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...
Endo/Perio Considerations & Recent Article Crestal/Furcal Defects & ProTaper Ultimate
Season 8 opens with some news from the off-season, including a recently released Special Report and a podcast update. Then we turn our attention to endo/perio considerations: Ruddle discusses the importance of treating root canal systems, specifically as it relates to crestal and furcal defects. Next, Ruddle and Lisette present some highlights from the ProTaper Ultimate article published earlier this year in Oral Health. The show concludes with a Ruddle flashback involving another sport’s legend, Wilt Chamberlain.
Show Content & Timecodes00:55 - INTRO: Off-Season Update 06:09 - SEGMENT 1: Endo/Perio Considerations – Crestal & Furcal Defects 29:57 - SEGMENT 2: Recently Published ProTaper Ultimate Article 48:46 - CLOSE: Ruddle Flashback – Meeting Wilt Chamberlain
Extra content referenced within show:
Downloadable PDFs & Related Materials
Ruddle Shaping & Finishing Technique Card featuring ProTaper Ultimate
This article will describe the sonic advantage, focus on a system-integrated technology that may be utilized for 3D cleaning in root-appropriate shapes, and provide the clinical protocol... If you have the desire to treat root canals and are looking for predictability, possibility, and practicality, look no further than the Smart- Lite Pro EndoActivator.
Dental radiographic examination frequently depicts radiolucencies approximating root surfaces. Apical radiolucencies in particular tend to cast suspicion on pulpal health and are often associated with endodontically involved teeth...
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.
…Just like I can change, you can change, and I wanna encourage you to change, because I can change, and if I can change, you can change, because we can all change. And if we change, we can get better – of course, better change...
INTRO: Off-Season Update
Welcome to Season 8 of “The Ruddle Show.” I’m Lisette, and this is my dad, Cliff Ruddle.
Welcome, and welcome to you, and thank you for coming back! We’re getting a lot more people coming, and that makes us excited, because we’re trying to help you. So, what else do we have going on now?
Well, we have a great season planned and eight shows. We plan to welcome a couple guests who are leaders in endodontics. We have a few new segments that we’re going to offer. And then, we also plan to make every effort to bring you the same, high-quality content that you have come to expect from us. So, when we left off last season, we talked about what our plans were for the off-season. And some of it actually happened, some ideas have needed to be modified, but we did make some forward progress. We did mention that you were going to be lecturing in Provo, Utah, at the end of July. That happened. And then, next week, you actually have a lecture in San Diego for AMED, the Academy of Microscope Enhanced Dentistry. So, how did Utah go, and are you ready for San Diego next week?
Utah went terrific, Practical Clinical Courses. Don’t be a fool. Sign up. Gordon Christensen, little plug. Yes, being there physically, interacting with colleagues was really, really fun again. And I’m telling you, touching people, giving’ hugs, guiding’ their hands, reviewing postoperative films, geez, the group got a lot of lateral canals, went around curvatures. It just reminded me, you can do it, too! Yep, and amen. Okay. So, I’m real excited about that. It’s two hours. I have 4, 30-minute segments. I’m gonna talk about microsurgery. I’m gonna talk about retreatment and disassembly. Oh, yes. And I’m gonna talk about the advantages of the microscope in clean, shape, and pack. Phew!
Okay. The fun part, though, was the first 30 minutes, and that was Ruddle’s wild dash through history and a little bit about how I got started from clumsiness, awkward, indignities and upsets, to proficiency and ever closer towards mastery.
Okay. Well, maybe we’ll feature some highlights from that lecture on “The Ruddle Show.” So, one thing we did accomplish during the off-season is, we did do a Special Report on the KISS principle related to dentistry, and KISS stands for “keep it simple, stupid.”
She’s talking to me again.
[laughs] And we focused on the importance of simplicity, quieting the noise, and getting back to basics in endodontics. So, without actually reenacting the whole Special Report, why don’t you tell our viewers, just give them a general overview what we discussed.
Notice the subtlety there. Special Report, yes, we knocked that out. I guess when one assesses the current position of clinical endodontics as a healing art, one is struck by our success rates really are really maybe up less than two percent! And that’s not what Ruddle says. That’s what many professional people say that are in teaching. There’s a lot of reasons for that, that we explored, and I won’t go back, because that’s what you’re supposed to do is watch the Special Report.
But I think with all this technology, you’re thinking it should’ve gone up. I mean, there’s been an explosion of technology. But technology isn’t what does the endodontics. It might guide the endodontics, but it’s actually still you. So, go watch the Special Report and get more streamlined, get more effective, get more efficient, be your full potential.
Excellent. Yes. Definitely check it out if you haven’t already. Another thing we had mentioned that we were planning to do is something like a start-to-finish endodontics week, where each day we would focus on a different aspect of endodontics. Well, that idea is still in the works and evolving. We hopefully soon will have on our website something similar. It’s gonna be called Portals. So, definitely stay tuned for that fun and exciting development. What about the podcast idea? How’s that going?
From my portal to your portal, be ready! Well, what I’m excited about is, I’m always on the show. By design, I’m restricted pretty much to about 20 minute on my teaching set, Set B. Set B! Wake up over there! I see you sleeping.
All right. Look-it. We have a chance on a podcast to drill down into some of the great questions and controversies in endodontics and go much, much deeper. So, that’s what Ruddle’s been doing his whole teaching life is drilling down a lot deeper, and most of my all-day courses are all day. I’ve done week-long courses. So, 20 minutes is like, you know, say, a U-2 plane flying at 60,000 feet. You know, we barely see the target. We don’t see the target.
