Artificial Intelligence & Endodontic Concepts Update on AI in Dentistry and Q&A

This show opens with Ruddle and Lisette revealing some summer plans… specifically, some special summer plans for The Ruddle Show! After that, Ruddle and Lisette resume discussions on a few exciting and expanding applications of AI in dentistry. Then, in a Q&A, some important endo concepts, like rotary first and deep shape, are covered. Finally, Season 7 concludes with a new Close, “Favorite Places.” Enjoy getting a fresh perspective of one of our favorite, secret Santa Barbara spots that is not featured in the tour books.

Show Content & Timecodes


00:55 - INTRO: Summer Plans
06:47 - SEGMENT 1: Artificial Intelligence in Dentistry
21:23 - SEGMENT 2: Q&A – Endodontic Concepts
41:16 - CLOSE: Favorite Places – Top of a Parking Garage

Extra content referenced within show:

  • Practical Clinical Courses: www.pccdental.com
  • Academy of Microscope Enhanced Dentistry (AMED): www.microscopedentistry.com/2022-annual-session/
  • Western Society of Periodontology (WSP): www.wsperio.org/2022-wsp-asp/
  • Elani HW, Batista AFM, Thomson WM, et al: Predictors of Tooth Loss: A Machine Learning Approach, Plos One, 18 June 2021, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252873
  • Machine Learning Predicts Who Is Most at Risk of Tooth Loss, Dentistry Today, 24 June 2021, https://www.dentistrytoday.com/machine-learning-predicts-who-is-most-at-risk-of-tooth-loss/
  • Low SB, Chang P: A Roadmap to Success in Managing Early to Severe Peri-Implantitis, Dentistry Today, 5 May 2022, https://www.dentistrytoday.com/a-roadmap-to-success-in-managing-early-to-severe-peri-implantitis/
  • University of Michigan: AI helps predict treatment outcomes for patients with diseased dental implants, ScienceDaily 12 May 2021, www.sciencedaily.com/releases/2021/05/210512115654.htm
  • Ruddle Article on ProTaper Ultimate (see downloadable PDF below)
  • More Content on ProTaper Ultimate SLIDER and the ‘Rotary-First’ Concept: www.endoruddle.com/PTUltimate
  • Advanced Endodontics (Ruddle’s Educational Website): www.endoruddle.com
  • Advanced Endodontics Just-In-Time® Video Library: www.endoruddle.com/jit


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

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

    Downloadable PDFs & Related Materials

    Ruddle Article
    "The Ultimate Shaping System: An Opening for 3D Cleaning & Filling Root Canals"
    May 2022

    New and potentially disruptive technologies come to market each year, proclaiming to improve on what came before. Many of these newcomers have virtually no evidence-based research to support claims of better, easier, or faster...

    Ruddle/West/Machtou Article
    "Deep Shape in Endodontics: Significance, Rationale and Benefit"
    Feb 2022

    The goal of endodontic treatment is to prevent or cure, when present, Lesions of Endodontic Origin, at times referred to as apical periodontitis. The role of bacteria in the pathogenesis of endodontic disease is well established, and therefore, it is critical to eradicate these pathogens by employing the highest level of presently developed standards...

    Ruddle Article
    “Current Concepts for Preparing the RCS”
    Jan 2001

    Successful endodontic treatment requires that the clinician predictably shape root canals for three-dimensional obturation. In this article, the guidelines for successful access and the concepts and strategies for canal preparation will be discussed...

    Ruddle Editorial
    “Focus On: Minimally Invasive Endodontics”
    Mar 2014

    Clifford J. Ruddle, DDS, discusses predictably successful endodontics in the context of preserving healthy tooth stuctures...

    Ruddle Technique Card
    "ProTaper Ultimate"
    Mar 2022

    Ruddle Shaping & Finishing Technique Card featuring ProTaper Ultimate

    Related Polls
    Disclaimer

    This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.

    OPENER

    Cliff

    …It’s 20 at the tip. A D-1 it would at 7, 27. A D-2 it would be 34…

    [music playing]

    INTRO: Summer Plans

    Lisette

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

    Cliff

    Good morning. How are you?

    Lisette

    Great; how are you?

    Cliff

    I’m doing great. And I’m curious what all our viewers are going to be doing this summer. There must be a lot of plans out there.

    Lisette

    Yes, well we are shooting today our last show of Season 7.

    Cliff

    Yay. Oh, oh, the last show.

    Lisette

    It seems like it went really fast. We have Season 8 planned for the fall, and we’ll start shooting that later in the summer. We do, however, have some ideas in the works for the summer for The Ruddle Show, and we still plan to bring you some content, some special content, but in a little different format. But first, some really big news. And this is big news because you are resuming a travel schedule related to lectures and workshops. And you and Mom, so everyone knows, have been at home for the last two years basically because of the pandemic.

    Of course, you’ve still been doing The Ruddle Show and some Zoom lectures and stuff like that, but this is exciting. Where are you going and what are you doing there?

