Much has changed in global endodontics over the past 40 years and a great deal of this change has been driven by the relentless introduction of new technology...
Working Length & Microscope Tips Determining Accurate WL & Microscope Q&A, Part 2
This show opens with a look at what is key when it comes to great leadership. Then we turn our attention to a specific scenario that still trips up some clinicians: determining an accurate working length. Next, Ruddle and Lisette continue with Part 2 of the Q&A on helpful microscope tips. The show concludes with another installment of What Does Phyllis Think? Get ready for Close Calls, Part 2, in which Phyllis shares how the family has managed to survive wildfires, surprise storms, earthquakes, and even tornadoes.
Show Content & Timecodes00:55 - INTRO: Keys to Great Leadership 07:18 - SEGMENT 1: Specific Scenario – Working Length Determination 32:21 - SEGMENT 2: Q&A – Microscope Tips, Part 2 44:49 - CLOSE: What Does Phyllis Think – Close Calls, Part 2
Extra content referenced within show:
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Downloadable PDFs & Related Materials
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Successful endodontic treatment requires that the clinician predictably shape root canals for three-dimensional obturation. In this article, the guidelines for successful access and the concepts and strategies for canal preparation will be discussed...
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.
…Well, the Ruddle family has definitely had its share of close calls. So many, in fact, that this installment of “What Does Phyllis Think?” is “Close Calls: Part 2”…
INTRO: Keys to Great Leadership
Welcome to “The Ruddle Show.” I’m Lisette, and this is my dad, Cliff Ruddle.
How you doing, Lisette?
Pretty good. How about you?
Absolutely great. I’m really excited about the entire show today.
Okay. Well, I sometimes look at Dentistry Today news articles to see if I find something interesting. And I came across an article that I thought was interesting, called “Communication, Transparency, and Honesty” --
-- “3 Keys to Great Leadership.” And it’s by Dr. Roger P. Levin, who is a recognized expert in dental practice management and marketing. So, I saw this and I thought, well, this is good for our show, because if you ask any dentist if they want – aspire to be a great leader, most will say yes. But even if you don’t want to be a great leader, you’re kind of in a situation that demands it, because being a dentist, you are by default the leader of your dental team and practice. So --
Can they delegate leadership? [laughs]
-- [laughs] the good news is that Dr. Levin said that most any dentist can become a good leader when emphasis is placed on three things: communication, honesty, and transparency.
Yeah. Well, Roger Levin formed many years ago the Levin Group, and that’s a practice management consulting firm. He’s helped thousands – tens of thousands of dentists and specialists alike. We did something on this show, and I don’t know which one it was. It doesn’t matter, but we did feature one of his articles. And it was interesting to me, because it was like he was implying that maybe dentists are focusing too much on technical excellence and not enough on business excellence.
And so, I thought that was very good, because we want to be technically excellent, but obviously, you know, if you’re not running the practice like Lisette said, with leadership, or you haven’t delegated somebody to be a leader to deal with these things, you’re not gonna be the best you can be, even if you have Leon Archie – Leonardo [laughs] da Vinci hands. So, yeah. I thought that was pretty good. And I think this article right here on leadership is very timely.
Yeah. Well, he identified – and I’m going to say it again – communication, transparency, and honesty as the keys to great leadership. And we’ve talked a lot about these things on our show. Maybe just remind our viewers really quickly why they’re important.
Well, communication, of course, is really the ticket. Any problem I think that you’ve had or that I’ve had in almost anything in life, it’s been failure to precisely and clearly communicate and have clarity. So, it should be a two-way street. We should have great communication, all be on the same page. Transparency, I think just be open and honest. If you’re gonna do something different, or they wanna do something different, everybody at least knows through communication. But there’s no secrets, there’s no whispering. It’s like everything should be open. That’s a healthy team. If you have a problem with somebody, there’s ways and mechanisms to air that out in the right time and place.
And then, the last one I guess you said was --
-- honesty. And I don’t know if I should say a thing about that. Honesty, I don’t know, if you’re a dentist, and you’re not honest with your staff, are you honest with your patients? So, I would just think it’s critically essential to be – if you have to be even bluntly honest.
Yeah. I mean, it’s really important. You have to have that trust in the practice.
You have to be able to tell the truth.
Okay. Well, we’ve also talked on our show about how early on in your career you took a business course, and it greatly influenced how you ran your practice over the years. And one aspect of this course was leadership. So, maybe tell our viewers some behaviors or qualities that you think make good leaders.
I think leaders have to be selfless. I think you should be willing – you and me should be willing to do anything we ask of anybody else in the office. And that’s right down to toilets. Okay?
Cleaning the toilets. [laughs]
Cleaning the toilets. Yep. And making sure the esprit de corps is perfect. So, be selfless and lead by example. On my notes here, I see we – leaders oftentimes – everybody has ideas. Show me who doesn’t have an idea. But float those ideas in a way that people on your team can grab it, embrace it, and then let them run with it because it’s way more powerful when somebody is promoting their idea. They own it. And when you have ownership, you try even harder. So, be willing to pass it around.
You don’t have to get – in fact, leaders should be kind of invisible a lot of times. Put people in positions where they can thrive. You know? If you have a great chairside assistant, maybe she’s not gonna be somebody at the front desk that does computer billing. So, really get the right people in the right place, and then grow them. Send them maybe even to special courses. Because people want a future. Leaders create futures, and futures give people possibility, and possibility is access to infinity. So, to the extent we have a happy team, an honest team, a transparent team, a good communication team, and we have access to infinity, geez, what can we not accomplish?!?
Right. I mean, maybe it – it’s recommended to have a little bit of a pleasant personality, too, so that – leaders should maybe have some likeability [laughs].
Well, it’s nice to be liked. But I would have to say I might disagree respectfully with you, because I can think of many great leaders like Vince Lombardi was not necessarily liked.