Well, we got a set, a podcast set, set up. So, that’s --
We got that built.
-- some progress. And we had – we talked about some ideas, did a lot of brainstorming. Sometimes plans have to be adjusted, and there’s some delays, always. So, hopefully, by the end of the --
Oh, John Lennon. John, here – John Lennon. I think John Lennon said, “Life happens while you’re busy making other plans.” Yes, that’s what happened this summer. We didn’t quite launch it, but we’re on the verge. I can feel the rumble and the power of the engines. I think I heard Isaac say, “Ignition!” All right.
Yes, coming soon. All right. Well, we have a great show for you today, and we’re excited to get going on it. So, let’s go. [Music coming up]
SEGMENT 1: Endo/Perio Considerations – Crestal & Furcal Defects
It’s great to be back with you today and talk about something that’s very familiar to me over all the years. When I came to Santa Barbara many years ago, I’m in a medical complex, and there’s, I don’t know, 15 or 20 dentists along with physicians. But I had a periodontist exactly next door to me, and still do. And that endo/perio thing saved me so many times because we always had the opinion, me and the periodontist, Dr. Phil Smith, at that time, you know, if he could come over, he would take a look at something, my patients chairside, and give a quick opinion, save a patient another visit and a future consultation. And I would run over sometimes to his office.
So, with that said, endo/perio’s very dear to my heart. And of course, back in the ‘70s, there were a lot of hemisections and root amputations that have kinda given way to implants, as you know. So, today we’re gonna focus on the endo/perio interrelationships or the various considerations. And of course, we’re gonna focus on furcal and crestal defects. So, here we go! We’re not gonna look at middle one-third problems so much and apical problems and the whole thing. We’re looking at a very narrow field or discipline that addresses furcal and crestal defects, because a lot of these periodontal lesions are masquerading around as lesions of periodontal origin. In fact, they’re lesions of endodontic origin.
So, this won’t be a how-to lecture. I’m not gonna tell you how to do anything. This is gonna be a thinking clinician’s lecture, so that you’re gonna learn to do the pulp testing that we’ve talked about, and you’re gonna learn to do all the things we’ve talked about. Let’s get started.
So, there are a variety of reasons – this isn’t even a complete list – but certainly, endodontic fractures come to mind. And you can look at a preoperative film, and you can see this is a little bit from the mesial. This is more straight on. But you can see, the bone looks perfect. This is a 35-year recall, but it’s draining. It has a probeable pocket. It’s through the lingual sulcus. How about CBCT? And if you take a CBCT image, you can begin to see, even with beam hardening and all the artifacts, you don’t’ see the fracture, but you see evidence of the fracture because you see a big halo lesion wrapping up the side of that bicuspid. So in this instance, that is an endodontic fractured tooth, creating a periodontal defect.
Well, we can have problems associated with iatrogenics. And certainly, Ruddle did the root canal. I down packed, I back packed. I sent it back temporized, provisionalized, and the dentist was only requested – he requested – to leave a post space, because he was gonna place a post in the tooth to build a prosthesis on. And when the endodontics failed, he said, “Go see Ruddle. There’s a problem with the root canal.” Funny stuff, huh? How we communicate.
But when you see this kind of problem, you could say, well, it looks a little bit like the last one. Well, this one is solvable, because – theoretically – because you can get the bridge out of here, get the post out of here, and if you can do a repair material in here, who’s to say we don’t get back the crest of bone and have an anchor. But it’s a load on a tooth that’s now very, very compromised, a lot of unnecessary loss of tooth structure, tooth weakening, and a predisposition for a longitudinal fracture. We’ll look at that case later, at another time. It has a remarkable ending, but this is just very disappointing to see, that we don’t get lined up. We’re in a hurry.
Well, we can look a little bit more, and we can say, well, we have pathological defects. 90 percent of my practice for over 20 years was – the last 20 years – was all basically redoing other people’s work, and that includes general dentists and endodontists alike. I had people traveling from out of state to come and see me. And you can see these old silver points that were done by a dentist, because that’s what was taught in most dental schools in the U.S., back in the ‘40s, the ‘50s, the ‘60s, and the ‘70s. So, lots of people got silver wires, okay?
And when the treatment was incomplete and tissue was left behind, sometimes you can get an internal resorptive defect going that actually perforates, and you can see a little bone loss in here and a little shadowing in there. And so, this lesion is destroying the periodontium or the attachment apparatus. So, that’s an example, then, of a fracture, a perforation secondary to iatrogenics and a perforation secondary to internal pathological resorption.
The topic I’m gonna focus on today pretty much is root canal system anatomy. In other words, do furcal problems, do crestal defects occur secondary to endodontic breakdown and disease flow? And the answer isn’t always a resounding yes. But you have to have the ideas and the methods and the treatment approaches that can address root canal systems that might have been either previously missed in the retreatment situation or that you’re thinking you wanna pick up on your current treatment that’s planned.
So, this is a gutta-percha point. It’s going through the sulcus, buccally, and it’s going into a big osseous defect. The tooth is broken down. You can see a little evidence down here of lesions of endodontic origin – lesions of endodontic origin, just like that’s a LEO. You don’t know that it’s a LEO. Could be perio. So, these are consultations where you talk to the general dentist. You might want him to refer to perio after endo, based on healing, but you start by ruling out the etiology, the culprit. That is necrotic teeth. So, we’ll look at this in a little bigger blow-up. And now you can see a full-size pre-op. Nothing’s changed.
