Tough Questions & Sealer-Based Obturation The Loose Tooth & Guest Dr. Josette Camilleri

This show opens with another Tough Question, this time regarding one all parents eventually face: Should you pull out your child’s loose tooth? Then Ruddle and Lisette are joined via Zoom by Dr. Josette Camilleri, esteemed colleague and researcher, who discusses the sometimes controversial, but ever-trending, sealer-based obturation techniques. The show ends with a new Close, “Aesop’s Fables and Endodontics,” because lessons of morality and endodontics should definitely go hand in hand.

Show Content & Timecodes

00:56 - INTRO: Tough Questions – Should You Pull Out Your Child’s Loose Tooth?
07:14 - MAIN SEGMENT: Zoom with Dr. Josette Camilleri on Sealer-Based Obturation
44:39 - CLOSE: Aesop’s Fables & Endodontics

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  • Additional Content re: BC Sealer: Reference Listing (see downloadable PDF below)
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    Feb 2020

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    …Should you pull out your child’s loose tooth? What are some things to consider?


    Probably the most important, is it loose? [laughs]…

    INTRO: Tough Questions – Should You Pull Out Your Child’s Loose Tooth?


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


    Hi, how you doing today?


    Pretty good. What about you?


    Well, I’m real excited about our guest, the mystery guest.


    Okay. Well, today, we have a “Tough Questions” opener for you. Now, if you’ve seen a “Tough Questions” segment on our show before, usually, it’s in the body of the show, and it’s where we explore a question that doesn’t really seem to have a clear-cut answer. And our hope is that after some discussion, you’ll have a better idea where you stand on the issue.




    So, some examples of tough questions we have covered on “The Ruddle Show” are, who pays for treatment if it fails, and what is appropriate canal shape? Well, today, we have another touch question, and this is a challenging one. Should you pull out your child’s loose tooth? I’m pausing now for dramatic effect.

    Okay. So, to start, what are some things to consider?


    Probably the most important, is it loose? [laughs]




    And then, I’d want to know which tooth it is, because you know, back here’s a little different than up here, and I’ve never had anybody ask me to help them back here. But – I only had two kids, but there are some grandkids. But it’s usually up in the zone, the anterior zone. So, where is it? How loose is it? I don’t mean this wrong, but are they a whiner?




    Well, what it could mean by whining is, every time I bite into an apple, I hear crunching noises beyond the apple itself. Carrots are a problem. Corn on the cob, I’m whining loud! So, if there is a lot of whining, then you must ask yourself, what is my relationship with this child? [laughs]




    You might explain what that means [laughingly].


    Is it adversarial? Do you have a trusting relationship?


    Well, am I gonna step in on – ride in on my white horse, and then step in and be a hero?


    Are they gonna bite your fingers if you put your fingers in their mouth? That kinda thing.




    Okay. Well, I remember when I was a kid, and I had a loose tooth, and you asked me if you could feel how loose it was. And so, I said, okay. And then, you proceeded to just push it inward, and I heard cracking, breaking noises. And before I even knew it, the tooth was out. So, I have to say I felt a little tricked, but I did also feel very happy that the tooth was out. And I, you know, subsequently tried this on my kids when they had their loose teeth. And it worked, but it only works once, because they’re never gonna let you back in their mouth to [laughs] – to try it again, because --


    Because you betrayed their trust!


    -- exactly.


    So, when you’ve betrayed their trust, then you have to be encouraged to get in there and make amends. And how you can do that is give them a little bear hug --




    -- tell them how proud you are of them. They showed incredible courage! They were really, really the ideal person. And then, you show them the tooth, and you look at that tooth, and you point out anatomical features they’d never heard of. The big words will throw them, that this is very important. And then, of course, you go to the mirror, and you show them the new toothless look, and you tell them it’s phenomenal, even though your tears are rolling down your face. They lost their first front tooth. And then, you know, you tell them all about the Tooth Fairy and the pillow and – anyway.


    And the money? Yeah.


    Big, big payouts sometimes. Sometimes.


    So, after I pulled out my kids’ first teeth, they got a little savvy about how to do it, and they actually did it themselves after that. Do you recommend any creative methods for extracting a tooth – a loose tooth?


    Oh, yes! You – this is where it all comes out, the enlightenment that you’ve gathered over all the years of your life. Yes, use your imagination. I like what I call the outbound bow-and-arrow technique.




    Now, you don’t shoot towards the patient, your kid. You use the outbound technique, with a string and a floss, and the arrow flies very quick. I like the remote vehicle idea.




    That’s very clever to tie a little floss onto the remote-controlled car and have it hooked to their tooth and then, boom! Hit it hard.