Right. It just might actually be a little bit helpful. It might make things a little easier if your staff can get along.
Sure, it does. And a lot of the people out there that are endodontists, just as an example, understand how you might not have liked your mentor, but ten years later, you loved your mentor.
You worship your – I – okay.
Yes. Well, we’ve now talked about Dr. Levin’s articles a couple times on our show, and I think he’s written an enormous number – I wanna say over 4,000, and I don’t think I’m exaggerating – articles. It’s --
It was thousands.
-- definitely, he’s written a lot. Maybe we should even have him sometime on our show as a guest.
Excellent idea, and maybe we can all figure out how to make it work even better.
Okay. Well, we have a fun show for you today. So, let’s get going on it.
SEGMENT 1: Specific Scenario – Working Length Determination
Glad to be here with you today. Glad to talk about something related to endodontics. And in this case, we’re gonna talk about something very basic: working length determination. You might wonder why on “The Ruddle Show,” with the viewers being dominantly endodontists and general dentists, why would we talk about something so mundane? But we also have a lot of dental students. So, whether you’re a dental student, a well-trained general dentist, or an endodontist, let’s look at working length determination and some of the factors, because although we all do it, it might be the only thing we all have in common, because we all do different things, and we approach our work with different styles and use different methods and techniques, different instruments. But we all learned working length! But working length doesn’t mean the same.
As a teacher traveling the world, working length was all over the place if you started to really drill down and find out what do people really mean about working length. Well, of course, besides the tools that we’ll talk about shortly, the methods and anatomical knowledge is gonna be very helpful. As an example, the distal root of a lower molar, we know that the canal terminus bends frequently and ends on the distal aspect of the distal root in its apical one third, not at its radiographic apex. But yet we use a lot of slang and terms. I’m gonna work to the apex. I’m gonna work to the end of the root. I’m gonna work here. Okay.
Today, we’re gonna clean a lot of that up. But having the anatomical knowledge is important. I didn’t put these other two in, but I’ll write them right now. A lot of your working length determination depends on your philosophy of treatment. So, you tell me where you went to school, and I’ll tell you your working length. Okay? It’s just really that kinda crazy. The other thing is – I mentioned it – terminology. Okay. Got those big words written. Terminology. In other words, how you communicate in life, whether it’s endo or with family or staff, is how it is. So, communication and the words we use are critical, because it conjures up pictures, and everybody’s mind doesn’t have the same photo snapshot. So, that’s a little bit about working length and some of the philosophies behind it.
But now, let’s look at the methods. And we have several methods. And of course, everybody knows about the importance of electronic apex locator. Most people are using them. Most people are on the latest generations that can work in electrolytes like sodium hypochlorite or better yet, they work in viscous chelators like Glyde, ProLube, RC Prep. These are the kinds of lubricants that help stabilize electronics. You might wonder, what does gauge and tune even mean, for some of you? It’s a term I introduced back in the late ‘70s. Gauging was, how big was the foramen, and tuning was the clinical activity to validate the final file to length. So, if a 20 was at length, each larger, successively bigger instrument uniformly stepped up and out of the canal, then we knew the terminus was the diameter we really thought it was. That all has to do with working length.
And then, of course, I talked about this, and it was published later in time, in Pathways of the Pulp, but paper point drying. We’ll get to that, too, because that might be on the list, one of the most accurate ways, but it happens late. And you’ve already committed, and the shape is already done. But paper point drying is a poignant way to dial in and get another opinion, maybe a second to third opinion on where is the actual vertical extent of this canal, and where does it terminate.
All right. So, let’s get going. This is a review – and I’ll go very quickly. We’ve done this many times on many shows before, but we’ve talked about the importance of pre-enlargement. And you can use anything you want. I used the auxiliary shaper from the ProTaper family. This is a ProTaper shaper, and it has a big taper. It’s appropriate taper, but it’s confined to the body of the canal. But if you get a little room going, a little space, and you have a loose 10, then we know it will accommodate the tip of the instrument, and that instrument can follow the secured part of the canal – secured part of the canal – and then, we can use this short of the secured part.
So, we just served to remove canyons of restrictive dentin. Now, removing restrictive dentin gives you a more direct path to the foramen, the terminus. That means working length’s going to change. So, the reason we’re talking about pre-enlargement, a very, very old concept, because we have research that shows that working length and more curved canals can change up to one millimeter after pre-enlargement. So, people working along, rips and tears and causes postoperative problems, wet canals, bloody canals, surgical procedures, extractions. All that’s needless. A lot of 6s and 8s can be discarded. A lot of times, you can discard them. Why? Because when you do pre-enlargement, oftentimes the file that would not go to length now will easily slide to length.
And you know this, if you’ve taken workshops. A lot of times, you can take a 10 or a 15, even a 20 sometimes, and introduce it into the foramen of posterior teeth. Oftentimes that’s common. It’s normal, which means the foramen’s already that big. So, when the file doesn’t go down, we have to recognize it’s binding in the body. It’s binding in the body. That’s an important concept. And we’ve talked about, again, the advantages. I’m only gonna focus right here. If we have an improvement in a pre-enlarged canal of determining working length, all apex locators, all radiographic images improve, because bigger files are accepted to length.
Oftentimes with pre-enlargement, you can put a size or two bigger to length. And that means our apex locators are more stable on the electronics, the digital readouts. That means when we take a film, radiographically we can see the radiopaque metal easier on a little bigger file, so we’re more confident. So, just a couple little things to be thinking about.
And of course, you can review this old chapter that we wrote to get more information on that. Now, I want to talk a little bit about this, and I want to talk about it in a little different way than you’ve maybe heard it before. We were trained in Boston – this is Schilder driven – that’s where the file meets the edge of the root, radiographically – say after me, “radiographic terminus.” Oftentimes the radiographic terminus, the files are exiting at positions other than the radiographic apex. So, when you say you work to the radiographic apex, I smile inside. I know you’re just kidding. But you don’t really mean that, do you? You sometimes work to the radiographic apex, as I do, and other endodontists. But oftentimes the position of the apex is not the same as the terminus. So, let’s clean up our terminology.
