That hasn’t been proven. Just because a paper, a case report, is published and so there’s a big lesion, and six months later the bones filled in, round of applause, but like didn’t that happen to most of us across the last 50 years of our practice? In fact, I have a whole section of my lecture where I show how important it is to shape canals because so-called instrument canals are neither cleaned nor shaped. So, if we shape canals, we’re doing a lot of clean, we have a bigger reservoir, and you’re going to get a preponderance of endodontic anatomy routinely.

So, I want the GentleWave doctors to know I’m proud of you because you have taken a step forward to try to improve on your cleaning. You must have recognized there were some deficiencies in your cleaning because why would you buy something unless you want to see more anatomy. I’m just saying there’s a lot of ways to do endodontics, and you don’t have to have high technology to do it.

I think another advertising claim was that it’s you’ll save time somehow, like doing just one visit endo, but it sounds like there’s a lot of time that it takes to build the platform and –

Okay. Since – bless your heart. For – since the 50s and the 60s, let’s – now, let me say the 70s. For sure by the 70s, one visit endodontics was a big argument against multi-visit endodontics. That was solved in the 70s everybody, so don’t wake up GentleWave and tell them you can now do one visit. For most of us, for my whole career, predominantly one-visit endodontics. Obviously, there’s exceptions, emergencies, swellings, things like that. You used to do palliative treatment.

But yeah, they talked about, you know, you can do one visit. I don’t know that that adds anything to the party. This guy that you’re reading his letter – and incidentally, that is one of many, many letters that we receive, or emails, and you hear the same stories over and over again.

Well, he goes on in his email to talk about bleeding and post-op pain. And he says that at best, it’s just discouraging and it’s a nuisance, but at worst, he’s actually concerned of a malpractice suit, and I think actually there are some lawsuits against Sonendo right now, but we can save that for another show. But I think you told me that.

Yes, there are. There’s multiple.

And so, he does say he uses it in certain situations, necrotic teeth, and complex anatomy. Do you agree with that? And maybe you want to expand on that?

Sure, if you can get a platform on the tooth, and incidentally, be good at doing build-ups. I mean we learned to do orthodontic bands and copper bands and now there’s a whole new technology with matrix bands. But you can build teeth up rapidly and that means you can put a platform on it, cause you got to have a platform. But in necrotic teeth, you could be using it. That would be a good indication if you could have a stable system, a closed system. You’ve got to have a closed system. C-shaped molars come to mind. They’re very complicated.

I would think you could use it in situational retreatment. A lot of retreatment there’s transportations and perforations and the foramen might be a little bit bigger. Definitely on Sonendo’s website would suggest you should use their technology. So, when I say, “situational retreatment,” it’s got to be cases that were probably filled short, so when you extend treatment vertically you can keep your foramen around a 20 or a 25, things like that.

But I certainly if I’m out there and I’m listening to this, you don’t want to start changing 60 years of shaping ideas. Pretty controversial, what I just said. Because you’re going to try to integrate a technology, now you’re going to work 2 millimeters short.

Okay. I have a couple of comments. One, it seems like, and this is regarding the $100 disposable handpiece. It seems like maybe you just incorporate – if you’re going to use it on every patient, maybe you incorporate that cost into your treatment fee so you don’t have to feel like you’re losing $100 every time you do Gentle –use GentleWave on someone.

And then secondly, I think that, you know, it sounds like it’s a little bit cumbersome to integrate into your workflow, your current workflow, and you know, it sounds like there’s a little bit of tedium with the building the platform. But if you were seeing really great results, then maybe it’s all worth it. But I think that you were telling me that there’s some studies that have come out recently that are putting into question both GentleWave’s efficacy and safety. Is that correct?

Yeah, you’re exactly correct and, you know, the great equalizer is always time, because what time does is it allows studies to happen, and they don’t happen very quickly. It takes maybe six months to a year to do the study, but it might take six months to plan the study and the methodology so the paper is going to be valid. And then you do it all, you gather your data, you do your statistical analysis. Then you’ve got to submit the paper. And then you’ve got to get in the pipeline. So, it takes time.

But yes, there’s a really good study here out of the University of Minnesota. It can be found online. And it’s by Joseph Crepps, and he submitted this for his thesis, and the paper is called Chemical Evaluation of the Apical Extrusion of Sodium Hypochlorite using the GentleWave System.

