SPECIAL REPORT: THE KISS PRINCIPLE The Importance of Simplicity & Getting Back to Basics

In the last 2 decades, there has been an explosion in endodontic and dental technology; yet, we are not seeing this reflected in success rates, which have only increased around 2%. Alternatively, the avalanche of new products – combined with dental politics, endless controversies, conflicting research, and the need to be competitive – has only served to complicate dentistry. In this Special Report, Ruddle and Lisette discuss the KISS Principle (Keep it Simple, Stupid), look at ways clinicians are over-complicating things, and explore solutions like streamlining and getting back to basics.

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Lisette

Welcome to our Ruddle Show Special Report. I'm Lisette, and this is my dad, Cliff Ruddle.

Cliff

Great to see you again. And it looks like you have a Special Report hairdo.

Lisette

Yes, this is my summer hairdo, and hopefully all of you are enjoying your summer, right?

Cliff

Yeah, it's been a really good summer. It's been a really busy summer. So, yeah, what are we going to be doing today?

Lisette

Well okay, so here we are in the middle of summer, and for a lot of us summer represents simpler time. The kids are out of school. Vacations are planned. There are longer days and warm evenings. Barbecues come to mind, popsicles, ice cream, lots of outdoor activities, so what better time for a Ruddle Show Special Report on keeping it simple. So, you recently had a conversation with a future Ruddle Show guest, and you'll meet her next season, Dr. Josette Camilleri. And when you were talking with her, the topic of your conversation actually sparked the idea for the Special Report. So, why don't you share with us a little bit of your conversation?

Cliff

Okay. So, Josette doesn't feel singled out, I actually heard the number I'm going to mention shortly from several clinicians that have been around for like 40 to 50 years. And it has to do with success and failure. So, you're thinking you have a pretty high success rate, right? And you can go to the literature and you can support that by finding, you know, lots of studies have put it somewhere between 89 and 94. The one I want to point out though is the one that was done by Salehrabi, from USC with Ilan Rotstein, and they looked at insurance from 50 states and they looked at almost 1.5 million patients, and they had retention of those teeth at seven years, 97 percent.

So, what we were talking about, back to Josette, is we were talking about the explosion in technology and is it really impacting success and failure? Well that was a 2012 study, I believe. No, it was 2004. So, that 97 percent on almost 1.5 million teeth was many years ago when we didn't have a lot of the technologies. Let me explain it really quick. I'm talking about lasers, I'm talking about CBCT, I'm talking about microscopes, oral scanners, X-NAV, whatever is on your list. These oral scanners are really popular.

So these are the technologies that have really influenced the last 15, 20 years of dentistry, but yet the success rates we're not feeling have really proportionally moved up, and maybe you could argue how could they move up, they're already so high? So, I guess what we're saying is there is a lot of technologies, and we get confused sometimes about these technologies because each one is heralded to be easier, better, faster, and maybe even more profitable for us. So, these success rates really haven't gone up that much with all these splendid technologies that we're all fighting over and scrambling.

And then, of course, another thing that's happened with success that sometimes sabotages a little bit is the controversies. In dentistry we have up and down articles, we have different products that manufacturers made claims, and this one if better than that, but this one – no, it's not as good as that. And so we get caught up in the controversies, the politics, the up and down literature. And then of course this is this technological list that everybody seems to want to have. I found in one magazine it was Dentists Wish Lists, those technologies I just rattled off.

So, I think that's basically it. But at the end of the day, if you want to simplify your endodontics, I think that's the theme of it, keep it simple, stupid, and I think keep it simple means we can approach our work with more confidence. Cause there's really only just a very few steps that we have to do in mechanical endodontics that require technical skill, experience, perseverance and desire. And those are just a few instances. And so everything else says you've got to ask yourself, does it work? Is it making your life easier, better, and more profitable?

Lisette

Okay, well you just said the expression that probably a lot of you have heard of, “keep it simple, stupid.” And I actually always thought this was meant to be an insult, like that as in stupid people should try extra hard to keep things simple. But it is actually more than that. There is a thing called the KISS Principle, and if you get it – Keep It Simple, Stupid, the KISS principle. So, why don't you tell our viewers about what this – where this principle came from.

Cliff

Well there was a guy named Kelly Johnson, and he was in the Air Force, and this is about the 50's, so the war, World War II had just ended a decade earlier, and everybody was trying to go to the air, and aviation – aeronautical aviation was just taking off. And Kelly was a huge success story in and of himself because he was involved in designing and building perhaps 40 or 50 of our fastest, most technologically advanced planes that we have on this earth.

And what he noticed was mission creep. He called it mission creep, because as all these fabulous new technologies came into being and they were trying to stuff it all into these planes, and of course, the pilot is overwhelmed with all this available information coming in. And there's two things he noticed. One is the pilots getting overwhelmed with information and this pilot is supposed to be flying the machine on a mission. So, he thought maybe they could get all the same information there but do it in a much more simple way. So, that was one thing about the KISS rule that he wanted to integrate.

The most important was “things break” and the most sophisticated, the more things tend to break, and sometimes a five cent part, you know, like the Indianapolis car that blows a $1.50 gasket and he rolls across the finish line instead of accelerating. So, he thought things are going to break so we got to have all of our systems and structures designed so simply that the engineers and the technical people need to have the tools and the knowledge to easily make the fixes without having to go to enormous extra training.

So, that was a – he became known for that, “Keep it Simple, Stupid.” He was involved in what they called the Skunk Projects at Lockheed Martin, and that took off and now it's integrated into all aspects of life, primarily with software programming.

Lisette

And I think there's a quote by Einstein that kind of represents this principle. What is it?

Cliff

Oh, Einstein said, "Everything should be as simple as possible." And I think what that really means is that you should simplify the design.

Lisette

"As simple as possible, but not simpler."