The main thing here is to talk about cementum. I don’t even know if that’s gonna read, but we might just go to a different case. Can’t see. We’ll bring our eyes to it. Cementum. So, I’m depicting the cementum as this brown, taupe color. Remember, it covers the roots. It comes through the anatomical foramen, and it moves up through the canal, and guess what? You were taught many times to work to the cemental-[dentinal] junction. And just to be really clear, you were taught to work to the cemental-[dentinal] junction. Well, what is that? Where is it? I’ll tell you this very quickly. It’s available to a histologist on a bench. It is not available to a clinician doing everyday endodontics. It’s a grand idea to say, work to the [CDJ]. Work to the constriction! Work to the minor diameter! All these terminologies. Oh, my goodness. It’s confusing me!
So, Schilder said, since the invasion of cementum through the foramen is uneven, that means it extends up the walls – the internal walls of the terminal part of the canal, sometimes several millimeters, and sometimes only a few millimeters, and sometimes it’ll just come in a few microns. So, when your teacher and your textbooks say, work to the constriction, work to the [CDJ], it’s an irrelevant landmark. And then, if you talk about pulpitis and inflammatory conditions, you start getting some resorptions going, and all of a sudden, it’s not a reproducible landmark. So, Schilder said the only reproducible landmark from country to country, from state to state, from city to city, from doctor to doctor is the RT. And it can be all agreed upon around the world.
So, when we know we work to the RT, I want you to know that I know the file is minutely long. The file is to and minutely through the foramen. But importantly – and another time we’ll come back and harp on patency – all canals are patent. And canals that are patent can be shaped, and canals that can be shaped can be cleaned and filled. Well, I’m having a lot of fun. If I can get the eraser going. So, let’s continue. So, you’ve seen part of this clip before, but not in this context. So, as you work these files down, notice in tighter canals and more curved canals, there’s no space.
So, sodium hypochlorite, it should be obvious, it's inappropriate. There’s gonna be almost nothing. Your chamber might be brim full. Watch us pluck a partial piece of pulp! Four P’s! Light them up! All right. And as you pluck out pulp, you’re generating debris with the file, you’re packing debris into tubules, into portions of clean-out lateral canals. And so, you can hear your apex, beep, beep, beep. But as those beeps get closer together, you’re knowing you’re arriving. And when you get a solid tone, and I mean right at the apex, that’s where Ruddle works. Most of you wanna work up in here by training. You’d like to be a little short.
And we can talk about that histologically another time, but as a clinician talking to clinicians that do everyday dentistry, including endodontics, we don’t want to have problems. So, working to the RT doesn’t mean we’re gonna pack to the RT, but it means we have a flow channel where reagents can cycle and exchange into the deep lateral anatomy. So, go to the apex. And that’s the truth. Now, let’s continue. When you get to length, don’t leave length. Stay there. Hang out. Have a cup of coffee and work that instrument, in, out, in, out, up, down, repeatedly, deliberately, intentionally, at length. And you’re making sure every stroke you’re carrying more viscous chelator in, you’re lubricating the file, and you’re taking longer strokes now to see if the glide path is just over a millimeter or two, or do you have a nice slide path over the entire apical one third.
Listen. Viscous chelators lubricate the file. They keep debris in suspension. We begin to keep tissue from re-adhering to itself, emulsification. We’ve talked about all that. So, if we don’t work to the terminus, and we work short, have you noticed – have all you noticed, around the world – when you work intentionally a little short at the beginning of the treatment visit, by the time you stepped over to the finish line, and you took your last file out, oftentimes you were one to two millimeters shorter than you thought you wanted to be. Raise your hand out there if you have many times worked short and ended up even shorter than was your intention. That’s because – what? Debris begins to accumulate apical to the file. Debris – the debris begins to get packed. And if you’re not clearing your foramen with patency files, that debris will push the file back out of the canal, and you’ll lose vertical extent of treatment.
So, that’s a little comment about working to the terminus to avoid blocks. What’s an internal transportation? It’s nothing more than what we say would be a ledge. So, you like block. We’ll bail this one out. Block. So, these happen every day. Now you have trouble with cone fit. You don’t have a real good flow canal for irrigations. You’re not gonna get the same physics. Okay? So, these are things to understand. So, you’re working to length to avoid iatrogenics. You’re working to length to avoid transportations. An internal transportation is a ledge. An external transportation is moving the physiologic terminus on the external root surface to a new iatrogenic location. Okay? This happens a lot. Worse cone fit, how do you drive these things, how do you pack into reversed apical architecture instead of positive capture zone?
And finally, for those who are really, really diligent and keep up that old – you know, grind that file in, get that rubber stop backed out on the chosen, selected reference point, because I don’t wanna lose working length! And now, you have a great big what? Have a transportation, and now we have a big perf. So, please, no perfing. The secret is small, most flexible files are carried to length between every instrument, just to make sure I’m still patent. I’m still patent. Everything’s good. I’m still patent. You’ve seen this case before, but it’s gonna be a great example of all the things I just talked about. Let’s take a look. I’m just gonna show you a few snippets.
It’s a bridge abutment. You can see that. But it’s a terminal abutment, and it’s the terminal abutment in the most funereal sense. Probably has a furcation problem. You can see we have a neurovascular bundle traveling through here. We have root in proximity to that. So, it’s a very, very strategic tooth. So, we’re gonna take the bridge off. That’s another lesson, another time. And I’ll grab a file, and I’ve already done my access. And I want you to just notice, working width, I have space. And if I have space, I can immediately use a more efficient tool. This is a auxiliary shaper, the SX from the ProTaper family of instruments.
