There are many factors that influence the long-term retention of critically essential teeth. Certainly, endodontic procedures pose treatment considerations when performing restorative dentistry...
Artificial Intelligence & Common Errors Incorporating AI & Endo/Restorative Errors
When did you last do a random act of kindness? No excuses, no delays, do one today! Then, in this final show of Season 8, Ruddle and Lisette turn the discussion back to artificial intelligence, this time looking at how to incorporate AI into your practice. Next, Ruddle discusses common endo/restorative errors and subsequent failures; make sure you aren’t an offender. The season concludes with Ruddle and Lisette venturing out of the studio to another one of their Favorite Places! Hint: Roses and Colonialism.
Show Content & Timecodes01:01 - INTRO: Random Acts of Kindness 08:16 - SEGMENT 1: Artificial Intelligence – Incorporating AI into Your Practice 20:33 - SEGMENT 2: Common Endo Errors – Endo/Restorative Failures 45:56 - CLOSE: Favorite Places – Santa Barbara Mission
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Downloadable PDFs & Related Materials
Dr. Herbert Schilder used the title, "Predictably Successful Endodontics," to describe many of the lectures he gave over about a 40-year timeline. In the most simple and direct way, these words promise longterm treatment success that is not only possible, but attainable...
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.
…In the real-time scenario, I’m just wondering how that – we were actually just talking about how that might work. Do you have a laptop in front of you, and it’s actually giving you instructions? Maybe you even have an earpiece [laughs], and someone’s talking to you to say something. [laughs]
Abort! Abort! Abort!… [Music]
INTRO: Random Acts of Kindness
Welcome to “The Ruddle Show.” I’m Lisette, and this is my dad, Cliff Ruddle.
How are you doing, Lisette?
Pretty good. How about you?
I’m really excited. Hi out there, everybody, and we’re really excited about the last show of the season. But not the last show ever! [knock on wood]
Okay [laughs]. Well, random acts of kindness. What are they? Well, they’re actions that help people or positively impact their lives without the giver expecting anything in return. And since we are heading now into the holiday season, we thought it fitting to start our show off today talking about random acts of kindness. Now, I don’t want to suggest that you should only practice random acts of kindness during the holidays. Rather, every day should be filled with kind actions.
But for a lot of people, the holidays can be very stressful and pressure filled. So, taking a little bit of time out of your busy day to, you know, help someone with a gesture of kindness, whether it be big or small, is maybe even more powerful than people generally realize. Correct?
Yeah. I think that it’s very much misunderstood. The New York Times did a recent article based on research, and it actually showed that people benefit greatly from random acts of kindness. It makes an emotional boost for them that’s unbelievable. What was ironic is the people that were practicing the random acts of kindness didn’t seem to know the effect it had, so they pretty much didn’t do it as much as they could’ve or should’ve or would’ve.
Right. I think that people are even more touched by – not just by the action, but that someone thought of them. And --
And it’s not just the size of the random act of kindness. It’s actually the big boost it gives these people. And I didn’t talk to you about this, but actually, when I see you give a random act of kindness, or I do, I actually get a little benefit myself. So, there you go! You might want to do it.
[laughs] It’s contagious.
Okay. Well, it makes me think of something you had told me and Lori when we were younger, and that is that there are givers and takers in the world. And I don’t mean in the material sense. So, for an – as an example, when you’re having a conversation with someone who’s a giver, you might feel uplifted. You might smile or laugh. And when you are done with your conversation, you feel maybe inspired or just like more – good energy. Alternatively, when you talk to someone who’s a taker, you leave feeling drained, and like all the good energy and life has been sucked out of you. I kind of think of like a Dementor from Harry Potter. [laughs]
Yeah. I did say that, didn’t I? Givers and takers. Yeah. I just had to lay down and sleep because I was thinking about some of the takers that left me completely --
-- rode hard and put away wet, as they say in horse work. Okay.
Yeah. So, anyway, reminds me of my dad. I think you called him the MVP. For those who don’t know, overseas, that would be the Most Valuable --
-- Player of random acts of kindness. But my pop led the way. And one thing that I noticed that I actually learned as a kid, four, five, and six, walking through the streets of Seattle – Seattle was like – was not so easy, even back in [laughs] the ‘50s, everybody, and especially on the waterfront before they took down the overpass and the freeway. So, it was a tough area.
And we would walk down the streets. There was no purpose to where we were going. We were only going to help people. So, we’d get in the car, and he’d say, we’re gonna go try to help some people today. And he would never give people money because he knew they would buy drugs or beer, but he knew he could get them a meal. So, I had many [laughs] meals as a small kid with some homeless person, and we sat there for like 20 or 30 minutes, maybe 15, because they ate like really fast --
-- and they ate a lot. But it was – it really impressed me. And he did lots of things. He’d help people put roofs on their house. He mowed lawns. He did gardening. He would get groceries. He always was doing this stuff and I always thought, he’s crazy. And then, as I got older, I realized he was getting a lot of juice out of that, and the people were benefitting.
Yeah. Well, if you can’t think of any ideas – maybe you want to do random acts of kindness, but you’re like, what can I do? Well, I – we have this list. I have this list here. It’s “100 Random Acts of Kindness Ideas.” And we’ll have it in our Show Notes, along with a link to the New York Times article, too, if you’re interested in that. But I’m looking at the list. I see some of these things are so simple and easy to do, like hold the door for someone, pick up some garbage and throw it away, maybe return – help someone return their shopping cart or give an unexpected compliment. Do you have any that are kind of your go-to’s?