Cliff

Yeah, Einstein said it should be as "simple as possible, but not simpler.” It has to work. And I think what that means is we should design every single product and success would be achieved when we reach maximum simplicity.

Lisette

Yeah, and then there's also Ockham's Razor, which kind of influenced the “keep it simple, stupid” principle, and that's a 14th Century theory that states, "In a series of hypotheses, the simplest one is most likely the correct one."

Cliff

So, if dentistry listened to Einstein and this Ockham's Razor, we probably would all be a little better today, wouldn't we, because we wouldn't be having closets full of technology we purchased and are not using.

Lisette

Exactly. All right. Well let's look at some of the ways clinicians are overcomplicating things, and see if we can find some solutions. And let's start with file systems. So, if you're a clinician looking for a file system, it's hard not to be overwhelmed by the multitude of file systems on the market. So, what should a clinician look for in a file system?

Cliff

Well, we'll get that slide up and I'll try to tic through a few of them. I think probably overriding everything, everything is safety, and by safety, you probably think I mean a broken file for example, but no, I'm talking about a file that's not flexible enough to make the curve, and it may dig into the outer wall, and then we start getting into problems. So, also, you know, pick a file system that actually cuts upon loading. That sounds kind of funny. You'd think they all cut, but if there's excessive heat treatment, files are soft, they unwind, and then, of course, how affordable is that file if you have to replace it? And maybe a couple times during a procedure.

So, you want the safety. You want a cutting file. You want great efficiency, you want performance there. And then finally, whether you're using one or a short series, it should be two or three, maybe four at the most, it should be affordable, and you should have permission to change a file without messing up the whole profitability for the day, but on the other hand, patients come first, and sharp files cut better, and you'll be more profitable because you'll be doing cases easier, less drag on the file, which means sharp edges don't get dull, drag and then unwind or break.

And then finally, not finally, but there's two more concepts I'd like to go over. Research. There should be some evidence, and it's really kind of funny when you see so much up and down research on the same single file. And sometimes on that same single file you'll find this paper says it's not so good. This paper says it's just terrific. So, we have to really be aware of the methodology used, and that's going to tell us a lot about was it a good paper, can we quote it.

And I guess then try to get a file that's system based. They're pretty much all that way now, but it hasn't always been that way. Your file should cut a shape that receives a system-based paper point, a gutta percha master cone, a carrier based obturator if you're using that thermal softened method, but it should be something that is a workflow that encourages all subsequent steps of clinical endodontics.

Lisette

All right. Well you did a good job explaining it, but just in case anyone got a little lost and there was confusion, we have our list, and it's just very simple. Safety, Efficient, Affordable, Validated by Research, and System-based is recommended.

Cliff

And they're not all on the files, and the 200-some on the market, they don't all follow those five things.

Lisette

Well I wanted to ask you about hybridization. Is that very common for clinicians to use files from different systems because they feel that is the only way they can get the shapes they want?

Cliff

You know, hybridization was a big deal ten years ago, and it was normal for a clinical to use two or three different systems to accomplish a shape on a single canal, much less multiple canals of the same tooth. So, basically, it's not so common now because manufacturers have learned with this work-flow and system based concept to give us everything we need to support all subsequent steps. So, remember, shaping is just a single step, but you have to have in your mind, you know, how are you going to fill, how am I going to clean? You have to be thinking ahead, so you have to have a system that is good for you.

And so, I would just say that's something I hear, primarily today, ironically, it's the teachers that are spreading what I would call a lot of unnecessary – I don't know if it's misinformation, but they'll teach one file on Friday, they'll teach a second system on Saturday, and the next meeting or congress, they're on a third system, and so you're wondering what they really do. And I've heard questions asked, "Well what do you really do when no one's looking?" "Well, you know, I carefully analyze my preoperative film and I looked at my coronal, sagittal, maxilla slices, and I then go, eeney, meeney, miny, moe. This one for that X-ray. This one appears to be successful.”

You know what, that's really not very good thinking, because think about files. Different tapers, different D-0 diameters, different cross-sections, different helical angles, rake angles, cutting angles, my God, I can't remember it all. And so, they have – there's this thing called tactile control and feel. Remember that? Well, if you're changing files all the time, that would be like watching the All Star Game last night in the United States, in Los Angeles, and you might have noticed that when the batter goes up to bat, regardless of the pitcher on the mound, regardless of whether the pitcher is throwing the fast ball, slides, curve ball, sinker, they're using the same bat.

How about in golf? We just watched the British Open. My goodness, you know, that Smith guy, he won it all. He had the same set of clubs in his bag. Isn't that something? He didn't get different putters for different greens. So, think about how foolish it is, my little jokes I'm trying to make, learn to do something really, really well. So when you use a lot of systems you kind of become good at everything and a master of nothing.

Lisette

All right. Well I want to go back to you.

Cliff

Did you like that?

Lisette

Yes, I did.

Cliff

Okay.

Lisette

I wanted to talk about your recommendation that you go with something system-based. And I know that a lot of file systems are like this nowadays, and just in case you don't know what we're talking about, like just an example, Pro-Taper, they have gutta percha master cones and carrier-based obturators, obturators that match the last file in size, the last file carried to length.

Cliff

Right.

Lisette

So, and this does seem to be a trend now among dental companies, and – at least from what I hear from you regarding Dentsply Sirona, to really emphasize concepts like system-based endodontics and workflow with the concerted effort to simplify things for the clinician. So, do you find this actually to be the case?

Cliff

I do. You know, the trend really is going towards workflow and system-based. And just to make sure we're understood, first I'll make a little quote here in the middle camera, but you know, I think it was Theodore Roosevelt said, "Do what you can with what you got where you are." So today I'm working, and I don't have GentleWave, I don't have lasers, I don't have CBCT. I just told you you've got to plan to do the case today that's in front of you, like the next match you're going to play. That's the one that matters, so you've got to think how am I going to shape, and do I have the disinfection technologies aboard that will be supported by my shape?