    Cliff

    July 29, 30, we going to – well, we’re going to still go to Utah. I think it’s Gordon Christensen. Is that his name, Gordon Christensen? Yeah, we’re going to Gordon Christensen. Everybody around the world knows Gordon, and he gives the Practical Clinical Courses, PCC, and it’s his hands-on courses, so it’s two days. And one day didactic, and then one day you get to pick up all the tools and we’re going to look at your shapes. We’re going to see how you pack. And you’re going to do start to finish endodontics. So, that’s exciting.

    I heard the course is sold out, but I’m telling you anyway because people always change their schedules and things are dynamic and volatile and moving, so have that on your radar if you’re in Utah and you’re in the Grand Tetons and you want to come out to the mountains, the state parks, and you want to learn endo, I’ll be there. And then the other course will be August. It will be August 16 maybe.

    Lisette

    I think it’s September.

    Cliff

    September.

    Lisette

    Yeah.

    Cliff

    September 16, yeah. And that’s in San Diego, and that’s a combined meeting. That’s the Western Society of Periodontology along with the Academy of Microscope Enhanced Dentistry. And they’re coming together. Actually the third branch is the Hygiene, the National Hygiene Meeting is also part of this. So, it’s three big entities coming together under one roof, and I’ll be talking about microscopes for two hours.

    So, I’ll be talking about my deficiencies, my adoption working to get proficient and then the documentation and teaching and then how I integrate it and do some difficult cases. So, I’ll show the importance of magnification lighting.

    Lisette

    Okay, well that sounds exciting.

    Cliff

    I am excited.

    Lisette

    So, back to some of The Ruddle Show ideas, one thing we thought we might do is a start to finish Endodontics week, and it’s how that would work is that each day we would feature a specific aspect of endodontics. So, like maybe the first day would be diagnosis. And what we would do is we would go back through segments we had shot on The Ruddle Show and compile in a large show all the segments on diagnosis, and then maybe we would also offer some additional commentary.

    Cliff

    We’d want to spice it up, right?

    Lisette

    Yeah. And then maybe next day we’d do abscess until we go all the way through start to finish endodontics. So, that is one idea we had, and hopefully, we can do it. We’re still trying to work out all the details on it. But then, what else? Maybe a podcast or two?

    Cliff

    Well, you have this son that I call The Shooter, but he does have a name. His name is Isaac. He’s the youngest member of our Ruddle Show team, and to tell the audience something maybe you don’t know, but Lisette and I, we meet regularly on non-show days to work on shows. And so, we Zoom, and Isaac puts the meeting together and I join the Zoom call. And then Lisette kind of like – and I start creating, creative thinking, and we start thinking about possibilities.

    And anyway, he’s been watching this for some time, and he’s noticed that it’s quite interesting because we go in a lot of different areas, and it’s very creative. And he said, “Well why don’t we just have a less formal session and maybe we could do some podcasts and you guys could just drill down and go all over the place.” And he thought it would be very fun. So, that got my attention because that’s something new, and I always like to do new things and keep stimulating myself so I can be the best that you guys expect me to be.

    Lisette

    Yeah, we’ve actually had some requests from some younger clinicians who really like the podcast format, that maybe we would consider doing a podcast. So, Dr. Randy Cross, if you’re watching this, we have some podcasts in the works. So, then we also might do a special report or two, we’ll see, so we definitely will be, you know, present and we plan to bring you some special content. We’re still just trying to work out all the details of how – of what we’re going to do.

    Cliff

    We might even change our set I heard.

    Lisette

    Yeah.

    Cliff

    We have three sets, and the set that they see less frequently, Set C, is going to probably turn into something that’s more where we can do some of these things Isaac has seen that he likes. And incidentally, lots of young dentists are permanently wearing their buds and they’re permanently on bicycles and they’re running on treadmills, and anyway, they could watch the podcast.

    Lisette

    Okay, so watch for –

    Cliff

    Or listen to the podcast.

    Lisette

    – what’s coming, yeah. Well we’re going to probably do a video podcast so they’ll be like video and sound.

    Cliff

    Good.

    Lisette

    Maybe we’ll just only do video. Okay, well we have a great show for you today, and let’s get going on it.

    SEGMENT 1: Artificial Intelligence in Dentistry

    Lisette

    All right, well today we wanted to devote another segment to discussing artificial intelligence and its applications in dentistry. So, just for clarity and so we’re all on the same page, AI refers to machine or software that can mimic human intelligence. And the idea is that by analyzing a large body of data and employing certain algorithms that AI will be able to predict outcomes and problem solve.

    So, previously on our show we talked about how AI could be used for diagnostics, like detecting root fractures and caries. Today we wanted to talk about how AI could be utilized to predict outcomes like who is most at risk for tooth loss or how people will respond for treatment for periimplantitis, so we’re going to talk about it in that sense. So, to start, why don’t you tell us about the Harvard study where AI was used to predict who is most at risk for tooth loss.