Big furcal problem. You notice this little line right here? You notice this little line right in here? That’s the edge of the root. That’s the furcal side concavity. That’s the incavity. So, we gotta be careful and shape away from furcal danger. I like to show this, because I used to give lectures routinely to large periodontal groups, the American Academy of Periodontology, different component state groups. But we would talk about endo/perio. And most periodontists had never seen a furcal canal coming off the floor. Most dentists haven’t. But are you packing your floor, are you addressing the floor? I’m only throwing these things out. I’m not explaining how I pack the floor, but I pack the floor.
We have Clorox sitting there the whole visit. That’s the good news. So, we probably clean a lot of them and don’t fill, because most dentists aren’t trying to -- hydraulically to three-dimensionally pack the furcal floor. So, maybe you’re not gonna do it now routinely. But if you see through your CBCT scans, your axial slices, or you see on well angulated preoperative films, you see furcal lesions, maybe you’re thinking, this case might need a little extra tender loving care. And of course, the sulcus does heal up. And just on a 30-day check, you can see that here is the 3-millimeter level. So, we’re in there about a couple millimeters with good attachment. See the tissue’s blanching a little bit. So, we have attachment, healing begins four days after cleaning and shaping. How about that.
So, let’s look at root canal system anatomy. If you wanna pick up the ideas that we’re talking about today, they’ve all been on previous shows. We’ve talked about the importance of diagnosis. We’ve talked about how to do the three-phase endodontic exam. We’ve talked about complete access, Ninja access. We’ve talked about orifice directed access. All of that’s gonna influence this. We’ve talked about glide path management, getting to length. We’ve talked about appropriate shape. We’ve talked about 3D irrigation. It's all on previous shows. Go check it out!
Maybe you were just coming in to watch the show recently, and some of you are wondering, do you start at one, or do you play catchup and maybe just start in now. Well, if you start in now, that’s good news. Welcome aboard! But you might wanna go back and pick up some of those segments, because we planned them to play off of those. So, if you think about this, if you can 3D flush, irrigate, and clean systems 3-dimensionally, with technology that’s readily affordable, you don’t have to go buy $100,000 lasers, $70,000 GentleWaves. You can do this a lot of different ways, very, very affordable, anywhere in the world. And let’s watch the inevitability of the capacity for lesions of endodontic to heal after shaping and cleaning and filling.
So, you can see how this works. You can see the lesions are beginning to resolve. That’s why you recall your patients. It’s to monitor this, to make sure they’re doing well, to check on Ruddle to see how Ruddle’s doing. And that’s kind of like what we’re gonna now show, the subsequent cases, the kinds of conventional treatment that led to success. So, when you see restorations on teeth, you see breakdown. But what you really notice is this massive lesion. Roots aren’t particularly -- pretty bulky here, but kinda thin here. And again, I’m gonna come back and beat this to death.
But when you see this little line right in here, and you see this little line right over in here, again, that speaks to the depth of the furcal side concavity. It means shape away from furcal danger, shape to the greatest bulk of dentin. How about that? Get rid of that, please! All right. Outta there. So, you do the post off. The crown came off during treatment. So, I built up the tooth, I put an orthodontic band around the tooth to give me a pulp chamber, to have a reservoir reagent. It’s the reagents that clean root canal systems. None of the things we’re talking about today are you going to be putting files into. These are lateral ramifications that have serious potential consequences.
So, one off the mesial, one off the distal, and the flap comes back, just for teaching. This is how it looks after the crown has been provisionalized. You can see I started my access through here. The crown flew off. So, I patched that after I put the crown back on. But look at with the flap back, just take a picture, look at that massive furcal blowout. Here it is, two years later. Watch the bone come to the surface. No GORE-TEX. No ridge augmentation stuff. No regenerating materials, just endodontics!
How many of you would’ve wanted to reach in here with a curette and get that cement out of there. You don’t need to do that. The body can tolerate our cements, so why are you still living in the past, where you’re so interested in getting that curette and curetting all that tissue out. Then, you can bring in the shopping cart, and you can start to shovel stuff into the furcation. Don’t do that. Just do endodontics. There’s how it looks in two years. That’s how it looks at two years, and you can see at two years healing apically, healing laterally, the sealer is well tolerated, no reason to curette out that surplus.
So, you say, that’s a foreign body. Remember, our sealers are biocompatible. Before they set up and become dimensionally inert and biologically stable, of course, there’s inflammation, because it’s not set. But once the cement’s set, then, everything is inert, and the body can start to repair. And it’s inevitable the bone will fill. So, that’s a little comment on some furcal problems. We see these sometimes even in anterior teeth. The dentist that referred this from out of town said, “Ruddle, I’m gonna do this one. I feel real comfortable treating apical lesions, and it’s an anterior tooth. It should be quite simple.” Nothing is quite as simple [laughs] as it appears. But that was fine.
He said, “You do the central.” Why? “Because” he said, “the central has a big draining pocket [laughs]. The tissue’s edematous.” And you know what? There’s pus and bleeding. And he said, “There’s a big radial lucency.” And I think you can start to see, we have this, and we have this, and we have a little thickened PDL around the tip of the root. So, Ruddle’s treating the central, general dentist is treating the lateral. Let’s get to work. Make a careful access. Castings can come off. I did my shaping, irrigated over a little bit of time, down packed, out with the anatomy, back pack.
And a few years later, the general dentist, after I got this done, there was no surgery, no antibiotics, just good hygiene, and the patient’s tissue got firm. It got stipulated. It got really healthy, nice and pink. And while this was healing, he went on and took this one, and both doctors’ lesions are healing. So, what I told the dentist was, “If you can treat apical lesions, why not treat crestal lesions”? How about that. Now, I’m gonna show this, too, later. It has another whole element to it on how to work bifidities and how do you fit two cones or one cone and all that.