Well, yeah. Because of my dad, I – actually, it’s kind of a game with me, but it’s not really contrived intentionally. It just sort of happens. But I walk every day, as you know, early in the morning, and there’s usually walkers out there. And one day, I saw this old guy coming up his steep driveway with his walker, and he was trying to get his paper. His newspaper was up the road a little bit. And so, I ran over, and I grabbed it and put it under his arm, because he was on his walker. And he just looked at me, and he couldn’t believe what just happened. And I said, “Have a great day”!
So, just stupid little things like that. You don’t have to go way out of your way. I like to do a spontaneous email. Remember, if you do it all the time – like I get Phyllis coffee on Friday, Saturday, and Sunday. That’s not a random act of kindness, because it’s a regular thing. It’s gotta be random, and it should be very creative. And you’re going to see people smile, and you’re gonna bring out a moment in their life that is joyful.
Yeah. Because now, I guess if you didn’t bring Mom coffee on Saturday, she’d be a little irritated, like, what’s going on? Why – where’s my coffee? [laughs]
Hell, I want a cup of coffee on Saturday, and that’d be a random act of kindness for Philly Girl.
Well, for me, I like to – especially during the holidays, I – like at the grocery store, I’ll see like a little, old lady that just has like the full Christmas-themed outfit on or [laughs] something, and I, like, compliment her on her sweater or something. And you can just see their faces light up. Like, when they’ve taken time to actually put together this whole thing, and someone notices it, then that’s really nice. Sometimes I’ll plant an orchid in a nice pot and give it to an acquaintance, you know, some – and they’re – the people are just blown away, you know.
That’s really cool. You know, everybody should try this. But if you walk down the streets of life, you’ll see lots of people coming at you. If you just glance at them, everybody’s preoccupied, everybody’s got something going on in their head. They’re somewhere else. Usually, the expressions are not joyful or happy. They’re stern or – you know, they’re focused or whatever. If you just nod at somebody and smile, you will see this person kind of hesitate, and the most amazing smile will frequently come across their face, and you know you made their day.
Yeah. Well, definitely, I think a good goal is to try to do at least one random act of kindness a day, or maybe even two, one to someone you know, and one to a complete stranger. I don’t know. It’s just some ideas. Well, we have a great show for you today. So, let’s do this.
The last show of the season. It’ll be a random show of kindness.
[laughs] [Music coming up]
SEGMENT 1: Artificial Intelligence – Incorporating AI into Your Practice
All right. So, today, we thought we would devote another segment to our artificial intelligence series. And I say “series,” because this will be our third show that we’ve done on artificial intelligence and its applications in dentistry. So, just to remind everyone, “AI” generally refers to a software or machine that can mimic human intelligence. And the idea is that by analyzing a large body of data and applying certain algorithms, that AI will be able to problem solve or predict outcomes. So, previously on our show, we talked about how AI could be used for diagnostics, specifically, detecting root fractures and caries. And then, we’ve also talked about how it could be used to predict who is most at risk for tooth loss or a periimplantitis.
Today, we wanted to talk about how AI can be incorporated into your practice.
Yeah. It allows us to go far beyond ourselves or what’s actually humanly possible by using vast datasets to better interpret and identify, if you will, diagnostic issues. And of course, it can help us do our treatment planning. And if you think carefully, treatment planning really means probably better outcomes. And then, of course, it can help us educate insurance to be more efficient and to be more objective.
Okay. Well, let’s start with talking about improving diagnostics. Like, how does AI help with that?
Well, with diagnostics, you know, we have to remember that these vast datasets are millions and millions of cases. And when you can train machines to see pixels, which doctors don’t really see – we see groups of pixels – they can start to see things we can’t see. So, that should improve the identification of caries, periodontal defects, bony pockets, horizontal bone loss, vertical defects. It can prognosticate teeth that might need coverage, restorative work, things like that.
So, probably, if I keep looking here, I can see – we might not think about this, but it can also detect cancer. And – in other words, you can take an internal picture – it’s digitalized. You can send it to a database, and it can be compared to a vast group of lesions that look similar, whether it’s raised, smooth, pedunculated, things like that. And you know, we always talk about, do you want a second opinion? Well, how about getting not only a – you know, patients trust the second opinion, but that would be trust with verification.
Right. Like a second opinion in the office.
Yeah. In office, in real time. So, that’s good for patients to see. And I don’t know that our audience knows this, but not only can you – as an example, for caries, you can pretty much prognosticate how close it might be to the pulp. When you get close, what is the base you should be using to protect the pulp? Should you go ahead and do it? They can tell you all these things and send you a written report – a written report.
Okay. Well, like regarding treatment planning, now, we’ve talked, like I just said, about how it can be used to predict who is at risk for tooth loss and periimplantitis. But how else can AI be used to treatment plan?
Well, I’m not an orthodontist, but there was a whole group of pages I read about, you know, arch wires and how tight and how fast you can move teeth, what’s safe, what’s not safe. Again, you’re dealing with vast datasets that have looked at – you know, you move them too fast, you might get apical root resorption, as an example, or replacement resorption. So, orthodontics. I can see here we can do this in implants. We did last – a few times ago. Not only was it about sites to place implants but prognosticate about their prognosis and the outcome of that implant, based on other conditions AI can detect.
