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Knowing the Difference & Calcification Esthetic vs. Cosmetic Dentistry & Managing Calcified Canals
This show opens with a discussion of why the patient’s “waiting room” experience is so important and should be maximized. Then, are you confused by the distinction between esthetic and cosmetic dentistry? Some top experts weigh in to set the record straight! Then, Ruddle is back at the Board with several technique tips on managing calcified canals. The show concludes with another favorite Unsolved Mystery, this time discussing the escape of 3 men from the infamous maximum-security prison, Alcatraz.
Show Content & Timecodes00:57 - INTRO: The Waiting Room Experience 07:36 - SEGMENT 1: Knowing the Difference – Esthetic vs. Cosmetic Dentistry 25:02 - SEGMENT 2: Intracanal Challenges – Managing Calcified Canals 54:42 - CLOSE: Favorite Unsolved Mysteries – Escape from Alcatraz
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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.
…10, 15, 20, 25, 30, 35 – 6 files, takes maybe 30 seconds. You’re just goin’ really quick. It’s like an orchestra. You’re a maestro! You’re directing! Going to length…
INTRO: The Waiting Room Experience
Welcome to “The Ruddle Show.” I’m Lisette, and this is my dad, Cliff Ruddle.
How are you doing today?
Good, how about you?
Great, and I hope everybody out there is doing just as great as we are.
Okay. Well, I thought we could start off today talking about a Dentistry Today news article. So, I recently came across this article, and it’s called “3 Reasons Why a Great Patient Experience Begins in the Waiting Room,” written by clinician Dr. Chris Bockrath. So, I thought, this is good “Ruddle Show” material. So, I brought it to you, but before I could even tell you what the three reasons were, you found issue with the article title. So, why don’t you explain?
Well, a waiting room is a room in which people wait. So, I had a little problem with that, because one of your goals that is talked about frequently in staff meetings and stuff is being on time. And so, you don’t want to start referring to a waiting room, because that sounds like you’re never on time.
Right. Well, yeah. People don’t like to wait. So, you know, I guess a great patient experience begins with a very short wait in that room, whatever you want to call it.
In the reception room.
Okay. [laughs] Right. Because you had said that you had called it reception room in --
-- your own practice.
That’s where we receive people. They come in from the cold and the sun, and they come in, and we – okay.
Okay. Well, there’s these three reasons that are presented in the article. I’m gonna tell you the reason, and maybe you can give a comment.
So, the first reason why a great patient experience begins in the waiting room is that first impressions matter.
Okay. So, physical structure. We’re not talking about anything right now except physical. So, when you walk in, she said, you have one chance to make that first impression. So, you don’t want dark, dingy, dirty, and unorganized, to use a few adjectives. You want clean, bright, happy. You want the environment to be not – what’s the word? – not gaudy or fancy. You want it to be kinda like a little reflection of maybe you, but project maybe something like, you know, technology, the environment itself, and maybe things that are talking points.
Yeah. I think my favorite waiting room is my dentist’s office, Dr. Stuart Sato. They always have a couple of really nice orchids in the waiting room. And you might remember from a past show that that is my favorite flower.
All right. The second reason is, it’s the first interaction with your team.
Yeah. So, we talked about the physical environment. So, now, we’re with people. So, you do not want this to be an intrusion into an otherwise busily scheduled day. You should be welcoming this person, because you’ve trained your whole life to be ready for this moment. So, when they come in, I want everybody at the front area to drop everything, greet them, say hi. This is when you might say, are you good? Do you need anything? The doctor’s gonna be with you shortly if you can honestly say that. Kinda get – set expectations. And then, you might offer them a drink or something and maybe a Wi-Fi number or something like that, just to make them comfortable during this brief wait.
Now, if it's a completely new patient, you and I talked off-camera, and we talked about there may be some forms to fill out. Hopefully, in this day and age, they’ve done most of that online, and there’s not that tedious thing on a clipboard and – okay. So, that could be done. And if it’s an older patient, I taught my staff just to go out and help them with the – like an interview process and help them fill out their forms.
Okay. I do have one comment. One thing I’ve noticed before, while waiting in the waiting room, is I have heard the staff talking about another patient. And they weren’t really saying anything necessarily mean, but it kinda made me wonder, gosh, I wonder if they’re talking about me when I’m not here. So, maybe don’t talk about other patients, like, in front of other – in front of the patients.
You know, one of this is – that you’re mentioning has been magnified over the years, because offices have – we’re kind of in cycles with the COVID thing behind us a little bit, but still present in society. But we were closed, and we had doors and windows and sliders, and then, open it up, was the environment, like clean, bright, happy. You can see everything through the office. You can see sterile – you get a glimpse of sterilization now. So, you wanted to show them everything. And so, you’re saying, be careful with that speaking because I’ve heard that, too.
You’re wondering what they’re gonna say about me, after I leave.
So, I give them usually something remarkable to remember me by.
All right. The third reason why the waiting room is an important – for the – for the patient’s experience is, it sets the stage for the rest of the visit.
Oh, yeah. So, if they come in, and the environment is like, wow, it’s pretty special around here, I really like it, it feels good, just feels good. You don’t have to even think about the words. And then, they’re met and greeted, and then, somebody smiles, and we’ll be right with you, yeah. That’s gonna trans into what might be going on back behind, with organization, technology, training, cheerfulness, polite, empathy, kindness, all those kinds of words that set the stage for a remarkable experience. Notice, I didn’t say a “good” experience. You want it to be a remarkable experience. In fact, I always told my staff, we wanted to have so much energy and electricity and kindness that we want the patient to say, I don’t know what’s goin’ around here, but I wanna be part of it!
I’ve also heard you say that you had some books, some of your favorite books, on bookshelves in your waiting room. And sometimes the patients would look at a book, but then, the first thing that they talk about when they were with you is the book that they were just talking about – or just reading, which happens to be one of – a book you really like. And so, it was – you were able to make a connection with them right away, from a book from the waiting room.
Boom, boom, boom, boom. As it is in life, as it is in business, it’s about relationships.
Okay. A couple other things the author suggested in the article was, you might want to have some educational materials lying around or even a sign that tells them how to access the Wi-Fi. So --
Perfect! So, I think if we do all that, we’re gonna have a good stage set for a nice visit and appointment, and kindness goes a long way.