We’re not talking about that. We’re talking about lesions that wrap around the roots and extend all the way to the crest, and it’s probeable. The tooth is big! Are you noticing that root? That was kinda like, you know, a story I’m gonna talk about later! You know, like where this guy’s really big! Maybe this is his tooth! I don’t know. You’ll see that later. So, it’s just bread-and-butter endodontics. Open up the tooth. In this case, we fit two cones, down pack, back pack. Five years later, notice how tight the bone is.
See, these could be misinterpreted. The lesion alone doesn’t tell you the etiology. It could’ve been a vertical fracture like I showed earlier. It could’ve been a lot of other things, but you gotta do your pulp testing. And you gotta rule in or rule out a lesion of endodontic origin. What if this is necrotic? If it’s necrotic, you got permission to play, and the expectations would be probably good healing. Okay. So, this comes in as a block of dentin. And later this season, I’m gonna be talking about how to get into these calcific canals and these mineralized canals and these canals that have no space. No, the slider will not go into no space. It needs to have something to follow.
So, when you start to see almost no pulp chamber, you see a pretty decent pulp chamber, you see a nice big pulp chamber, almost no pulp chamber, notice the PDL lines are nice and sharp, nice and sharp. But you notice it’s ragged in here. It’s ragged in here, and it’s draining, and it’s probeable. There’s a probeable pocket. In fact, a lot of my referrals come from periodontists, because they want to work with somebody that actually can help their field, because aren’t we both curators of the attachment apparatus? Ha, ha! All right.
Now, this is a fun case, because the rope of gutta-percha with the sealer trail out into the sulcus, this is significantly bigger than where I put my files apically here, and it’s approaching the size of the file in the distal terminus. So, these can be serious events. They’re serious, and when you think about tissue coming out of here necrotic, and it drains out, it’s gonna destroy the bone. And then, of course, there may be some little remnant of something going on in here, and you see there’s another feeder. So, all of a sudden, endodontics is about the anatomy. It’s about doing a million little things right to get the result.
I want you to do this. And if you’re watching “The Ruddle Show,” and many of you started joining – and I mean, we’re kinda like in that parabolic curve now, because [laughs] we’re really climbing, because we hear about how many of you are coming and joining us, go back and watch those shows and figure out how Ruddle cleans and shapes, and I’m not using extensive technology. I’m an endodontist for the common dentist. I travel all over the world, teaching. Not everybody’s gonna go out and buy a $100,000 laser to support their quest to treat root canal systems! You don’t have to. You do not have to.
Let’s get this over and see what happens down the road. And I don’t know if you’re excited. I’m actually ready to go schedule a patient for this afternoon. I mean, I’m in the studio; it’s nice and cool. And I thought, just get in the car, go through the gearbox, because I have a manual transmission. I think I can get a little rubber as I get outta here. And I can get out there and schedule a patient. Because when you see the bone rise to the surface, and you see the crest here, and you got that three-wall osseous defect, that triangular defect, those are so amenable to endodontics. Don’t let them become so chronic that you blow out a lot of bone, and now you have a big, combined endo/perio.
So, yeah. Still, etiology’s primary endo, secondary perio, but the perio’s less predictable, the outcome, as the lesions get more chronic and do more damage. Just about done. This lady has maintained this molar abutment for many, many years. This is a through-and-through furcation. You can take a pipe cleaner, stick it in the buccal and pull it out the lingual. This lady has nothing else to do. She’s very, very resourceful. She does it, and she’s maintained that abutment for about 10 years.
And now she has another problem, a toothache. And then, you start to notice this. There’s the crest on one side, and then, on the buccal or the lingual side, there’s the other side. Take your CBCT images. But we have a three-wall defect. We’re not gonna ever get this to heal. We don’t expect it. But she’s draining, and the periodontist is suddenly seeing a tooth that was really well cared for have some pocketing and some erythematous tissue. Love erythematous tissue. We packed the case. Did you notice the two portals of exit? There’s two POEs, portals of exit.
Don’t try to give them big names, fancy names. I notice some of these people in these magazines propose a new nomenclature. You know, like they were born five minutes ago? The world of endodontics has been going on for 10,000 years, and suddenly, uh, uh, I’m gonna propose a new international vocabulary. Why don’t we keep it simple? LEOs, lesions of endodontic origin, POEs, portals of exit, and what do you think this is? Root canal systems! That’s all you have to know in endodontics, because that’s your north star, and that’s your guiding light.
And notice again the size of the more coronal portal of exit is bigger than where I put files apically – bigger! Some of these are serious. There’s a smaller one a little bit inferior to it, but it’s feeding that three-wall defect. And when you get that out of there, notice how the bone comes to the surface, and the pipe cleaner can continue doing the thing it does in a blind, through-and-through furca. How about that? Well, I threw this one in just for fun, because I knew you were gonna need to have some hope, because this is 2022, and we still have a lot of hope. You still have a few months to get it done and to get on the bus and start rolling towards – what? The future you.
The idea of “The Ruddle Show” is to grow people. The idea of “The Ruddle Show” is to help you go beyond Ruddle! So, I couldn’t find my pre-op yesterday, and I looked for probably two and half hours, and finally, Phyllis said at dinnertime, “Are you ready for tomorrow? It’s Season 8!” And I said, “Yeah. But I can’t find the pre-op.” I’ve been looking through a library that has about 30,000 slides. I have it, but I couldn’t find it. That’s my post-op. You might say, why are you doing this procedure on that patient? And I’m gonna tell you the story. It’s a funny story.
