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Moving with the Cheese & Delving Deeper A Better Understanding of Change & File Brushing
Season 9 kicks off with Ruddle and Lisette out on a hike, having fun and searching for inspiration (aka Cheese). Then, back at the studio, they do a book review of Who Moved My Cheese, a story about embracing change. Next, Ruddle is at the Board presenting a new segment, “Delve Deeper.” Tune in for an in-depth discussion on why a “brushing” action is so crucial when shaping canals. The show concludes with a baffling case report, one of many to come that will be featured in our new “Head Scratchers” Close.
Show Content & Timecodes00:36 - INTRO: Inspirational Hike 07:59 - SEGMENT 1: Book Review – Who Moved My Cheese? 22:39 - SEGMENT 2: Delve Deeper – File Brushing 42:18 - CLOSE: Head Scratchers – Cemento-Osseous Dysplasia Case Report
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This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
Be careful you don’t fall…
INTRO: Inspirational Hike
Welcome to The Ruddle Show. I'm Lisette, and this is my dad, Cliff Ruddle, and we are starting Season 9 right now. So, we're on the trail. We thought we'd go out of the studio and do a little hike.
I'm inspired. You look behind me, and you see mustard hillsides, and you see blue sky, I'm guessing, and you probably see mountains. Well, it reminds me of a lot of things that we'll talk about in just a little bit.
So, don't fall [laughs].
Okay. So, as you can see here, the trail's closed due to unsafe conditions. And we're just gonna risk it. There's been some rain recently, and the trail's been a little bit washed away in some places, in some places, greatly expanded.
There's lots of things that are closed ahead, but life's about adjustments and adaptation. We'll talk about it shortly.
We're not going to let a "Trail Closed" sign stop us. [Music coming up] Be careful.
Careful on these rocks.
We actually are taking a break so that my dad can tell you a little story. Go ahead.
We've been talking about adaptations and adjustments and adjusting to the path ahead. So, I'll tell you one of my little adjustment stories. So, I'm at LAX, and I'm gonna fly to Singapore. I think it's about 18 hours. I'm by myself, and I sit in my seat, and guess what? There's nobody with me. So, I'm thinking, this is a long, long flight. And so, I'm going to have it very quiet. Everybody stopped coming in, and all of a sudden, there's a guy with a lot of badges, and he's wearing a hat, and he looks at his number, and he looks at me, and he nods. And I realize -- spring up -- I'm on the aisle seat, and he gets in and stores his gear, and there he is. So, we taxi, and we take off. We come to altitude, there's some service, and of course, we're talking lightly. And finally, after service, he said, ‘Well, what do you do for a living?’ I said, ‘I'm a plumber.’
And that just shut that down immediately, because nobody wants to talk about plumbing. Really? So, I said, “Well, what do you do”? And he said, “Well, I'm a long haul pilot. I fly 7-7-7's.” And I said, “Well, then, why aren't you in the cockpit [laughs], like you belong”? And he said, “Well, I'm actually flying with you to Singapore. And then, I'm gonna take a 7-7-7 full of about 300 passengers, and we're going to go to Seoul.” I said, “Wow”! So, then, we start talking about what happens in the cockpit. I wanted to know everything that happens in the cockpit. So, I mean, even these people walking by would like to know what's happening in the cockpit --
-- if they really didn't know.
So, he started telling me. He said, “Cliff, these things just fly themselves.” He said, “Really, it's only intense a little bit landing and taking off.” And he started telling me about coming into the east coast of Asia, and he said, “You know, winds can blow form the west, sometimes getting up to close to 200 knots.” He said, “It's a little tricky. There can be shears.” But he said, “Really, it's just landing and takeoff.” And then, he turned to me and said something that was startling. He said, “Cliff, you know, these planes are off course 99 percent of the time.” And I said, “What!? They're off course 99 percent of the time”?
And he said, “Yeah. It's about all the little adjustments that we make to guide the plane in to a successful landing.” We got off. He was going to his gate, I was going to my gate. I was going on to Mumbai. That's another eight hours. And I was up in the air, on the next flight, and I started thinking, wow, he's talking to me. Because he said, “You're off course 99 percent of the time.” And when we do endodontics, you're off course all the time, but it's those little adjustments you make because of experience and training that guide that case to a successful conclusion.