Okay. Well, we have a very fun show for you today. So, let’s get going on it.
SEGMENT 1: Knowing the Difference – Esthetic vs. Cosmetic Dentistry
So, it’s time for another segment of “Knowing the Difference.” And just to remind everyone what this segment is about, I’m gonna give my little spiel. So, sometimes --
-- products or techniques or even disciplines of dentistry might seem very similar, and you might even think they’re pretty much the same and interchangeable. But often, the seemingly similar have important differences that should not be overlooked. The 18th century French author, Madame de Stael, said, “Wit consists of knowing the resemblance of things that differ, and the difference of things that are alike.” So, with this in mind, today we are going to compare cosmetic dentistry and esthetic dentistry. So, when we were discussing this – doing this segment, what was your first impression?
You know, it’s interesting, because my whole life, I’ve seen these two words used almost interchangeably. And to be very clear, I’ve seen them in journals, I’ve seen them in trade journals, peer review, trade. I’ve seen them on door signs, going into an office, aesthetic dentist, a cosmetic dentist. I’ve seen them in lectures, I’ve seen titles of lectures. So, I realized, I think a lot of us are a little confused, including myself. To me, there’s a clear difference, because I was a member of the American Academy of Esthetic Dentists for many, many years. So, I think getting into that culture, I kinda had some self-imposed ideas about it. But actually, I didn’t think I was an expert at all, and I thought most dentists could probably benefit from that.
Okay. I know you also said, “Well, I’m an endodontist. I don’t think I’m really” --
Yeah. My second thought was --
I am an endodontist, and although our work is amazingly esthetic --
-- it’s deep work. It’s the deep work of endodontics, you know, not so visible, right? Who walks around down the street and has an x-ray machine? Anyway, I thought I’d better ask the experts. And so, I went out and found five experts, and I mean, these were all – they’ve done a lot in their life with publication, international [laughs] lecturing, running seminar businesses. And there’s Kois, and he’s sailing in his yacht, and he’s moving through the water! They’re very interesting people, Frank, Cherilyn, all – so --
And all past Presidents of the American Academy of Esthetic Dentistry.
-- and they’re all past presidents. So, I asked each one of them if they could do a little favor for us and give us about a one-minute discussion, what it means through their eyes and their experience. And I got lucky, and all five decided to do it.
Okay. Well, before we start our own discussion, let’s see what the experts have to say.
[Dr. Gordon J. Christensen Video]
Cliff asked me to answer an impossible question, and I just asked the staff, minutes ago, “What’s the difference between esthetic and cosmetic”? And we all had about five different answers. You look it up at Merriam’s “Dictionary” and consider that. And one is supposed to be superficial, temporary. Which one would that be? Probably cosmetic. Which one is supposed to be beautiful, long-lasting, exciting to look at? What do you think that one’s supposed to be by definition? Esthetic. But the argument rages on and on and on, and I don’t know what to say. So, I think it’s six of one and half a dozen of the other. He’s asked me to take one minute, and I’ve just about taken it. You have to make your own choice. I’m one of the founders of the American Academy of Esthetic Dentistry. That should say something to you. Thanks, Cliff, for an impossible question.
[Dr. Cherilyn Sheets Video]
Hi. Cliff asked me to give you my definition of cosmetic dentistry and esthetic dentistry. I’ve always felt that cosmetic dentistry has to do with more what a person sees socially at a distance from you, like your smile, the color, the arrangement of your teeth, and the impact that your smile provides on other people. Esthetic dentistry is deeper than that. It goes into the entire way that the mouth is functioning, not only esthetically in that social impact part, but also mechanically, biologically, and phonetically. And I think that that more comprehensive, oftentimes interdisciplinary approach is really what esthetic reconstructive dentistry is all about.
[Dr. Robert R. Winter Video]
Hi, Cliff. Thanks for inquiring about my thoughts on the difference between cosmetic and esthetic dentistry. I think cosmetic dentistry traditionally is focused on the outcome, the beauty of the outcome, and maybe hasn’t focused enough on other details, where esthetic dentistry is always focused on, yes, we want a beautiful outcome for the patient. But we’re also focused on the structural concerns, the biologic concerns dealing with the teeth and the patient, as well as the functional aspects of the teeth and the restorations that we’d be creating. We wanna create restorations that are long-lasting and enduring and yet have a beautiful outcome. So, that’s my primary thoughts. Have a great day. Thanks, Cliff.
[Dr. John C. Kois Video]
Hi, Cliff. Hi, everyone having an opportunity to view this. Cliff had asked me to describe the difference, if any, between the word “esthetic” versus “cosmetic” dentistry. Obviously, you can look up those words in the dictionary and do that for yourself. I really think the importance between describing maybe what those words mean is what they really mean to the patient you’re about to treat. And so, for me, with today’s era of modern technology and all the things we can do, I think what it really comes down to is the ability for the dentist to create a shared decision-making process of what the patient really wants to look like. We have so many different options, and people have so many different preferences that it’s not such an easy task. So, what I really think about when I think about the two words is not the difference in the meaning of the words. It’s the ability to please the patient. And what you would do in order to figure that out, maybe that requires some type of photographic mock-up or some sort of cosmetic mock-up or esthetic mock-up, whatever you wanna call it. It doesn’t matter to me. What matters to me is what the patient wants. That’s how I would define it.
[Dr. Frank Spear Video]
Hi, Cliff. Frank Spear, here. Yes, the decade-old debate, esthetics versus cosmetics. Back in 1987, I did a 50-minute presentation to the American Academy of Restorative Dentistry in Chicago. The presentation was on enhancing patient’s appearance by offering gingival levels. At the end of the presentation, the audience had the opportunity to ask you questions. And Dr. Lloyd Miller, who was one of the dentists I most admired in dentistry, from Boston, got up and asked, “You used ‘esthetics’ and you used ‘cosmetics’ in your presentation. Can you give me the definition of each?” And I actually couldn’t.
Well, Lloyd and I got to be good friends later on through dentistry, and in fact, we used to go to dinner together one night every February in Chicago. And one year, when we were at dinner, he said to me, “Do you remember in 1987, I asked you the question about esthetics and cosmetics?” And he says, “Let me tell you my definition.” He said, “Cosmetics is like taking a patient that has worn teeth and putting veneers on them to make the teeth pretty, but not asking the question about what caused the tooth wear, or what do I need to change in the occlusion. Esthetics is about identifying that something caused this, and there needs to be alterations in the occlusal relationship. And that needs to be done, and then, you still put the veneers on.”