So, the periodontist sent it over and said, “It’s hopeless. I wanted you to look at it, though, because the patient said, ‘Isn’t there anything you can do?! Anything, Dr. Smith!’” So, anyway, I said, “Okay. I think we should do endodontics. It’s necrotic.” Just imagine no endodontics, and just imagine you got a bifurcation problem, you got a massive lesion. But this one’s the big one. It comes around like that. The bone’s pulled way back off the tooth. It’s been going on for a long time. And so, here was the deal. I said, “I think we should treat it.”
But I’ll tell you what. Because the periodontist was really nervous that the patient was gonna spend Ruddle fee and then lose the tooth anyway, and then, all of a sudden, you know, where was he gonna – what kinda money was gonna be generated to do the implants that he was already, you know, salivating over, all the implants. And I gotta get a fixture in here. You got one in here, and you got one in here. Oh, it’s gonna be a marvelous morning production. The game was, Ruddle, if you do the root canal, and it fails, you eat it. So, the patient’s paying nothing. I’m doing this one on the house. If I do it, and it works, the periodontist pays me my fee! Ha, ha! Not so bad, huh?
And if it doesn’t work, and the tooth’s extracted, Ruddle eats the fee! So, we were having this really fun thing behind us, and who was gonna owe who how much money. Oh, we made the wagers very, very big. I decided to double my fee because I was so confident. And here it is! And here it is in just one year. One year! I mean, this is why I love endodontics! This is why I teach. This is why we’re doing a little different thing today. See, we’re focusing on those crestal furcal defects. We’re talking about the interrelationships and considerations of endo/perio.
And you can begin to see with just a handful of cases – I mean, I used to have thousands of these cases, and I still do, and I used to go around, like I mentioned, and talk to perio groups, because they saw the value. I want you as general dentists and well trained endodontists -- if there’s any periodontists watching, I know you believe this – and if you wanna have more success in your procedures, make sure you have the endodontics either eliminated and ruled out. It’s not endo. Or if you’re gonna do endo, let’s do it three-dimensionally, and let’s do it to win. Thank you.
SEGMENT 2: Recently Published ProTaper Ultimate Article
All right. So, you published two articles earlier this year, one on the new EndoActivator system, in Dentistry Today, and one on the new and improved ProTaper Ultimate system, in the Canadian journal Oral Health. And last season, we devoted a segment to telling you about the EndoActivator article. So, this season, we wanted to take some time to talk about the ProTaper Ultimate article that was, like I said, published in Oral Health, in the May issue, and is called “The Ultimate Shaping System” – get it? – ultimate. “The Ultimate Shaping System: An Opening for 3D Cleaning and Filling Root Canals.”
Did you get the opening part? The opening is judiciously removing restrictive dentin so you have a shape that can be 3D cleaned and filled.
[laughs] Okay. So, ProTaper is a unique system for many reasons. And momentarily, we will go into a lot of the details of why this is the case. But first, I wanted to point out that ProTaper stands out from the multitude of file systems on the market today in that it is one of the few that has endured over time and continues to grow with each new generation designed with the singular focus of continuous improvement. So, why don’t you just tell us a little – like, give us a little overview. When did ProTaper first launch?
Well, before I answer the launch part, to get a little overview and to play off of Lisa, there’s really not been a system like this. I think it’s probably easiest if you just see it kinda graphically. We’ve sold over 371 million files, saved probably 200 million teeth, and I guess there’s been about 1,200 scientific peer reviewed articles, as you can see over my shoulder. And for at least the last 10-plus years, it’s been Dentsply Sirona’s number one sold file. And if you think of the size of Dentsply Sirona internationally, that means essentially it was the number one file sold in the world. So, it’s because success leaves clues. People migrated for a lot of different reasons.
But to get to the fundamental question on the launch, we started in ’95 with the concept and the idea. 2001, we launched ProTaper, and it was just 21s and 25s. That was it. ProTaper Universal came in 2006, and that was 31-millimeter lengths added along with system-based paper points, master cones, and carrier-based obturators. So, that grew it up. And then, we found 2014 Gold metal, and Gold metal gave us a lot of metallurgical excellence, and that has been the ride. And then, of course, Ultimate launched in September of 2021. So, that is a glimpse of the ProTaper that we talked about in the paper.
All right. Well, when we did our Special Report a couple weeks ago – or a few weeks ago now – we talked about the vast multitude of file systems on the market today and how it can be very complicated or at least seem complicated to choose one. And you had identified some criteria of what to look for in a file system. And coincidentally, a lot of those criteria actually appear in the paper. And so, why don’t you remind us what they are and also just the concepts that have guided ProTaper along its journey.
You know, that’s interesting you word it like that, because I – I’ve never really – I’ve talked to a lot of people that build files, but usually, they’re teammates. But when you see some of the other files that emerge on the market, you’re wondering, what did they build it for, and what were they thinking? But I’ll just say right here, we’re basing this on biology. And so, we’re basing it on mechanics and the biological objectives. That’s true. So, you can’t – you can have a nice mechanical file, but it’s gotta fulfill the biological objectives of what it is you’re trying to do.
So, when you look at this, this is the triad. And there is some kinda shaping in a triad. We don’t agree. There’s some kind of three-dimensional irrigation, but we don’t agree on what that method is. And the paper emphasized there’s different ways to fill root canal systems. But that is, in fact, the triad. Now, back to the file building, the file building had to be built on two primary principles. What are we trying to do? Treat root canal systems. And the second thing was Schilderian endodontics. Schilder introduced the five mechanical objectives for shaping canals. And that article has been the most recited article internationally over the decades, because it wasn’t a measurement, it wasn’t a – anything. It was conceptual. It was a way to think about it.