So, it's pretty early in the year, just February. So, I wish you great luck in the adjustments across this year.
And that actually reminds me that we've already had to pull you back onto the trail many times as well. [laughs]
Oh, like I -- have I deviated? Oh, I was off the glide path? Oh, I was supposed to stay on the glide path is what she told me.
Yeah. You need to stay on the trail. If you wander off, get back on it. [laughs]
But I want Eva to come over here. She's my granddaughter. She's off camera, but this is my daughter, and then this is my granddaughter, and the shooter, of course, remains Isaac. But what a beautiful little hike they're taking me on, on our way to Inspiration Point. You know, Inspiration Point. It's like a place where you --
[laughs] Looking for some inspiration [laughs].
-- wanna go, and you're looking for --
-- and that would be called what?
And we're still on our quest for inspiration.
Okay [laughs]. [Music coming up] [laughs]
Be careful you don't fall.
All right . So, we've just now reached the point where we are gonna actually turn back. It does go up higher another few miles to like a ridge. But we're not gonna do that today because we recently went on that trail, and there's a lot that was washed away, because we had some really big rains recently.
Yeah. We got like a few feet over a few days.
And all of our reservoirs filled up. This whole hike is just spectacular right now. We have to stop now because I had to have cardio resuscitation.
It wasn't as pleasant as I had expected, but now that I'm feeling really very fit, we're gonna go back down the trail. It's gonna be much like a canal, and there's gonna be turns, and it's gonna have torturous splits and divisions. There'll be probably rocks that we'll think are like calcific stones. Oh, it's gonna be a thing of beauty when we get to the terminus.
So, maybe one thing you really can't appreciate because you haven't been on this hike before with us, but if you would've come here last year with us, you would've seen none of this green. This is all -- all this greenery around us, that's new, because we've been in a drought for so long that it's -- mostly just looks like a straw field, normally.
Yeah. But that's kinda California. We get really green for a few months like December, January, February, maybe. And then, we get brown, because that's an arid climate.
Yeah. This hike is normally like a golden color of dryness, and the creek is barely trickling. And so, [laughs] this is actually kind of exciting to have so much green and -- and the water in the creek. It's really nice. All right. We're gonna head back now. But I just wanna really just drive it home that the reason we're out here is we're looking for inspiration, it's the new year, we're just excited to be out in nature, somewhere out of the office, out of the studio.
[Gentle guitar music] All right. So, we made it back to where our car's parked, right over there. And now we're gonna head on over to the studio and get started with our first segment of Season 9.
Ooh, let's get going.
SEGMENT 1: Book Review – Who Moved My Cheese?
Okay. So, here we are back in the studio, and we thought we would start off Season 9 with a book review. And since the takeaway message from the book we have chosen is so powerful, we thought we would devote an entire segment to it. So, the book that -- that's gonna be the focus of our discussion is the number-one bestseller, Who Moved My Cheese? published in 1998 by Dr. Spencer Johnson, and it is essentially a book about embracing change. But before we go into the plot, themes, characters, et cetera, why don't you tell us how you were first introduced to this book.
Good. I guess the book was published in 1998. So, I think it was within the first couple years I got it, say 2000. And it came to me from some of my friends that -- well, we'll call it The Old Days, Tulsa Dental. But now, you know, it has a lot more names. But anyway, Tulsa Dental, there was a bunch of really firebrand reps, and they were really gung-ho, and I loved their energy and their enthusiasm. And so, you know, we were out on the road traveling, and up comes the book, and everybody was talking about it. I didn't know anything about it. So, somebody said, “Well, here, you got this one.”
So, that's how I got it, and I read it. Ken Blanchard -- many of you probably know him. He's famous from The One Minute Manager, and it was also [laughingly] a number-one bestseller. And he coauthored The One Minute Manager with Spencer Johnson. So, that's a little bit of connection there. And then, I think --
Because he wrote the foreword or something, is why you bring him up?