And I’ll read you his conclusion. “The GentleWave system causes significantly more apical extrusion of sodium hypochlorite compared to the conventional needle irrigation.” And then his final remark was, “There is zero literature that has been published that links GentleWave system to better outcomes as compared to traditional methods.” So, that was a really important paper because that’s a more recent one. But he had a very sophisticated study how he collected the sodium hypochlorite exterior to the tooth, and he had a lot of sodium hypochlorite got through the foramens. And he was using a protocol of about a 20 or 25 size terminus.

And then there’s this other paper. We’ve talked about this a lot when we’ve been publishing lately. And it was by the Ordinola-Zapata group, and there’s a whole bunch of them. But basically, they compared a 35-04 preparation with a 20-02. The 35-04 was traditional irrigation; the 25-02 was GentleWave irrigation, and the GentleWave group of teeth demonstrated significantly more microorganisms harbored in the roots post-GentleWave disinfection cycle. So, these kinds of things keep casting doubt in my mind.

And yeah, you can have people on the board of GentleWave pumping out from academic really great papers. It cleans great, it’s this, it’s that. Well let’s start looking at its efficacy in terms of safety, because that’s going to be what limits its ability in the marketplace to be its full potential. We can’t just talk about how clean it does a root canal. You’ve got to talk about can you use it widely, is the cost effective for the patients.

And incidentally, if I buy a bicycle for riding, can I charge each patient, because you just said that GentleWave, we could take that $100 handpiece and we could just bill it into our fee. Could I build a bicycle into my fee so I can ride to work and be really energetic and have great juice in the tank to hit those patients all day long and really do some great work?

Well, putting in the extra GentleWave fee, the extra CBCT fee.

And the bicycle fee and the running clothes, yeah.

Okay, well, some interesting things to think about regarding GentleWave and patient protocol. And it does appear that the situation is very fluid and constantly evolving, so I’m sure we’ll be talking about GentleWave again, like a broken record.

And didn’t we say on the last show, “Don’t let your education interfere with your learning”?

You did raise one thing that I had not thought about and that was how clinicians tend to have one GentleWave unit in one operatory, so what – how do you get GentleWave to the other operatories? Maybe they have long cords?

I have the answer. On the discussion forum, we’ve talked about DSOs. The coaching is join a DSO because they’ll put GentleWaves even in your garage. Every operatory, even in the bathrooms, they’ll have GentleWave, everything for it, just they’ll pay for it.

Okay, well –

Oh, that’s a joke.

– hopefully you found this segment helpful and are maybe a little more clear in your own view. So, thank you.

There’s an old expression, you only know what you see and you only see what you know. And never does this become more important than when we do surgery. So, when we look at endodontics as a field, and we have now evolved from like kind of archaic things if I look back over my career 10, 15, 20, 30 years back. I mean then we got the microscope, see, and that elevated everything, so we could see pretty good with the scope. But today we’re going to talk about hemostatics. And we’re going to talk about the importance of hemostatics so you can see what you’re looking for.

Probably everybody out there that’s listening and that being many thousands of you, you would probably do a little bit more surgery if you felt that bleeding was not going to be an issue. Well then I might recommend that you work on cadavers. But if you’re going to work on live patients, it would all start off with your block anesthesia. I think everybody knows this, but just to be true, we can talk about all kinds of different hemostatics, which we will, but you might not have thought of the anesthesia.

One to 50,000 Xylocaine, okay, is going to give you vasal constriction, and it’s going to shut those vessels down and the capillaries down so that you have better sight in the field. So, don’t forget to give your blocks with one to 50,000. Usually for surgery, I’ll give two carpules, maybe two and a half. It depends on maxillary versus mandibula. You can see up here we have our posterior superior alveolar nerve, okay, so you can see if you give a PSA injection, you’re going to have pretty good anesthesia to the posterior teeth.

But you might want to give some infiltrations in the palate. Don’t forget to use ice to numb so it’s not the painful event that you recall when you had your first palatable with no anesthetic. Use the ice. And then, of course, down in the lower area you can give a long buccal, you can infiltrate from the lingual, but that will get a lot of the soft tissue bleeding under control. That might be your half carpule.

So two to two and a half carpules, and then you’re going to be doing surgery for probably – I’m going to say something to alarm you. You might have the patient in the room for two hours, but the surgery is going to go – the actual surgery part will probably be about 30 minutes, maybe 45 minutes, and then you’re out, okay? There’s a lot of discussions post-op, start compressions, different things that go along and are attendant with surgery, but the surgery itself is probably 30 to 45 minutes. So, this is a huge deal. Don’t forget to block your patients and get a lot of good vision just from the blocks alone.