    Send it [laughs].


    Yeah. And then, you know, there’s the door-slam technique with the floss. But my favorite, my absolutely favorite is the Rube Goldberg machine for removing teeth. And this gets the kids so excited that they want to be part of it!


    Yeah. Well --


    Everybody wants to sit here, right?


    -- [laughs] --


    Maybe not.


    -- well, we’re not gonna go into all the details about these techniques now.




    Maybe I can find something to put in our show notes. If not, you can Google them. They’re in – on the internet. My last question for you is, what are some of the risks of not removing a loose tooth?


    Well, you didn’t want me to get too serious, but I guess if we leave teeth in too long, you, the dentist-o, knows you could deflect the permanent tooth bud. That would be called malalignment. And now, you’re off to ortho. Good start. Sometimes these kids, they work around and eat stuff, and the tooth does come out with the food. And all of a sudden, if they bit down, I’ve even seen kids that have broken another tooth, because they bit down on the tooth that was loose and was gonna come out. But from a – I think a script standpoint, we want to save the tooth, find the tooth, and get it under that pillow so all rewards can be paid.


    Yeah. Your child is gonna be really disappointed if they lose their loose tooth and have nothing to put under the pillow. That was – is probably the biggest risk factor. Do not lose it on the playground at school. You want to be able to find it.

    All right. Well, this is all great information to consider. Hopefully, you’re a little clearer on where you stand on the issue. We have a guest on our show today, who is going to answer some other tough questions that we have about sealer-based obturation techniques. So, let’s get to that.

    MAIN SEGMENT: Zoom with Dr. Josette Camilleri on Sealer-Based Obturation


    Today, we are joined by a guest endodontist, Dr. Josette Camilleri, who is a reader and honorary specialty dentist at the University of Birmingham in the UK, as well as a visiting professor at the University of Leuven and the University of Oslo. She is well known for her research, which has primarily focused on hydraulic dental cements. And her work has been so influential that in 2018, the French Endodontics Society awarded her the Louis Grossman Prize to recognize her significant contribution in endodontics. And I believe she was also the first woman to receive this award.

    She lectures internationally. She has published over 150 peer-reviewed papers in international journals, with her work being cited more than 12,000 times. Three of her papers on the chemistry of MTA are in the top 50 most-cited works in the International Journal of Endodontics. So, we are very honored to have Dr. Camilleri on our show today, to talk about sealer-based obturation techniques. Welcome!


    Hello, Lisa. Hello, Cliff. Really good to be here. Thank you very much.


    Well, I’m just delighted you found time in your busy life to join us on “The Ruddle Show” because you have been a mentor to me. And you might not know that, because you – people that publish, you know, you put your papers out there, and you probably don’t know exactly who’s reading them. But I would be one who would read your papers, because you are the authority. So, it’s just delightful – and this is a really – I think Gordon Christensen one time talked about restorative dentistry and what was the hot button. The hot button today in endodontics in filling root canals – hopefully, systems – is BC, bioceramic tricalcium silicate cement. So, you’re the authority. So, thanks for coming.


    Thank you very much, Cliff. It’s a really honor to be here. And I have been reading everything that you have published and using what you put on the market as well in the meantime. It’s a great honor to be here. Thank you very much.


    Okay. Well, I briefly introduced you. And I want to emphasize the word “briefly,” because you’ve done so much, I could’ve gone on for quite a while. Before we get into talking about the sealer-based obturation techniques, though, I wanted to ask you how you got to where you are now. Like, why have you been so interested in endodontic materials like MTA and sealer, and why are you so motivated and passionate about research?


    Well, I think most of it is coincidence and lack of opportunities, mostly, because to choose, you have to have something to choose from. If you have nothing to choose from, you just take what is available. So, essentially, I never wanted to be a dentist. I was brought up from a very simple family and the scope was education, yes, but not even tertiary education, just finding a nice, honest job. Then you do exams, and you start looking around, and I found dentistry.

    I thought it was a challenge because I lived in Malta. I am Maltese. And the course just took 12 students every 2 years. And I said, ah, this is a good challenge for me. Let’s say I’ll apply, and I will see if they take me. So, I applied for dentistry, medicine, and pharmacy. I got accepted. I started the course, and we didn’t have much there. So, I did the course, finished, and then, the Dean at the time told me, there isn’t anybody to teach endo within the school. So, is it something that would interest you?

    In the meantime, I had got married. I also had two children. So, I didn’t have much time on my hands. So, what I did was, I started doing some research in-house. So, all I had was a mechanical saw. And I just got some teeth, obturated them, did the old, very old studies. And I had the saw, cut the teeth, and looked at them under the microscope. And nothing that I published, but I was just getting my hands dirty. Eventually, I needed somebody to guide me.