And in this case, I’m working dry so you can see what I’m doing. Notice I’m brushing away from furcal danger. I’m brushing to the outer wall. I’m brushing to the greatest bulk of dentin. Okay? So, you see debris. You see pulp hanging out of the isthmus. You see pieces of pulp extending. Isn’t that something. We’re not even close to clean, but I’ve got around the horn. I’ve opened up the body so I can get in here and begin working the apical one third. This 10 file’s about 2 stops short of my reference point. So, I’m about two stops short, and it’s not moving. So, I’m going to a smaller instrument. An 8 is useful. So, 8-100ths is better than a 10th.
And I’m not picking. I got a little stick. It’s tacky down there. And notice when I get about a stop short, it’s a slide. I’m not doing this. Dentists around the world love to be screwing the instrument back and forth like a screw going into wood. It’s a slide. And I’m working, and I’m gonna reproduce the pathway. And watch the finger. Just tap, tap, tap on your nose. Tap, tap, tap. A loose 8 already is a 10. So, a 10 gets there quite easy, and a loose 10 is already a 15. So, learn how to use your smallest files deliberately, repeatedly, intentionally, until they are loose at the radiographic terminus! Terminus! Loose 10 at the terminus. Isn’t that a thing of beauty?
So, if you look, you can see the work upstairs in the body of the SX file. You can see we’ve done pre-enlargement. You can see by taking pressure off the file, we can now thread it around and see already, I’m a little longer than I might’ve thought. Little bit longer than I thought, about a millimeter long. This might be a millimeter and a half to two millimeters long, and obviously, I’m trying to demonstrate a path down to the apex. This is about knowing your anatomy. Remember that? Know your anatomy.
So, I’m gonna show this quickly. Why am I gonna show this quickly? Because I want you to catch on that as we shape through multiplanar curvatures, working length progressively decreases. The astute clinician will reconfirm working length. So, we can chuck up a ProGlider. Okay? That was before Ultimate came out with a slider, but it’s much the same kind of idea. It’s a different cross-section, but only in a few seconds, with a glide path, it’ll travel right to length. The stop kisses the selected reference point, and kiss and say goodbye, we’re out of there.
But when we got to the film, I want you to know, working length changes again! Look at that. It's now a little long again. I already adjusted. I was at one and a half. Now I’m a half long. So, be sure to reconfirm working length in longer, more curved, and more calcific canals. It’ll save you a lot of headaches. And of course, you’ve seen the post-op before. Furcal canals. What we couldn’t do because of my inabilities, my frailties, is slide a file into that other branch, we can pick it up through irrigation and hydraulics during packing.
So, we’re getting down towards the end, and I wanted to show you this case. I take a lot of crowns off. I make teeth shorter. I like to work with 21s as an example, instead of 31s. That’s obvious to you. But the closer you are with your fingers to the length of the file, the D0 dimensions of the instrument itself, the more tactile control, the more dexterity. So, get the crown off if you want. I did. And of course, I’m gonna fill the pulp chamber, once I’ve identified the orifices. And I’ve done some pre-enlargement already, off camera. That was in another movie.
I’m gonna grab the 10. And the 10’s going in, wiggle, wiggle, wiggle, back and forth, a little reciprocation, all right? And that’ll draw the file down into the canal. Every time the handle is snug, pull. So, wiggle, wiggle, wiggle. That draws the file in. When the handle gets snug – I didn’t say tight – snug, the blades are engaging, maybe too walled in, circumferential dentin, depends on the anatomy, the cross-section. But you’re cutting on the outstroke. You’re cutting away from length. You’re cutting to the bigger diameters. That’s safe. Don’t cut in. Cut out. Wiggle, wiggle, pull. That’s one cutting cycle. Check it. Check it.
You know, I said look at the apex in a previous case. Now I say ask, is it true? So, the fingers, when you’re moving the file in, should match the electronics. On the digital readout when you’re pulling out, they should be in sync. And that confirms that everything is fine. So, clear the foramen. And now I’ll show you gauging and tuning. We talked about this in the early ‘80s. My last file to length with a mechanical file was a 20. So, is it a 20? We say, is it a 20? Is it true? Because Ruddle’s off course 99 percent of the time. It’s always those little adjustments that guide us back to take the path towards the successful conclusion.
So, every bigger file comes in, the assistant just reaches over with the pliers, pushes the stop down. Push the stop down. And if each larger file is uniformly backing out of the canal, I say, show me the shape. I say, show me the money! Okay? Because this is just what we did. Okay? This means every dentist in the world has a mental picture of how the internal intaglio of that canal looks. You can imagine – you can’t see the fins and the cross-section of the lateral canals, do this. But you definitely can see you have shape as you come away from the foramen, and your files confirm it, because each larger instrument, the stop is moving progressively away from the bottom of the plastic handle.
So, that is a great way to say, do I have an accurate working length? Is it a 20, not only for the diameter, the gauging, how big is it, but do I have shape? But this is also gonna come back and help you confirm your working length. So, you have the post-op, the crown’s provisionalized, shapes are not remarkable. Maybe the shapes are a little smaller now in this era, but the principles of working length are absolutely the same. All right?
Paper point drying. I’ve talked about a lot of this stuff 25, 30, and 40 years ago. I’m still talking about it because a lot of people don’t know about it. But we fit – Ruddle fits the gutta-percha master cone to the radiographic terminus, because that verifies all the operative steps to date. But is that the terminus? See, I’m asking a lot of questions, aren’t I? If I talk to my staff in the operatory, I’m usually asking questions because I want confirmations and validation.