We’re gonna look – in the future, you told me we’re gonna have a continuous series. But we’ll look at AI as it specifically relates to endo, but there are a lot of applications in endo. I’ll just leave it at that. Well, AI can look at, again, pixels on photographs and images. It can be used to look at medical records. It can be used to analyze – how about prescriptions? Who doesn’t come in? Our patients are 60, 70 years old, and they come in with a vast array of meds that they’re on. A lot of times, they even pull something out, and it’s like – well, you can feed that into AI, and they can give you all the drug-drug interactions, possible problems. Maybe that saves you a call to the physician and wastes their time, your time – not “waste their time,” but take their time. So, AI is gonna have a lot to do with improved safety as we deliver patient care.
Yeah. I think the key takeaway with this in the treatment planning is that it can take from – it can look at so many different areas, the photographs, the x-rays, the CBCT images, the patient’s medical history, and then put the – cross-check everything together and put it all together to help come up with some global treatment plan that maybe you might not only think of, just being an individual, just yourself.
You recall perfectly the show we did about – you said “medical.” And there’s socioeconomic levels. And it really was used to prognosticate – you can do a lot of really great stuff, but maybe it’s not going to be able to be afforded or can’t be taken care of or – or maybe you get them well slowly over time, but AI can help be the North Star.
Okay. So, let’s – this does seem very promising and exciting, I think. But what comes – like when we talk about just managing your day-to-day practice, like how can AI be used here?
Well, you might not like this, because you know, there’s this expression, “Big Brother [laughs] is watching.” But you can have systems and structures in your office – we’re speaking about your computer and a camera – and it can watch expressions, intonations, gestures, you know, things you’re doing. And you know, the patient may walk out and say, I want to think this over [laughs]. Or they might want to say, I could get another opinion. But in real time – it’s coming very soon – I think you told me it was three hours, some time ago. And then, they got it down to 15 minutes on feedback. And pretty much now, they’re getting towards real-time feedback.
But you might be able to go back to that patient – because we always say, you only have one chance to make a first impression. So, you might have you redo that first impression if AI’s detected that maybe you were a little snobbish, short, maybe you were distracted, you weren’t your usual fabulous self. And then, maybe you can get back to the patient and do a little corrective action and steer things back to normal.
Yeah. I think that it – I’m trying to – like we were talking about how it used to be 3 hours, then it’s like about 15 minutes now, which is still a good amount of time, you know, that if you do make a mistake, you know, you can make a course correction. In the real-time scenario, I’m just wondering how that – we were actually just talking about how that might work. Do you have a laptop in front of you, and it’s actually giving you instructions? Maybe you even have an earpiece, and someone’s talking to you, to say something? [laughs]
Abort! Abort! Abort!
All right. Well, with all this change on the horizon, how does a clinician not feel overwhelmed? Because if – especially if you’re an older clinician, and you might be kind of set in your ways, like, how – like, how can you even go about incorporating this? Or do you even want to, really?
Both are correct. The answer’s both. [laughs]
Well, we’ve all – if you’re anywhere around my age and generational chronological time on this earth, you have already seen hesitancies and tendencies. You know, change creates upsets. Change creates chaos. And so, how we manage change is by talking to others, looking at what it can do, and potential, because change could be the key that unlocks the future. Examples that we’ll all understand, were you the first to use rotary when it came out in ’91 and 92? Nickel titanium’s an example. Were you the first to have CBT in your city? Were you the first to use the microscope? Were you the first to do anything?
Most people -- you know, there’s the early adopters, and then, the next wave comes. And then, there’s the people that, I don’t need this technology [pounds fist on table], because I am so perfectly trained that nothing escapes my uncanny abilities. So, anyway. You can use this a lot, and I think we’re gonna see it come in, because these people that are a little bit reticent, if they start classes, and there’s formal instruction at the dental school, just like when we did microscopes at the AAE, it had to get integrated into grad programs. But by 1998, all the kids coming through thought microscopes had been at the schools for years.
You told me the story about how when you were in dental school, and you would look at a case, and you would come up with – like, you would talk – would share with everyone how – what you would do, how you would treat it, and then compare everybody’s ideas of what they would do. And – but you needed a classroom to do that. But now, it sounds like there’s – they’re developing software where you can just by yourself look at a case on the computer, maybe come up with – you know, like test yourself, like, what would you do. And then, you could check it, based on the AI, what dentists generally do, or endodontists generally do or what they say should be done, you know. So, it’s just kind of like – it’s a way to – it’s almost like flashcards, kind of. Like --
It’s amazing! You could sit there, and you can look all over the world about, quote, best approaches [laughs].
You know, you wonder who programs it. And of course, then we’re gonna have programs that reflect their philosophy. But again, it’s based on huge datasets. So, at some point, you kinda get rid of the things over here and the things way over here, and you kinda have what most – what the preponderance of the most people would be doing, if they saw this kind of a case. So, yeah. It’s a great feedback, isn’t it?