All right, so now we can lay a flap, and we’re talked in previous exercises on the segments. We’ve talked about the intrasulcular flap, we’ve talked about the attached gingival flap, and we’ve talked about the combination flaps. So always try to make your releases running vertical because when you make releases that run horizontal, you’re going to cut across more vessels. The vessels run vertically, they run vertically, so when we make a release we want to make it parallel to vessels so we’re not going across lots of vessels and getting a lot more bleeding.

You can see the target area here as we have a big osseus break in the cortical plate, and we have another one, so the combination flap was so we had complete view of that root in case there was a dehiscence or fenestration. But you can begin to understand when you get your curette in there and you start enucleating the lesion and freeing up the, you know, the granuloma or whatever it is, cyst, from the surrounding bone, there can be a lot of bleeders inside the osseus crypt.

So, this is why you should start to expect, okay, this is all under control. Now I can go after it. Well don’t worry so much about this area. Don’t worry about little bleeders in that area. You only need to have good hemostasis right where you’re doing surgery.

All right. So, you’re now aware that anesthetic is going to help you with your soft tissue stuff, and then we’re going to go in deeper and look inside. What can we use? You know, many years ago, I think it was in the 80s, I went to a periodontal meeting, and I was introduced to Cut-trol. Cut-trol is ferric sulfate. And you can see right here if you choose this particular brand from Ultradent, it’s going to be about 15 percent. And what happens is ferric sulfate dissociates into a ferric ion, and it combines with blood proteins to form a ferric blood protein complex. And what happens is you get agglutination of tissue.

You actually get the sealing off of vessels and capillaries and you form quite a coagulum as you might expect. Those of you who’ve used it, you know that. That is not harmful for the patient, but I will say this. We’ll get a coagulum, so ahead and finish all your surgery. When you’re done, get your curette and vigorously curette the crypt and stimulate all fresh bleeding and get all that coagulant pretty much out. There will be a few places, and I’ll show you, it’s going to be okay and healing will not be deterred.

We have many articles in the Journal of Endodontics showing the difference between vigorous curetting post-surgery to stimulate fresh bleeding, versus leaving big globs of coagulant behind in the crypt because that could even be a culture medium for future bacterial infections.

So, this device is the dental metal infuser. It has a little brush at the end of the cannula, and I want to give you the idea you do not use the syringe like this. You’re going to get Astringedent everywhere, and remember, it shuts down bleeding. If you got it outside the crypt, it’s dangerous if you get it out on the free bone and then you think of it touching the medial aspect of the flap that you’ve just elevated, you could shut down bleeding to your flap and you could have a flap slough and that would be a very bad event. So, keep the Cut-trol under control, keep it in the crypt. Keep it in the osseus crypt. The dental systems are very good at holding that suction all around the crypt to protect it.

So, what I like to do is put the Cut-trol or the Astringedent, the ferrous sulfate, in the syringe, it’s a brownish color, and then I would like you to, outside the field, move the plunger just a little bit and just wet these bristles, and then hold it like a pencil so you can’t inject any more Astringedent. Now you’re just using the wetted brush bristles, and you go to the bleeder, the nuisance bleeder, and you’ll notice a shutdown, a very good hemostatic. It will shut off a lot of bleeders. Okay. So, that’s a little bit about Astringedent and the dispensing device, the cannula, the special cannula with the bristles.

I like SURGICEL. SURGICEL is oxidized regenerated cellulous and it’s another hemostatic. So, we’re now talking about three: anesthesia, we have Astringedent, and now we have SURGICEL. SURGICEL then can be used – it comes in sheets inside this box. There’s a whole sheet here. And then, basically, you cut with a scissors the appropriate size that you’re looking for. And then you can carry it into the field. And when you carry it into the field, you can use ball burnishers or different packing devices to crush it up into the bone.

And I’m saying use vigorous pressure. You can tell the patient, you’ll feel some pressure. And you’re trying to – as this collapses, it will become black and brown and kind of orangish and it’s agglutinating just like the Astringedent. It’s closing off those capillaries, the nuisance bleeders. And so, you can then begin to burnish it and then the free part is just flushed out. But this can be very good to close off a single bleeder that might be almost a little spurt, like a little bump, bump, bump. Okay, so now you have a third idea.