So, we wanted to build files that would address the anatomy and allow us to get our irrigants in there and to fill root canal systems. The other thing is, we wanted – the paper was emphasizing what – what’s the job of these instruments. Do they all do the same thing? Do they just make the hole bigger and bigger and bigger until you say, stop! I wanna fill now. No, shapers work because of progressively increasing tapers. The paper illustrated how they work dominantly in the upper two thirds. Well, the finishers are decreasing percentage tapers, and they work dominantly in the apical one third.
So, we’re the only file system that sequences treatment like this, get the body open, pre-enlarge, so you can get the finishers in there and get decreasing percentage tapers. You know, 7, 8, 9, nobody has that. So, if you’re gonna have that kind of shape, you’re gonna have bigger volume. Bigger volume means better exchange, and exchange means better potential for cleaning and filling root canal systems. So, that’s a little bit about – we talked about in the paper about the distinction between shapers and finishers.
And the last thing I’d like to do is just talk about, when you see a set of files, they should be easy to use, they should be efficient, they should be affordable, they should be safe, and there should be research behind it. And we have all of that on this.
Okay. So, just to – I know that we talked a lot about – in the paper about root appropriate in this conceptual part. And you kind of defined what that was, and I think you just kinda said it, based – like you want something that has deep shape in the apical one third and something that conserves dentin in the --
-- coronal two thirds. So, that kind of has guided these increasing and decreasing percentage tapers.
Yeah. In the paper, we went into – I didn’t do it now, because it’s just an overview. You’re supposed to read the paper. We use one-millimeter wire. So, we used to have 1.2-millimeter wire. So, our shaper’s now one-millimeter wire. So, automatically, the body’s smaller.
Okay. All right. So, we talked about the concepts in the paper. And then you went on to introduce the files. And then, I see there’s the five core files and then the three auxiliary files. And so, maybe give us a little description of these, but maybe focusing on what has changed from ProTaper Gold.
Well, when you look at these files, and you look at the core instruments, with blue shading behind them, everybody knows internationally, the first instrument you use, you don’t even have to know how it’s designed, you don’t know its cross-section, you don’t even have to be – you can be blindfolded. It’s purple if you could see it. So, it’s purple, white, yellow, and that’s the sequence going from left to right. The first file would be the slider. The slider is innovative, and the paper went into great detail about the pros and cons. The pros are, about 67 percent of the time, according to the key opinion leaders in Europe, they can reach length in molar teeth with no hand files. [clapping] That’s a round of applause.
That doesn’t mean each time, every time, all the time, but it means 67 percent of the time, you’re not breaking out your hand files. So, please, I hope the audience doesn’t get over enthusiastic. Ruddle never said, “no hand files.” I said, “fewer use of hand files.” So, when they go to length, and you float, follow, and run, like we spoke about in the paper, and they get to length, you’re gonna be auguring debris up, peaceful patients post-treatment, less postoperative problems. You have a beautiful slide path. It’ll allow the next instrument to follow. Once you get anything to length, like this one, it’s in the bag.
So, you know, some of you have written in and said you love the system, you’re using it, but maybe emphasize sliders aren’t all things to all people at all times. That’s true, but it’s still the first instrument. If you have an orifice, if it has a little bit of diameter, stick the instrument in, and let it run! See what happens. If it bogs down, no pushing, no pecking, and no pumping. You love to pump, don’t you? Pump the brakes and take the file out, grab your hand file. So, that’s what we talked about.
The shaper would be – well, a little fun thing here. So, one of the big things was to evolve the instruments and evolve the most tedious, technically difficult part, and that’s glide path management. So, a lot of times -- and we used a lot of hand files, didn’t we, you know, 10, 15, and 20, back in the day, before we brought rotary in. Then, you know, finally, we thought, with the instruments improving, the mechanical ones, we can now maybe just use the 10. Then, finally, John West said, ‘Well, if it was just loose, that would be enough, just the 10. Not the 10, the 15.’ So, he went from a trike to a bike to a motorcycle.
So, if you’re using ProTaper, and the slider’s the first instrument, when it goes to length, you’re gonna think you’re roaring into the future. So, when it doesn’t go, you don’t have an upset, you just grab your hand instruments, you use your viscous chelator. We stress this over and over in the paper. I think you need to read the paper several times. I don’t – you know, when they said keep it simple, stupid, they were talking to me. But I read Schilder’s paper every year, as I’ve said, over and over, and I always squeeze one more thing out. As your experience evolves, you’ll find your experience in how you read the words will change.
We talked, then, about the shaper. We used to have two. The paper says, now we have one. So, we went from two to one. So, rotary’s a big deal for glide path, the purple slider. One shaper’s another evolution. That’s good. The cross-section’s another evolution. There’s three things. Wow! Are you ready to buy yet? Anyway, went from a rhomboid towards the tip to an ever-changing parallelogram up on the active portion, lots more chip space in here. That deactivates that two points, one point, two, one, two, one. That deactivates the file and gives you more chip space to hold debris, and you have a safer instrument and efficient instrument. So, that’s really nice.
Alternating offset machining, I wasn’t gonna go into that. I’ll have you read the paper. But it really keeps your file looser in the canal and still centered. Finishers, you have three finishers, yellow, red, and blue. And if you look at the yellow, red, and blue, you need to understand it’s the same cross-section. It’s changing, evolving, but our fixed taper is only in the apical third. Remember, finishers have regressive tapers over the back end. That conserves dentin in the body of the canal.