So, Lloyd’s definition was pretty much, esthetics is about appearance and function. Cosmetics was primarily about appearance, like putting on makeup. And I have to say, I pretty much agree with those definitions. Now, what I would say is, I think that the gap between quote, cosmetic dentists and esthetic dentists has really narrowed over the 30 years, where now, a lot of people that are quote, calling themselves cosmetic dentists are very concerned about function and occlusion and all those other things. So, that kinda gives you my two cents’ worth. Thanks, Cliff.
Okay. Well, a big thank you to these five bosses of dentistry. So, we know they are super busy, and we really appreciate them taking the time to help us out on “The Ruddle Show.”
Yeah. I wanna thank all of them as well. And just to the five that you heard, I wanna personally thank you, because I got quite a few insights with your humor, and it helped me narrow my thinking as well. So, very good job, you guys, and I know our audience is gonna really appreciate it.
Okay. Well, let’s start with what Gordon Christensen said. So, it sounds like our question sparked some discussion in his office, among his staff, and that’s great, because that’s what we like to do on “The Ruddle Show,” is spark discussion. So, he started off by referring to the dictionary definitions. So, let’s look at these. These are the dictionary definitions I found, and I’ll read them now. So, cosmetic is “superficial measures to make something appear better, more attractive, or more impressive.” And esthetic is “a more scientific or philosophical sense of beauty, the study of the mind and emotions in relation to the sense of beauty.” Those are dictionary definitions.
I think what I learned from it was, esthetic dentistry – I don’t want to – I could be wrong, and I don’t wanna offend anybody. But it seems like, to me, esthetic dentistry is more in-depth look at the whole oral health, the medical and biological factors that influence success. And so, there’s something way built into the foundation that finally, when you build the beautiful teeth, you know, it’s gonna last, because everything’s been accounted for. Whereas with cosmetics, I’m thinking, I chip a tooth, and you can repair the chipped tooth, and it looks fine. But it was a single thing you did amongst a whole bunch of things going on.
Dr. Christensen was kind of saying that it’s more superficial, cosmetic dentistry, and that esthetic maybe goes a little deeper.
And then, he also said something about maybe cosmetic is more temporary? And --
Yeah. I think, as in imagine, you have some discolored teeth, or they’re malaligned, or the sizes aren’t quite right, and a lot of people will come in and say, I want a nice, beautiful smile. Well, a lot of dentists – because I’ve gone to these classes – they’ll have veneers done on 6 through 11. That would be the anterior maxillary teeth, for our international people. But if you haven’t looked at the orthognathic part of it and the occlusion and the function and the work and the balance and protrusion, they might blow those laminates right off the front teeth, might crack a few, and you could have a premature or early failure, from the patient’s perspective.
Okay. All right. So, let’s move on now to what Drs. Sheets and Winter said, because they kinda seemed to have a similar answer to me. They both emphasized the interdisciplinary aspect and functionality of esthetic dentistry. And while Dr. Sheets was talking about cosmetic dentistry in terms of its social impact, in other words, what others see regarding your smile and the color, size, and arrangement of your teeth, both she and Dr. Winter emphasized esthetic dentistry was concerned with the entire function of the mouth. So, maybe you can explain that a little more.
Yeah. They – both Sheets and Winter went into great detail about the mechanics, the function, the structure, the phonetics, the esthetics, and how all those elements come together to give you an esthetic result. It is more than just quote, appearance. So, yeah. They really made a big deal about that. Winter liked to talk about – he was – he said that he thought that cosmetic was more just focused on an outcome. Patient’s happy, smile’s good. But he said that esthetics to him was much like what Cherilyn and him had talked about up above, the biology, the function, the structure, the phonetics, the appearance, the esthetics, all that. Those – it was a comprehensive look.
Yeah. I don’t know if someone said this exactly or if it – if I have got this from just my understanding, but it sounded like cosmetic dentistry’s kind of covering the problem, whereas esthetic dentistry is both covering and fixing the problem.
Yeah. And I want to not be redundant today, but again, you can put a crown on a tooth that looks fabulous. But just imagine, underneath, if there is no core buildup, say it’s had root canals, maybe it needed a post but didn’t get a post, maybe it’s just barely hang- – maybe the restorative is just barely hanging to the root. So, there’s a lot of things that in esthetic dentistry, at least my background is, we look at the function of the bite, the work, the balance, the protrusion, the habits, things people do, you know, break things off and chew and eat and stuff.
You have to look at all that, because if you just do some little superficial thing that makes them happy, it’s not necessarily lasting. I saw so many people present with a crown that fell off or this and that, and it really was because they didn’t do the crown lengthening, they didn’t increase the height of the prep, they didn’t have the retention in the – they didn’t have the ferrule. They didn’t have all those little things that we talk about all the time that build for lasting, predictably successful results.
Okay. I thought what Dr. Kois said was pretty interesting, because the stance he took was that it’s not so much about knowing the difference in meaning of the two words, but rather, learning what the patient thinks and wants.
That was really interesting.
In other words, it’s about pleasing the patient and working together in a shared decision-making process.
Yep. I’m looking here at my notes and I can see that what I do in my work is what they’re dong in their work. And when you have a patient in the chair, you know, we used to just sit down and “rrr” and then “rrr”, and we’d yell out code words and fancy words and words that were not even understandable. But there’s a whole concept about co-diagnosis and co-discovery and co-treatment planning and get that patient right in there and get them to start to think like you’re thinking in an understandable and easy way to comprehend it.
Okay. Well, Dr. Spear closed out the video with a story, where he was put on the spot, back in 1987, when he was asked this same question that we’re asking today, by someone he really admired, an older clinician, Dr. Lloyd Miller.
In a big ballroom, filled with hundreds and hundreds of dentists.
And he was saying that he didn’t even know how to really answer it, back in 1987. But now, he’s had decades, literally decades --
-- to form his answer. So, it came through on the video today. But he kinda echoed what our other experts said and that that was that cosmetic and esthetic dentistry are both about outcome or appearance, but that esthetic dentistry goes a little bit deeper, to also consider functionality as well.