So, you're shaping not just to make a hole in the root that makes a white line on a film, you're thinking ahead, how am I going to irrigate today? I wonder what I have? Do I have something even simple that I can do or just a lot of irrigation or heated sodium hypochlorite or the Endo activator or I have a laser, I have GentleWave. That will all start influencing how you decide to shape. How are you going to fill? Single cone, are you going to squirt it in, are you going to do a carrier-based obturator? Are you going to do vertical and down pack a la Herb Schilder? All right, System B, there's lots of different ways to pack.

How are you shaping? The shaping has to support that idea. So, I think when we look at the shaping and we look at the cleaning and we look at the filling, the shaping is the table that is set for the other two. It still is a triad, and each one of those things in the triad influences each and all the other steps. Do one visit. You know, that's just the decision, but it's a decision that requires the staff to be onboard so that you don't get sabotaged. If you need an hour and a half to do the case, schedule for an hour and a half. When the patient goes up to see the receptionist, they'll go well, spill over there, well we'll just give him an hour, he'll make it, he'll make it happen. Well those are a lot of times reschedules.

So, if you knew how much nonproductive time was spent, we've talked about that on shows, it's tens of thousands of hours a year, then you'll start scheduling for completion. You won't take chances, you won't take risk. And finally, if you're starting to think about the end in mind and how you're going to do the whole case, it's going to be a rehearsal. Wow, think of that, a rehearsal, before he ever treated the patient. And you'll know all the steps. The staff will know all the steps.

And this will keep you out of iatrogenic problems, broken instruments, being in a hurry, missing a canal. Know your anatomy, get trained up, you know, get those skills going, and then bring your staff aboard and treatment plan for no surprises.

Lisette

All right. Well, let's turn our attention now to some higher end technologies that are on the market today that are purported to be gamechangers that will increase success rate. But these technologies do have a higher learning curve, and may, initially at least, seem to complicate your workflow. So, let's start with the microscope. So, say you're looking for a – you're a clinician who's looking for a microscope, and maybe you're even looking for two or three, if you wanted one in every operatory. But you're feeling overwhelmed by how you're going to integrate it into your workflow and become proficient at it. So, is this really simplifying things?

Cliff

I think the answer is yes and no. I won't tell my stories about how I started my microscope use in the mid-80s. I think you've already heard them on this show. But the answer is yes and no because it will simplify things if you're willing to battle a little bit in the early phase of your integration. Sometimes you have to give up your hard fought for proficiencies to get to the next level, and that's what I would say with both CBCT and microscopes, but microscopes first.

You're not going to get three or them or two of them. You're going to get one of them and that's if you decide to get one of them. But I'll give you some encouragement. You only know what you see and you only see what you know. How about that one? Another one I like really even just as equally as well, if you can see it, you can do it. Well if you're thinking as an endodontist, you're going to probably want to get the microscope. There will be some indignities. There will be a learning curve, and so everything will be a little longer. You might be a little bit more awkward. You might feel a little bit more clumsy.

But if you stay at it, especially today because it's not the mid-80s. Now we're approaching the mid-20 – what are we in? 2022? So, we're rally marching in towards the middle of this decade. There's courses – I mean Cherilyn Sheets in Newport Beach, Oral Facial Institute, I mean she gives fabulous courses on chair positioning, and I was just talking to her on the phone last week, and she said, "Cliff, by the second day their shoulders are relaxed and they're working under the scope." She said, "It's a thing of beauty."

So, if you go get help early and it's not the blind leading the blind, you'll learn quicker with help and all of a sudden you'll be very quick at finding the MB2, the mid-mesial. You'll see cracks down axial walls. You'll begin to employ this technology and it will be crawl, walk, run, but once you get it onboard and you're comfortable with it, you can't imagine you ever practiced without it. That would be the microscope, a learning curve.

CBCT, okay, it's not something you're going to look through and work through, but it has its own learning curve. I mean you can get the $100,000 unit onboard, and you can get some coaching, and there'll be quite a bit of coaching because you have to take the images, store the images, retrieve the images, manipulate the images, and by manipulation, you got to take your mouse, you know, and do you want to look at the coronal, do you want to look at the sagittal slice? Do you want to look at the axial slice? And you got to move these slices around. This might be like daunting with all the other stuff going on in your life, remember because you are practicing.

You're going through the gear box of life, you know, operative, crown, bridge, removal, all that stuff. But if you stopped and take time to learn it, and you're not alone, there's courses, and there's coaching you can get from sales reps and people, get a staff member that's really sharp, you can integrate that, and I think between those two technologies, those are probably the most profound technologist to impact clinical endodontics if we're going to try and move up a little bit beyond maybe 2 percent more success. I don't even know if I hit that very hard.

But a lot of the people I've talked to, Camilleri, Gordon Christensen, people who have been practicing for 30, 40 years, they're not really seeing the success rates creeping or inching up. In fact, some people have even said they might be going down a little bit. So, that's in the face of all the technology. So, it must now be about the technology, huh? It must be about the clinician.

Lisette

Yeah, and what you were just saying about microscopes and CBCT, I mean if you just – just from a common sense perspective, if you imagine doing anything you do in life with your eyes open versus a blindfold on, it's like pretty much simpler to do things when you can see.

Cliff

Eyes wide open?

Lisette

All right, well what about a technology like GentleWave? Because from what we've reported on The Ruddle Show, it does not seem that there is really anything simple about GentleWave with its growing list of contraindications.