Yeah. And if dental schools start incorporating AI, like regularly, then the graduating students will already have some knowledge of it when they come out of school. And I can actually see a reality where maybe a more established practice group might want to take on a newly graduated resident because they can maybe help them incorporate AI into their practice. Because it – it’s not new to them. They just learned it in school, and they think this is how it works. So, I mean, it’s kind of like what we have here on – we have Isaac helping us on “The Ruddle Show.” [applause] He kind of keeps it all kind of young and more – well, hip [laughs], whatever. Like, to use [laughs] --
Well, Hell, he sure does, because I had to use AI to even get from the house to the studio this morning.
I think you told me a quote that I guess is by Pearl Buck. What is that quote? It’s about young people.
Oh, gosh. Young people – the last page, I believe. Well, something about --
Here, I have it. “The young do not know enough to be prudent, and therefore they attempt the impossible, and achieve it, generation after generation.”
Yeah. Because they don’t know what failure looks like, exactly. And they’re – and you know what? When you’re young and you fail, you just get up and try it again.
Okay. Well, that – it’s – it sounds like it’s all going to be an exciting future. And this is not our last artificial intelligence segment, because you actually were just telling me before we started shooting this segment that you just saw another article about specifically the applications of AI in endodontics. So, that will probably be Part 4 of our series [laughs].
All right. Well, that’s our segment for today, and stay tuned for more AI next season. [Music coming up]
SEGMENT 2: Common Endo Errors – Endo/Restorative Failures
Hi, again. Ruddle at the board. Cliff Ruddle. Here we go. Listen, this is the eighth board section that I’ve done just this season, and I’ve tried to pick a variety of different topics that I think are pretty common. And one of the things that’s really common are errors. But yet, I look at the screen, and I don’t see the word “errors” anywhere. So, maybe for help, we could just write down, “errors.” Okay? Because failures can be because of errors, and failures can be because people just bit down and broke something, and that’s really nobody’s fault.
But I’m talking about iatrogenic stuff, things that we tend to induce or cause or by not using good thinking, critical thinking, not having maybe the sufficient experience to pave the way ahead, we do things that sometimes aren’t as predictable. I’m gonna show just three cases today. They’re very, very simple. And one of the things I’d like to talk about first is decision making. Okay? That seems like – yeah. I do that, Cliff. What can I learn from you on that?
This patient is sent into Cliff Ruddle to analyze the previous endodontic treatment. You can see its silver points. Recall Jasper – Dr. Jasper – introduced silver points in the 1930s. They were taught at countless dental schools. Thousands of dentists learned to use them and place them, and millions of patients received them. And of course, they were a pretty good filling technique. We could use these wires to go around curvatures, and they were rigid, and they were very opaque, and they look very dense, radiographically.
So, when you look at this, you know it’s an – a silver point trying to fill into, if you will, an irregular cross-section. And if you think of the distal root, at any level, as we go down through that root, that root typically, in a cross-section, you might have a root with a furcal side concavity, and you probably have a canal that looks like an hourglass, maybe. So, a silver point is not gonna remotely fill that cross-section. So, there’s a big reliance on sealer, and sealer washes out when exposed to oral fluids.
So, I didn’t try to push the patient, nor should you, into let’s roll up our sleeves, and with great enthusiasm, let’s remove the silver wires, because these silver wires are pretty parallel. They’re binding in an underprepared canal over a lot of distance. That means they’ll – it will be a little bit difficult or pretty difficult to remove them. Now, I have great opportunities in the distal root because of the cross-section. I can usually place a file lateral to the silver point. But after all the discussions, risk versus benefit, pros and cons, what if we don’t retreat, and if it fails later? What would we do then? After all those discussions, the patient has to decide. My job is to present information. It’s the patient’s job to make a decision.
In this case, I was outvoted, two to one. The general dentist took the side of the patient and said, okay. You just see caries. Your tooth is fine. You can chew equally well left or right. You can really bite down, and you can really load this tooth. So, let’s just clean it up and put a new crown on it for you. And that was what was done. And six months after the cleanout and the new casting – and you can see our access is misdirected – but six months after that, the patient was referred back in because the patient said the tooth is sore to mastication, to biting pressure. And of course, the film tells the story.
So now you can argue, even if we had a perfect seal with the margin, there was enough substrates in that root, and even though it was sealed off coronally, they had substrates to continue to proliferate, and they continued to grow. And the egress of breakdown products was out of those terminuses apically and out of the bone. That’s osteolytic. Bone pulls away, and they got a frank lesion. So, I never saw the patient again. And this is just a simple example how errors that are made in thinking – so, I’m not talking about maybe making an error, and you drill a post path that’s malaligned with the long axis of the tooth, and you deviate off axis, and you get close or perforate.
I’m talking about a decision just as simple as, should we retreat it first and do the new casting, or should we do the new casting and hope it works? Maybe neither one’s wrong, as long as your patient is advised and knows the risks versus the benefits. All right? So, that’s case number one.
In case number two, this is a patient that flew in on a plane. They came from Arizona. And that means, in this instance, they had about 60 to $75,000 worth of dentistry. It was full-mouth reconstruction. If you think I’m exaggerating, real quick, let’s do the math. There are 28 teeth. Every one has a PFM on it. So, 28 times $2,000 a crown, that sounds like that $56,000. I didn’t even get to the core build-ups, the endodontics, the posts, and all of that. So, pretty much full-mouth reconstruction. I would have to say, aesthetically, it looked quite good. I would put it more in the cosmetic world than the aesthetic dentistry world. But more or less, the occlusion was there, the morphology was there, the look was there, the perio was pretty much there, the embrasures looked good.