Right. And another thing he mentioned is what I think I’m noticing in my own experience as a nonrestorative dentist is, the gap’s closing.
Because a lot of dentists that I wouldn’t have let them even touch my dog to do any kind of work, you’ve now seen them grow. They’ve taken classes, and when they say, “cosmetic dentistry,” they’re thinking about a lot of things more than just cosmetics. So, I think the gap is closed, and maybe the words have become, for some, interchangeable.
Yeah. I think maybe from the public’s perception, they think cosmetic, they wanna get their teeth looking better, you know. Maybe they’re not really understanding esthetic. I’m not saying that the average person doesn’t know the meaning of the word “esthetic,” but they might be more open to a word like “cosmetic.” So --
Right. And esthetics and cosmetics is ultimately in the mind of the beholder.
[laughs] Okay. Well, hopefully, you are a little more clear now on the distinction between esthetic dentistry and cosmetic dentistry. I know I am. Thanks again to our experts, for weighing in. We really appreciate it. So, thanks.
And what I’ll say back to the experts is, for endodontics, it’s esthetic endodontics. [laughs]
[laughs] Okay. All right. Thanks. [Music coming up]
SEGMENT 2: Intracanal Challenges – Managing Calcified Canals
Hi, everybody. Here we are again, on Set B, and we’re gonna talk about management of calcified canals. Now, listen! There are so many things that go into this segment. We’ll try to focus on maybe two or three things that will definitely help us get more success as clinicians treating our patients. How about that.? Well, when we talk about calcified canals, what’s glaringly missing is, they might not have any access ease, because the chamber could be mineralized, there could be pulp stones, there could be denticles.
And I’ve shown some of these on previous segments that you’ll wanna go back and look, on access. And we talked about the truss access. We talked about orifice directed. We talked about the complete access and the Ninja. Okay. So, today, you can see in the tooth we’re not gonna treat -- we’re gonna treat over here – you can see we have a pulp chamber in here, and it’s pretty calcified. Heavily restored tooth, the crown probably wasn’t the first casting. So, repeated episodes of dentistry. The pulp chambers want to pull down. They wanna shrink, and they’re getting smaller at their own expense. And of course, as they get smaller, we lose blood supply, and as the vascularity vanishes, so does the vitality of the tooth.
So, if we look at the second molar -- I’ve shown this on another segment, but I showed you the access. So, I’m not gonna show you the access today, but I’m gonna show you, when you’re accessing a tooth that has apical extension, when it is sore to percussion, when it’s irreversibly involved, you’re gonna need to get in. So, you might have your three well-angulated films that we’ve talked about their importance. Should be very thoughtful as you analyze those films. Of course, you have a whole bank of anatomical knowledge here, from all your practice experience, right? And then, you might have CBCT.
And if you have those tools, you can give the anesthesia, you can isolate the tooth, and you can carefully begin to move down towards the roof of the pulp chamber that doesn’t really appear to be present. But you know about the right depth, 8, 10 millimeters down. And remember, we’re brushing in, we’re not drilling in, and as we brush in, we have better control and more tactile dexterity, and we begin to feel little nuances. And then, of course, we’re looking for color and texture and all the things that begin to identify chambers and their related systems. Clear the board.
So, in this case, you’re going to get in. You will get in, and if you have to stop periodically and take a working film, and even if you want to have the clamp off so you can really see, you know, what a bitewing film would reveal, then you can begin to study, am I a little bit to the mesial or the distal? You wouldn’t see buccal or lingual as well, but you could begin to see, is your pathway in that you’re creating, is it appropriate for the crown, and is it lining up with where you believe the systems should be lying? This is a complicated tooth. I don’t wanna get too involved in this. But you can see -- you know, when you see that little line on the edge of your radiographs, you see that little line, that’s the concavity. That’s the concavity.
Now, when I erase this line, you’ll really see it. Look at it and look again. So, we gotta shape away from the concavity. You can see there is some semblance of maybe some systems that are hard to read, kind of a guesswork, maybe a little something in here coming off the floor. But our access does look appropriate. So, when you’re in the tooth, we can start talking about management of calcified canals. I want you to learn to use your Explorer, like we’ve talked about on other shows. And remember, you can use a West, you can use a DG, Dudley Glick, you can use something that is very sharp, that metallurgically is hard, and you’re punching.
You’re trying to punch through a little roof, a little lip of dentin that’ll oftentimes identify, there it is. You get that stick. You get that catch. That’s what we love, right? When we get the stick, when we get the catch, we know we have just identified the coronal-most aspect of that mineralized system. So, use your Explorer. That’d be a really big trick. I’ll say it different. I go through Explorers like you go through ten files, because I push so hard with my Explorer – sometimes I take my off finger, my thumb, and push it on the contra-angle part of the Explorer, and I’ll tell the patient, you’re gonna feel some heavy pressure. You’ll be fine.
But oftentimes, that Explorer will collapse and bend over. The point is, it’s a lot safer to use an Explorer to find an orifice than it is to use a drill, because any size or any ultrasonic instrument you bring in there is gonna be more invasive. And we don’t want to offend our minimally invasive people who are maximizing tooth structure. So, that’s a little bit about what I’m thinking. I would say immediately, lose the 06 and lose the 08. You’re not gonna need them at the chamber floor. They’re too small. They tend to collapse. They tend to bend over. They don’t have the rigidity. So, you want a stiff 10.
Now, I’m not gonna go into this today, but all 10s are not created equal, and all manufacturers of 10 files only have to abide by, the tip is a 10 at D0, they have 2 percent taper. That means they’re 32 hundredths bigger at D16. They abide by all that, but there are different metallurgical, heat hardening, heat softening procedures that can be done along with the fluting. And I didn’t mention the words “C file” or “C+ file.” They’re a little too big, aren’t they, because they’re – I mean, a lot of you guys just love them, and you report it. I see it on different discussion forums.
But they’re double taper. A lot of times, it gets stiffer. Double taper means they’re not gonna fit in the hole. Okay? So, we’re not talking about down here yet. We’re talking about getting started in mineralized canals. So, it’s gonna be your faithful 10. Grab the 10. And the 10, which should be a 21-10, because the closer you can get your fingers to the tip of the instrument, you’re gonna have more control. The instrument will be a little stiffer, because if you go to a 25 or a 31, you know, you’re over here, and the tip of your file is in another ZIP Code, and it’s easier for it to bend, crimp, you know, become non-usable.