People that love minimally in endodontics, you should’ve loved this. But yet, you didn’t love it when we offered in 2001, but now you’re really loving it. We’re getting comments you really love the smaller shapers. Well, the concept of decreasing percentage tapers is not new. But it passed over. So, deep shape you still get with a smaller body. Okay. And you can see that animated out for you. And then, finally, to get to those auxiliary files – you want me to do that now, quick?
Well, we have the SX – well, you’ve known the XS. It’s been the number one sold instrument, regardless of all the file systems, just that one instrument. But we’ve made it better. How about that? We changed the cross-section, it cuts more efficient, doesn’t grab, and it removes impediments. The paper really emphasized, you know, the things it can do, triangles of dentin, negotiate really difficult calcified canals that have a little glide path, a little slider activity in the top part. Now you can get the bigger shaper in there, and you can get that restrictive dentin out. And now your instruments begin to move, because the canals are more open as you move down the canals, even the ones that are calcified.
So, this is good for pre-enlargement, brushing, moving the canal away from furcal danger, more centered roots. You’ve heard all this in the paper. You’ve heard it. And then, the auxiliaries, I wanna talk about those just briefly. We have an FX and an FXL, an auxiliary finisher and then a large auxiliary finisher, 35-12, 50-05 -- 50-10 – 35 – okay. 35-12, 50-10. You get these cases. They come to you. They’re either younger patients with big systems, they’re previous cases that have been treated and they’re failing, and the apex has been over-shaped and prepared, and then, you have iatro- -- pathologic problems, resorptions and stuff.
You finally – for the first system in the world, you finally have files that are engineered and designed for these kinds of cases, and you’ll be able to take these retreatment cases and still get a capture zone where you can mold that thermosoftened GP into the narrowing cross-sectional geometries. Okay.
All right. Well, in the paper, after you introduce the files and describe them, you then go on to describe the clinical technique. And is that very different from the ProTaper Gold clinical technique?
Yes and no. If you’re just talking instrument for instrument, the concepts of ProTaper are always never pump, never push, never press. Okay? Same. If you just put it in, you’re gonna use it like a brush if it’s a shaper. You know? If the handle’s off axis, you’re gonna wanna upright the handle. So, the paper talks about that. So, you’re doing it to get control of a case and get good access into the apical third.
So, yes, they are the same in the way they’re used. What you will like better is that rotary first concept with the slider. The cross-section, you’re gonna notice, changes things. And of course, you got those big auxiliaries. That’s gonna open up a whole new realm of cases you never were able to treat before. Or if you did, it was more difficult.
Okay. So, if you were using ProTaper Gold, and you’re making the switch to ProTaper Ultimate, is it a pretty easy transition?
Simple, simple, simple.
Okay. Well, the paper is a very clear and simple overview of ProTaper. It explains the concepts that have guided ProTaper. It describes the files and tells how to use them. So, I also want to add that on “The Ruddle Show,” we’ve done two detailed Q&As on ProTaper Ultimate. And last season, we had a guest presentation by Dr. Gary Glassman. It was a live demonstration on a patient using the ProTaper Ultimate files. So, if you’re interested in learning more about ProTaper Ultimate, check out those segments. And then, you will probably do something again very soon, on ProTaper Ultimate [laughs]. So --
And just one last comment. These are two cases from the Johnny West clan. This is John West on the left and either John, Jason, or Jordan did the one on the right. I wanna just be real clear about that. But what we’re saying is, how do they work compared to the old ones?
The old ones worked very, very well. Anybody that can go around a 180-degree candy-cane root is not looking necessarily for a new system. But if you’re looking for a little bit shorter system, if you’re looking for a little smaller shape, compare the shapes over two different teeth, completely different everything. But you’ll notice the shapes are smaller on the right than the ProTaper Gold. So, you have ProTaper Ultimate, ProTaper Gold. Still, the benchmark is we’re building off of the best from the past, and we introduced the best new technologies available today. And then, with some ingenuity and creativity, that was what we emphasized in the paper, ProTaper Ultimate.
Okay. Do you have any just final closing remarks but – other than that, but like something that if – if they read the paper, like maybe one or two key takeaways?
Well, what I’m finding in Utah, going back to the workshop, colleagues were thrilled. They were running around telling each other and showing – we had digital films there. So, they were showing their slider going around multiplanar curvature and arriving at length, and they were thrilled, because a lot of them said they either couldn’t do it before with hand files or they screwed it up and had a ledge or a block, and they lost control of the case. So, the big thing that they’re gonna be [laughs] really excited about is, the 67 percent of the time when it does work, the 37 percent [sic] of the time that it didn’t, it’s not a failure. Just means it’s a tough, tough case, and we go back to our training, and we grab our 6, 8, and 10, and off we go.
I think actually, part of the problem – or not really “problem,” but I think the idea of the slider just seems counterintuitive. Like it just seems like, well, why would you just – that be the first thing you put in, something that’s rotary? You know? So --
Well, you know what? I’m glad she’s bringing this up again, because I’m getting emails from around the world, like, Ruddle, you taught faithfully, you must use manual! The 10 has to be at length! The manual can’t – did I say that’s a hand file? [laughs]
And a 15 would’ve even been better, if you go back a few years. If you go back a few years earlier, better get the 20 in, so you have a little bigger space, so that shaper can go in there and work! Have a glide path to follow that pilot hole. So, even Ruddle can change, is the comment. And we didn’t just dawn on doing this in a couple sessions at Maillefer in Switzerland. It happened over two and a half years, and there were hundreds and hundreds of canals treated. And Pierre and I and West had a big competition on getting the most calcified teeth we could and just push it to the limits.