So, is it true? Is it true we’re at – we’ll take a film and confirm it. But that’s not where we pack to. That’s where we instrument. When we instrument to the RT, we’re like the surgeon in medicine that makes a broad incision to include complete enucleation. They don’t just take out the exact tumor. They make a little wider margin to make sure they got all the pathology. Working to the RT is to make sure you get all the pathological tissue out. It’s to make sure you have a slide path. It’s to make sure you have a flow channel, and it’s to make sure we can be three-dimensional.
So, is it true? Bring in your paper points and start drying the canal. That part of the paper point that is clean, white, and dry – clean, white, and dry – is that part of the paper point that is inside the tooth? The part that spots, it could be an exudate of blood, or it could be a serous or a purulent exudate, anything that spots on the end or the paper point at the distal end kind of accordions, kinda collapses into your gloved nail, that’s beyond. So, we will trim the master cone in accordance with paper point drying, so we can work to the physiologic terminus. How about that? This is the physiologic terminus.
So, we’ve talked about radiographic terminus, physiologic terminus, radiographic terminus. Wow! That’s a lot of things going on here. Radiographic apex. See, here’s the radiographic apex. You don’t work to the apex. You’re working to the terminus! Not the apex. You know, how you speak is how it is, and I’ve noticed that almost every problem I’ve ever had in my life is failure to precisely and concisely communicate. So, maybe this’ll help you. And there’s the reference. We talked about it all through the ‘80s, the paper point drying technique. And finally, we got it into Pathways to the Pulp and it was published in my chapter on obturation.
So, working length. What about working length? I guess you’re learning that it’s more than just a number. It’s more than just [CDJ] constriction, minor constriction, major constriction, terminus, foramen. It’s knowing the terminology, marrying the terminology with your philosophy of treatment, and bringing it all together with your anatomical skills and knowledge. And then, with the right methods, you can discover an accurate and predictable, reproducible working length.
SEGMENT 2: Q&A – Microscope Tips, Part 2
Okay. So, we started a Q&A a few shows ago on tips for using the microscope. And so, we’re gonna continue it now. Ready to continue on?
So, question number four. I wear glasses. Should I be using my glasses with the microscope, or will I feel less constricted if I just adjust the microscope focus to my poor eyesight?
Very quickly, if you need magnification or glasses for good vision acuity, then you will wear your glasses into the operatory as per usual, because the microscope can be adjusted. There’s two little eyepieces, and what they’re called is cups, and if you screw the cups all the way in, then you can bring your glasses – because see, there’s a gap between the focal point of your lens and your eyeglasses – and then, you can see fine. On the contrary, if you do not wear glasses, the cups should be counterclockwise, screwed all the way out, and then, you can come in with your glasses or your eyes to the cups, wherever they are, and you’ll see fine.
So, I guess you probably would wanna wear your glasses, because then if you look away from the microscope, you can --
-- still see around the room.
I was saying to Lisa before we started, that there’s a lot of things going on in modern-day operatories, with assistants, and you’re looking across to see that they have it mixed right. You need to see. And then, people come in, there’s a note, you’re gotta read. So, I would say, go into the operatory with your best vision, whatever that is, if you wear lenses, and then you’re good.
Now, what if you have somebody else that you work with in the office that also uses the microscope but might have different vision than you? Then, do you have to just adjust it every time, or you --
Well, now, that’s a little different question, because the first one’s eyepieces and the cups. And that’s for glasses, no glasses. If you have multiple people using the same room, now you’re talking about focal length. And you have to parfocal. So, parfocal would be different, I promise you, between me and you, and even people that are 20/20 in both eyes might not have the same parfocal. So, parfocal numbers – it’s easy to do parfocal. You can Google it and do it. But you – the assistant would write that down or memorize it, because I don’t know how many doctors we’re talking about that share the same scope. But in other words, part of the setup for the room is setting that doctor’s parfocal up.
Okay. So, I know it is a different question, but it’s still a valid question.
Well, that was probably even more important than the eyepieces. [laughs]
Okay. All right. Next question. My eyes seem like they are getting more tired now that I am regularly using the microscope. Do you know why this might be, and what do you recommend?
Back in the day, and that means before microscopes were in dentistry, and I was trying to figure out how to work, I talked to a lot of physicians and especially neurosurgeons that used big microscopes, and I was more concerned in Googling their literature, would there be damage to my eyes. And it’s really not gonna damage your eyes, but if we work at too high of a power, too big of a mag, over periods of time, versus just to go up in a big mag and take a look, and then come back down where it’s comfortable, that’ll help fatigue, and that’ll offset and mitigate a lot of that.
Also, if the little halogen light – xenon lights – they’re bright – if you have too much light, that can be hard on your eyes. Another thing is that sometimes we used to cut the lights down in the operatory to have shadows and a little darker around the theater of activity, and then, really the good light right on the field.
Okay. All right. I get everything focused, and then the patient moves and I can’t see. It feels like I am constantly refocusing. How do you deal with this?
These were all my questions in the ‘80s [laughs].
Where were you in the Q&A? [laughs]
Well, you’ve gotta remember, people are not asleep usually in dental offices, and they are awake and conscious by design. And so, they’re gonna move a little bit. And if they don’t move a little bit, they’re gonna be doing [deep breath] – well, just breathing --
Still a little movement.
-- at 9X, you’re gonna go in and out of focus. So, you gotta realize, your mouth mirror is fine focus. So, like in baseball, we used to say, choke up on the bat, you know, you show a little heel, a little knob down here. Choke up, get your bat around faster. Well, in dentistry, choke up on your mirror.
So, then you have two things about, a rest point. So, you might put your ring finger down, and you have a fulcrum, or two fingers, or whatever you do. Change your fulcrum – your fulcrum. By changing your fulcrum a half a tooth, they’re right back in sharp focus. So, you can kinda chase them around a little bit. Then, you can let the mirror out a little bit, or you can pull the mirror back a little bit, and that’s fine focus. So, the mirror – took me about two years to figure it out. Mouth mirror is fine focus.