Yeah. Blanchard wrote the Foreword for Who Moved My Cheese?, and it was a very poignant, nice, really -- that was worth the read. And then, I think the book is powerful and it's exciting. It seems pretty simple, but I got so excited about it, I was giving it out. I had Phyllis buy me, I don't know, 10, 15 copies, and I started passing them out to different friends and patients and -- you know, I was really passing them out.
Well, this copy, you actually gave me --
-- 20 years ago, and it's actually inscribed and dated July 2003. So -- you probably can't see it, but -- anyways, I mentioned just a moment ago that the story's about embracing change, and it guards against complacency. And it takes place in a maze, which is basically the maze of life, and the characters run around looking for cheese. And cheese is a metaphor for anything that you want in life. It could be a rewarding job, a loving relationship, lots of money, a nice house, or even like inner peace and spirituality. So, here's the characters. Why don't you tell us about the characters in the story?
Well, there's four of them. And there's two little mice. You can see them behind me. And if you look carefully, you'll see their names, Sniff and Scurry. Sniff and Scurry are pretty simple, you know. They're not so complex. They're about eating, sleeping, and eating and sleeping. And so, that's what they do. Life's pretty simple. You just need enough to eat. So, they're neat little characters, and they work in the maze. And by trial and error, they look for cheese. And when they go down a long maze area, if it's empty, and there's no cheese in various rooms, they -- they know not to go back there. So, they're -- they have good instincts.
The other little characters are mice-sized humans, and their name is Hem and Haw. So, we have very complex minds. We have human beings now. So, these human beings have memories and experiences, and they become complicated with overthinking things. They don't really worry about the eating part. That's sort of important, but you know, they think a lot different, because they have memories, and they have experiences. So, that's a little bit about them. And -- what else do I need to say about these guys?
Well, they're -- they're pretty emotional, and they have a lot of different traits, belief systems. You know how that could be complicated. So, they approach everything in the maze through that lens, unlike the mice. So, together, they're in the book. And when you read it, you're probably going to identify with one of the characters, if not maybe all of them. I could identify with more than one. I won't tell you which one I can't identify with.
But anyway, I can identify them. You're gonna identify with them. And it's really a really important thing to look at this book and read it. And then, you'll begin to see how you -- really, in this little, simple book, you'll begin to see how it might even reflect a glimpse of your life.
Okay. And we actually learn more about the characters as the story unfolds, because -- he gave you a pretty simple way to look at them, and that is the way you should look at them. But they do have a little -- like some idiosyncrasies that are interesting as well. So, the story begins with the four characters finding a room -- a big room in the maze, and it's filled with cheese. And they go there every day, and they feast on the cheese, and they just have a great time. But over time, the cheese supply begins to shrink, and it eventually runs out.
So, Sniff and Scurry are quick to adapt, and they jump into action and head out into the maze to find new cheese. But Hem and Haw, they have a hard time accepting [laughingly] that the cheese is really gone. And they think it might come back if they wait. They feel betrayed, they feel cheated, they start to blame each other, they get more and more frustrated, and they start to grow weak with hunger. Haw does suggest a couple times over the days, “Maybe we should go out into the maze and look for some new cheese.” But just -- Hem flat-out refuses. He doesn't wanna go out there. He wants to wait for the cheese to come back. So --
-- [laughs] then, one day Haw just starts laughing at himself. Get it? Haw, haw, haw. How absurd it is to think that by doing nothing but whining and complaining that they're gonna have any success. So, he asks Hem one more time, “Do you wanna come”? And Hem says, “No.” So, he puts on his tennis shoes, and he heads out into the maze to look for some cheese. So, what does Haw discover once he's in the maze?
Well, once Haw's in the maze, he begins to kinda feel lighter, and although he's not finding -- well, he gets enough cheese, just the little crumbs along the way, along the maze to keep going, but he's feeling free. He's feeling really quite powerful out here in the maze, and he's discovering. And then, he says, “Well, you know, I'm feeling so good about this, I'm having revelations.” So, he decides to write the most poignant revelations on the wall because Hem might come out of the -- okay. There's a Cheese Station. And so, Hem is in the empty Cheese Station, and he's thinking, well, if he ever comes out, maybe he'll see my messages on the wall, and it'll encourage him.