And then, of course, there’s one more idea. I’ve tried a lot of ideas, but these tend to be the ones that we’re always going to, and that’s Telfa. Now the thing about a Telfa Pad, the Telfa Pad, you can get it at a drug store. You can get it at most pharmacies. And it’s used a lot on wounds because it doesn’t stick. So, you know, how you have something that sticks on a wound, you go to pull it off and it can be quite painful. A Telfa Pad will never stick.

And I want to show that you can get creative. You can cut the pad. You can tear it out and free it out of the packaging. So, we can just show that here a little bit better, but we can tear it out of here, and then you can see it’s outlined, it’s right in here like this, but then you can cut off little pieces, whatever you think is necessary or appropriate, and you can just go with that.

All right. What am I doing down here? I am taking the dental metal fuser that I just showed you from UltraDent and I’m wetting those bristles, and then I’m having the assistants outside the field just streak a little bit of the reagent that you’re looking for. So, if you’re going to just – you can just streak a little bit in here and do a little bit here and a little bit here, and you don’t have to have the whole think painted like I showed, but it’s to show you that you had put this to the medial side. This would be on the backside. On the outside, you get a back stop.

So, we have the white Telfa Pad, the microscope light is going to come in, refract back, so it’s going to brighten the crypt, you’re going to see better, and then on the back side on the medial side of this, you can have some of this painted, and that will serve as a very powerful hemostatic during surgery. This won’t stick, so you can just grab it and pull it out. There’s no cotton fibers left behind because that’s not what it’s made out of.

All right. So, let’s go on. You’re getting pretty good at hemostatics. I can see many of you are rustling in your chairs. You’re thinking maybe I should go schedule a surgery patient right now while this is fresh on my mind. Well, it gets fun when you can see like that. So, the things I just talked about you can go from an upset and a broken instrument in a transportation and you can do apicoectomy type procedures. You can bevel those roots after the curettage. You can do the retro-prep, and then you can place your retro-filling material in the retro-prep, but guess what, if you can see it like this you’re going to be very excited because what you can see is look at this, right in here, okay?

That’s SURGICEL. That’s SURGICEL. That’s SURGICEL. So, once we get hemostasis, then we can use retro mirrors and we can even use the retro mirror to look up into the prep. These retro mirrors, they’re like zinni mirrors or sapphire mirrors, they’re very, very small compared to a number 3 or 4 mouth mirror. So, they actually fit into the crypt and there’s different shapes and configurations of these mirrors. But here I am looking at the beveled and prepped root, and I am not looking directly.

I’m looking through the mirror, and you can even see the Gutta Percha right here that we’ve prepped back up into the preparation as we begin to consider how we’re going to cork the end of the root, the material you want to use. So, you can begin to see little evidences. Post-surgery I’ll get my curette in here and I’ll scrape this vigorously. I might leave a little bit of black. You might see a little bit of black. That’s the agglutination but it’s really going to not be too much. The curette will stimulate oftentimes fresh bleeding.

So, we can now go quite quickly, but if you come back, you can see how in this drawing we might want to try a different color. Maybe we’ll try this one, but you can see we have our bundle coming in, and we’d have a bundle coming in, and a lot of times it will swing up and it will swing up and then exit through the middle foramen. So, we have a middle foramen, and here we have the neural-vascular bundle.

So, when we’re doing surgery in lower quadrants, we have to be very careful where we drop our releasing incision, and basically make broad incisions to stay away from danger. And then what you probably didn’t think of, actually go find it. We are always trying to go find the middle foramen if we’re operating on the mesial root of this guy, this guy, this guy, the bicuspids, maybe not the canine, but you might even put a question mark in your mind, but you want to drop your release, vertical, remember, stay parallel with the arterial beds, and then when you reflect your flap back, you’re actually looking for this so you can know where not to be and then stay away.

If you never see it, you don’t know how close you were. Maybe a retractor is resting on it and causing impingement and this can cause paresthesias. So, basically, plan this out carefully, and then you can see in this view over here, this would be your neurovascular bundle, this part right in here, but you can see then how it moves up and exits through our middle foramen, just like you see here. So, it’s kind of nice to look at a skull just to get a little bit of refreshment going.