    Cliff

    Very good. Harvard. in concert with the University of Watauga, New Zealand and Sau Paulo, they wanted to find out just what Lisette said, what is this patient’s potential risk for tooth loss? You might see them at any time in their life, so you might want to know that. So, they did five algorithms, and the algorithms were pretty interesting because normally we just see people chairside and we do an exam.

    So, the question was how does the dental exam compare to these algorithms, and the algorithms were on the medical conditions. They wanted to know more about the medical. We all chairside have a medical history and we can do the oral exam and we have radiographs, so that’s not real new, but what was new is the socioeconomic. And they kind of looked at things in terms of just when I classify these things, just think of low, medium and high.

    But really, your education might dictate the kind of job you have, so education, job. The job might dictate how much money you have to spend, especially if dentistry is considered elective. Gender and race plays a role, and then finally, people that went on the internet. So, they looked at all these variables, medical report, your medical history. They looked at socioeconomic, and they looked at dental. And they found out that those three things with their algorithms were far more superior. They were far superior to prognosticating future tooth loss than just the dental exam and medical history alone.

    Lisette

    Well, that is interesting. And it makes me think a little bit of what we’ve gone through with the pandemic in the last couple years because I personally, and I am not – I’m a little embarrassed to say this, but I didn’t realize how big a role socioeconomic factors play in a person’s overall health. And we saw early on in COVID that deaths were disproportionate depending on race, wealth, the region of the country a person lived, education, and it seemed that poor and less educated individuals as a whole, the group as a whole, tended to be a little less healthy, maybe more overweight.

    And whether this is because of diet, living in an inner city where you’re breathing more polluted air, what else? They were maybe – had less access to healthcare even or maybe they even smoked more. So, it seems that they also tended to work more in the essential businesses exposing them more to COVID, so it really definitely makes sense that socioeconomic factors would also play a big role in a person’s dental health.

    Cliff

    Yeah, I saw this personally. You were a little kid at the time. I mean you were like, well I don’t know, you can’t see back here, but I don’t know, she was probably, I don’t know, three or four years old, but I was in Boston, I was in grad school, and it was critical that I have some curriculum outside of Harvard. I needed to work to pay my way through. Phyllis always said that she’d help me with dental school, but when I went to grad school. I was on my own.

    So, I had Phyllis and two little kids. And so, I worked in Mattapan. Mattapan is a suburb of Boston’s inner city. And it’s a very poor area. It’s predominantly people of color, and I noticed when I went and worked in the clinic, I had been at Harvard and I was seeing patients, and they had crowns and castings and amalgams, and their mouths were always pretty good, but they had a chief complaint. But when I was at Mattapan, I saw no tooth, blown out teeth, I saw hopeless teeth, I saw hopeless perio, I saw a lot of people in severe pain because caries’ exposure.

    So, when we did do endodontics, we were going through carious lesions right into the pulp, and I had a rude awakening when I came to Santa Barbara because every access was through heavily restored teeth. It seemed like I had to drill 10 millimeters through occlusal gold just to find the roof of the pulp chamber. So, yeah, that’s an example, and then, of course, if you looked at the history of the people that are working with you, they fall right back into your education, they fall right back into well what’s your job, what’s your income, and what’s your gender and race, and those kinds of things.

    So, I really saw first-hand for two years. It was a great job and I learned a lot and I treated some wonderful, wonderful people.

    Lisette

    Okay, so if AI can predict who is at most risk for tooth loss, how is this helpful?

    Cliff

    Well, if you could prognosticate tooth loss with these algorithms, then you might, if they’re small patients, which I saw in the Mattapan Clinic, cause we had one of every specialty. At that time we had seven different specialists in that clinic. Well the pedodontist could do resin on the occlusal surfaces, they could use these different things to prevent caries, so prevention was very big in the young patients.

    And then in the older patients the main thing is a triage, you know, like take care of pain, get them out of pain, and then stabilize what is left. That means get rid of the losers and clean up their mouths, and then maintenance. And maybe they can have a few teeth left that can hold a partial denture. But we’re not going to be doing implants and sophisticated restorative dentistry on these patients.

    Lisette

    Okay, yeah, I mean keeping your teeth is definitely a high priority, and it definitely seems like in our society, there’s more and more importance placed all the time on having nice teeth. And you might even remember on our last show we talked about how the rules are starting to change in hockey to actually benefit a player’s dental health. So, definitely there is this trend to trying to save our teeth.

    Cliff

    Are you saying there should have been an algorithm that these three universities put together and qualify were they or were they not hockey players?

    Lisette

    That wasn’t one of the criteria.

    Cliff

    That wasn’t.

    Lisette

    But it’s understandable why researchers today are really motivated to develop algorithms to find out who in the general population is most at risk for tooth loss and maybe prevent it. So, do you have any closing remarks before we move on to the next topic?