Yeah. And he writes down quite a few. But we identified some that were our favorites, and let's bring up that graphic. So, why don't you read these ones that you've said to me were some of your favorites?
Well, the one that -- the one message was on the wall, "What would you do if you weren't afraid?" And I thought, you know, don't really be afraid of anything. I mean, I'm not talking about jumping off of a mountaintop or something. But in your daily life, don't be afraid, because failure's normal, and failure is the steppingstones to greater success.
And sometimes you even can ask yourself, like what's the worst thing that could happen? You know, like maybe your fears are not really proportional to what might actually happen. Like maybe they're way greater than what could actually happen.
That's always the case, because just like the freedom when Haw went out there, he got really excited because it wasn't as scary as he thought. So, yeah.
The other one I like -- I guess there's several, but the next one was, "Movement in a new direction helps you find new cheese." And what I would say about that is, in life, what I've learned over my life is that there's lots of thinking that goes on. It might be with other people, private thinking, joint thinking. But there's finally a conversation. And the conversation develops the action plan, and through the action plan, we get a result. So, if you don't like your conversation, make a new one.
And on the other hand, conversations always get used up. So, the conversation that invented the game, it -- the game's gonna get used up, because you're gonna need a new, fresh conversation, because things are changing. And you gotta adapt to change, so you need a change of conversation. Different action plan, different result.
And we've actually talked about this a lot, like just changing your environment. Like moving in a new direction, just changing your environment could spark new ideas. I like the next one, "Imagining yourself enjoying new cheese leads you to it." Visualization, I think that's probably really important. Visualize what you want every day, all the time, and you'll get closer to achieving it.
Yeah. I always -- I used to have a graphic in my lectures, and it said, "Think, Visualize, Plan, Execute.”
Then, we have, "It is safer to search in the maze than remain in a cheeseless situation." Well, you're not gonna starve to death in the maze, probably. You're still gonna find some bits to survive on. I do also like the last one, "Old beliefs do not lead you to new cheese." Like it's important to have a change of perspective sometimes, maybe get out of the boxes that you're in and -- and look at things in a different way. That might be helpful.
Yeah. Create a future. And I like to say this. It's been misunderstood, so listen carefully. Create a future that's not about the past, but it must take the past into account.
Okay. So, eventually, with a lot of patience and perseverance, Haw comes across a huge room, and it's just filled with more cheese than he could ever imagine. So, he's in that room now enjoying the new cheese, and he thinks about his experience and everything that he was thinking about while he was running through the maze. And he decides to write down what he's learned, and that's called "The Handwriting on the Wall.” And you have a graphic for that. So, basically, it amounts to, change happens, you need to anticipate it, you monitor it, adapt to change quickly, change, enjoy it, and be ready to change quickly and often.
So, that's basically the story. Is there anything in the story that maybe was your favorite part, or maybe you wanna tell about an experience from your life that really makes you think of this -- the theme of this book?
Well, there's a whole bunch of them, but I -- I think the story's not about -- really, as you read this book, it's not about who moved my cheese. That's like -- we already said that. It's how you interpret the book and then how you apply it to your life, because it's really, really simple. And if I were you, I'd get one for yourself, then I'd get one for everybody in your office, and then I'd get one in your family, and not necessarily in that order.
I mean, I guess I could think of like just a really glaring example from your life is when you tore the retina on your eye and you couldn't practice for a long time, and you had to go in a new direction. And then, what did you do? You started focusing on innovation and inventing. So, that was like -- that is like a major change of direction, and you got a lot new cheese [laughs] in that other direction. So --
Well, there's always something good out there for all of us. And if we're willing to change and understand change is inevitable, then you're already halfway there.