    So, the school always had very good collaborations with Kings College, London. And at that time, they had introduced me to Tom Pitt Ford. Now you get the how I got into the MTA. So, I met Tom Pitt Ford, and he told me, Josette, if you’re interested in working with me, let’s choose something that I am interested in. Otherwise, the interaction will be very difficult. So, I had a huge challenge, because I had two children, I had no money, and I needed to fund myself to study in the UK.

    So, I applied for a Commonwealth Scholarship. I was successful. When it is the thing that is for you, things start happening. So, I just the Commonwealth Scholarship. I went for – it was not the full Ph.D., part of the Ph.D. – to Kings College, London. And that is where I started going headlong in love with cements. Because I was there, and I started testing this MTA, and it gripped me, and that is when I started working till the middle of the night, I think, because I just could never get enough of it.

    And again, since I had nothing -- because when I went back to Malta, I didn’t have the labs that they had at Kings College -- so I went back, and I needed to find labs for myself, I went into the Civil Engineering Labs, got totally involved with civil engineering. I spent eight years working in civil engineering, not only on MTA, but also on waste in construction industry. So, I have – with those 150, I have 3 on waste in construction industry, which I found fascinating. It was going from small specimens to huge specimens, different scope, but with the same material.

    And I think that was the game changer for me because what I learned from the Civil Engineering Lab, I could never have learned from a dentistry lab. Civil engineers look at things in a different way. So, that is how I became so passionate, not because I wanted that, because that was what was the only availability I had. No choice: you just do it.


    Wow. Well, that’s another thing I found out that’s common about us. When I was a kid growing up, I – a lot of things just happened by accident. And I used to work on construction, and I was the guy that poured the concrete that you were studying in another country. I was pouring it into forms around rebar and steel. Anyway, I really learned a lot in construction, and -- we won’t do it now, but I could tell you how it influenced me in dentistry. So, I can – I can totally understand.


    And it’s actually the same for me. I was assigned this job on “The Ruddle Show” so --




    Okay. Well, so, by now, most of the endodontics world has heard of BC sealer, bioceramic sealers. Why are the materials called bioceramic, and why do you prefer to call them hydraulic? And is there a difference?


    Well, what I ask Cliff now, what is a bioceramic? I mean, it is – when I tell you a bioceramic, does it ring a bell in your head, Cliff?


    I’m thinking MTA. I’m thinking tricalcium silicate sealers [laughs].


    [laughs] Yes. Yes, rightly so. You think that way, but it is a bit of a nonspecific term. You think that way because you know what the material is, and you are assuming it is a silicate.


    Okay. Good point.


    Yep. You are assuming it is a silicate. So, when I call it bioceramic, it can be anything. It can be a silicate. It can be an aluminate. It can be a glass ionomer. It can be anything.


    That’s true.


    So, essentially, I have been against it because so far, with all the research that we’ve done, we know how the silicates work. We know how MTA works because it is a silicate. You mix it with water, and it forms calcium hydroxide. And everything that we know, everything that is beneficial, is this formation of calcium hydroxide. Let me take you to what is happening in the dentistry market currently. You buy materials, and you are assuming because they’re called bioceramic, that it is a silicate. Most of the materials that are on the market are actually aluminates or mixtures of silicates and aluminates. The chemistry is different. Byproducts are different. Interaction with the tissues are different.

    So, I decided to help the practitioner and to help the researcher, to help myself as well, that I should call them hydraulic calcium silicates, because hydraulic shows that the materials interact with the environment, which is a very, very important property. But also, we have the chemistry. The chemistry is calcium silicate. It is not an aluminate. It is a silicate. So, in that way, if there is another material, which is similar but not the same chemistry, you can define whether it is hydraulic or not because it is a very, very important characteristic in clinical practice, because that is why these materials work, because they are hydraulic. And also, I know the chemistry. So, if it is an aluminate, I will call it a hydraulic aluminate. But the clinician will know that they are an – it’s an aluminate, not a silicate.


    You know, one thing that I – that was a very nice answer, because I was in a lecture room as a student learning – I won’t mention the name, but he’s known all over the world – well, maybe I’ll give a little hint. He had –




    -- something to do with Resilon. But anyway [laughs] – okay.


    Are you sure [laughs]?


    Anyway, he was talking in the early parts of his lecture, and he was speaking about hydraulics. And hydraulics, the whole audience thought he meant condensation loads and pressures to move materials into the system, assuming it was void of tissue, and there was available space. So, your definition is very different, and I understand it, and you weren’t speaking in terms of the byproduct of a plugger loading or a spreader. You’re talking about the chemistry.