Everything was good except the maxillary left first bicuspid. Now, this is a big error. You know, we can talk about a failure. It’s also failing. So, it’s an error that’s failing. How about that? And you think common. Should we use the word “common”? Well, if you’re an endodontist, it’s quite common to see posts. You know, there’s direction and diameter. And we always look at, are they appropriate for the root that holds them. We always look at, are they going up the long axis. So, we might want that axial slice, even with hard beam refractory artifacting [sic]. We want to see is that post centered in the root in any direction.
Certainly, three endodontic angles can tell you that. This is an example where it was sent in for surgery. I do not think Ruddle – you know, we can kind of see the bone scalloping across here. We’re – it does not probe. I can probe with or without anesthesia. And with anesthesia, I can probe a little bit more intentional. There are – is no probing around that tooth, circumferentially, two- to three-millimeter pocketing. So, I know if I lay a flap, I’m going to get about a millimeter at least or a millimeter and a half of crestal recession.
Decision making. I know that when I make a repair, I am not just repairing. I have to grind this post back into the root and make a box prep so I can get this sealed up. And then, there’s a silver point, and it’s not going to length. And then, there’s gutta-percha in the other one. This has a little bit of everything. This is like a variety store. A patient comes in with a little bit of everything, and we can do almost anything we want, because everything’s possible, because everything’s already been done. Oh, come on! Get serious! If you don’t laugh about these cases, you’re gonna cry, because when you see this kind of dentistry, you’re wondering, who would make an error like this?
I mean, who would do all this dentistry and not get the post up into the canal? Don’t tell me they bounced off the silver point and deviated inadvertently to the lateral aspect of the root, because silver points in that size, you can probably bite them apart with your incisal edges of your teeth. So, the drill should stay on the silver point. You should be following the silver point if you’re not gonna take it out. You should be looking constantly, am I on the silver point? The silver point is presumably inside the canal and centered in the root. Okay?
Pins. So, what are we gonna do? I can’t do surgery. I think we have to disassemble the tooth. And we have to talk about an implant because you could extract the tooth. You could go and take the tooth out. And then, you might say, we’ll do a bridge. But then, you’re gonna lose this casting at 2,000, and you’re gonna lose this casting at 2,000. You’re starting to really open up a complicated differential diagnosis and treatment planning. And the treatment planning is going to dictate precisely the prognosis. So, with all these considerations, long-distance calls with the general practitioner, the patient’s going to fly in, we decide to disassemble, take the tooth apart. And that was the treatment decision.
Then, here we go. I’m not gonna include all the photos. That would be another time if we’re actually teaching how to do it. We’re talking about treatment decisions and common errors that lead to failures. So, the crown comes off. That’s not a big thing. Cut it off, make a slot, up the buccal, across the occlusal, down the lingual. Use a crown splitter, boom, pop off the mesial and distal sections, and now you got access. Look at that pin. Okay. So, we can keep going. We can get the post out. Yes, I got the post out with the Ruddle Post Removal System from SybronEndo.
Listen. You can use vibration. A lot of you say ultrasonic piezoelectric. It’s gonna knock them all out. It knocks a lot of them out. It does not knock all of them out. That’s why we invented the Post Removal System, so we could very mechanically grasp the head of the post, in a very controlled manner. Pressure down equals pressure out, and we can jack that post up and out of the canal. And once we get that, we have to have another decision. Decision making. Critical thinking. Are you going to then go after the silver point first and get that out and then clean and shape and pack? But when you pack, will you push a lot of stuff out, and now you got a enormous cleanup, it’s probably impossible? Or should we go ahead and at least put our CollaCote out and get a barrier going? And we’ve talked about this on previous shows.
And then, I can lay a little bit more material in here, and then I can go ahead and clean and shape, keep my irrigants in the tooth, no bleeding to worry about. But I don’t want to do my actual repair until I pack, because I don’t want the 2,000 pounds per square inch – PSI – I don’t want that to build up hydraulics and maybe dislodge my just-placed lateral repair material. So, think about all the steps and how they’re gonna work together in unison to guide you to a successful conclusion. So, we got that. Got this walled off. So, this is all walled off, and now I’m down to getting out the silver wire and getting up to the end of the root. And you can see, we’re kind of mapping away up towards there. But you look at these roots. These roots are pretty broad. These roots are pretty broad.
And a lot of times, when somethin’s coming up and bending off like that, you’re thinking, should there be something that comes off like that? So, all of these things, experience helps. Experience helps. There aren’t really textbooks, chapters in dental school [laughs] that tell you how to do this. I never learned any of this in grad school at Harvard, okay? Just didn’t. But we got patency. I’m thinking we’re not symmetrical. We’ve had shows on the 13 or 14 ideas to find previously missed calcified or aberrant canals. Then, we can come along, and we can get the shape – the shapes appropriate for the roots. We irrigate a lot. We get hydraulics during the pack.