Okay. I think probably one of my favorite parts of the book was, this story is being told to a group of people in the story. So, at the end, the storyteller asks the group of people, “Who here is afraid of change”? And no one raises their hand. And then, he says, “Who here thinks other people are afraid of change”? And everyone raised their hand [laughs]. So, perhaps we are all in a little bit of denial about how we feel about change. I think the important thing is, is to not let fear, anxiety, and your emotions get in the way of all the cheese you might find, running through the maze. So --
Yeah. I like the part at -- at the end where the group that is reading the book, they're talking about it, and you know, there's a lot of interpretations to what it meant in their lives. But the thing that was kind of fun for me is, don't get too overwhelmed by stuff. And change is inevitable. We've said that over and over. It's gonna be happening. So, be willing to put on your tennis shoes, because I didn't say this, but Sniff and Scurry, when they got into the first big Cheese Station, they kept their shoestrings tied together, and they had them around their neck, so they would be ready to scurry if they had to.
You know, Sniff was the brains. He found, he [sniffs] smelled the cheese. Scurry was off, he's very fast. So, keep your tennies on, okay? Be ready to go.
Yeah. And I do wanna just add one other thing that was emphasized in the book, and I think this is really important, is to have a little bit of sense of humor about yourself and be able to laugh at yourself and not take yourself so seriously, because it's just gonna make the whole process a lot easier, honestly [laughs]. So, definitely check out the book. It's a short, fun read. Maybe you read it and you think, I don't really get anything out of this, but it's entertaining, you know. But maybe you read it, and you have a change of perspective, and it really changes your life for the better.
So, you really can't lose. Check it out. And if the -- this book in this format looks a little bit intimidating to you, we also have this. They made it in a kids' version, too, and it has lots of pictures. So, you might wanna check out either one of these. It's a -- virtually the same story [laughs].
I will close this off by saying this. I read the book in about 2000. And so, Lisa prepared sort of a rough script here to guide me back to my memory. And then, she said to me, “You must read it. You must read it again.” And I said, “Really? I have to read the book again”? So, the good news is, the book was read in a couple hours, and already I can tell you -- I will tell you on another show and another time -- something so powerful happened because I read the book again. So, read the book.
You'll learn something new every time. I read it 20 years ago, and I read it again in the last couple weeks, and I learned new things, and it was a good reminder.
All right. Well, that was a great segment. Thank you.
Go with the cheese!
SEGMENT 2: Delve Deeper – File Brushing
[Music coming up] I'm really excited today to be with you again. And this is the first session at the board for teaching in 2023. And I'd like to go back and revisit the past, because everything old is new again, but it will have future implications for better cleaning and filling root canal systems.
So, let's delve a little bit deeper today into brushing. I've talked about brushing a lot, haven't I? On stage around the world, if you've been in my audiences, I say, “Brush,” and you go, “Yes.'” I make you say, “Brush” and then you say “Brush” back to me. So, I'm trying to get you mentally prepared so when you go to that workshop on day two, we can see those habits beginning to build. So, let's delve a little bit deeper, and we'll start off with a book that I've showed many, many times on this show. And I promise you, it'll be shown several more times in the future because everything we do as endodontics or general dentists doing endodontics is related to the anatomy of the human teeth.
So, if we want to know how something might be relevant, like a laser or maybe a file or maybe a new filling idea or maybe some kind of a innovation, it all has to come back to is the anatomy going to be addressed? Because anatomy is destiny, and to the extent you can treat root canal systems, you'll have inordinate success over the life of your practice. So, here we go.
So, when we open Hess's book, you remember it was published in the 1920s, but the work was done in the early 1900s, and he's showing all these Vulcanite specimens. I won't review how that was done -- we've done it before -- but you can begin to see there's 10,000 of them in this book. And so, by the time you look tooth by tooth at 10,000 Vulcanite recovered specimens, it begins to get your attention, how that anatomy really looks in reality.
So, you know, you can look a little closer, and you can begin to see the canals aren't round. We have rounder canals, and we have ovoid shaped canals, we have irregular cross-sections, we have figure-eight kinds of cross-sections, and of course tissues inside these spaces. So, a word that I'd like to introduce -- at least it's a new word for me, for Cliff Ruddle, I've not heard it yet -- anatomical shaping. So, when you start to look at the distal roots of lower molars as a single example or maybe a ribbon-shaped central mandibular incisor, Schilder called these like flags flying in the breeze. You have these interconnectors, these anastomosing, but a lot of these things are ribbon shaped.