So, get short, get stiff, and get some viscous chelator going. You can get, as an example, RC-Prep, Glyde, or you can use ProLube. But you can buy these in a method that you see, syringeable, but you would never use that on a patient. You’d file it out from cross contamination. So, if we’re thinking about the sepsis chain, you’ll offload enough for a single patient use. You’ll use a White Mac from Ultradent on any kind of a little syringe, and you’ll squirt material and start to fill up your pulp chamber, so you have viscous chelator. I want you to pass the file through the viscous chelator.
Now, obviously, you found the orifice [laughs]. You’re not filling up the pulp chamber, right? You’re not filling up the pulp chamber and hoping – there’s that word “hope” – very nice religious term, but it doesn’t work in the operatory. So, we don’t work with hope; we work with confidence. And I want you to try to get that viscous chelator in there. Once you’ve identified you have a stick, you have a catch, you are ready to go. The 10 file is your first instrument. And you can start making some little watch-winding motions, little back-and-forth reciprocation motions. That’ll draw the file down and pull it in. That’s fine. But a lot of times, it’s just a block of dentin, and you’re trying to get here.
The common error is trying to get to length. Everybody goes, I gotta get to length! Hand me an 08! Hand me a 06! I’m going in now! I said so. All right? Be patient. All good things come to people who have a little restraint. Think it through. Have a plan. And here we go. I’ve worked my way through without showing you tricks, but we’ve talked about several things that ideas that are already helpful. And if you bring in the post-op, and you line them up, you can be seeing that even calcified systems exhibit apical bifidity, which is the important portal of exit.
How about all these teeth with lingering symptoms? Could it be that there’s pulp tissue harbored in an avascular pulp, after pulp death? Is it possible it’s leaching out, causing symptoms of endodontic origin? The shapes are quite normal in the mesial system, and back to the general dentist for the restorative effort. So, we’ve gotten started, and now, let’s go a little deeper. How do you get to length? Most of you can find canals. You’re still looking. If you don’t, think about a scope, think about a headlamp, think about glasses. We’ve talked about this. Think about all your diagnostics tricks, your x-rays, your CBCT. But there are some tricks that you can do right now, without having to spend $1.00. It’s having a little idea planted from experience. So, I’ll share my experience with you.
So, we’re gonna go into this tooth. It has a really receded pulp chamber. You can see, the roof and the floor are almost coalesced. You can see, the entry angle from the mesial system is quite abrupt. So, there is your triangle of dentin. And then, you can begin to see what I learned, is the importance of pre-enlargement. I was talking about it in ’78 and 1979, and I’m still talking about it, and I’m much, much older! But I’m still talking about it because it’s one of the most important tricks. Pre-enlargement! Say it! I can’t hear you. Oh, yes, I can hear it coming in from Asia. Yes, Africa, yes, coming in from South Africa. Oh, yes, Europe, Russia, yeah. It’s all coming in, pre-enlargement.
Pre-enlargement! You need to understand that once you open up this tooth, and this amalgam’s gonna fall out as we go along in treatment. We’ve already taken some alloy out in here that fell out during the access. We can argue all day, the access is too big, it’s too small, it’s just right. Basically, the access cavity, for me, isn’t an opinion. It’s dictated by the orifices on the pulpal floor. So, you see, you have an MB and the related groove, got a DB, and look at the color. Look at the color! Coming right over, follow the brown line! That’s where the lobes of three teeth come together. And then, you’re going over here to the palate, and you can’t see it.
So, let’s just cut ahead. I’m gonna show you how to open up that. That’s the MB2. That’s a more restrictive canal, isn’t it? It’s always narrower. It’s harder. It’s the one that gives us all trouble, including Ruddle. But it’s there over 90 percent of the time, so it needs to be found. But we’re talking about mineralized canals. So, I’m gonna show you. This one’s now all opened up, because as I opened that up, my irrigant’s moving over into that fin and that interconnector, and it begins to identify the MB2 orifice, and it makes the job easier. So, get one of them opened up so you’re oriented.
Now, I’m gonna go through a whole bunch of files very quickly. Each file is gonna be used at a given level. I’m not trying to go apical. Did you hear that part? I’m just – wherever it goes is where it goes – clockwise, counterclockwise, clockwise, counterclockwise, forward, backwards, engagement, disengagement. And wherever it goes, it’s going. You’re just making lateral space. Learn to make working width! Forget working length, working width. So, as I go through this, I don’t have any material in here. I don’t have any irrigant in here. I don’t have any viscous chelator in here.
You could say, he’s doing everything wrong. I am doing this so you can see what Ruddle’s doing. Normally, I would have viscous chelator in here. But even not using viscous chelator isn’t dangerous when you’re not forcing instruments. Just go in, when you engage, the files pull down. But you don’t wanna go too deep, or you’ll block. So, go counterclockwise to disengage. You just cut more width. Remember the taper of the file. Here it is! The taper of the file exceeds the taper of the canal at this moment. So, you recognize that, because you, the learned one out there, understands that files all have taper, and if their taper exceeds the taper of the canal, they might be binding in the body and not towards their working length. How about that?
So, you can see, as we go along, we’ve opened up. Now the 10’s really down in there. 16 millimeters of cutting flutes, we’re almost on the occlusal table. We’re almost to length. So, just opening it up, 10, 15, 20, 25, 30, 35 --6 files takes maybe 30 seconds. You’re just going really quick. It’s like an orchestra. You’re a maestro! You’re directing! Going to length. Okay? So, we can come back. We got everything opened up. We can use mechanical files now to do the rest of the pre-enlargement, after there’s a pilot hole that we made with our ISO 02 tapered files. Throw those babies in. I haven’t even hardly tried to get through the apical third, because the apical thirds aren’t so calcified.
Remember, disease flow is crown down. So, oftentimes, the orifice is pinched off, the body is closed, and there’s canyons of restrictive dentin. But the apical thirds of most systems are available and open to those who are patient. So, there’s 2 10s in, your case is in the bag, you got it. We can just look at the befores and afters, so we did a lot of work right in here, a lot of work! Here’s the floor, there’s the canal, we did a lot of work, about six millimeters in, just to get this opened up a little bit – ugly drawing – to get access to the apical one third. Apical thirds are typically open. So, the shapes are not complicated, they’re smooth, they’re flowing like rhythm and music, and everything is good. Keep the foramens as small as possible, pack into resistance form, and have another good result.