If you do 3D irrigation, even before the EndoActivator, even with the EndoActivator, even post-EndoActivator, some method that can get into the areas where you can’t clean, because you’re doing retreatment on a very strategic tooth. Everything you do should really be your best effort to set this abutment up and have it serve as a foundation for long-term, predictable success. I used, in this era, Super EBA – Super – we’ve talked about this on other shows, E, ethylbenzoic acid. That’s the powdered liquid that goes in here. It makes the number one – this is the number-one case in your heart and the number-one case in the program for this date – and you go ahead, and you get the pack, and you’re feeling pretty good about it. And then you keep working, and you keep working. Okay?
So, the patient – this is exactly post-op, little different angle. Learn to have your assistants come in, in those horizontal angles and move that cone several degrees to throw things around, you get different, second, third, tertiary opinions that are always helping to guide you forward. And then, of course, a little bit later in time, the patient flew back in. It wasn’t so easy to get this guy in. But when he comes in, you can see the remarkable bone level coming right across. I’ll get this out so you can see it before and after. But you can see the bone has come in here, and it’s butting up against the lateral aspect of the root. We still don’t probe.
We have a great result. And hopefully, this will go quite a bit more time in terms of years. Years. So, on this error, on this failure, what I did was, disassemble the tooth and went back to basic fundamentals, starting from the beginning, and working my way towards complete endodontics and getting the coronal seal with the lateral repair.
Let’s look at another one. The last case. Gosh, I’m having fun on the last session at the board! And now I’m really getting ready with Lisette behind the scenes, and we’ve got shows coming in 2023, always about what you’re doing out there in the field. Always to have you thinking and getting a little bit better. This is an interesting history. This patient came in with her husband. She is 78 years old, just a little bit older than I am now, but this was many, many years ago. And her husband was the general dentist. The husband had done a lot of work in his wife’s mouth, and he was not so happy that he was with her with me. But he had referred his wife to a periodontist, and the periodontist said go see Ruddle.
So, the guy – the wife was very kind, and she was very hopeful that something could be done. She had just gone through a lot of recon work. And you know, her husband had done the work, and he has to tell her that the lateral incisor’s not doing so well. And you can begin to see several things. If you look here, you see a little debris. Well, yeah. There was a history of endodontic surgery and going to the endodontist and having an apicoectomy. If you look carefully, you can see the PDL up here. That is filled flush, but it’s just because it’s a double root, and it’s the limitations of two dimensions of a three-dimensional object. Sinus tract’s being traced with gutta-percha, massive lesion.
Always get the other angle. Always get the other angle. You know, I know, we all know that if any one angle shows something as significant as this error, it’s not right. And that would be more representative than the other angle, which tends to superimpose the post over the gutta-percha. So, now, we know that it’s mesial. There’s a vector of perforation probably mesial. There is certainly one is to the palatal. The last case, I said I couldn’t approach it because the post perf was too far crestally. Well, I might have a little bit more vertical bone here than I had on the previous case, but the previous case, it was better in the patient’s interest to disassemble.
I wanted to take the crown off. I wanted to get the crown out. I wanted to get the post out. I wanted to take the gutta-percha out, and I wanted to reclean, reshape, and repack, do an internal repair, because it doesn’t matter. Right? Surgically, it matters where the perf is, but non-surgically, it doesn’t matter if it’s on the east, west, north, or south wall. Doesn’t matter. Buccal, lingual, mesial, distal, does not matter. But I was vetoed by the doctor, and he said, you are not going to be doing any of that kind of work. You’re not gonna take this tooth apart. We’ve been through too much, getting all these crowns in here.
So, I said – he said, I want you to do it surgically. I said, I don’t think I can approach it surgically. It’s going to be too palatal. How do I get behind the root, come back in and prep a metal post back into the body of the canal and make a repair from the lingual, all blind? Even with Zeni mirrors. These are those little micro-mirrors we use in microsurgery. You’re gonna have a hard time getting them into the field and seeing properly to – if it makes sense to do it, it makes sense to do it right.
So, I finally said -- and this is a long story, but this is errors and failures and what needs to go into the conversation, because it’s going to pave the way for the result. So, I basically said, okay. I’ll try surgery, but you’re gonna be right here. I know you’re gonna come back, right? You’re her buddy! So, you’re gonna be right here helping me, probably even telling me, now go left, Cliff! Now a little more – okay. Thanks a lot for your help. Thanks a lot for your help. So, basically, let’s just – I’ll pull up a flap. We can both inspect it. If I’m lucky, and it’s a mesial, palatal perf, I can maybe get to it. But if it’s on around the corner and more directly palatal, I’m not gonna be able to approach it. He said, great.
And then, he said, then what? I said, well, what are you going to do if I can’t approach it? He said, she’d lose her tooth! I said, right. What if I extract her tooth, repair it in my hands, and replant it? He was not happy about that. He actually called the periodontist, and the periodontist said, Ruddle is our last actor. If you want to save the tooth, I would go along with the plan. So, this is what we did. I don’t like this photo, and I wasn’t even gonna include it, except I wanted you to see just raising up an intrasulcular full-thickness flap, you can – I want you to see that without doing any work, there’s our lesion. It’s busted through the facial cortical plate. “Busted” in European language, around the world means it’s broken through the cortical plate.