Cliff

Well, I don't know whether to go off on a tirade or stick to the script and the script is kind of loose. Well we'll just do a little bit of both. I was reading a blog yesterday. It was an endodontist, a group practice in Arizona, anonymous are their names, but you could find it if you went to the blog. You could find it. It was out there. Anyway, they've had the GentleWave sales people come into their office every six months for two years, and they keep telling the GentleWave salespeople no, not at this time.

And this guy is very thoughtful. He went and got all their – because they always – all these companies want to come in and say look at my literature, here, I got – we got lots of evidence, now are you ready to get your checkbook out? Your pen or mine? You know, they want you to sign the contract. So, I guess I would basically say if you want to complicate treatment and not keep it simple, stupid, you would get GentleWave immediately and probably one in each room, because it would really slow everything down. It might even bring it to a halt.

But back to the blog, let's keep that as our North Star. The blog looked at all the research and it was up and down, and a lot of the claims were anecdotal, and some of the great healing they saw at six months is like what we've seen for 50 years if you do careful cleaning and shaping and obturation followed by restoration. So, it would be more complicated to build the platform. That's like five to eight minutes. And disinfection cycle, eight more minutes. Oh my God, I can't fit my cone. I better get my files back in here and improve my deep shape so I can slide that cone to length. Oh, my God, did my file make a new smear layer? Do I have to make another platform? No, those clinicians go right on a path.

I guess what I would have to say – I have lots of thoughts in my mind. If you're using GentleWave, smile, you spent a lot of money, be happy, you have this really expensive technology. And it does clean pretty well. We've said that repeatedly on this show. I just don't know why we would want to go through all the hassles. So, back to this technology, I guess I'm wrestling with a thought, and I'll say it. Why did GentleWave become so popular?

When we could treat root canal systems for 50 years and anybody that wanted to were doing it, and there was evidence of it, we could see post-operative films from all over the world. Why did suddenly this narrow group of clinicians decide to get GentleWave? Because they too wanted to treat root canal systems. They just choose a $100,000 solution instead of a $2 solution. So, to each their own. If you make it work and it's going well in your practice, that's great, but that's not an easy thing to introduce because back to the blog.

The guy went through the literature, it's up and down, it's not – there's no compelling reason. It adds a lot of cost to every case. It takes more time for every case. And he said at the end, "I'm not seeing any more anatomy." And he said, "Look at the few films on closed several post-ops." There's like five or six post-ops anatomy everywhere. And I was going, "God, how do they do it?" He said at the end, "Those were done with the Endo Activator."

Lisette

And it probably also further complicates things because you're going to have to give warning to your patients now you might have some extra post-op pain, you might – there might be some excessive bleeding.

Cliff

This is what the GentleWave users report themselves just to be clean. They have more bleeding, that's a hassle we haven't really talked about today. But they can go listen to previous shows. And then, of course, you mentioned, maybe you've got to give your post operative instructions just a little bit different because there are some known accidents, not all are serious, but if you extrude sodium hypochlorite, well you could probably expect a couple calls maybe.

And then, of course, you've changed your shaping scheme, right, to fit the technology. And technology should fit right into an existing shaping scheme. You shouldn't have to, you know, dump everything in the operatory and start afresh because you ordered a new paper point.

Lisette

Okay, well what if –

Cliff

You didn't like that one, did you? You know, a five cent paper point, I'm changing every way I work now.

Lisette

All right. Well what if you wanted to use a laser for laser activated irrigation? Are you going to have a lot of the same issues as with GentleWave?

Cliff

Lasers I feel very, very different about. We just did a show, but I'll say it again. With lasers, Er:YAG or we could talk about the Er,Cr:YSGG, those are all in that mid-range of the electromagnetic spectrum of light, blow up a water molecule. They – well lasers aren't all the same, but the one I'm talking about is Light Walker, and it goes in the pulp chamber, the fiber optic wand is confined and limited to the pulp chamber, and it irrigates all the canals at once. So, it's GentleWave. So, you'd say –

Lisette

That's being simple.

Cliff

– but you didn't build – but you didn't build a platform.

Lisette

Right.

Cliff

Okay? So, I think that should be brought up. I was a little harsh on the lasers that are instructed where the wand is taught to go below the orifice and maybe to mid-root or even within one or two millimeters of length. And I've talked about frontal pressure. I've talked about the shapes are smaller than they used to be so we don't have a lot of volume. When you stick a wand into a smaller prepared canal, you have a tendency to displace liquid. Now the wand, you know, can touch the wall and there's going to be dental burns. We've talked about that.

I don’t want to be hard. A lot of this we're still working out. Lasers are going to be fine. And just so the audience doesn't get too worried about that last laser show, Chuck Goodis is coming to Santa Barbara, and we are having breakfast on this coming Monday, and we're going to talk all things lasers, so it's all good because the conversation is what is the opportunity to start changing the game and make it more simple for you.

Lisette

Okay, so it sounds like with a lot of these higher end technologies, you might initially run into a learning curve that you're going to have to learn to become proficient at it, but for at least some of them, in the long term, it will simplify things for you.

Cliff

You reminded me, and I forgot to say it, but there's quite a list of contraindications for the GentleWave use, and I mean I have to disinfect every tooth I see. It's not just oh, one that's away from the middle foramen. Oh, I can do it if it's not close to a maxillary sinus or if it's not touching the neurovascular – oh, it's too big at the apex. No, you've got to disinfect each time, every time, all the time. So, you do not want to use a disinfection tool just limited to like Monday mornings and Thursday afternoons and sometimes on Saturdays.

Lisette

Right. So, it sounds like if you're going to choose GentleWave as how you want to irrigate, you're probably going to have to have a backup method as well for the cases that don't quality for GentleWave.

Cliff

That's right. Yeah, you have to – I mean it's part of the shaping, shape to clean, shape to fill.

Lisette

Okay, back to the idea of keeping it simple, I wanted to ask you if there are any clinical procedures that you feel clinicians tend to overcomplicate.