So, you can see middle foramen, there is your major neurovascular bundle, like a waterfall cascading out of that middle foramen from deep, and you can see the beveled root is way up here. And we used to have a root that would come down like this, so it would have been in pretty close proximity because right in here guess what that is? That is your neural vascular bundle. It's moving anterior and it’s exiting through the middle foramen. We’re not trying to pack SURGICEL on these guys. It will cause major problems. Just the point here is these can be big bleeders, know where they are, and avoid them.

So, if you have a sinus communication, you better whisper because you don’t want it to echo. There might be an echo chamber. This is a joke. But notice, the root’s beveled down away – this is where you might put a big sheet of Telfa, right in here. You might just want to block that off, have a back stop so nothing in the surgical field gets into the maxillary sinus. So, be aware of that. And then, again, notice the root. You can see it’s beveled. You can see it’s quite curved, see that? So, you can get a nice hemostatic, you can bevel the roots, you see perfectly. You can prep the roots like we’ve been talking about, and then you can use MTA or some kind of a Biodentine material if you choose to go ahead and get your corkage.

But again, you’re not so concerned about bleeding in here. We don’t really worry about bleeding in there. The assistants can just sweep across these areas as they can see through the oculars of the microscope, the assistants, too. And they can see where you need help. But if this is bleeding a little bit, no problem. This is the point right in here. That’s the target area, that’s where you have to see.

All right. Now we can keep going, but now we have a – this is not a molar; this is a maxillary three-rooted bicuspid. So, again, a big Telfa sheet over here is commonly used when we’re getting ready to close and we take our last photograph and we get all of that out of there, but yeah, be sure to block things off for protection.

Okay, so you got a molar, you can see you got a big break in the cortical plate. You can palpate a lot of these things pre-surgery and they’ll say it’s tender. That means it’s broken through the cortical plate so you can begin to anticipate obviously with your X-rays, not to mention you have CBCT. So, all this is known before you go in. There’s treatment planning for no surprises. And so, you know when you start to cure wrap this out, granulation tissue is typically in these lesions of endodontic origin that persist because of deficiencies in primary treatment.

So, when you start to curette, you’re going to get a lot of bleeding. Remember, granulation tissue is the first tissue that’s formed in disease. It’s the first tissue that forms in healing, so it can go kind of either way, but it’s very vascular. That’s the point, very vascular. So, anticipate.

And then, of course, when you get in here and knock those buccal roots down, again, we can have vision where we need it, we can see with total control our distal buccal. You can see the MB. A little bit of it’s out of sight over here. Comes around and you can see the shape of it. Isn’t it interesting that the shape of the furcal side concavity corresponds with the furcal side concavity? So, we can maximize this distance in here.

All right. Hemostasis, and then a case and we’re out. So, this is the kind of case that I attracted over decades. It was a normal kind of a patient I saw that had previous treatment by a dentist. It had surgery by an endodontist, and now it’s my pre-op. And you can see these silver points are pretty parallel and they’re pretty long, and so it might be a little tricky getting them out.

But it’s also tricky putting a metal amalgam against a silver point. Metal to metal can be like a battery and you can even have current going across that, and that’s well reported in the literature. So, you don’t want to put dissimilar – you want to put dissimilar materials against each other, not similar metal materials. So, you got to kind of plan this out. So, we took out the silver points, so we made access, and we got those silver wires out. We’ve had presentations right here on the board about how to remove silver points, and there were six ideas if you can recall.

And then you’re butting that file against the retro, so in the consultation you tell the patient that you might knock the retros out. If you did, you might have to go after it surgically. In this case we were telling the patient we were going to be doing ortho treatment. We were going to be taking the silver points out and if I had problems conventionally from the occlusal access, then I would have my flap back and I could push that silver point up apical to coronal. So, I could do that.

So, here’s the rubber damn on. We had isolate canine to canine, use dental floss to hold the damn down so I don’t have any clamps. And you can see our files are in there, and you can see if you look really carefully right there you might see a little white part of my file extending past the retrograde. The retrograde wasn’t even sealing the mother canal. How about that?

So, we go in and it’s kind of a ragged cavity as you could see from the pre-op. You can look very carefully. I think you see Ruddle’s file right there sticking out on the lingual side of that alloy, and these alloys are kind of big. They’re kind of I think inappropriate for this mandibular incisor tooth. I think they could be a lot more discreet and I think, of course, with ultrasonic root-in preparation, thank you Gary Carr, we can go up the long axis of the tooth and we can get more columns instead of just round dots. But if you look at this case, it cleans up quite nicely. So, there’s our file, and now we have crypt control. You gotta have it, crypt control, crypt control.