    Cliff

    Yeah, I mean tooth loss, especially when you’re working in the inner city, it can be catastrophic physically and emotionally. And physically, that could be can’t eat or chew so well, maybe your speech, there’s a lisp or you hear wind between teeth, and so this makes people insecure so their interpersonal relationships are a little less than they could be optimally, and they’re less secure. So, if we can stabilize people and move them towards health, that’s going to help us in the long term help people keep all the teeth they can.

    Lisette

    Okay, well we learned about this study from a Dentistry Today news article, but if you’re interested in reading the whole Harvard study we’ll try to have a link to it in our Show Notes, or even just a reference. But now let’s go on to the next topic, and that is how another recent study out of the University of Michigan where AI was utilized to predict treatment outcomes for patients with diseased dental implants. Why don’t you tell us about this study?

    Cliff

    Well, maybe I should set the stage a little bit first. First of all, internationally, we’re approaching $6 billion, just the implant game. I didn’t talk about the casting on top of the implant or the bone augmentation. I’m talking about just fixtures, about $6 billion. And in the United States, it’s $2 billion. So, what’s the point? Well what if you knew that 25 percent of all implants develop periimplantitis. In fact, that’s not so uncommon. And it’s not so unusual to see somebody who’s had an implant and a year later there’s an infrabony pocket, maybe two, three, four wall.

    So, the point is how can you prognosticate this? So, what was pretty interesting is the University of Michigan, they were able to write programs and algorithms to develop who would respond best post-surgery. So, first you’d want to get the implant, and we’d want to emphasize recalls and maintenance, but when they see it, then they would typically, they might try antibiotics for a round or two, but usually they get flap procedures, pull the flap back and try to clean out the infrabony pocket and use reparative and regenerative materials, put the flap back and suture and then the question is how many of these cases that had surgery can go on and improve or deteriorate further?

    So, they were able to take crevicular fluid out of a sulcus and you can do immunoassays on this fluid, and immune cells that were able to fight micro organisms were superior to immune cells that help in tissue repair and regeneration. So, that really threw them by – that caught them off guard because they were thinking regeneration and repair, that’s what you need after you’ve done the surgery around the peri-implantitis problem. But they found out it was much more – it was much better to control pathogens.

    Lisette

    Well, it is surprising that roughly one quarter of implant patients will develop periimplantitis, and in the article, the researchers said a large part of their motivation to develop these algorithms is because of this emerging endemic of periimplantitis that is really compromising the long-term success of implant dentistry. So, knowing the high incidents of periimplantitis and learning that better regenerative outcomes occur in patients that have more immune cells for microbial control, how does this new information serve to guide a patient’s treatment?

    Cliff

    Well, I kind of answered it, but I can go a little deeper. If you can take crevicular fluid and you can do a chemical assay on it, you can look for t-cells, macropsias, osteoblasts, and all these can be turned on, turned off, to different levels to balance repair, but mainly killing microorganisms. In fact, people that have some medical conditions like arthritis or diabetes, it would be wonderful if you could know before you ever put the implant in is this a good candidate based on machine learning and having huge databases.

    You could start to tell people chairside on the consultation, you are – well, you’d have to have a consultation, get the report back, but you could tell people who might be good candidates and who is not. So, long term, in some hope I’ll say this just quickly, if I have time.

    Lisette

    Yeah.

    Cliff

    Sam Lowe from, he’s a great periodontist and he’s in Florida, he wrote an article in Dentistry Today, he was the cover guy, and what he showed was that, you know, usually they reflected on the periimplantitis problem and they would curette the diseased tissue out, granulation tissue, we all know that, but the problems have been how do you create a good site environment for healing? And of course, traditionally we haven’t had lasers, so they were scraping implants and scratching them. They were ruining the titanium surface.

    Anyway, he found out that this ERCRYSSG laser by Biolase, it has an affinity to not damage the implant. The laser rays can be absorbed into the implant, it can give you completely squeaky clean surfaces, and he found out that he was able to see decontamination of the implant. They were able to see that there were complete areas where tissue reattached to the implant, and they were finding that they got much better healing. So, it looks like we’ve talked about lasers a little bit; it looks like lasers have a role in this periimplantitis treatment.

    Lisette

    Okay, well that sounds actually kind of promising that there might actually be a little bit of a solution that can come from lasers as well as just knowing what kind of immune cells a person has and what their ratio of wound healing cells are to microbial control cells, you know.

    Cliff

    Right.

    Lisette

    Okay, so that’s some interesting information. If you’re interested in reading the study from the University of Michigan, we’ll try to have a link or a reference in our Show Notes. So, that’s all we have for today.

    Cliff

    When are you guys coming?

    Lisette

    Last time we talked about AI or we’ve mentioned it in a few shows, but we talked about it in terms of diagnostics. Today we talked about predicting outcomes. Next time we want to talk about how you can actually incorporate AI into your daily practice.