And you have a round file, you have round gutta-percha cones, you have round paper points, and you think it's round down there. So, you can run a file down this wall, maybe we go to black. You could run a file down this wall, you could run a file down that wall, but what about the isthmus? And we can't always pass files through an isthmus. I get that. But to the extent we can begin to think about a way that round file can do more than a round job.
So, distal roots of lower molars, mandibular incisors, second bicuspids, there's many, many teeth that hold canals that aren't round in cross-section. And we brush for a lot of other reasons. In a quick review, what about the triangles of dentin? We talk about these triangles of dentin. You notice how these canals merge up and come into the pulp chamber? Do you realize that when the canals begin to bend into that pulp chamber, it means the whole body of the coronal part of the canal is moving closer and closer to furcal danger, if we just shape with no knowledge of brushing. So, we've shown that in the research. Other schools have shown that in the research.
But again, triangles of dentin. And then, once we've made our access -- here's a little residual triangle of dentin -- but you can begin to see we need to have our files not coming in off axis. We need to have these files come in on axis, and how we can have them come in on axis is, we can simply -- we can just simply think about using Shaper X from the ProTaper family of instruments. It has compressed geometries, and it's a 19 at D0, has 19 percent taper. But listen carefully, you minimally invasive people. About 2/3 of the way up, it's an 80 to an 85. That's what you're so thrilled about.
The people that are making these 17 04 preps, they're so thrilled because they're so skinny, and they get scared when they hear 19 percent, don't they? Well, just think about it. 04, that's 64/100 of taper over 16 millimeters, add 17, the tip diameter, and I don't know what that is. What is that, an 81? Maybe it's an 81. 81/100 of a millimeter. So, that's about what a 17 04 is, that's what an SX is at about 2/3 of the way up. So, if you think that about that, you can use a very popular instrument -- it's the most sold file in North America -- to open up the body, and we can come in there if we have a little space, a little glide path's been confirmed with a 10, and if we have a little space, a little working width, the tip at 19 will follow perfectly.
It's gonna push the workload up. The progressive tapers pushes the workload up on the bigger file flutes, the bigger cross-sectional diameters, where it's safer to cut, and it can cut more effectively. And notice, I'm brushing to the outer wall. I'm -- I'm brushing to the greatest bulk of dentin. I'm not just peck, peck, peck. That makes a round hole that's pretty much concentric around the axis of orientation of the original canal. So, you can see very quickly, we can get the body opened up almost to the junction of the middle and apical third. But watch the arrow, watch the arrow, watch the arrow.
Brushing moves the canal intentionally away from the furcal side concavity -- the furcal side concavity. The people that don't brush, you make emanating concentric circles around the original pathway, and your preparations drift and move towards furcal danger. This weakens teeth and predisposes to longitudinal failure. So, just a little idea. Gosh, I wish I had my hairbrush right now. I think I have one offstage. I -- it's time to brush a little bit, maybe. I don't know. But it's time to erase, for sure. So, that's a little bit about that.
You've seen this tooth, but I'm gonna show you a little trick again. How many of you have employed your hand file -- that's everybody that's watching, or you wouldn't be watching this if you were an orthodontist, unless you were misguided -- but if you're a dentist doing endodontics, you grab your 10 file, don't you? How many times has that 10 file not moved to length? How many times does it go down pretty deep and all of a sudden, it's like, won't go. Do you jump on it? Do you try to force it? Do you drop to an 8, do you drop to a 6? See, these are all clinical decisions.