So, as I thought about putting this together, I wanted to share what I learned back in the ‘70s. But when we used to do these exercises on the bench, in other words, extracting teeth, and I was a teacher, and I wanted to be a more effective teacher, I started living in your shoes, because I think you’re having the same issues I’m having. Right? So, maybe we could just learn together. I learned that as you get the bodies opened up, as you focus a little bit more on the body of the canal, the instruments can move in, and they can go around dramatic curvatures. This doesn’t look so curved to you, but there’s curves that are in and out of the primary beam, and you can see sometimes, for radiographs, you’ll take – put all the files in, and you can see the complexity up here.
And then, it should be a lesson to us. If you wanna use GentleWave, lasers, EndoActivator, if you wanna irrigate, you need a flow channel! Say, flow path! Well, when I watched the discussion forum at the AAE, a lot of endodontists can’t even get to length! And I really feel bad, because they’re talking about maybe the GentleWave will overcome my inability to get to length. Listen, you can get to length. If you can find the orifice, you can get to length. If you can’t, you need to train. It – there’s people that can help you do this. So, you can begin to see, you lean a lot from looking at your extracted teeth and in working on your extracted teeth.
And I think what you need to realize is, if you look at molars, sometimes these things remind you of Merry Christmas! This is the Merry Christmas root! It has a candy cane that can hang right on the old pine tree! Here, we have a dogleg, a crooked number going left. There, we have another candy cane, multiplanar curvature. But what’s the trick? Every one, the orifice was identified, the body was gently opened up, and the small size files, maybe 06 now, slides right to length. The case is yours. It’s in the bag. Understand the value, the importance, the benefits of pre-enlarging.
Oh, yes, Merry Christmas is not so far away. Yes, I have a very powerful show for Christmas, but we’ll talk about that later. So, what I just told you in two slides, one slide, two images, is, you’re working that file down, right, index finger, thumb. You’re working that file down, and the handle gets snug. Many of you are going to the 08. It goes a little deeper, it’s snug. You go to the 06. You’re thinking, I’m a hero. I’m getting close! But close isn’t that important. We want you to get to length. And a lot of times, we block canals. Collagenous tissue gets pushed into openings, and it then is very difficult to remove, the canals become obstructed, and there’s a complication that was introduced by the doctor.
So, if you realize you’re wiggling the handle, and it’ll only go so far, rather than to go on the attack or go to a smaller file and make it more complicated and use more instruments and take more time and push more debris out the foramen, why don’t we just pre-enlarge? Now, we can take a 10 that wouldn’t go. And oftentimes, it’ll slide – say, slide. We’re not screwing these things in. This isn’t Wood Shop 101. This is endodontics! So, we’re gonna slip and slide with a viscous chelator, and once we get to length, we’re gonna move that file up and down in little, short, one-millimeter-amplitude strokes until the file is loose! Say, loose. Loose! Till the file is loose. And when the file is loose, you own the glide path, and you got it.
Bingo! So, pre-enlargement. The advantages, I’ve talked about them many, many times. But we’re talking about how to manage calcified canals, mineralized canals. As soon as you do pre-enlargement, you have more tactile control. And that would be called color change, and that would be called check! Oh, my goodness, we went to the wrong color! And we gotta go back on that color, and we gotta go to a new color! And we gotta call it point. Check! Okay. When you get a little pre-enlargement going, you have a pathway to liberate debris coronally, up and out of the canal. So, that’s an advantage.
And as we open it up and pre-enlarge, we have a bigger tapered pathway. The tapered pathway now can hold more reservoir, more viscous chelator. So, we’re gonna clean, and we’re gonna start to clean laterally into the anatomy. Okay. Another checkmark. And then, of course, you know, I talked about the post-op pain. But you’re going to be encouraging debris to come up and out of the canal, where it can be liberated. When you try to get to length, and this is not pre-enlarged, and there’s a lot of dentin, and it’s holding that file and resistant to going to length, you’re gonna have more tendency to have post-op problems, because more debris tends to get pushed periapically.
So, we have this, this, this, this, and then, diagnostics. We all need to know what is working length, whether it’s a film, whether it’s an apex locator, whether it's manual dexterity, you’re a gifted one. Oh, my goodness, you’re gifted, and you’ll find that dexterity. Some of you have it. I like that. But you’ll find a reliable working length because you’ve made a more direct path to the terminus and working length will be less subsequently to change. So, you’ll actually have improved diagnostics. When you have a pre-enlarged canal, a lot of times, it’s a 10 or a 15, instead of a 06 or an 08 that you’re trying to see or visualize. Apex locators are more reliable in a pre-enlarged canal.
End of story for this day. All right. So, this is a maxillary molar. You can see in this – it’s a mesial view. And you’re seeing that classic stairstep MB root. You can see that it’s a broad root. It’s no wonder that about 92, 93 percent of the time, clinicians can find a definite orifice. They can negotiate the canal. They can shape the canal. They can clean and fill the canal. So, that’s what we find clinically. If you’re not getting up into the 90s, think about taking a training course. How about that?
And of course, I do this all over the world, when I do workshops. We just did one at Gordon Christensen’s earlier this year, I told you. We have kids take their extracted teeth and put files in the foramen. The files will always go up these very visible foramina several millimeters. Okay? Several millimeters. So, in other words, they’re there, and they’re open. So, it – what did I just show you? That’s a teaching moment. Are you catching the teaching moment? Are you on the edge of your seat? What’s the moment, Cliff?
I’m showing you that the vast majority of all extracted teeth are open and available at length. They’re not necessarily available through the pulp chamber floor and down through the body of the canal, because the canal is more mineralized, and we’re managing calcified canals. So, if you know the foramen’s open, let me just bring the teaching moment home. So, you know it’s open. But you’re wondering, why won’t the 10 file go through the pulp chamber, into the canal, and go to length? And you know that the 10 file is 0.02 percent tapered. We know that over 16 millimeters, then, it increases 32 hundredths, 32 hundredths of a millimeter.