    Cliff

    Oh yeah.

    Lisette

    So, we already have that planned for next season.

    Cliff

    Maybe we’ll be in training this summer so that when we come back in the fall we can show our hand.

    Lisette

    Yes, well thank you for explaining those studies and for the great information.

    SEGMENT 2: Q&A – Endodontic Concepts

    Lisette

    Okay, so here I am at the board joining my dad because we thought we would close out this season with a Q&A. So, today the Q&A is going to revolve around endodontic concepts, but before we start, it was pointed out to us by one of our viewers that you made an egregious error on one of the earlier shows this season. We all missed it, but Dr. V.K. Karthikeyan noticed it. So, why don’t you clear that up for us all right now?

    Cliff

    Thanks, BK. Normally, when you lecture live, there’s a handout there, and there’s like I’m having a problem with something, so you could just identify it. But in this case, there was nobody here except the set people, so I’ll identify the problem right now. But if you want to know what we were talking about, we were in the segment of ledge management. And we were talking about how to buff out the ledge. And I was talking about a 10 file.

    And the egregious error is I misidentified the cross sectional diameters as 0, 1, 2, 3, 4, 5 millimeters, working up the file, in the file, D0, 1, 2, 3, 4, 5. So, the diameters are there. I guess some of you probably would really benefit if I said millimeters, but anyway, that is 10, 12, 14, 16, 18. At D5, it’s a 20.

    Lisette

    So, you do know it.

    Cliff

    I do know it.

    Lisette

    Okay.

    Cliff

    I just – well I started off correctly, and then I cleared the board and then I got off.

    Lisette

    Okay. All right. So, here –

    Cliff

    Thanks, V.K.

    Lisette

    Now we’re going on to endodontic concepts. So, the first question is this. I hear you often speak of root-appropriate shapes. How exactly do you define a root-appropriate shape?

    Cliff

    Well, that’s a good question, and so often misunderstood. And “root-appropriate” sounds like it’s totally subjective. Let’s put some ideas around it, and then it will make more sense. ProTaper was the first system in the world. It was launched in 2001, and one of the IP’s that did expire 20 years later was regressive tapers. We were the only file, the first file and the only file in the world, that didn’t have from the tip of the file as you move up that instrument, all the files had fixed tapers. They were 2 percent, 4 percent, 6 percent, so they were getting bigger every time you moved up the file 1 millimeter, a little bit like that last drawing.

    With ProTaper we decided, since as you get to the bigger finishing files, they would be enormous at D16, we decided to have regressive tapers. So, the file came to market in 2001, and we could have tapers of 7 percent, 8 percent, and we could have tapers of 9 percent. The secret is you can’t run that taper out over the whole length of the file. So, our concept was, if we just look at a real simple tooth, and we divide it into thirds, so we have coronal one-third, middle one-third, apical one-third, we wanted to have a zone in this region, pretty clever, huh?

    We wanted to have a zone where the file, instead of getting bigger and bigger and bigger, it would be getting smaller at a smaller rate. We still then wanted the classic deep shape. So, what makes a root appropriate shape then? For me, it’s to have deep shape in this apical one-third, and then have a smaller body to respect minimally invasive endodontics and the restorative effort that lies ahead.

    Lisette

    Okay.

    Cliff

    So, that’s a root-appropriate shape.

    Lisette

    So –

    Cliff

    And incidentally, we’re the only system still today that offers tapers of 7, 8 and 9 percent on example, the F1, the F2 and the F3.

    Lisette

    All right. So, the second question. Is MIE, minimally invasive endodontics, is MIE and root-appropriate shaping basically the same thing in theory?

    Cliff

    Yes and no. Everybody likes to think a root-appropriate shape is minimally invasive. But the problem is most people today in the world of minimally invasive endodontics, they’re using instruments that are like 15/04 or perhaps they might be using a 20/02, more or less the same file. For novices out there, don’t feel bad. It just means the tip is 15. It’s a 15 at the tip, D/0. And then the file is getting bigger by four. So, it goes 15, 19, 23, and blah, blah, blah, all the way up. So, it’s getting progressively bigger. It’s usually a fixed-tapered file, same thing.

    So, they would say this is very appropriate for minimally invasive endodontics. I would tell you that is far different than 7, 8 or 9 percent in the apical one-third. So, they’re going to have apical thirds that are, you know, we have a 20/07, we have a 25/08, and we have a 30/09. And this is F1, F2 and F3. This could be ProTaper Gold. It could be ProTaper Ultimate. With Ultimate, the body is even smaller. The body at about D12, D8, D12, it’s about a 70 or an 80, so the older files we regressive had tapers, but the tapers allowed the file to be a little bit bigger to facilitate people with different needs and wants across the world.

    So, this is very different than this, so these people can have skinny preps over their whole length, but they’re not getting deep shape. In fact, their shapes are almost non-existent.