You don’t care so much around the periphery, but once you’re in that osseous crypt, we really want to have good hemostasis. I just keep pounding on that because if you can see it, you can do it and you only know what you see and you only see what you know. So, don’t forget that. Make sure you take the time to get the crypt control. Your blood pressure goes down. Your assistant is happier. The patient can feel the vibes.

And there’s our post-op. That’s immediately post treatment. We have temporized. The dentist is going to go back in and do the definitive. And then here we are at – I think this was six months or nine months. It’s less than a year. But you can see the inevitability of the bone to grow back in when we do complete endodontics. When there’s no communication from inside the root canal space to the attachment apparatus. So, pretty good healing, and that’s how we handled that case. And I’ll say my kissoff line. If you can see it, you can do it!

All right, time for another episode of What Phyllis Thinks. So, thanks for joining us again, mom, Phyllis as you know her as. So, throughout our lives we sometimes experience close calls, and by a close call, I mean a narrow escape from danger or disaster. Well, the Ruddle family has definitely had its share of close calls. And on this very show we’ve talked about trying to dispose of the Christmas tree in the fireplace, we’ve talked about close encounters with bears and mountain lions.

Don’t make it personal.

We’ve talked about you almost cutting your thump off with a skill saw. So, we thought it would be a good idea for this episode of What Phyllis Thinks to talk about some of the Ruddle family close calls. And maybe get my mom’s insight on what happened exactly, maybe if something could have been prevented, if anything was learned, that kind of thing.

Life lessons.

Okay, so to start, let’s go back to little eight-year old Phyllis and the hornets. Why don’t you tell us about that.

That was probably my most dramatic life altering experience that happened, and I used to climb trees a lot, every day. I was always climbing trees.

Amazing, huh Lisa?

Wherever we lived sat a big tree somewhere in the yard, and I would climb it. So, we were up at our cabin and the three of us, my younger brothers, three years younger and two years younger, so I’m guessing I was around eight years old. So, we were down from the cabin maybe, oh 100 yards. It was quite a distance down from the cabin. We had walked down to the “big tree” which we loved to climb, I loved to climb, they weren’t big enough yet, and all around the bottom was a rock pile that they had cleared the road and made this huge rock pile.

So, I climbed clear to the top of the tree so I can see out and see the cabin and the woods and everything, and I’m just enjoying the breeze on my face, and I glance down and I had climbed right past a hornet’s nest, bald-face hornets, huge, like a big ball, that’s how they built them. And the minute I saw it, I froze, and at that very moment, they swarmed me. And so, I had gone past and my only option was to drop. So, I just let go and fell straight down, and at the last minute, something told me to grab, and I grabbed a limb which broke my fall before I hit the rocks, and landed on my feet and started running, and all the hornets were swarmed on me, and as I ran up the trail, my dad heard me screaming and crying.

So that’s what happened.

Yeah. He came running down to see what happened and the hornets were all over me, and so he got them all off and they rushed me up to the cabin and packed my head in mud cause that’s what you did, and I remember I couldn’t see. Everything was sort of – it was just my head that got stung by all these hornets which they can sting multiple times. They don’t lose their stinger. So, for the weekend, there I was with my head packed in mud. I don’t remember anything after that. I just remember the experience and –

Well, what was your takeaway from the incident? Did – was there anything that affected your future behavior?

I didn’t climb as many trees, and if I did, I paid very close attention, and I was terrified of bees and still get uncomfortable when there are bees around, which I know is the same for you.

Yeah, we’re not talking about what I think about bees though today. You also had a couple other close calls. I know you fell off a hay wagon at one point, and you almost got hit by a semi-truck trying to chase a little bird out into the street. So, how did your parents react to this type of situation?

I don’t remember it being discussed much other than the family I grew up in, we talked about miracles a lot. It was a very religious family, and we didn’t ever go to the doctor or anything like that. Everything was dealt with by prayer and hoping you survive. And so, everything was considered a miracle if you survived it, and, you know, it may have been true. I had vague memories of the little bird running into the street, and I went after it, and I physically felt something throw me back as the big truck roared by, and there was no one around me except my mom in the background, and she hadn’t reached out and grabbed me. So, there are things that happened in my life, and that’s just kind of how I grew up and never questioned it. So, didn’t get punished for those things.