Now, I’m probably taking one of your questions away. You also have pedals. I have pedals. Not everybody has pedals. Oh, yes, I have a bicycle. I have pedals.
No. No, pedals on the floor to run the scope. So, you have focus in, focus out. You can mag up, mag down. So that means you’re hands-free. So, for a little extra money, you can get cables that are, you know, out of sight, and they’re plumbed in. And then, you have a little box at your feet, like a rheostat, and you can use these pedals, or your assistants can use them.
My God, these are a lot of tips!
Okay. What do --
Oh, my God, the tips are incredible today!
-- what do you prefer for your microscope, a floor stand, wall stand, or a ceiling mount?
Well, I did all of those [laughs]. And I ended up on the ceiling. So, that should tell you everything. Get your sculpture – or kinda big, especially if you can get rid of the whole stand and the wheels, then they get smaller in their profile and their body, so they can be hung on the wall, like Lisette said, or on the ceiling. But you might get a floor stand first, because some people erroneously think – so, now I’m spreading disinformation – think that they’ll wheel the scope from room to room to save money. And the scope will then always be in the wrong room. So, suddenly, you realize you need a second scope. And if you really get into this, you’ll have a scope in every operatory.
And it should probably be on the ceiling, because of the traffic patterns. Whether you have dual entry in the back or single entry, people are walking through, patients, the staff, you know, even patients sometimes have with – parents and adults are with them. So, you keep your floor all open, and it’s just a – you know, like chair’s going back, you don’t even look up there, do you. You just kinda fumble. How you doing, Mary? Everything’s good today? You fool around, and you find that light, and you pull the light in! Well, you just kinda fumble around. But there’s the scope. You just pull it in, just like you pull in your overhead light.
I’m just wondering, like, say you have multiple operatories. Would you get a microscope for every operatory, like at the beginning? Or do you just get one to try out in one operatory, and then you decide whether or not you need to see for a particular case, whether you seat [laughs] the patient in that operatory, or --
Usually, you have an operatory – one’s called “No Sight” and one’s called “Sight.”
And so, when you seat your patients, they’re seated according to whether you need to see or not.
No! If you believe that, you’ll believe anything I tell you. You get one scope at first. That’s great coaching, because you don’t know what you don’t know. And it might not even be the scope. I mean, you might get enrolled in scopes, but maybe not that scope. So, you don’t wanna invest in something that you don’t really need or want or prefer something different. Get a scope and demonstrate you’re gonna use it.
It really is gonna change your life. You’re gonna have more fun. You’re gonna sit straighter. You’re gonna have lumbar support. You’re gonna have arm rests. Chairs change, so you don’t have to go like this all day. Your arms are at rest. Pivot moves are what you’re doing. And then, if that’s really working off, you’ll go through the wall, the ceiling, the floor stand, and you’ll know exactly – they will know exactly what’s appropriate for them. And they’ll get their second scope.
So, maybe you have – like, I’m just wondering how you would place the patients, then. Like maybe if you were just gonna have a consultation, you might not need the microscope. So, that patient would be in the operatory where there’s no microscope. But then, if you’re gonna actually do work, that patient’s seated in that operatory with the microscope.
That probably works if we say this. See? That was pretty thoughtful. Consultations, you’re probably thinking, you’re just reviewing stuff, and you’re gonna speak to the patient. A lot of times, you’re doing diagnostic work so you can better speak to the patient and map out the more appropriate treatment plan. But maybe with transillumination, which isn’t a microscope, we can have a lot of transillumination of – there’s different wands and stuff for diagnostic work. So, maybe in a consult room, I would agree. You want it for working and looking, but maybe not in a consult room only, but you could do transillumination over there.
Yeah. I guess you just would figure out a system that’s working for you, if you just start with one. But you’re thinking maybe long – down the line, you might want one in every operatory.
Most everybody I know, and this is like since the ‘80s -- the mid-‘80s, when we got our first scope, almost every endodontist has them at some point in every room.
Okay. All right. I think we have time for maybe one quick question or a couple. So, I sometimes notice glare issues that affect my documentation. Do you know why this is the case, and do you have any recommendation on how to fix this problem?
Yeah. Thanks. That’s a great question. It really isn’t a big problem for non-documentating [sic] people. So, if you’re not documenting, you usually don’t have this. But if you’re documenting, and you’re giving presentations, or you’re publishing, or going on the internet, you know, that kinda stuff, you might notice streaks. You see these big, bright streaks across your work, and it drives you crazy. It’s because you’re getting glare off of metallic instruments. So, what we do is, we have them matted. In fact, I might’ve been [the first guy in the world to have rubber dam clamps matted. And I’ve talked about it publicly.
And it’s so often the case, I always get a kick out of this, companies started making matted clamps [laughs]. So, you don’t have to go out to a machine shop and say, could you sandblast this, because that would give it that less than shiny look.
Okay. Well, I just wanna remind our viewers that the inspiration for this Q&A on microscope tips came from the meeting you recently attended and lectured at, the Academy of Microscope Enhanced Dentistry in San Diego. So, do you have any, like, closing remarks about that meeting, maybe any things you wanna say to just close out on that meeting?
Yeah. With big pleasure. Your friend, my friend, Cherilyn Sheets, Dr. Sheets at Newport, runs the Newport Coast Oral Facial Institute. She would be a wonderful choice for you to go train. Her and Wu and Jacinthe Paquette, they run that Oral Facial Institute. They’ve ran it for decades, and thousands of people have matriculated through there, and they have basic instruction on how to use the microscope. John West teaches at IDEA. What is that? The International Dental Education Academy, perhaps? Anyway, you can Google the acronym, IDEA, south of San Francisco, just a few minutes, and they teach how to use the microscopes.