    Lisette

    But maybe the people who do root-appropriate shaping, for them, they’re being as minimally invasive as possible.

    Cliff

    They are, and a lot of these people –

    Lisette

    And have a good result.

    Cliff

    To be fair they’re using lasers, they’re using GentleWave.

    Lisette

    These or these?

    Cliff

    These people here. This is our minimally invasive crowd. And the minimally invasive crowd, they’re not all making these shapes. They might use a 25/04, but the point is they’re really emphasizing small shapes. Small shapes means small shapes coronal, middle and apical third. And I don’t want to do this right now, but if you do – well, we’ll do this one. A 20 file, and you can hold up your finger, it’s 20 at the tip. But at D1, it would be at 7, 27. At D2, it would be 34, and at D3, you could add another and it’s 41. The point is we’re getting a nice, deep taper.

    So, you’re going to ask me about that a little bit later, but you’re getting a completely different shape between these two concepts. This concept you have no chance to clean or fill unless you’re using $70,000 technology or perhaps $100,000 technology. I know that this was the Er:YAG but then we had, last time we talked about EdgeEndo’s, they have a $30,000 machine. But you’re using a lot of expensive money to overcome deficiencies from a minimal preparation.

    Lisette

    Okay, I think the issue here is maybe how you define minimally invasive because for someone like you, you want to be as minimally invasive as possible. That’s a positive thing. But some people might think that what you’re doing is not actually minimally invasive, that it has to be these sizes.

    Cliff

    Oh, they would probably argue that completely.

    Lisette

    Okay.

    Cliff

    The thing is the numbers of people that have this technology are probably less than 1 percent of a million dentists on planet Earth. So, that means what do we do with the other huge population of dentists that aren’t going to use this technology or don’t want the technology or doing maybe the EndoActivator. So, they need a little more shape in the deep shape area, but we can still be very minimally invasive up in that coronal and middle one-third, because that’s where we have historically as a profession overprepared teeth, and that’s predisposed to fractures.

    Lisette

    Okay. Moving on. What is deep shape and why is it important for irrigation?

    Cliff

    Okay, well we’re kind of skirting around it, aren’t we? So, here we’ll just do another little drawing here. And we’ll try to do a deep shape.

    Lisette

    Well, my question is why is it important for irrigation, but also does it impact obturation as well. Maybe you can answer both of those.

    Cliff

    If we just look at a section through the apical one-third, then if you have a 20 down here at the tip, deep shape, if you have 7 percent, we already did this, at D1, D2, D3, D4, D5, and if we had 7/27 – help me out, 34. What’s the next one? 41, 48, 56.

    Lisette

    55. Or 55.

    Cliff

    And where are we, one, two, three. Anyway, you’re going to be about a 60, a size 60, in the junction of the bottom of the middle one-third and at the top of the apical one-third. This means we have more volume, and if you have more volume, you have more reagent in here. And if you have more reagent in here, you can stick a device in to agitate that like the SmartLite Pro EndoActivator. And you can begin to see more movement laterally into this un-instrumental part of the canals. That’s lateral cleaning.

    So, deep shape gives you a bigger volume of liquid. It allows you to activate a bigger volume of liquid to clean better, and of course, it – the taper alone prevents what GentleWave reports constantly, we even cited an article last time that there was significant more sodium hypochlorite dispensed to the root with a 20/02 preparation as compared to standard irrigation. So, that leaves the sodium hypochlorite action.

    So, the deep shape is also holding your reagent and the deep shape is also holding your obturation materials when you three-dimensionally fill, thermal soften, and then give that press and mold and adapt the gutta percha into the cross-sectional geometries.

    Lisette

    Okay. I did have one question. If you have a deeper shape towards the apex, is it easier to obturate because you can maybe get the cannula down, or whatever you’re using to press, down further?

    Cliff

    Well, you can get your cannula down deeper, and when you’re irrigating, okay –

    Lisette

    Oh okay, so I mean for the –

    Cliff

    You’re meaning the plugger.

    Lisette

    The plugger, right.

    Cliff

    And you can get your plugger closer to length, and with Nathan Lee’s new conform fit gutta percha that Dentsply sells internationally, it has a longer heat wave, so you don’t even have to get within 5 millimeters anymore. You can get back 6 or 7 millimeters and you’ll still get a heat wave right to the terminus of that cone. So, when your plugger is up here, you know, and you’re pushing vertically, you know, and you have a canal down here —well, when you thermal soften your gutta percha in the apical third, you’ll get a heat wave.

    So when that plugger comes down on that thermal softened gutta percha, it captures the lateral walls, and that’s what tends to hold it, as you vertically compress it and cork the apex. So, deep shape helps you irrigate better. Thank you. If the cannula is placed deeper easily, passively. And then the pluggers can fit nicely through the body of the canal. Generally, the coronal two-thirds is the straight away portions of the canal, or less curved, and you can get your pluggers closer to length so you can adapt your gutta percha.