    Exactly. So, in civil engineering – I mean, this is not a term I invented. In civil engineering, “hydraulic” means contact with water, hydro. But “hydraulic” can be a hydraulic pump. So, a hydraulic pump, plungers and so on, yes, but you can use the same word to mean two different things in two different contexts.




    What I disagree with is people calling obturation with a hydraulic cement “hydraulic condensation.” It is –


    Bingo! [laughs]


    -- it is not.


    That’s the distinction.


    Exactly. But any condensation is hydraulic because you are applying pressure. You are applying pressure. So, it is very important that we do not invent terminology that doesn’t make sense. Buzz words. A lot of people use buzz words. We are clinicians. We are scientists. We should know better than to use buzz words. So, “bioceramic” sounds very nice, because it’s bio.




    Yes, but the biological activity is not guaranteed. That is simply for marketing purposes. If you mix mixtures of aluminate and silicate, actually, you kill the bioactivity. You kill the biological interaction, which is why I always specify the chemistry. The chemistry is a silicate. A silicate is biologically active. It interacts. As soon as you add an aluminate to it, it stops being interactive. So, you cannot call it “bio.” You call it “bio” to sell it. But you cannot guarantee the biological interaction. You see? So, that’s – that is why there is a lot and a lot of confusion with all this.


    You know -- I’m off script a little bit. But I wrote down a list of all the -- BioRoot and EndoSequence and TotalFill and Edge BC. And then, we have AH Plus bioceramics. And these are like marketing schemes. Could you – my question would be, maybe you have it later, then you’ll talk when Lisette asks you more questions – but they’re not all the same, are they?


    No, they are not the same. So, what is crucial is the chemistry of the cement, whether it is silicate, aluminate, the quantity – because you can start from five percent – in fact, this is the lecture I gave at European Society meeting. Something that has a 5 percent cannot be considered to be as active as something that has a 50 percent. So, this is something that the clinicians need to know. If you have five percent only, what is the rest? Radiopacifier? Maybe. So, the radiopacifier is obviously something that makes it appear on a radiograph, which makes the clinician happy.

    But it may not make the patient happy, because if they have very small amount of cement, in the long term, the material may not set properly. So, the cement component is crucial. Another crucial factor is the [inaudible]. So, if the [inaudible] is water, let’s say you have BioRoot. BioRoot is mixed with water. The setting of BioRoot is guaranteed because the water is part of what you mix. Okay? When you go to the syringeables, the syringeables are modified, but you have to be more careful with the clinical protocol, in my opinion, because you have to have a clinical protocol that allows the water to come back from the dentin and tubules. Okay?

    So, if you are irrigating with alcohol, which desiccate the dentin and tubules, if you are leaving smear layer, if you leave the smear layer, the pushback by the liquid is restricted. So, you need to remove the smear layer. Also, the setting is affected by the final irrigating solution. If you leave final irrigating solutions that do not allow the cement to set, that could be problematic. And to date, nobody has told the clinicians whether to remove the smear layer, what is the final irrigating solution, and to match the irrigation with the obturation. We use one irrigation protocol, whether it is a hydraulic cement, whether it is AH, or a zinc oxide.

    I think that is wrong. It needs to be specific. So, when I do a case, rather than look at the radiograph, after making the diagnosis, I have to decide primarily how I’m going to restore this tooth, because if I need a post, I cannot use things that have chloride in them, because all the systems’ resins do not like chlorides inside the canal. So, obviously, I need to remove those chlorides. So, I have to decide the restoration first. Then, it takes some skill, but you need to decide what kind of obturation technique.

    So, if I have an obturation technique which has very complex anatomy, where I’m going to push huge amounts of sealer, I have to find a reliable sealer or else opt to go for more vertical. It takes skill. I mean, one needs to be skilled. If you are not skilled, you have to refer the case. So, you have to think before you start because that is another problem. When clinicians receive cases that are already a mess, the success rate is not going to be that great. So, people have to be mature enough, look at the case, start planning from the end. Restoration, obturation.

    Once you decide on the obturation, you have to decide on the irrigation protocol and then how to prepare, whether you’re using rotary or whether you’re using manual. And all this is not dependent on your skills. It is what the tools and the patient needs. If what the patient needs is not your skill, you refer the case. At any level, if you think you cannot restore, you send it back at the end. But this should be decided when you see the patient for the first time, and you see the radiograph for the first time. At least you make some predictions of case complexity, how you’re going to finish the case, match the obturation -- the irrigation protocol, decide on the obturation, and so on.