Cliff

Yes, there's many things that are done needlessly. Let's just start off with the first mechanical step. You've got the tooth isolated. What kind of an access are you going to cut? Are they going to cut a complete access, de-roof it, look right down in there and see that funnel right into the floor? Or are you going to cut the world's smallest access? You're feeling your oats today. We're going to save precious tooth structure, and we're going with Ninja, hoy-yah! Well, that's good.

I learned a lot from that Italian paper. Marco Martignoni was part of that, but they talked about the different accesses and certainly you can use a big caries exposure and use that as part of your access to save tooth structure. But in general, think ahead. It's not just the access, and are you really clever, and can you really snake those files through underprepared chamber walls and can you blindly thread it into the orifice, and are you that skillful?

Look ahead to disinfection. What's your method? I don't really care what your method is, but what is their method? Because the method will depend on fluid dynamics. So, when you have an orifice directed access as a third example, complete ninja orifice directed, the last two are directly sabotaging fluid flow, especially if you're using GentleWave and lasers. So, I see these people using lasers, and they're cutting a little hole over here and a little hole over here.

If you took a little physics, and you understand about fluid dynamics, you'll know that you’ll reduce sheer wall forces if you get those walls peeled back, so access could be one thing you could really simplify every subsequent step. Obviously, don't make it too big. Tooth structure is important. Restoration of the endodontic treated tooth comes to mind, but think about your pluggers and your cone and your sealer and all the stuff you're going to do up in front and cut your access with that in mind.

I would say we also then probably complicate shaping. Again, we talked a little bit about needlessly hybridizing when a system – listen, if a system comes to market and it's touted as safe, efficient, research behind it, you know, great experience, in my hands works well, then why are you throwing in more files? So, just think about your shaping, one file, single file, primary goal. That will cut almost 90 percent of your shapes.

And then finally, if you want to use like a pro-taper system, you're going to use two, three, four files maybe; it depends on the case. If you use another system, I don't care, they can all cut and they can all make shapes. But shape with what is in front of you in mind.

Lisette

You skipped over glide path management.

Cliff

Oh glide path is probably – I'll be a little kinder to the group because a lot of times in glide path, only five and 10 years ago, we went from having a 10, a 15, a 20 at length. In other words, we would use a lot of hand files, stainless steel stiff ones, to get enough space that we could deploy the mechanical shaping file with safety. Well, then we started realizing well just the 10 and the 15 usually works. That was 10 years ago. Then we thought, finally, with technology and the files getting better and better and better, all of a sudden, we could use less stainless steel hand files just going like this.

And so, now we can just use a 10, so if a 10 was loose at length, we had already transitioned the foramen to almost a 15 file. Most brand-new shaping files from anybody's system could follow that pathway, a smooth reproducible slide path to the terminus. So, what's new now is mechanical. So, get rid of all the stainless steel stuff, all the manual stuff, and think about mechanical stuff, and Pro-taper Ultimate made the first dedicated system based glide path file in the world. Many people have said they have something.

I'm saying this fits into the rest of the system. It has a new cross-section. It has new tapers. It's a little stiffer than you might think, but that's what you need, and we found out that about 67 percent of the time for brand-new students who've never used it before, they could use no hand files, 67 percent of the time. You want to keep it simple? You want to keep it simple, stupid? You could get rid of several hand files. What about the hand files? They notoriously are used in different motions. That's a dexterity thing.

So, we see blocks, ledges, transportations, rips and tears, bloody canals, wet canals, a lot of post-operative problems, and we can clean up so much of that with just a mechanical file. So, think about keeping it simple by just changing a little bit of your ideas on glide path. Thanks for reminding me. That might be the most important thing I talk about today. It can save a lot of time.

Lisette

I think – thank you. Well also, there was one thing that you were saying about shaping, and I don't know if you really touched on this, but I think one of the things that is tending to overcomplicate shaping is the whole concept of minimally invasive endodontics, which is a noble concept, but maybe clinicians are trying to make the smallest shapes that they possibly can. But then they're running into problems with how they're going to irrigate and obturate. So –

Cliff

Wow, did you hear that? From the non-dentist, understanding what your problems really are, where they really lie? Maybe you should go out to office to office and give coaching, endo coaching. What she said is important. If you cut a really small shape, you're compromising all subsequent steps. Now you laser people go, oh wait a minute, we can have minimally invasive shapes and still clean. How are you filling, doctor? Oh, I use a single cone. How much do we know about single cone? How much do we know about the tricalcium silicate sealers, how much do we know about all this stuff?

We won't really know until five, six, seven, eight, nine, ten years, 15, 20-year recalls. You'll start to see the edges of the truth. Right now it's the blind oftentimes leading the blind. Keep it simple. Think about simplicity. Think of Einstein. Should be as simple as possible, but not simpler, so you need a few files, but not too many. I got to talk about one more thing that they could be really simpler on.

Lisette

Intracanal reagents?

Cliff

Yes, intracanal reagents, thank you. You know, intracanal reagents for me are – we can first divide all reagents into viscous, like toothpaste. That's RC Prep Glide and Pro Lube, and Aqueous. Aqueous, we have sodium hypochlorite, we have EDTA. Oh my God, you want me to keep going? Smear clean. We have – oh, gosh, we have what? We have MTAD. We have bottles in a solution now where you can buy them and for thousands of dollars you can irrigate flawlessly. I'm just kidding!

But wherever you buy sodium hypochlorite, or some little, you know, concoction that's inside a little vial, do you think you're paying almost nothing for that? You can buy a whole gallon of Clorox, 6 percent, you know, something around that concentration, and it's like a buck fifty, two bucks. You're going to spend like $50, $70 buying these little bottles. So, we have CHX solutions. We have – it just goes on and on.