And finally, I’d like to end by saying, Randy Shoup, Dr. Randy Shoup from Indiana, he was the President – is the current President of the AMED group, and it was really great seeing all of his energy and passion with the colleagues. And you know, he really believes in microscopes. He’s a general dentist, and he doesn’t believe you should be doing – okay. This isn’t Ruddle. Randy says, you should not be touching a patient if you’re a general dentist unless you have a microscope. And that just came out on his radio show that I participated in last week. So, thanks, Randy, for letting me be on your radio show. And the rest of you, you now know a little bit about how to integrate microscopes and you know where to go if we didn’t get all your questions asked.
All right. Well, thank you for the information, and we’ll see you next season for a Q&A.
CLOSE: What Does Phyllis Think – Close Calls, Part 2
Okay. So, throughout our lives, we sometimes experience close calls, and by that, I mean a narrow brush with danger or disaster. Well, the Ruddle family has definitely had its share of close calls. So many, in fact, that this installment of “What Phyllis Thinks” is “Close Calls, Part 2.” [laughs]
Now, last season, in “Close Calls, Part 1, The Learning Curve,” we learned about little 8-year-old Phyllis getting stung by hornets.
We talked about near traffic misses, leaving kids in the car, kids wandering off, and dangerous relatives. Talking to you, Rosichs!
So, this segment of “What Phyllis Thinks” is gonna be “Close Calls, Part 2, Natural Disasters,” which is pretty self-explanatory. We’re gonna get Phyllis’s insight on natural disasters, what happened, how it could’ve been worse, was anything learned, that sort of thing.
Okay. So, let’s start with tornadoes. Now, we currently live in California, and we don’t really worry about tornadoes here, but you haven’t always lived in California. Why don’t you tell us about the tornado that hit your family’s farm when you were a kid in Michigan, is it?
I was about six, I think.
Yeah. So, we lived on my grandpa’s farm, my dad’s family. Huge farm, dairy and crops, and I don’t know, 80, 100 acres. It was like its own world. And I remember in the summer, every afternoon, the ladies – the older ladies would sit and rock on the big veranda thing, and they’d say, mm, it’s tornado weather today. It’s tornado weather. And nothing really ever happened. But the sky would get weird, and there’d be like a – you know, a stillness, and –
-- so, us kids would hear that. I love weather. I have always, my entire life, loved weather. It’s never scared me. Lightning, thunder, all that stuff, I have always been a huge fan of weather.
So, I would listen to them, and I’d think, oh, I wonder what a tornado is. And so, then, this one afternoon, the sky was getting more and more yellow and weird color, and all the birds stopped singing, and it’s like this stillness. And I thought, well, this is quite exciting. And they were just like, yeah. It’s definitely tornado weather. And then, all of a sudden, it starts to rain a little bit, and the wind sorta picks up, and we decided, well, we’re gonna have to go inside. And then, we’re just in the kitchen and just whatever, and it’s getting darker and darker. It’s probably mid-afternoon.
And my dad comes racing up the steps, and the farm – the barn was probably a good maybe 200 yards away, on the other side of the big driveway – comes running, and he hits the front door. He says, everybody to the basement! And he had seen the tornado coming. So, we are headed all down to the basement. We’re on the stairway when it hits. And it took off the front – the whole front porch, not the veranda we were sitting on, but the front porch of the house, by the living room. We hear this big loud bang!
And we’re – I mean, it’s like – I don’t really remember what we did next, except we stayed in the basement for a while. But the chickens were all gone, never saw them again.
The barn doors were gone, but the barn was fine. My dad had been up in the haymow looking out and watching the sky, because that’s what everybody did in tornado country is watch the sky. We didn’t have sirens back then. And he saw it coming. And they kinda weave as they come down the road. He saw it and jumped out of the second story onto a pile of hay and hit the ground running to come to the house.
So, that was my excitement. I thought it was quite exciting. I think the adults were a bit traumatized.
Well, like I said, we don’t worry about tornadoes much in California, fortunately.
But we do have earthquakes and fires a lot.
So, would you rather worry about a tornado coming or would you rather worry about earthquakes and fires?
My worst fear is earthquakes, because you do not know, period, when they’re coming, and it doesn’t matter if you’re sitting in bed, if you’re sleeping.
Don’t the birds stop singing?
I mean, it just – if it’s during the day, they do.
They will stop singing. It’ll get quiet. Dogs know it’s coming before humans do. But usually, you don’t know that. So, earthquakes, to me, are like not natural.
Okay. Well, why don’t you tell us about the first pretty big earthquake that we were all in, at the Arlington Movie Theater, when me and Lori were kids?
That was – we had moved here, might’ve been about two years in, in the late ‘70s we were here. I had never been in an earthquake. I don’t know if you had ever been in one. I don’t think so.
Oh, Montana, that’s right, when you were a child. And so, I had never been in an earthquake. Had heard about them, saw them on movies, that sorta thing. So, we go to a matinee in the afternoon, and sitting there, I think we were 10 minutes into the movie in the Arlington, which is the oldest place in town, and all of a sudden, the rows – or chair’s kinda wiggling a little bit. And all of a sudden, it’s moving more and more, and I thought – first I thought that a truck’s going by, which makes no sense, because it’s a huge, huge theater. And then, everything is moving, and my first thought was, save the children. So, I dive onto you two. They’re sitting between us. And he’s trying to get out of the row.
And so, we’re colliding and chaos, and --
I think I heard him scream, every man for himself [laughs]. No, I – no, I’m just kidding [laughs].
-- and it was – I mean, it’s dark. Everything is dark. The movie went off. We run out the side door, which you’re never supposed to do, because it’s an old building with tile roof. And when we got out there, everybody’s standing. And then, we still didn’t know what had happened. I’m thinking a bomb, something. And then, the Safeway next door, the entire front glass window had blown out, and there was glass everywhere. I remember that.
And then, he had forgotten the keys. He had to go back in and get the car keys so we could get home.