So, we have a file go in here. This is D0, D1, D2. You can see we’re getting bigger by two, by two, by two. But let’s look. The problem is —the problem is, the file’s tapered over all 16 millimeters, and because of that, it’s going to bind. It typically binds in mineralized canals in the body before it’s ever binding at length. Notice it’s totally lucent length. That’s why on the extracted tooth I could put the file through the foramen. It would go up about four millimeters, about four millimeters. I’m lovin’ the writing. I hope you love the writing. I’m very learned with the writing pen. Actually, very awkward.
All right. So, this is an example – I’m gonna do it wrong. Hear that part? W-R-O-N-G, wrong. So, I would never use a file like this, but I’ve just shown you, it’s really tight. And I can get in. I found the orifice. I started my 10 file. I could drop to an 08 or a 06, I know you’re raising your hand. You’re desperate to add that little, you know, helpful hint that you know. But really, the taper of the file, whether it’s 06, 08, or 10, it’s too big. So, if you know that, you have an idea. And the idea is what? I showed you how to do this manually. Now I’m showing you how to do it mechanically.
See, we came from the ‘70s, and now we’re 2022. Whoa! We’re in the present time. This is a shaper access, the auxiliary shaper from the ProTaper family of instruments. It’s the number-one sold file in the world to pre-enlarge. It’s a tapered file. You can see us taper. We’re brushing. We’re not pecking, we’re not drilling, we’re not pushing. We’re floating and following! Float, follow, brush! Float, follow brush! Now that you’ve got that thing in there about halfway down, and you’ve got – brrupp! – got some bodywork going, and you remove the restrictive dentin, you can take a 10 file, easily thread it through the pre-enlarged canal, and it will arrive at length. And we’ll just cut that, and it’s there! Okay.
So, now that we’re at length, if you’re going, that was easy, well, what was easy was the idea. The idea was, remove restrictive dentin from the body of the canal to the access and negotiate and slide to length. That’s the new you. That’s the person you’re trying to find! Now you’ve discovered that person! Look what you guys are gonna do together, you and your alter. So, if we continue on -- we’ll go to two, three cases, and we’re outta here. But this is a big, big internal resorption defect. Notice – I wish we had a little bit more time – but notice the working width of that canal.
All the roots are blunted. They’re all short. There’s been a history of ortho. There’s been trauma. The trauma’s related to probably the resorptive defect. The shortening of the roots is orthodontically related, but here you have a big, fat canal, a big, fat canal, and you see nothing! If you look at that central incisor, where is the canal? Well, you say, I might see something right in there. Maybe! But I’m gonna have to get there, aren’t I? So, it’s the same thing. It’s a careful access, stop and take some films, maybe take the dam off so you can get the angulations right, palpate the roots to feel if there’s a lingual inclination, which there might be more in some teeth than others. You’ll figure it out.
But the shapes maybe are, I think, totally appropriate for the lateral remaining dentin, and we’re packing right up against the foramen. And we can take a case that a lot of people would’ve done surgery on, already have a short root, and they would’ve made it even worse for the crown-root ratio. Okay. Another one. Trauma, avulsed teeth, they’re gone. Again, notice the big, fat canal next-door. This one’s shut down. Now, I know that most of you will never see this, but Ruddle sees this stuff a lot.
But maybe that’s because of almost 50 years of looking at films. But you get to have a discerning eye. And if you look with a little bit of thoughtfulness and reflectiveness before you race to grab your handpiece, you might start to see, yes, this is the premaxilla. Yes, the two plates have come together, and you have the mid-length suture. But you might start to see a little shadow in here, a little shadow. I see that stuff. I don’t know what it is. But I’m thinking, what if it’s a lateral exit? So, if it’s a lateral exit, and I got a calcified canal, that means the lateral canal’s calcified, proportionately.
And so, I want you to be aware that once you get your shapes, and once we find the catch, and once we pre-enlarge, and once we negotiate the terminus, let’s get our fluids in there, and let’s agitate. Let’s move those reagents off the shape, into the uninstrumentable portion of the root canal space, so we can clean that just as predictably and so we have a way to do that, with $2.00 tips, with low-tech technology. This is not GentleWave going. This is not a laser of any kind. This is just the EndoActivator. And you down pack after fitting a cone, move that rubber and sealer into the intaglio of the root canal system, out with the lateral canal.
Look at that shadow. Look at that shadow! I’m wondering, it’s pretty much centered, it’s pretty much centered. And there’s the post-op. That’s a reliable abutment in a future treatment plan. How about that? So, a little bit of magic because you are magical. Dentists are magical people. You can be, and if you’re just a little shy of magic, and you’re working towards magic, you’ll find magic just around the next corner if you keep working on finding the magic.
Long time ago, I showed this case. This is another one of those really subtle deals. Now, you saw that. The whole world saw that. But did you see a little shadow. And even if you didn’t, it’s okay, because if you’re just doing the steps that we’ve talked about on this show, you’re gonna treat lateral canals in spite of yourself. How about that? Just get them because you’re thinkin’ about it. All right. So, it’s a block of dentin. It’s a heavily restored tooth. It’s carrying a partial denture. It’s a strategic tooth in the most funereal sense. And then, boom, here we are getting the careful access, drilling down, going through Explorers, finding the catch, getting the body opened up, and that’s redundant, but that’s what we did.
And out with that, and again, even here, you can sort of see something like that. Well, that’s why it’s there. So, there is anatomy in these teeth. And in closing, I wanna take you back to Frank Paque. We’ve shown his stuff over the years. I’ll continue to show it. It’s just the coolest stuff in the world. But your job, my job, as dentists doing endodontics, is to find and follow and fill mineralized canals.
CLOSE: Favorite Unsolved Mysteries – Escape from Alcatraz
Okay. So, it’s time for another installment of our favorite unsolved mystery, because of course, everyone loves a good mystery. So, last time, we talked about Amelia Earhart. This time, we’re going to talk about a prison escape. Now, it happens to be the 60-year anniversary of the infamous prison escape of three men from the maximum-security prison, Alcatraz State – or Alcatraz Island Penitentiary. Now, a lot of you might’ve already heard about this, because they made a movie of it in 1979, starring Clint Eastwood. Escape from Alcatraz it was called. What made this escape so mysterious is because the prison – they boasted that the prison was escape proof, and they never caught the escapees nor found their bodies. So, why don’t you set up the circumstances surrounding the mystery.