    Because most people do their diagnosis, and then they roll along and roll along until they come to a stage where they say, aha, but maybe this is – case is too complex. Seeing a single root canal does not mean it is a simple case. A single root canal can be very difficult to obturate. It may be too wide. It may be too tapered. You may have used the wrong instruments, because maybe you needed a certain type of nickel titanium file. I mean, you cannot have – I am trained to do, let’s say, reciprocation, and I am trained to do single cone, and I only do that for every single case. It cannot be right. Cannot be right. That anatomy is so complex.


    I have a question. So, as what I’m kind of hearing from you is when you are doing canal preparation or irrigation or whatever, it’s beyond – you – things you need to consider are beyond just mechanically how you’re going to do it. But you also need to know what you’re going to use, so you know the chemistry of the – like what cements or whatever are going to react properly with whatever you’re choosing to do. Is that correct? So, you have to consider --




    -- not just mechanically, but you also have to consider like chemically, like what’s going to be happening as well. Okay.


    Yep. Exactly, Lisa. Exactly. So, you need to work with it chemically.


    What we were saying for decades, start with the end in mind. And that’s what she just coached.


    Exactly. Start with the end in mind, but also consider the chemistry of things. Most people just look at it mechanically. So, you start with the chemistry. That is why I said you look at the obturation technique first. Okay? So, if I’m going to use bonding, for example, again, remnants of zinc oxide are really a bad thing to have, if you’re using bonding to anything, because the zinc interferes with MTA, let’s say. So, that is another thing that most people do not know. If you have zinc oxide in the canal, and you have a perforation, the chances of your MTA or anything else setting are remote. They do not set. If they do not set; you have a mess.

    If you’re using the eugenol, you cannot bond anything to the eugenol. So, that is why you have to think of the restoration first. Then, you go to size of canal, whether you are able to fit a cone. Well, you should be able to see. If I see something which I can – where I can machine literally the canal, that is the ideal case for a single cone. Slight taper, ideal case for a single cone. And again, a big problem with the hydraulic cements is the ability to retain them within the canal.

    I have got a lot of extrusions myself, nothing I am proud of. I mean, a puff is a puff. So, that shows you that I’ve cleaned everywhere that I can get a puff. But huge extrusions, because people say, oh, it’s biocompatible, it is a silicate. The body needs to make an effort to get it out of the system. If the body can take it, it’s fine. But ideally, again, especially with lower molar teeth where you have the inferior alveolar nerve, where you do not want extrusions, it is at pH level. You extrude, you literally burn the tissues. So, huge extrusions to be contraindicated and how to avoid these huge extrusions. So –


    And we learned that from calcium hydroxide. [laughs]


    -- exactly. Exactly. You see, we need to learn from what we have done in the past. So, essentially, I am trying to push also on the ISO standards, because the ISO standards give us the standards for materials of a different chemistry. Okay? So, to retain the zinc oxide in the canal, to retain anything which is resin inside the canal is easy, because when you retain, it – oh, sorry. That is my light. Can I stop and switch on the lights?


    Yeah. Sure.


    Yes, go ahead [laughs].


    It’s fine. This’ll give our audience a chance to take a short break.




    You may now grab a cup of coffee. You may fortify yourself for the evening with your second glass or third glass of wine.


    Is – this building is a smart building. So, when I don’t move, the light switches off. [crosstalk]


    [laughs] You’ve been too still. You need to be more animated with your hands. [laughs]




    Yeah. The Josette I know is very animated.


    I need – well, I need [laughs] --


    Okay. So, if you’re currently using a gutta-percha-based technique for obturation, would you – would it – I mean, would it be --




    -- like, possible? Or like would it be better to switch to a sealer-based technique? Or do – or would you do even something like, depending on the case, maybe sometimes you would do warm vertical condensation with gutta-percha? Or would you sometimes do a sealer-based cone thing? Or would you choose one or the other? Or do you do both?


    No, you have to do three types of techniques, in my opinion. It’s three types of techniques. So, not everybody has the skill and the training to do warm vertical. I mean, warm vertical is not easy. I mean, you know, Cliff, you need training, you need experience, you need to know how to keep the temperatures low, not burn everybody. So, that needs skill. If you are unskilled, and you have a tapered canal – if you have a tapered canal, I think one of the best techniques to use will be lateral condensation, because you can put the cone – you have space for the tools. You have space for the spreader.

    You insert the spreader, push sideways, put in further cones. And with that technique, I think a resin-based sealer is the best, because the resin essentially glues the cones together. So, you glue the cones together, it works, which is why it is still known as the gold standard. It is the gold standard because it works, because it makes sense. Also, with that technique, the irrigation protocol that we have of chelation, essentially – so, you chelate at the last visit. That irrigation protocol works very well with resins. So, everything works, everything is optimized, it does work.