Okay, so Phyllis thinks miracles happen. All right. so, let’s fast forward now to some of your own parenting close calls. So, we already talked I think when we talked about camping with you about how I wandered off in the woods that time, so obviously, every parent, it’s their worst nightmare to have their child go missing. Do you have any advice? How did you react in that situation?

Panic!

Okay.

It’s just, yeah, things like that happen so fast and we were so – we were terrible parents when we were really young. We had no idea what to do with kids. I mean we –

We were not terrible parents! We were unloading the camping gear from the car.

We just didn’t know. And we did tell you to stay.

We had to walk 200 yards to the camping site, and during one of those trips, this one went faster than the NBA player and disappeared in the woods.

Straight into the woods, so yeah, it was – that was terrifying.

Okay, let’s move on to something that happened with Lori. So, we hear a lot about the danger of leaving your child in the car, but mostly this is on a hot day. Now I guess that you have a little bit of a different version where you left Lori in the car at night when she was a baby. So, why don’t you tell us about that?

We were camping again, but not with a tent, just sleeping out in the open. And she was maybe – I don’t know, a year, 18 months old, she was pretty young. So, we decided she would be best off sleeping in the car cause it would be warmer, not realizing that a car – this is the Sierra Mountains, so it gets really cold at night.

About 8,000 feet.

Yeah, so it gets colder inside the car in that situation, and in the morning when we got her up she had a little warm sleeper on, so everything was covered except her hands and face and her hands were blue. It was terrifying, and fortunately she warmed up and everything was fine, but –

Miracle.

That was a miracle. That was a miracle.

Okay, well we’ve talked about you guys’ brother-in-law, Carl, already a couple of times this season, and he seems to have played a leading role in some of our Ruddle family close calls.

Adventures.

So, why don’t you tell us a little bit about those?

I barely knew them at this point. You were just a little baby, maybe six weeks old, and we went on a family – his whole family, not camping, but staying at a cabin up by Lake Tahoe, and went – I had gotten stung by a bee the day before we left because I was going barefoot and stepped on one, so my one foot was swollen and very uncomfortable. And we went down to – I think it was Echo Lake, and I decided to soak my foot because it was so swollen, in the cold water. So, I’m sitting out a little ways from the family, and I’m sitting on this big rock right on the edge of the lake and soaking my foot, and just kind of enjoying.

The family is off in the distance, and all of a sudden I hear, “Look out below!” And I look and Carl, his brother-in-law, had for some reason decided to dislodge a boulder straight up from where I was sitting. And it’s coming, and so I stand up in shallow water, maybe less than a foot, and I just dove straight into the water, hit my knee on a rock, which now I had a swollen knee. The rock landed on the rock I had been sitting on.

Oh gosh.

In other words, Carl’s and my plan didn’t work out.

That’s right.

And I think there’s also a time where dad was swimming under water because they were seeing –

A little competition.

Yeah, swimming under water competition with Carl, and Dad almost drowned.

Carl saved him actually.

Okay.

He was sinking and Carl grabbed his hair and pulled him out, so –

My dad is very competitive, so when he knew he was running out of air under water, he still did not come up for air. Okay, so what did you learn from those two instances?

Be very careful of relatives. I’m very, very careful around them.

All right, well, you know, we have – there’s so many close calls, and I don’t even think we have time to go into them all. There was, you know, the sailing on Lake Tahoe and the car accident, the wildfires, earthquakes, tornados, all of these things. There’s been many. We might have to do a What Phyllis Thinks, Close Calls, Part Two.

You should do one with her on just the sailboat stories because there was a BDI problem too where she – we blew out a main sail and there was another boating – I’ll just leave it at that.

Okay. One comment about some of my stories. If he and I go on a trip together, we come home and if we’re telling people the story about our trip they think we went on two different trips. So, there’s my story; then there’s his story. He’s the romantic, so we can have a whole show on that.

Okay, well what do you – just looking back, do you find any value in all of these close calls that we’ve had?

I just appreciate every day, and I don’t really focus on the negative things. I focus more on the positive things that you move past. And that’s in every aspect of our life together. I focus on the fun adventure, but I am very practical about the stories and what really did happen.

Well, I mean I guess having all these close calls at least it gives us like content for The Ruddle Show and stuff.

That’s true. I’m going to start keeping a diary.

Okay, well thanks for coming on and telling us, you know, giving us some more insight into just your world, and that’s it for today. See you next time on The Ruddle Show.

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