And if you look at this, if we open up the body of the canal, if we pre-enlarge -- okay -- you'll get the 10 file to length much, much more efficiently, and it'll be more predictable. So, I taught this all over the world. Stick a file in -- of an extracted tooth in a laboratory. Stick it in there, it'll go up about 4 millimeters, D4. I think I blew this in a previous season, but we got D0. That's the file itself. That's 10, and then at D4, we have 12, 14, 16, 18. That's -- boom! -- 18, 18/100ths. This would be a 10th of a millimeter, put the decimal over here. So, 10th of a millimeter, 18. So, when you have almost a 20 at length, you know the canal should be wide open. But is the canal wide open?
You're going, Cliff, you said the 10 file will go into an extracted tooth almost every time 2, 3, 4 millimeters. Well, it doesn't do that clinically, does it? You know why? Because the rate of taper of the file is much, much greater than the taper of the canal at this moment in time. And I'm gonna abuse this file. This would be completely incorrect, but I'm trying to force that file down to show you -- look at it wind up, maybe Ruddle'll snap it. Won't go. If it doesn't go, remember the basketball analogy. Schilder taught us this. Put the ball on the hardwood floor -- if you're in Boston, it's parquet -- and it'll bounce off resistance. So, bounce off resistance, don't attack.
The 19 tip will easily fit into the orifice. Let this thing float down, but notice how I'm bending that file away from furcal danger. I'm moving the preparation coronally to the greatest bulk. I want centered preparations with about equal amounts of circumferential dentin around the file. And you notice, as we brush and make lateral space, the file easily moves in. That's another trick. Brush laterally to go more apical. So, you can see with that done, the file can go right in where it couldn't go, with no more work with hand files. Boom! Slides right to length, and there it is locked down, and we're at length, just by knowing a little trick like brushing. All right.
So, we can keep going. So, when I speak about brushing, you know across the world, I've done this for years. Why? I can tell you I did it from the day I left grad school in 1976. Yep, I did it way back then. We were using Gates Gliddens, and we brushed with the Gates’, and we learned a lot about the Gates’, and we transferred that onto NiTi files. And then, there was heat treatment, all this good stuff. So, when I talk about brushing -- because I'm gonna see you in this audience, I'm gonna see many of you the next day in the laboratory, participation workshop -- so, I say, show me brushing.
Do you get it? Say, “Brush.” The whole audience, yeah. “Brush.” “I don't hear you.” And then, you yell it louder and louder, and all of a sudden, everybody's going, “Brush! Brush!” And we're all doing this, and we're having so much fun. And there's even clapping sometimes, they're so excited about brushing [sounds of applause and cheers] because a lot of dentists are not brushers. They are what? What are they? You fill in the blanks. That looks like pecking. Oh, it looks like a pecker. So, don't be pecking into teeth.
I don't know why that was taught, but it has been part of the culture of dentistry around the world for as long as files have come out. Peck, peck, peck, peck! And you have this misplaced expectation that I'll achieve length, and it'll be more than it was, and it'll be so easy for me. But you just keep pecking. So, then you go to the workshop and on day two, and what do you see? Peck, peck, peck. So, in closing, I'd like to say to you, don't be a what? Pecker. Be a brusher.
Now I've not shown this, and this is really my evidence. So, I did all that little pre-ramble very quickly, just to get to these slides from the Catholic University of Leuven. It was done with a -- with a really great team. I wanna acknowledge Lars Bergmans, okay? He was one of the principal people on it -- and his mentor. And what they did is, they chose the tooth in Belgium, they opened up the tooth, and then they took a camera, they went around the tooth and took around 2,500 pictures. Then, the computer software took all those images and modeled the tooth. They then mailed the tooth to Cliff Ruddle.
I receive the tooth, and I do some shaping. I package the tooth back up, I send it back to Belgium to the Catholic University of Leuven. And I want you to know, then they took the camera, went back around the tooth Ruddle had shaped -- the canals he'd shaped -- took another 2,500 images, modeled the tooth, and now we could compare before and after. This is brushing, and there's scientific evidence for it. And the reason I'm bringing this up, you people out there, especially academics, and I won't mention names, they love to say how files only touch about 50, maximum 60 percent of the internal walls.