And you can see, then, we have a big lesion. So, on the next slide, we’re going to enucleate the lesion. So, here we are, cleaning it out, using the business end of the curette against that palatal wall, the mesial wall, towards the central. Once that granulomatous tissue is freed up, it’s coming out, and there is no way – there is no way we can get – we can’t even see the post. Okay? So, he has – he’s looking in there, and I’m looking in there, and he’s looking in there, and he’s shaking his head, because the general dentist, the husband, he realizes the tooth is coming out. So, I gave him another choice. I said, I can put the flap back, and you can take the tooth out tomorrow, the next day, next week, next month. It’s your call.
He said, no, go ahead. He was pretty gruff about it. So, we go ahead. Here’s the tooth, out. I want you to look at the tooth carefully. I told you it had a history of surgery. But I want you to really focus in on the end of that root. I mean, this is what Ruddle sees a lot when we do surgery. This is why I like to do a preparatory, pre-surgical visit, where I redo the endodontics to set up the surgical procedure for the result -- the long-term result, not a five-minute result. Notice the black breakdown and staining around the gutta-percha. This thing was leaking like a sieve.
And of course, we can start to look at different views. So, here’s the central incisor, looking at it from the facial. You can see the bevel on the root. Here it is a little bit of axis from the lingual, the palatal side, and we got a big zone of attached tissue. We know not to curette these roots. We know not to scrape these roots clean. We know that from our avulsion research, the Andreasen work that we’ve talked about, even on this show, when we gave a tribute, when the – Andreasen passed away. And he gave us a lot of information about Sharpey’s fibers and how they tend to come across from the socket side, the bone side, and find the same damn fiber on the tooth side, and they find each other, and they reconnect. They reconnect.
And if we do a hard fixation, those fibers can’t find each other, and then we get more predisposition for – what? External resorption. So, we did have to scrape off enough, though, to actually expose the field of activity. And that’s the post that was leaving the root. So, what we did on this case is, you gotta prep this post back in the root, probably up to about right here, because I need to have – I need to have a finish line. So, you can have a big repair in here, but you gotta have a finish line so you can come over and get this all nice and tight.
So, prep it. It’s replanted. This is at about 30 days. We just got her out of the office. But she came back for suture removal at three, four days, the way I remember it, because we took sutures out less than one week, less than seven days. But at 30 days, she was more happy, and the sutures were gone. She was already healing quite well. This is the second surgery, so there’s some clumping of tissue in here from previous sites. But you notice we have a little splint material in here. We have a little splint material in here. I want that tooth to kinda move. I don’t want it to be a hard fixation. Remember Andreasen’s work, predisposition to external resorption. I want a little bit of movement so those fibers can find each other.
We’ve done a lot of these extraoral procedures, and I have many that I’ll show you in the future. It’s quite an idea when you have things rolling. Holding the tooth in bacterial static physiologic saline, the procedure has – the extraoral time and the procedure must be very preplanned. The assistants all know what to do. They could’ve done it with me not even in the room. I could’ve been remote, maybe like AI. I don’t know. Maybe could’ve used AI for remote distance to have these girls to like get the tools in there and get it done. All right. So, that’s kinda how it looks there. That’s 30 days. Everything’s looking good.
Massive lesion, you can see thickened zone for the reimplantation. And here we go out about three or four years. And you know, that’s -- got a little recession here, didn’t we? You can see that – you know, you extract the tooth, you can see that the general dentist, her husband, had all the margins tucked subgingival – sub-G, under the gingiva. It looks quite natural. And I of course had discussed, when we extract the tooth, you’re gonna have some recession, and you’re gonna have a little zone. Now, maybe you get a new crown, if we’re lucky and all this works, maybe have a new casting made five years from now, or maybe it’s gonna be fine.
And of course, look at the lip line once the lady smiles. Does the lip come up? Does it expose it? Or is it all gonna be fine? So, that’s just about it for today. I really had a lot of fun with you this season and all the past seasons. And until 2023, here at the board, on set, this is it for this year. But very excited, and I’ll be working hard on your behalf to bring you endodontics that you’re going to find relevant and on time and extremely useful.
CLOSE: Favorite Places – Santa Barbara Mission
[Music coming up] [Church bells ringing] Okay. So, we’re closing out the season at one of the Ruddle family’s favorite places, and that’s the Santa Barbara Mission. So, that’s that building behind us. I guess it has a 200-plus-year history. It was established by the Spanish in 1786, I believe. It wasn’t entirely built by the Spanish. The Chumash Indians helped quite a considerable amount.
Well, they have a lot of events here. You might have choirs here from different groups that come in from around the country for performances. It’s kinda washed out now, but on the asphalt, you can see the tail end of I Madonnari. It’s a famous Italian street painting festival.
They have it Memorial Day weekend.
Yeah. I mean, didn’t you say novice and experts?
Yeah. You can just purchase a spot, and there’s different sizes you can purchase. And they have everything from, like, school kids that come and do it to, like, professional artists. So, there’s quite a lot of variety.
So, bring your chalk!
Another thing they do here in August is we celebrate Old Spanish Days. And they have Spanish dancers that dance on the steps of the Mission. So, that’s something that -- this whole lawn behind me is just filled with chairs and people watching. So, what do we have over there, Dad, way over there?