So that was --
Well, I should just say I never like to carry things in my pocket.
Yes, that’s true.
So, I was sitting on the car keys.
So, when we leaped up, because I didn’t think we should be caught in between rows, I was thinking we should get out – so, anyway, the keys were where I had left them.
So, that was our big --
That is definitely the biggest earthquake I remember being in. I think it was like 5-point-something on the Richter scale.
But here’s my next question for you. How do you react when there’s an earthquake, and how does it compare to expert recommendations? [laughs]
[laughs] I scream and run outside.
And that – I know you’re supposed to get in a safe spot, and I’m – for me, I just wanna get out under the sky. I don’t wanna be around. I don’t wanna be inside. And I thought about that recently, because I -- think I’ve gotten a little bit better. I usually cry, too, but I’ve – the last couple times, I don’t think I’ve cried. So –
We – I’ll just chip in – she hasn’t gotten better.
She crawls to the floor [laughs] in a fetal position and cries. That’s what I remember [laughs].
We have quakes in town, as you know.
But they’re – they’re little ones. But they’re – if we’re laying in bed reading the paper or something, and she feels a little shaking, you know, she –
Oh, my heart stops.
-- she’s like hysterical.
So, I always just say, yeah. You’re right. Every man for himself.
Now, I wanna go back now to something you were saying about tornado weather, because I often hear you refer to earthquake weather. So, why don’t you describe to us what earthquake weather is?
Anytime the weather is suddenly different or more still, that means to me – maybe it’s from growing up in Michigan, I’m not sure. But that kinda says to me, there’s something coming. Something different is coming, and it might be a fire, might be an earthquake. We haven’t had one for a while. So, I think about that.
[Knocks on wood]
But that’s – I relate to that stillness as being related to natural disasters, and it’s kinda like the eye of the hurricane. I’ve never been in a hurricane, but I’ve always wanted to see how it is in the eye.
Yeah. I’ve always kinda been fascinated with that whole concept of it --
-- being like so quiet and calm.
Yes. I know.
All right. So, is there any way to prepare for an earthquake, in your opinion?
Keep your shoes handy. Don’t run out barefooted.
That’s the only thing I can say. Grab your phone and put your shoes on and run out the door. I still will head out the door.
No matter how prepared you are –
-- it’s still gonna be a surprise.
Yeah. And you have no idea if it’s gonna be a long one or a short one or what. [crosstalk]
Yeah. I know. That is something – like, sometimes they’re just so rolling, and they seem to last a long time. And sometimes it’s more like a jolt.
All right. Well, let’s move on to fires, because we don’t have a lot of time.
But didn’t you also have a home that burned down when you were a kid?
It was our family cabin. And that was – fires in Michigan were rare, because we don’t have forest fires. But this was the result of -- my uncle and his friends went deer hunting, and when they go out for the day, they hunt all day long, come back to the cabin at night. And it was in the winter, in the snow. And so, they packed the stove really tight with wood to keep the fire burning while they were gone, and it exploded.
Oh, okay. That’s like not recommended. [laughs]
So – no. Not recommended. It was quite a heartbreak for my – it was my mom’s family that lost this big cabin and even the big pine trees. Everything burned. It was very bad.
That’s hard to lose everything.
All right. Well, we have never had any of our homes burn down in Santa Barbara, but we have had to evacuate more than once. If you are told by authorities you need to evacuate, do you?
I do. Him, not so much. So, sometimes we are in different places for a short time. He wants to stay and fight it, but I --
-- I will leave. I don’t see – I mean, things are things. And you take your pets and go.
Okay. Yeah. I think that some of the footage we see of fires nowadays, it’s not just like you could stand there with your hose and put it out.
Yeah. This has changed.
Yeah. Definitely changed.
Okay. So, with tornadoes and earthquakes, there can be a lot of devastation, but they pass quickly. Fires can burn for days and weeks. What do you find most difficult about having a fire burning nearby?
Well, there’s the insecurity, but it’s mainly the air quality.
Yeah. Smoke and ash.
That’s what I notice, living in Santa Barbara. We get – even if there’s a fire in LA, the way the winds come, it will affect our air here, and that’s not good to breathe. And especially when there’s house fires, when you know, homes burn, there’s so many chemicals and things nowadays. So, I – I’m concerned about air quality more than the ash. The ash is annoying, and you’re not supposed to hose it into the sewer and stuff like that.
After that last fire we had, the Thomas Fire, and how it traveled almost like – I don’t even know, like 20 miles overnight or something --
-- it went so far in the night, that that’s kinda like – even now, I feel like even if there’s a fire burning, and it seems like it’s far away, it --
-- could come to us in the night. So, that’s like --
-- all right. Well, that’s about all we have time for. To close out, do you have any final thoughts or any advice you want to give viewers about dealing with natural disasters, or just anything you wanna say?
I say, enjoy them. I love a good storm.
I always have. I miss that in Santa Barbara. I don’t count earthquakes. Those are not exciting for me. But just any – I just love weather, and I’ve – I kinda follow my – the rest of my family lives in various parts of the country, and I follow the weather that happens in Michigan and Texas and the Northwest and – just enjoy it. Sit back and enjoy it and go --
An opportunity to mark yourself as safe on social media [laughs].
-- absolutely [laughs].
Okay. Well, thank you for joining us for – I guess this is your eighth time doing “What Phyllis Thinks.”
I think so. Yeah.
And I – and I –
-- do think, unlike what it says, “Does Phyllis Think”? [laughs]
Well, yeah. The way that we have this set up, it’s – I guess it looks like what – it looks like “Does Phyllis Think”? because she’s [crosstalk] --
She does think.
-- okay. Well, anyway, we’re gonna fix that graphic. [Music coming up]
Very little thinking.
All right. Well, thank you, and we’ll see you next time on “The Ruddle Show.”
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
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