Why are you using so many solutions? You don't trust sodium hypochlorite? It kills everything on contact in ten seconds. Key word was contact. All viruses, all spores, all microorganisms. So, why are we throwing in the CHX and the MTAD and the smear clean and buy all this stuff and the cocktails and the solutions you're mixing after hours. It's like careful, careful.

Lisette

So what – would you say you need?

Cliff

Sodium hypochlorite, 17 percent EDTA, and when you're doing glide path management, whether manual or mechanical, bring in some viscous chelator like Pro-glide or RC Prep.

Lisette

Okay.

Cliff

Three things at most. It doesn't – I have researchers, tons of – I had researchers as a grad student. I mean I looked at my own shape, so what I'm teaching is what I know is possible if you shape kind of like what Ruddle prescribes.

Lisette

Okay, that's all really interesting. I wanted to go back now to something you had said earlier when we were talking about using multiple file systems. You said something along the lines of pretty good at everything, but a master of nothing. And this kind of makes me think of the general dentist who has a lot of responsibilities and also probably feels that they need to be competitive. So, maybe your general dentist is doing some simple ortho as well, some perio, maybe an occasional root canal or placing an implant. Maybe a little bit of cosmetic dentistry or some simple bridges. Is this too much?

Cliff

You just described the general dentist. That's what they do, just what you rattled off, and they do a few more things. Well, if you're kind of getting into this keep it simple, stupid and we're halfway through the year so they can be making some adjustments now so that by the end of the year, it's so simple, you're looking for more endo to do, can't we do more endo, can we open up a staff's tooth? Can we open up the assistant's tooth? Maybe the hygienist would sit for a root canal. It's so much fun. We're so simple.

Well, what I was trained to do a long time ago is write everything you do down on a piece of paper. Everything you do, just write it down. Staff's with you because they're helping you remember what you do cause you don't know what you do. You just know what she said, but you're not thinking about the little repair of the crown and, you know, the little class three you're trying to sneak in there on that proximal side of the anterior maxillary tooth, and the cosmetic stuff that you're doing, all that stuff, write it all down! It can be a list of 15, 20, 30 things. It's going to make you tired. So look at the list at the end of the day so you can go home and go to sleep.

Now look at that list very carefully. Now I'm assuming they're successful. This dentist has been out awhile. This isn't like a brand new dentist, because when you're a new dentist you're all things to all people at all times. But now you're ten years in. You know your way around. You got the really perfect person at the front desk. Your receptionist is phenomenal. She's very – everybody loves her. They just drop by to say hi. Okay, your assistants know what you'd gong to do before you actually do it. So, your staff's arrived. You've taken a lot of classes; you're really quite good.

So, if you have a mature practice you can make this list coming back to that elusive list, the long list, and you can start to say let's put a checkmark by everything we love to do. In fact, we just like to do that. Well, be really aggressive. Just start checking the things you love to do, the things you're most passionate about, the things that are most profitable, right? They've got to be profitable. You really have a spring in your step at the end of that day. It was a long day, but boy, did you make money.

Start looking at what you didn't check and get rid of it. Okay? You either don't do it because now you get an associate, and they come in and they do all the amalgams and the caries cleanouts, and they do the extractions. They do all that. And the rest of it refer, and now you're doing more of those things you love to do. And if you do things you love to do, you get pretty good at them, and everything is simpler. There's more clarity. The transformation has already started.

Lisette

So, I'm hearing streamline, get organized, simplify.

Cliff

Organized, oh that's a great word. Get organized. Now your mom, Phyllis, watched me work in Santa Barbara in the mid-70s and was shaking her head, and she was a non-dentist, and finally, we invited her to a staff meeting. She invited me to the staff meeting. I could attend. And she started seeing things that weren't chairside stuff necessarily, but trays and how things went back to be cleaned and how the new trays arrived and, you know, you can always think of your office as like there's the bank.

You know, when you really need money you go to the bank. When you need a little bit of money you go to versa teller, I guess they still have that. And then, of course, if you have a little money on your wallet you're ready to go. So, you got three ways to get the money. Well she saw ways that we could improve our organization, so that's what I wanted to come back to. And it streamlined it and it's little stuff, but all of a sudden, it's like powerful stuff, and it gives you juice in your tank.

Lisette

Okay, great advice. Okay, so on our Special Report today, we've talked about how paradoxically the title wave of new technologies has only over the past couple of decades, has only served to increase success rates by about 2 percent.

Cliff

Right.

Lisette

And we have talked about some clinical procedures that clinicians tend to overcomplicate. And then we've also touched on how dentistry has strayed from simplicity and gotten caught up in the complexities of the new technologies, controversies, dental politics, and the need to be competitive, not only between clinicians but also dental companies. So, why is this the case, and why did it seem so much simpler to practice dentistry 20 years ago?

Cliff

Well, I guess I'm old enough to smile. I can remember when I'd pull over the X-ray and then I trained the assistant and she did it, but you know, we'd take some films and isolate the tooth, and we had a few hand files, they're all stainless steal and, you know, you pack your case, they had a Bunsen burner over in the corner and life was quite good. But then came the internet.

And so, I think to answer your question, what's gotten so complicated is the explosion, the unbelievable and remarkable and sustainable explosion of technology. And part of that technology is the internet itself where people can go online. And so I think what's happened is there's such a crush of new products, there's a crush of salespeople recently trained and they're like rabid dogs and they're going to sell today because they love it; it's in their bloodstream. And they're our pals because that's what we use. They help us – arm us so we can do our stuff.

But there's just a lot, and all of a sudden you're going to buy something new but there's five things just like that, and they're all different price points, and you're so busy practicing every day that all of a sudden, you know, you go online and you start going to this one, that. The problem a lot is we go online and we have these self-imposed gurus that throw a flag down anywhere in the world, and all of a sudden they're authority. So, it's easy to go there and get their spin and maybe it's good and maybe it's not good.