Well, that brings back a lot of memories when you were a lot younger and – you know, I have a picture of him. We were flying kites over there. So, over there’s the rose gardens. Behind the rose gardens, there’s some architecturally splendid homes. They’re very charming, with the distant ocean views. It’s quite nice. There was a pepper tree. We always found shade and had our picnic lunch under it, and then, it blew over! But that’s a new one, and it’s growing back up. So, yeah. The mountains – look at those mountains! They quarried stone from those mountains to build the façade on this Mission here. So, that’s nice. Then, you were giving me a lesson --
Wait. I want to add one more thing about over there where we --
-- I want to tell everybody that our family used to come here when the kids were little, every Wednesday afternoon, and have a picnic, and the kids would play on the lawn. So, that’s why it is very special to us. And the only reason we stopped coming after years of coming was because that tree that he was talking about blew down, and we didn’t have any more shade. So, now they’ve planted another tree. And for the next generation [laughs], if you want to bring your kids there, there’s a tree now, with shade [laughs].
Well, maybe you can even dig out and post that shot I have of Isaac. He was about this tall, and he was flying his first kite, and that was a pretty good experience. You told me that it was normal with missions that they had out-structures off the mission itself. And it’s quite nice with all the arches, and there’s offices in there, and some people live there that take care of the Mission.
Okay. So, a couple more things about the Mission. The Spanish built these missions all along the California coast, I think up to around Monterey or San Francisco. I’m not --
-- I’m not positive on that.
It’s the farthest north.
But this Santa Barbara Mission is the queen of the missions. So, it’s the biggest one. And what my dad was saying about the architecture, it’s normal in Spanish architecture of this time to have the main mission and then to have the outcropping with all the arches. That was where they – the people who ran the Mission slept and – I don’t know exactly what they’re called. The Fathers or Padres.
Do you want to tell the – our audience, some of them have been in Santa Barbara. What do they put in here around the holidays?
Okay. So, behind – like right over there is a cross. And so, they kinda drape a shroud-looking thing over it --
-- to, you know, mark the – what is it called, the crucifixion of Christ. And then, they put a manger scene on the lawn over here, and it’s a pretty big, life-sized scene. But --
With animals. Real animals.
-- do they have real animals?
Yeah. They have lambs.
Okay. I don’t remember that.
But on Christmas – you’ll notice that the creche where they put the baby Jesus is empty until Christmas morning, they put Jesus in. [laughs]
Yeah. So, anyway, if you’re ever in Santa Barbara, this is where you want to come and hang out, because it’s always nice to have a glass of wine, have a really nice picnic, or how about throwing the frisbee. How about the frisbee, huh?
Yeah. The only thing that you have to be careful of, and it looks fine right now, but on the grass, at certain times of the year, they have all of those little, tiny white flowers that attract bees. And there’s just so many bees on the grass! So, if you’re allergic to bees, this might not be the best place to come.
For about two minutes a year. [laughs]
[laughs] Anything else? Okay. Well – so, here’s the mission. This is our last show of the season. What are we gonna do until we start the next season?
Well, I know we’re gonna have a staff meeting, and we’re gonna talk about all the things that went perfect and all the things that need to get better and then the things that still need to be done.
We’re going to review film, we’re going to learn where we need to get better [laughs].
We’re going to go into the film room and watch a lot of film, post-game. Anyway, we’re going to start already thinking about the season next year, because I have some ideas, you have ideas, other people have – there’s no shortage of ideas. Remember I talked about – we talked about architectural type – archetypical – architectural --
-- archetypal leadership.
And then, we said roving leaders. Well, I’m a roving leader, and I’m going to get the show ready, my part. And there’s a lot of good things we’re doing. The podcast, we’re working on that.
Oh, Eva asked me. I said – she asked me when we were going to start. She’s nine. And I said, maybe start shooting early next year. And she’s all like, oh, you have enough content?
So, yeah. We have endless content.
You should tell Eva, we have about 20,000 cases that have never been shown.
So, I have a little – just a little bit left. Little bit left in the tank.
And you know what? We might actually still have a podcast coming, maybe a special report. So, you know, we’ll keep – we’ll be still present, even though --
And I think randomly, those random acts of kindness, I think we’ll let them have shows for free again next year.
Maybe that’ll be a random act of kindness, because we were going to charge – you know, do the Musk Model, $8.00 a man or a woman. But you know, it caused outrage across the world. They preferred to pay a bigger fee so they would know they were getting more value. So, we’ll talk about how to get to the value that they like, for the offramp. Some free shows, but with some offramps for deep drilling.
Okay. So, do you want to give a holiday greeting?
I do. Okay. This is serious. Cliff Ruddle, to all my friends and the people I don’t know, around the world, Merry Christmas, Happy New Year, Happy Holidays, so I can be all-inclusive here. [Music coming up]
Happy Hanukah, Happy Kwanzaa.
Oh, wow. You’re reaching deep into your bag of language tricks.
And Winter Solstice.
So, make great holidays, be with your family, make good memories, and we’ll see you on the show next year. How about that?
And enjoy all your traditions, whatever they may be.
And come to the Mission.
See you next season 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.
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 www.endoruddle.com/inventions.
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The Ruddle Show
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Progressive Tapers & DSO Troubles
The Dark Side & Resorption
The Resilon Disaster & Managing Internal Resorptions
Advanced Endodontic Diagnosis
Endodontic Radiolucency or Serious Pathology?
Endo History & the MB2
1948 Endo Article & Finding the MB2
To Be Determined
To Be Determined
To Be Determined
To Be Determined