Well, the U.S. had some pretty tough penitentiaries, but this was the granddaddy of them all [laughs].
Meant to house the worst of the worst.
The worst of the worst. I mean, just to give you a couple name drops, Al Capone.
And then we had Machine Gun George Kelly. How about that guy?
We’ll have to read that book, right? And then, we had the Birdman, Robert Stroud. So, anyway, why this was so impenetrable, apparently, was because it is a rock among water. So, there’s water, it’s an island. There was some big escarpments from the edge of the land to the sea. So, even getting off the land would be tricky in most of the places. There was a 25-foot fence. It had razor wire on top. And of course, the Bay, as you might know from travel, is permanently cold. It’s about 50 degrees. And I can tell you from sailing a lot with Phyllis on the Bay that when the tide changes, it’s much like a toilet flush. So, there’s big currents, and with those currents and the cold water, that you can’t really live in more than 5 to 7 minutes, in 50-degree water, they thought they had an inescapable facility.
Yeah. I think it’s like a little over a mile to the nearest shoreline.
Oh, yes. The closest land, because it’s out there, and there’s land all around it, but the closest land was 1.2 miles.
Okay. And then who are the players?
Okay. So, we had a guy that was quite brilliant, and his name was Morris. And so, Frank Morris was maybe the lead architect of this plan. And then, there were two brothers, and their names were John, and the other name was Clarence Anglin. And so, those were the three players. And they all had long histories of crime. They’d all been in prison multiple times, and they had been in very tough prisons that were impenetrable. But yet, they had gotten out before.
Okay. I just wanted to add, there was a couple things that could be important to understanding their escape. Frank Morris had a higher IQ than the average person, and he was the mastermind, as you said. And then, the Anglin brothers had grown up close to the ocean, but also up in North Michigan, too. So, they – and they had lots of swimming experience.
and we should tell our neighbors that he was one of 13 siblings or 12 – 13, big family.
The Anglin brothers.
And the dad and mom of the Anglin brothers was permanently moving around because they were farmers, pickers. They were harvesters, so they would go up to Michigan, and Lake Michigan is very cold.
Okay. So, let’s – I’ll give you some of the details of the escape. So, over many months, they chiseled a hole in their cell, in the concrete wall of their cell with a spoon. And the reason why they could actually do this was because the concrete was corroded from the salt-water air.
So, they were able to make a hole that they could escape out of their cell. Then, they also made papier-mâché dummy heads and actually put human hair on them from the barber shop, and they placed those in their beds, so that when the guards walked by on their shifts, the guards thought they were sleeping. And then, another thing is, they made an inflatable raft, which they planned to get across the Bay with, and they made it out of 50 raincoats that they had stolen from the prison.
Okay [laughs]. And then, there was also initially a fourth prisoner, Allen West, who was going to be part of the plan, but when the timeline was moved up, he couldn’t get out of his cell in time, and he was – ended up being left behind.
And that’s another whole interesting story, isn’t it.
Yeah. Which we don’t have time for today. [laughs]
And [laughs] – don’t have time for this, either, but just – you’re wondering how they dig a hole in the wall, and nobody sees it. There was a grate in every cell. It was under the sink, and the grate could come off, and then, boom.
Right. Okay. Well – so, what about – were there any leads after this escape?
Well, the FBI had the case open for probably – I’m going to guess about 15 years. And they dismissed it as, you know, they drowned. They were eaten by sharks, or whatever. So, they closed the case, and they were comfortable. But yet, the U.S. Marshal’s office was still keeping it as a viable case. It’s still open, to this day, although I think you told me that they would be in their 90s now, and that’s --
-- part of the end of the story. Anyway – so, yeah. There was these two law agencies, and they’d pretty much given up on it, but there was some clues that kept sparking interest. As things have developed over time, they found the raft that Lisa talked about. And it just showed up. And it was made of raincoats. And then, they also – there was report of a stolen Chevrolet --
By three men on the night of the escape.
-- but – yeah. So, they – there was – maybe that’s how they got to somewhere else, to take a flight to maybe wherever they were gonna go, Brazil. [laughs]
Right. I think that there’s some suspicions by a lot of people that the FBI might’ve tried to cover it up, because they wanted to maintain the whole, like, inescapable prison aura. But you know, who knows? There is a rumor that the Anglin brothers did survive, who fled to Brazil. And we mentioned that they had a large family. Well, their family produced a photo in 2010 that seemed to depict the brothers in 1975, which would’ve been over ten years after the escape. And facial recognition experts have said it is possible that it could be them. And they did some DNA analysis of some potential offspring down in Brazil, to see if they could find some more definitive answers, like if they were definitely related to the Anglin brothers, and I don’t know what ever actually came of that. So, I’ve not heard about that.
Well, yeah. There’s just these little stories that somehow can be grabbed, and you can try to make it into a timeline. But I guess Mickey Cohen – these are two more criminals – and Bulger --
Whitey, they had actually arranged to have a boat out in the Bay on the night of the escape to allegedly pick them up.
Well, that’s a rumor that --
That’s a – that was a rumor.
And then, of course, one of them sent a letter into the San Francisco Police Department years after, one of the Anglin brothers, if it was the Anglin brothers, but it seemed to be authentic handwriting and all that, and he said that he was very sick, the other two had died, and that he would be willing, if they would say on TV publicly, so the whole world could see it, that if he went back to prison for one year and got – could get medical treatment, then he would give himself up.
Right. And I – for some reason, that actual letter was put aside and not even found until five years after it had been received. So --
A lot of the rumors, I think the FBI just kind of swept them under the rug.
-- well, the prison is obviously not a prison anymore, but it is open for tours. I have not been there myself, but visitors describe it as like chilling, ghostly, eerie. Have you ever been there?
No, but what did your sister say, the producer, Lori?
I think she said she has been there.
She’s been there.
I guess – I don’t know when she went, but she must’ve gone on a tour there.
She might have been serving time.
[laughs] I don’t know. Yeah. But no, Lori went through it, and she had quite an emotional – how it made her feel, and you know, the acoustics and the noises and – anyway, the whole trip out, trip back was quite – quite an experience.
Well, it’s a very intriguing mystery, and I can’t wait to do another one. But that’s it for today.
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