    If I have, let’s say, a C-shaped canal, try sticking a lot of cones, and you stick, and you stick, and you end up filling everywhere with sealers. It doesn’t work. Do you think a single cone will work? I wouldn’t think so. You’ll have everywhere full of sealer.


    An ocean [laughs].




    And – exactly. Exactly. So, you’re everywhere full of sealer, and this sealer is everywhere. And if you have too much sealer, you will push it out, you will have a lot of space. So, it is not effective. People need to be able to gauge the situation and choose the cases well. Sealer based is fine. There’s nothing wrong with the sealer, but it cannot be one technique for all. It cannot be.


    I want the audience to know, I’ve read a lot of her work, and I made some notes. But what I got that was very clean and simple, that if you’re doing the sodium hypochlorite, EDTA, then remove the acids and the sodium hypochlorite’s final rinse, then we can do carrier based, we can do vertical, we can do lateral. But I liked that how you made the distinction, not so fast, if you’re thinking single cone. And you went into a big deal about these residues of reagents that – you talked about flexural – you talked about flexural strength of teeth, you talked about bonding, you talked about phosphate buffered saline can actually cause the pH to induce bacterial growth in tubules.

    And I’m going, wait a minute! We don’t even know this! The clinicians out in the street [laughs] doing the work, who’s talking about this? Well, you are, but –


    [laughs] I am [laughs].


    -- that’s why I want you on the show because single cone is like -- in the United States, it’s like boom! It’s off the charts. But nobody’s talking about changing your regimen of reagents.


    You have to, Cliff. You have to, because that’s why – now you understand, Cliff. We are agreeing that my terminology of “hydraulic” is important. Because these sealers interact with the environment, and the environment is modified dentin, irrigating solutions, and how wet the canal is, because if you dry excessively, if you have a sealer which is syringeable, it needs some moisture. So, we have to tailor make everything. Before, it was not a big problem, because the sealers were not interactive. So, using a zinc oxide, using a resin, doesn’t make any difference. It’s not the case with these material types.


    So, alert! Alert, to all you research and scientists and product developers. I know three people in the world right now are working on a paper point, and they want a big tamponade effect! And they want that thing dry! Well, maybe the question should be, what is your filling technique? [laughs] Maybe you don’t want it so dry [laughs].


    [laughs] It should go in systems, Cliff. It should go in systems. That is why I said decide on the sealer, decide on the type of filling, restoration, sealer, obturation technique. Then, work your way backwards. If you’re going to super dry, you may risk in the material not setting for you. So, it is a problem. It is a problem.


    Yeah. What’s our next question?


    I’m just wondering how a clinician might be able to figure out if they’re using things that react badly together. Like maybe – like, who do they ask? Like – or how can they find that out? Like maybe they’re you know, thinking, well, I’m wondering if my – I’m getting some bad chemical reaction in – when I do the cases. And I don’t know the terminology to use, because I’m not a dentist, but I’m just wondering how you would find out if you’re using different things that are contraindicated to use together.


    Yeah. The debate is always the commercial side, and then there’s the science that guides our clinical actions. And right now, there’s a huge heaviness towards new products, new technologies, advertisements everywhere. And maybe she would comment, but I don’t hear any of these sealer companies cautioning us about – be careful about EDTA! After they’ve pounded it down our heads for like the last few years, that’s how you get the smear layer out! [laughs]


    Yes, but that is why I always go for an evidence-based – right? So, the problem is that most clinicians get their degree, then the only thing they hear is the companies. So, fine. The companies tell you about their materials, but you need to know how to be able to do a critical evaluation. So, most of my research is based on queries I had on clinic. So, I will be working on the clinic, and I say, but how evidence based is this? Am I doing it because somebody told me to do it? And I always ask myself these questions. Then, I run to the lab and start testing things, and I say, oh, my goodness, but this doesn’t really work that way.

    So, all my research has been that way. So, I always encourage people, attend meetings, continue reading, do small courses, CPD. There are – there’s a lot. These days, even online – even online, you can learn. You see on – even looking at Facebook, you learn. I mean, you don’t have to swallow everything, but you listen, you read, and even going on social media can teach you a few things. Being isolated has never helped anybody. It’s important. That is why you watch the Cliff Ruddle Show, because you learn as well. When you watch “The Ruddle Show,” it is educational and is fun, and you learn something or another, always.


    All’s I’ll say, it has nothing to do with “The Ruddle Show” but thank you. I’m old enough that I saw big names come out, Goldman – Mel Goldman, Hydron. That was in the ‘70s. Then, we saw Trope, Resilon. Well, when you’re in academics, there’s a huge responsibility to be very investigative and thorough. And that’s why you’re on the show, because we need to see a little closer to the edges of the truth, because some of these have been colossal failures, led by academics at schools, and everybody said, okay. Let’s go! But you don’t find out for a few years, do you?