So, just like I can change, you can change, and I wanna encourage you to change, because I can change, and if I can change, you can change, because we can all change. And if we change --
-- we can get better towards better change. Oh, yeah. Plus, very --
Okay. Well, definitely check out the article if you haven’t already read it, or maybe read it a few more times. And we’ll have it in our show notes, so you can download a PDF of it. So, thank you for the overview, and that’s it for this segment.
CLOSE: Ruddle Flashback – Meeting Wilt Chamberlain
All right. Well, we’re gonna close our show today with another Ruddle Flashback, and it’s where my dad takes about five minutes to tell us about something that happened in his life. So, I have this vision in the future – this will be the 8th one we’ve done, for Season 8, and when we get about 12, maybe we’ll put them all together, and it will be “Ruddle Flashbacks, The Movie”. So, maybe we’ll do something like that. So, this time, we’re gonna go back to 1964.
Okay. So, this is really exciting. In 1964, I was 16 years old, and I was away from home, at an academy. My parents sent me to this academy because they wanted – forget that story. Anyway --
-- at the Academy, I was on the basketball game as a starting guard. And our coach, Coach Botimer, Lyle Botimer, came to us one day after practice, and he said, “I have some pretty exciting news” and we never dreamed what he was gonna say. And he said, “You know what? I have a friend who plays for the Boston Celtics, and they’re coming into town.” San Francisco was an hour and a half drive away. “They’re coming into town to play the Warriors,” the San Francisco Warriors. So, Boston Celtics, East Coast, San Francisco Warriors, West Coast.
Is it – was it called San Francisco Warriors, or Golden State Warriors?
San Francisco Warriors.
Yeah. And back in that day, they played in the Cow Palace, and that seats 16,500. So, that was a pretty interesting venue and a big history with the Cow Palace. So, he said, “I’m gonna take you down there. I’m gonna – after the game, I’ve arranged for you to meet maybe some players, but for sure, you’ll meet my friend. And we’ll see a basketball game.” We were excited. We couldn’t sleep for like several weeks. And then, we went.
And the game was really exciting, and it was just terrific for high school basketball players to watch the big boys. And after the game, we followed [Coach] Lyle Botimer down to the locker room areas that of course we weren’t allowed in. And so, we were waiting patiently, and you’d see a guy come by and walk out. And we’d say, we think we know that one. But all of a sudden, I looked ahead of me, and there was a phone booth. Most of you don’t even know what a phone booth is, if you’re less than 30 years old.
But they used to have phone booths before cell phones, because you could make convenient calls, and cell phone booths [sic] were placed around the city in different locations. So, there was a guy talking on the phone from the phone booth, but he wasn’t in the phone booth, because he was too big for the phone booth.
And I looked again, and I nudged Willy – Willy Brown, my pal, and I said, “Is that Wilt Chamberlain?” And he said, “That’s Wilt Chamberlain!’” And then, right after that, another guy, 6’11”, walked by. That was Nate Thurmond. So, you know, it was Nate Thurmond and Meschery and Wilt and all these guys that we knew, Guy Rodgers, Al Attles. And then, Celtics had Bill Russell, the Havlicek, Tommy Heinsohn, and the Jones brothers. And so, we were just out of our minds with joy, never said anything to him. He did look at me once, and we just briefly met eye, and he just nodded, but he was talking on the phone. So, that was a big thrill for me, and I decided after that, I’m gonna eat an awful lot, because I need to get really, really tall so I can do that, too.
Yeah. I guess I could ask you, like what was your takeaway from that experience? Maybe you learned that you maybe weren’t tall enough to play [laughs] professional basketball [laughs].
No, because when you go to those games, you always fantasize who you want to be. Well, I couldn’t ever be that. I looked back at my grandfather and further back and my father, and it wasn’t in the gene pool, height gene. But I was watching a lot of Al Attles. I mean, he’s in the Hall of Fame. And Guy Rodgers, I don’t – that was before you and I started watching basketball, in the ‘60s. But they’re both in the Hall of Fame. And you know, they were taller than I was then, but you could imagine maybe at 6’1” or 6’2”, you’re gonna be able to maybe play something like that if you’re really working hard.
Yeah. I think that for both me and you – our viewers probably know that we’re pretty interested in sports. But one of the reasons is because I just admire athletes so much, you know, what they’re capable of, you know, their discipline, and just doing something at that high level – kinda like you in endodontics. But I mean, it’s – it’s pretty exciting to me, I think, a professional athlete, I can say. I think that that’s more exciting for me than actually meeting an actor or an actress, to meet a professional athlete. Like, I met Andy Schleck once, the cyclist, and I was pretty excited about that.
Sure. And you – to play off you real quick, I think we get more excited about meeting people if we already have a love or a passion for something that they’re doing, that we’re doing in a much lower level. So, for me, we – I was on the basketball team, and here I got to see the Warriors, and I mean, it was a great game. The Warriors lost that game. Warriors went on to the Finals, played the Celtics in the Finals, and lost, four games to one.
Well, obviously, it was important enough that you remember the story pretty well. I mean, now, you’re what? 150? And you remember [laughs] --
How many times do you meet a 7’1” guy?
Actually, some people have him closer to 7’2”. So, it was the biggest guy I’d ever seen.
Okay [laughs]. Well, thank you for that story, and that’s our show for today. See you next time on “The Ruddle Show”.
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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Moving with the Cheese & Delving Deeper
A Better Understanding of Change & File Brushing
The Dark Side & Post Removal
Industry Payments to Academics & Removing a Screw Post
Special Guest Presentation by Dr. Don Tyndall
Controversies & Iatrogenic Events
Sharing Knowledge Pros/Cons & Type II Transportations
To Be Determined
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To Be Determined