    Lisette

    Okay. Next question. What does it mean exactly when you say rotary first? Isn’t that counter-intuitive and perhaps dangerous?

    Cliff

    Well, I guess I’ll go back the other way. Okay, for my whole life, that means 48 years of teaching, I’ve always talked about cathaterizing canals. Our group, Marsh Two, John West, we coined the word “glide path.” We’ve talked about secured canals. A secured canal was a canal that had a smooth, reproducible glide path over the apical one-third. So, when we have that, we could then go from manual, your question, to mechanical.

    Well. technology kept moving, and time intervened, and over the years, we had better metals, we had better cross-sections, we had different ideas that could be built inside the metal to produce files that were safer. So, when we were building ProTaper Ultimate, as an example, we did hundreds and hundreds of teeth, and what we began to find out is that mechanical could reach length in extracted mandibular molars about 80 percent of the time. That means about 20 percent of the time when the file wouldn’t easily go, we would have to grab a manual file and cathaterize those canals. And then once we had a 10 loose, we could go back to the slider, and we could expand the glide path and go ahead with our shaping.

    So, it sounds intuitive that you would want to try it, but there were so many broken instruments over the years that we always said you have to use a manual file, at least to – I used to say a 15. So, when rotary first came out in the 90’s, we said don’t even stick a rotary file in until you have a loose 15 at length. Well a loose 15 is almost a 20, but technology has changed since 2001, and files have gotten dramatically better, cross sections and like I said, metallurgy. So, when you start to think of those possibilities, we found out we could mechanically get to length.

    Well, the benefit of this is you are more efficient, that makes sense, but we wouldn’t do it if it wasn’t safe. So, I’m not going to give a lesson on how to use that file, but I want the colleagues to understand that about 20 percent of the time you’re going to need to use a manual file, and that’s okay. But if I can help you 80 percent of the time get to length, you’re going to be more efficient, you’re going to have the best glide path you’ve ever had, so your shaping files can easily follow. You’ll have less iatrogenics and less iatrogenics means things like blocks, ledges, transportations and perforations. So, you get safety, efficiency, and finally, you have less post-op pain.

    And this is huge because a file that’s spinning or a file that has unequal bi-directional angles is eventually always making circles, 150 minus 20. 30 is a net of 120 and 120 after three cycles, that’s even making a reciprocation probably making it a circle. So, when a file is making circles, it’s collecting debris, it’s augurated up and away from length, up into the pulp chamber. So, these three things are huge benefits, and patients benefit, doctors benefit, and you stay out of trouble.

    So, when it doesn’t go, don’t worry, just grab your viscous chelator, grab your manual file, catheterize, get to length, get a working length, and then do what you were always doing.

    Lisette

    So, this kind of actually relates to the next question which was –

    Cliff

    Caries?

    Lisette

    Not yet. Which is are there benefits to doing rotary first besides simply saving time? Well, you just kind of covered that right there. That was the next question. I do have just one other question. Now what are the minimum requirements again before rotary first? Is it to catheterize to a 10?

    Cliff

    Well we used to teach for years you don’t even think of a rotary file or I’ll just say mechanical because there’s reciprocation too, and that’s – okay. So, whether you’re spinning circles or reciprocating, that’s mechanically driven. We said don’t even go there until you had an original 15 at length.

    Lisette

    Okay.

    Cliff

    Then technology improved and we we’ve got it back to a 10. It’s much safer. The most dangerous file in the business is a 15 stainless steel hand file, everybody. I’ve talked about that for years, so you can just go to my website and read and you’ll see a whole bunch of that stuff. But when we got to a 10, that was a nice step forward, proverbially, but we hadn’t reached the summit yet. And so, with Ultimate and with all these doing hundreds of molars and these were long ones, narrow ones, curved ones, Machtou and I discovered quickly we could get to length a little over 80 percent of the time.

    Lisette

    Without even doing a 10?

    Cliff

    With no 10 file.

    Lisette

    Okay.

    Cliff

    It was our first file, so it was a rotary first concept. And then the proof of concept was the 80 percent. So, we realized if you hold the handpiece really loose, just bounce it between the index finger and the thumb and the webbing, and just let the handpiece supported there, and just let it get pulled in. It doesn’t get sucked in. It doesn’t get run in and dig and gouge and you’re out of control. It will just float and run. As long as it’s running, stay the course. If you see the rubber stop moving ever closer to the reference point, you’re good.

    If it bogs down and won’t go, take it out because it might not be that it won’t go; it might be there’s so much debris on the flutes of that file that it pushes the file off the wall and the file can’t grab the wall to engage and cut and get pulled in. So, clear the blades and put some more viscous chelator in and go back in, and if it doesn’t go that time, then grab your 10 hand file, your 10 file. You might have to grab an 8. You could even grab an 06, but normally you’re going to grab your 10 and catheterize the canal, then go back to the slider, which is the first instrument in the ProTaper Ultimate family of instruments.