    No. No. And unfortunately, a lot of the in vitro research is very low level. So, we do the in vitro research, everything looks really promising, you push forward. You have to remember, we do not have much stringency. Because it’s a dental material, it is classed as a food. So, you do not need to go a lot of rigorous testing. You just put it on the market, you use it. Then, you go to the clinics, and suddenly it fails. I’ve seen materials that have not even undertake- -- have not undergone in vitro research. Simply because it is similar chemistry, they just push them forward, or nothing toxic, and they just push them forward.

    What I will tell you, Cliff, is I will never be the one to say, go for this. A lot of people have asked me, give us a protocol. Tell us what to use. I’m sorry. It is a huge responsibility, as you say, and I will for sure always tell people, this is my opinion. Read, read my opinion, read other people’s opinion, form your own opinion. If it fails, then [laughs] it will be a failure, but also, not to change your system completely. I think that is very dangerous to change your system completely to go everything, do – done with the same material. You have to watch. Do a few. I was I think one of the last people to start doing single cone. I only started recently. I have 15 years of research behind me. I only started using the method just recently, and not all my cases. I still use epoxy resins. Yes, why not? If I have the right technique, I’m gonna use it.


    I’m sensing that you are comfortable with single cone, in the little bit we’ve spoken, if we have a pretty much shaped system that matches the last file.




    And if it’s pretty round, and it’s picking up that silhouette of the file, you’re very comfortable. But if you have an ovoid or a figure-eight shaped canal, that’s when you might use a different technique.


    Exactly. Exactly. I’m comfortable if I have something where I take a radiograph, I check – obviously, it’s two-dimensional, but it gives me an indication. I look with the microscope. I check how much space I have. I have to have very nice pack anyway, not just throw the cone. And even the insertion of the cone is important. It’s very important that you allow the sealer, because if the cone fits well, the sealer may not be able to come back, and that is where you literally ram it past the apex. [crosstalk]


    And venting! [laughs] You want coronal venting and air and --


    [laughs] Coronal venting, yes! So, we have to use larger amounts because of the sealer-based techniques. But you have to have the coronal venting. So, very gently insert – I’m looking into it. I have some colleagues where we are looking at where to place the sealer, because that’s crucial as well. Whether you inject it – I mean, remember these come with very slim injectable tips that literally go to the apex. Maybe go into the apex is not a good idea, especially with [crosstalk]


    I don’t like depositing cements with cannulas close to length because we’re all so different. And you and I might be able to pull it off and a group of other people that are really diligent, but just to get the masses that do every day endodontics and tell them to start – you know, throw that cone in, you gotta swirl the cone in, tease it in. There’s a whole bunch of stuff to teach. But anyway, I’m gonna go here.


    We’re about out of time, but I just wanted to ask you –


    Oh, we’re out of --


    -- if you have any, like, closing advice for clinicians or just anything else you want to close out, if you want to let our viewers know something that – maybe about you, even that they didn’t know before. Anything you want to say.


    Well, what I would like to say is, it is very important that the clinician puts on the scientist hat and reads, assesses, and does a critical evaluation of the materials that they’re using on the patient. The patient is our responsibility, not the manufacturer, not anybody else. It is our responsibility. So, it’s very, very important to check and to keep informed as well.


    That’s good advice.


    My closing comments for our audience, I’m just delighted, first of all, that we’ve had Josette as a guest.


    Yes, thank you so much for joining us.


    And I hope she would agree to come back someday, because from her reading, I formed six questions that need answers. And we’ve talked about just a little bit of it. We’ve kinda danced around, but we never drilled down. I’ll just say them as titles.

    I want to come back to the irrigants more, sodium hypochlorite, EDTA, and what we need to do to prevent microbial growth and that – the EDTA stuff. I want to talk about heat. When we plunge in with heat, what’s happening to the physical properties of material. I’d like to talk about lakes and pools of cement and irregular cross sections. Solubility. There’s all these sealers out there, but I have a sense that commercially, some of them are more soluble than others, and I’d like to drill down more there. And retreatment, we never even talked about it. Okay.




    You got a cone. And we all know how to take a cone out. But what about the eccentricities off the rounder parts of cones, the tubules, the lateral canals? So, I’d like to know, how do we get it out of there? And then, finally, what you say in several papers, we don’t have clinical outcomes established in the literature. And we – I’d like us to have a light from you from up above to show us what needs to happen so that clinicians can be more confident, what to choose, and how to use it and when.