Lisette

Okay, well not only are clinicians going online and getting a lot of information that's sometimes misinformation, but patients are also going online.

Cliff

Oh they are.

Lisette

And a lot of times patients might show up in your office and they might already feel they know what's wrong with them and how you should proceed with treatment. And maybe they even already have suggestions of technology you should use in their case. And then you also have to remember that –

Cliff

Good point.

Lisette

– the last couple years have been difficult and people in all professions tend to be a little bit angrier and have a little more anxiety and maybe they're more – even apt to sue if – for malpractice, if things don't go their way. So all of this is also overcomplicating things, and I guess probably the solution is this, which is to try to be patient and kind and be open to having discussions with your patients.

Cliff

Yeah, you know, you just said it. If we just slow down, you know, like they say in the pros, slow the game down, let the game come to you. If we just slow down, take time to smile a little bit, look in somebody's eyes and just smile, you'll be surprised how many people actually stop because they don't even realize they're just – they're here and they got a lot of questions, they got a long list of questions from the net. Just smile at them and say good to have you here, how can I help you?

So, I think how we get there though is with confidence, and when we remove doubt, confidence shows up, and how we can get our confidence is by training with people that are respected, people who have been around for more than five minutes, because a lot of times I see this newfound idea from somebody. Young people can have fabulous ideas. I'd like to think I had a few when I was young. But a lot of times how does that idea work in six months, over a year, the next five years?

And it might be kind of a flash in a pan, not really – so you put a lot of energy into something only to it kind of dies out. So, choose the net addresses where there's legitimacy, there's experience, there's respect, and I think you can go a long ways to modeling success because success does leave clues. And Schilder used to say, you know, I'll end my part with this, is many new techniques and many new products are needless complications to non-existent problems. Think about that.

Lisette

Okay, well that's our Special Report for today. We do have some other projects planned, and we may be coming back to you again this summer with some other way of presenting you some information. But if not, we'll see you in the fall for Season 8.

Cliff

I'll just interrupt, you know, this whole time we're looking at this brand new set back here that they don't even know. They've never seen it, and it's going to be fun. Hey listen, have a great summer. It's not over yet, so there's still time. I have a few friends out there on the high seas. They got that boat leaned over. They're doing that perfect tack towards that final destination. Make your destination fun. And I'll see you in the fall.

Lisette

Yeah, thanks for coming, everybody. And remember to enjoy your summer and keep it simple.

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.

Special Reports

48:47

special e05

SPECIAL REPORT: THE KISS PRINCIPLE

The Importance of Simplicity & Getting Back to Basics

51:45

special e04

SPECIAL REPORT: RUDDLE ON RUDDLE

Personal Interview on the Secrets to Success

52:52

special e03

SPECIAL REPORT: PROTAPER ULTIMATE

The Launch of an Improved File System

36:27

special e02

SPECIAL REPORT: COVID-19

The Way Forward

Watch Season 7

51:31

s07 e01

Articles & Preferred Access

Writing Projects & Ruddle’s Start-to-Finish Access

1:01:29

s07 e02

Patient Protocol & Post Removal

CBCT & the Post Removal System

57:51

s07 e03

Avoiding Burnout & Ledge Management

Giving New Life to Your Practice & Managing Ledges

50:07

s07 e04

Start-To-Finish Endodontics

Special Guest Presentation featuring Dr. Gary Glassman

47:02

s07 e05

Laser Disinfection & Obturation

The Lightwalker vs. EdgePRO Lasers and Q&A

52:19

s07 e06

Extra-Canal Invasive Resorption

Special Case Report by Dr. Terry Pannkuk

54:18

s07 e07

GentleWave & Microsurgery

Every Patient Considerations & Surgical Crypt Control

45:40

s07 e08

Artificial Intelligence & Endodontic Concepts

Update on AI in Dentistry and Q&A

00:53

The Ruddle Show

Commercial Trailer S07

Watch Season 6

47:48

s06 e01

Comparisons & NSRCT

Chelator vs NaOCl and Managing Type I Transportations

55:57

s06 e02

Special Guest Presentation

Dr. Marco Martignoni on Modern Restoration Techniques

50:41

s06 e03

International Community & Surgery

Breaking Language Barriers & MB Root Considerations

46:19

s06 e04

Launching Dreams

ProTaper Ultimate Q&A and Flying a Kite

52:01

s06 e05

Rising to the Challenge

Working with Family & Managing an Irregular Glide Path

45:47

s06 e06

Controversy… or Not

Is the Endodontic Triad Dead or Stuck on Semantics?

49:35

s06 e07

Endodontic Vanguard

Zoom with Dr. Sonia Chopra and ProTaper Ultimate Q&A, Part 2

54:32

s06 e08

Nonsurgical Retreatment

Carrier-Based Obturation Removal & MTA vs. Calcium Hydroxide

02:07

The Ruddle Show

Commercial Trailer S06

Watch Season 5

1:03:57

s05 e01

Common Endo Errors & Discipline Overlap

Apical and Lateral Blocks & Whose Job Is It?