    Lisette

    Okay. So, rotary first, but totally passively, no pushing.

    Cliff

    No packing, no pumping.

    Lisette

    Okay.

    Cliff

    And let’s say it again, totally passively.

    Lisette

    Well, that is all the time we have for the questions today, but thank you very much.

    Cliff

    Well, the one we didn’t cover was the one that was going to make the biggest difference for them, but we’ll get it next season.

    Lisette

    Maybe we’ll just do a Q&A on just that one question.

    Cliff

    Yeah, thanks everybody, because it’s always fun being up here with my daughter, Lisette, and this wraps up this season, but I hope you enjoyed it and we’ll have a lot of interesting stuff and informative stuff so we can continue learning together.

    Lisette

    You’ll see us in a moment because we do have a special close for you so –

    Cliff

    I hope it’s offsite.

    Lisette

    Yeah. You’ll see. It’s a surprise.

    CLOSE: Favorite Places – Top of a Parking Garage

    Lisette

    Okay, so we got in our cars and we drove downtown, and now we’re at the top of a parking garage, and there’s not very many cars around us. But the reason why we came here is because there’s so many of these parking garages in Santa Barbara, almost on every block, and the tour books will never tell you to go to the top of a parking garage to check out the view. But you can get some interesting perspective.

    Behind us right here we have the Courthouse. The tour book will tell you to go to the Courthouse. But then when you’re at the Courthouse, can you really see the Courthouse? So, but now you can see it really well. What time is it, Dad?

    Cliff

    Well I just heard 12 bells, so I guess we’re just after 12:00 p.m.

    Lisette

    Have you ever been up there at the top?

    Cliff

    Once. It’s a remarkable architectural structure in Santa Barbara. In fact, in destination resorts people will come here, they hit the beach, they go to the Wharf.

    Lisette

    The Mission.

    Cliff

    The Mission, and the Clock Tower, they like to go there. On the other side of the Clock Tower is the Sunken Gardens, and I’ve heard Jacque Cousteau there before, but a lot of people come into town, and they’ll give like a little speech or a talk, and they can – in the Sunken Gardens, it’s very nice. It can accommodate maybe 1,000, 2,000 people. So, it’s –

    Lisette

    A lot of weddings happen there in the Sunken Gardens.

    Cliff

    Yeah, you got married over there, didn’t you?

    Lisette

    We got married, but we just had a very, very small ceremony, just me, my husband, and the kids, and it was just on the lawn, like in the Sunken Gardens area.

    Cliff

    And then you notice we have fog this time of year, and the fog is breaking, and we’re going to have a beautiful, beautiful afternoon, but you start to see some blue sky, and it’s coming over the mountains. In fact, our families all live on the Riviera, so that hill right behind us that you see through the gloom and the fog, is the Riviera.

    Lisette

    Over there’s the Granada Building. And that’s a pretty famous building.

    Cliff

    You go to the Nutcracker, right?

    Lisette

    You see the Nutcracker there every year. I think the bottom part is a giant theater, but the top is offices.

    Cliff

    Right.

    Lisette

    So –

    Cliff

    Yeah, I have some referrals that used to practice up there in the Granada.

    Lisette

    Right on the other side of us is State Street, and that’s the downtown, and if you come and walk on State Street, you’ll probably see through the buildings, maybe the Courthouse Tower.

    Cliff

    Well you know what I’m thinking?

    Lisette

    What?

    Cliff

    They’ve seen the Wharf, they’ve seen City College, which is right out on the coast, and that’s where we flew the flight cause we were launching Ultimate. Remember that?

    Lisette

    Right.

    Cliff

    I took a little fall myself, personally. And then we’re now on a parking lot garage. So, maybe we’re giving enough information that they’ll have a compelling reason to visit us live for our live audience of The Ruddle Show.

    Lisette

    Yes.

    Cliff

    People don’t know that, but we usually have 50, 100 people in the theater watching our show live. So, you might want to be one of those people and get a ticket. Yeah, why not?

    Lisette

    One thing we’re always doing on The Ruddle Show is we’re trying to get you to think a little differently, get you to get a different perspective. So, maybe when you’re driving to work tomorrow you take a different route and get a different perspective.

    Cliff

    Yeah, we’re getting our different fresh perspective out here with the fog breaking up, the sun is coming out, and so get your fresh perspective this summer so when we join you in the fall, and you come to The Ruddle Show, we’ll be all juiced up and ready to go.

    Lisette

    So, thanks for watching Season 7. We’ll see you again for Season 8 in the fall, but we’ll also be kind of coming at you a little differently in the summer. So, thanks for watching.

    Cliff

    Thank you. See you then.

    [music playing]

    END

    Disclaimer

    The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.

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    03.03.2022 Update

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    2020

    01:52

    Behind-the-Scenes Studio Construction

    Timelapse

    The Ruddle Show
    Season 8

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