    Okay, Dr. Camilleri. So, you’re gonna have to start preparing for Part 2 of the interview, where you answer those questions [laughs].


    Part 2 and maybe Part 3 as well, because Cliff has a lot of questions. And I’d love to come back, and we will have that chat as well, Cliff. We can sit down, enjoy some time with you and Phyllis, and we can have a chat about anything you like.


    It sounds like you’re already working on Istanbul as that place.


    Of course. We have to! We love people. [laughs]




    All right. Well, thank you so much for joining us. It’s been really fun.


    Loads of fun. Thank you very much, Lisa, all the family. You are fabulous.

    CLOSE: Aesop’s Fables & Endodontics


    All right. So, we have a new close for you today, and it’s called “Aesop’s Fables & Endodontics.” So, some of you might be familiar with Aesop or at least heard of him. He was a slave and a storyteller who lived in ancient Greece. In his fables, of which there are approximately 725, generally, the main characters are animals, and they teach a moral lesson. So, these fables were originally told orally to adults, and they were not collected into a printed edition over three centuries after Aesop died. Over time, it became popular to read them to children, and they’ve been translated into many, many languages and even different dialects.

    So, how this works is, I’m going to read a short fable, and then read the moral as well, and then you’re going to relate it to endodontics. So, because of a lot of our viewers happen to be international and the language of the fables can tend to be a little archaic, I have taken the liberty to substitute a few words just to facilitate understanding. So, are you ready for the first one?


    Yeah. I just -- yesterday in the mail just arrived my transcript of the “Aesop’s Fables for Endodontists”.


    Oh, okay [laughs]. All right. So, the first one is “The Goat and the Goatherder”. A goatherder had sought to bring back a stray goat to his flock. He whistled and sounded his horn in vain. The straggler paid no attention to the summons. At last, the goatherder threw a stone, and breaking its horn, begged the goat not to tell his master. The goat replied, “Why, you silly fellow. The horn will speak, though I be silent.” So, the moral of this one is, do not attempt to hide things which cannot be hid.


    I think we have to remember that the radiograph will find you out. [laughs]




    The radiograph will speak very loudly, shrilly, even when the doctor is zipped up and not speaking. There’s even a Biblical text, “Be sure your sins will find you out.” What if we were to miss a – well, a radiograph oftentimes can identify a missed canal, maybe a broken instrument. Some perforations are noticed radiographically. So, when those things happen, you gotta sit down with your patients and talk to them.


    Not try to hide it and then refer them out, and then, they find out from someone else [laughs].


    Yeah. I mean, you know, the overfill into the neurovascular bundle. You’re not gonna tell them, right, because they’ll probably go home and be fine. But when they go home and they say, I’m drooling, maybe you should’ve told them.


    Okay [laughs]. All right. So, the second one I’m gonna read -- and this will probably be the last one for today – is called “The Donkey and his Shadow.” A traveler hired a donkey to convey him to a distant place. The day being intensely hot, and the sun shining in its strength, the traveler stopped to rest and sought shelter from the heat under the shadow of the donkey. As this afforded only protection for one, and as the traveler and the owner of the donkey both claimed it, a violent dispute arose between them as to which of them had the right to the shadow.

    The owner maintained that he had rented the donkey only and not his shadow. The traveler asserted that he had, with the hire of the donkey, hired his shadow also. The quarrel proceeded from words to blows, and while the men fought, the donkey galloped off. So, the moral of this is one is, in quarreling about the shadow, we often lose the substance.


    That’s what’s going on a lot on the Endodontic Forum.




    You know, we argue about such minutiae, and we forget it’s about the patient, stupid! You know? If you made yourself the patient, you’d have the answer. That was a Herb Schilder quote. Well, I was thinking that the donkey could be the dentist doing endodontics or endodontist. So, the donkey could be the endodontist. And while the owner and the renter of the donkey, yes, were arguing and fighting for the shadow, the donkey galloped away. Well, that was the person that was gonna deliver the treatment to the patient.




    So, that got away, and the patient didn’t even get the treatment, because they were arguing about Truss accesses. They were probably arguing about GentleWave. They were probably – had a terrible feud about – Josette comes to mind, which sealer should I be using. Right? So, all these things we argue about, but actually, there’s patients, and we just need to be a little smarter and read.


    Or the endodontic triad, dead or alive.


    Oh, right. We argue about that all day long, but yet, they stick their files in there, they use some irrigant, they use a filling technique, they make white lines. We argue about a lot of stuff that really, we should just remember the shadow.


    Okay. Well, that’s our show for today. Hope you enjoyed it and see you next time on “The Ruddle Show.”


    See you next time.



    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.

    DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at

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