53:04

s05 e02

Post Removal & Discounts

Post Removal with Ultrasonics & Why Discounts are Problematic

58:38

s05 e03

EndoActivator History & Technique

How the EndoActivator Came to Market & How to Use It

59:36

s05 e04

Gamechangers

New Disinfection Technology and Q&A

53:47

s05 e05

Exploration & Disassembly

Exploratory Treatment & the Coronal Disassembly Decision Tree

52:40

s05 e06

Advancements in Gutta Percha Technology

Zoom Interview with Dr. Nathan Li

53:35

s05 e07

By Design... Culture & Surgical Flaps

Intentional Practice Culture & Effective Flap Design

1:01:35

s05 e08

Workspaces & Calcium Hydroxide

Ruddle Workspaces Tour & Calcium Hydroxide Q&A

49:52

s05 e09

Cognitive Dissonance

Discussion and Case Reports

52:14

s05 e10

50 Shows Special

A Tribute to The Ruddle Show’s First 5 Seasons

01:04

The Ruddle Show

Commercial Intro S05

Watch Season 4

55:16

s04 e01

Tough Questions & SINE Tips

Who Pays for Treatment if it Fails and Access Refinement

54:02

s04 e02

Endodontic Diagnosis

Assessing Case Difficulty & Clinical Findings

50:12

s04 e03

CBCT & Incorporating New Technology

Zoom with Prof. Shanon Patel and Q&A

56:53

s04 e04

Best Sealer & Best Dental Team

Kerr Pulp Canal Sealer EWT & Hiring Staff

49:44

s04 e05

Ideation & The COVID Era

Zoom with Dr. Gary Glassman and Post-Interview Discussion

59:00

s04 e06

Medications and Silver Points

Dental Medications Q&A and How to Remove Silver Points

53:40

s04 e07

Tough Questions & Choices

The Appropriate Canal Shape & Treatment Options

53:15

s04 e08

Q&A and Recently Published Articles

Glide Path/Working Length and 2 Endo Articles

46:19

s04 e09

Hot Topic with Dr. Gordon Christensen

Dr. Christensen Presents the Latest in Glass Ionomers

50:44

s04 e10

AAE Annual Meeting and Q&A

Who is Presenting & Glide Path/Working Length, Part 2

00:52

The Ruddle Show

Commercial Intro S04

01:43

The Ruddle Show

Commercial Promo S04

Watch Season 3

48:42

s03 e01

Treatment Rationale & Letters of Recommendation

Review of Why Pulps Break Down & Getting a Helpful LOR

52:27

s03 e02

Profiles in Dentistry & Gutta Percha Removal

A Closer Look at Dr. Rik van Mill & How to Remove Gutta Percha

48:10

s03 e03

Artificial Intelligence & Endo Questions

AI in Dentistry and Some Trending Questions

58:54

s03 e04

How to Stay Safe & Where to Live

A New Microscope Shield & Choosing a Dental School/Practice Location

48:20

s03 e05

3D Disinfection

Laser Disinfection and Ruddle Q&A

48:28

s03 e06

Andreasen Tribute & Krakow Study

Endodontic Trauma Case Studies & the Cost of Rescheduling

55:22

s03 e07

Ruddle Projects & Diagnostic Imaging

What Ruddle Is Working On & Interpreting Radiographs

1:05:24

s03 e08

Obturation & Recently Published Article

Carrier-Based Obturation & John West Article

55:48

s03 e09

Retreatment Fees & the FRS

How to Assess the Retreatment Fee & the File Removal System

1:00:42

s03 e10

Research Methodology and Q&A

Important Research Considerations and ProTaper Q&A

00:44

The Ruddle Show

Commercial Opener S03

01:05

The Ruddle Show

Commercial Promo S03

Watch Season 2

51:43

s02 e01

ENDO 101: WAVEONE GOLD

Product History, Description & Technique

51:42

s02 e02

Interview with Dr. Terry Pannkuk

Dr. Pannkuk Discusses Trends in Endodontic Education

58:21

s02 e03

3D Disinfection

GentleWave Update and Intracanal Reagents

1:04:53

s02 e04

GPM & Local Dental Reps

Glide Path Management & Best Utilizing Dental Reps

1:01:10

s02 e05

3D Disinfection & Fresh Perspective on MIE

Ultrasonic vs. Sonic Disinfection Methods and MIE Insight

53:03

s02 e06

The ProTaper Story - Part 1

ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos

57:53

s02 e07

The ProTaper Story - Part 2

ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos

1:06:40

s02 e08

Interview with Dr. Cherilyn Sheets

Getting to Know this Top Clinician, Educator & Researcher

1:13:21

s02 e09

Broken Instrument Removal

Why Files Break & the Ultrasonic Removal Option

49:01

s02 e10

3D Obturation & Technique Tips

Warm Vertical Condensation Technique & Some Helpful Pointers

01:05

The Ruddle Show

Commercial Promo S02

00:44

The Ruddle Show

Commercial Opener S02

Watch Season 1

45:30

s01 e01

An Interview with Cliff Ruddle

The Journey to Becoming “Cliff”

52:35

s01 e02

Microcracks & the Inventor's Journey

Ruddle Insights into Two Key Topics

47:17

s01 e03

Around the World Perspective

GentleWave Controversy & China Lecture Tour

40:29

s01 e04

Endodontic Access

What is the Appropriate Access Size?

52:13

s01 e05

Locating Canals & Ledge Insight

Tips for Finding Canals & the Difference Between a Ledge and an Apical Seat

53:14

s01 e06

Censorship in Dentistry

Censorship in Dentistry and Overcooked Files

50:22

s01 e07

Endodontic Diagnosis & The Implant Option

Vital Pulp Testing & Choosing Between an Implant or Root Canal

55:30

s01 e08

Emergency Scenario & Single Cone Obturation

Assessing an Emergency & Single Cone Obturation with BC Sealer

49:36

s01 e09

Quackwatch & Pot of Gold

Managing the Misguided Patient & Understanding the Business of Endo

58:05

s01 e10

Stress Management

Interview with Motivational Speaker & Life Coach, Jesse Brisendine

00:56

The Ruddle Show

Commercial Opener S01

Continue Watching

01:56

CHECK IN with CLIFF

03.03.2022 Update

01:53

Happy New Year

2020

01:52

Behind-the-Scenes Studio Construction

Timelapse

The Ruddle Show
Season 8

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