Is that true? Do you ever ask questions when people are talking to you? Just kinda even subconsciously, is that true? Really? Is that true? Because you might wanna come back with a question, not an accusation, but like to learn. So, does -- do files really only touch 40, 50, 60 percent of the internal walls? That's the question. Is it true? It's in the literature. It -- people pound on their chests, oh, you need to irrigate better! Of course, they need to irrigate better, but can files touch more walls? That's the question. What if we use the file a little bit different? Oh, my God, it brings more things into play.
So, if we peck, peck, peck, yes, 50, 60 percent. You're gonna have lots of eccentricities off the rounder part of that file, where those walls are not touched. So, if we begin to brush, we can begin to touch more walls. And I'll show it with this evidence. So, here's the information that they sent me. These are all their pictures. They are not my pictures. Okay? So, here's your evidence for endo. There's the article. It says, no, it's about 95 percent if you do a little different idea called brushing. Read the paper. Peer reviewed. That's a peer-reviewed book. Martin Trope, Ove Peters, I think were the -- the lead authors, and then there was different chapters and things.
Well, green is before, and that's the straight-on view. And this is the off axis. So, straight on, bam! And then, come a little bit -- few degrees in a horizontal angle around like that, and that's this one. That's before. Straight-on and off-angles. So, untouched walls are green. Well, then they took analysis of the before and after work that we shared back and forth across an ocean, and they showed -- I want to bring out this attention, though, to this furcal side concavity. When you see that little line right there, and you see that little line like that, that's that invagination.
So, green is before. When Ruddle brushed, I pulled the canals away from furcal danger. Remember, there's a furcal side concavity in here. These roots are like this, right? So, wow, this is fun today. You can see the work of SX. And it could be anything you like, but SX has compressed geometry, so it gets big properly, but it's not used to length. SX is just used to open up the body. Not the orifice, the orifice and the body. Okay. So, then, if you look at some more exciting angles, we'll look at the slice right through the floor of the tooth. Notice because the canals -- you know, we talked about how canals -- oh, let's try this color. This might be very exciting.
We said that canals come up, come up, come up, and then they bend in. So, when they bend in, they get closer to the furca. So, notice green is before. Notice after I've done my intentional relocation. Notice green is before, superimposition is red, and notice we have just about equal amounts of tooth structure on the furca side -- the furca side -- or the outer wall. And we're brushing out to the line angles. We're not just brushing mesial. We're brushing to the greatest bulk of dentin, always that way. So, just to get you a little bit more excited, there's even better news.
We'll look at the slices all the way down. Now brushing has less and less and less effect as we go down. But up high, where the blades are big, and they can be very efficient, very safe, and cut very well, you can see, here we are, coronal slice. You just saw that one. Here we are in the middle. Notice that the file is engaging all the original green anatomy, and it's including it. And then, notice in the apical slice, not quite at terminus, but just about two millimeters up, you can see we've included a figure -- yeah. That's a figure eight. So, it's two systems merging. So, they're not round, but as they come in, they're round. And when they meet, they become ovoid. And we've included that.
You're probably worried about cone fit and all that, but we'll talk about that in a moment -- another time. So, if you look at the before, there's after. So, I got into a -- a pretty heated debate with a fairly well known academician. I don't think he's a clinician, but he might think he is. And he said, “You can't touch 90 percent of the walls”! And I said, “Look at the histology. I didn't even do it.” In fact, Paul Lambrecht’s group -- I should've mentioned his name. Paul, if you're listening, I love you still. You're still the best in the world at research. I mean, my God, you've done it for a long time, and your students continue to do it. And I just read an article you did last week.
But look at red. This was a water study. It wasn't a sodium hypochlorite and file study. It was just ProTaper with water. So, you see no dissolution of tissue. There's no eating away and getting that tissue out through chemical mediation. It's all mechanical. Of course, we're not gonna instrument the webbing between the two systems. Files never get in those areas. But if you look, you know, you can say he missed a little bit there, he missed a little bit there, missed a little bit there, and a little bit there. I don't know what you think that is, and we could disagree all day long or we could agree, but I think everybody'd say that probably is close to touching more than 90 percent of the internal walls with just a different idea.
Let's keep looking. Let's flip it around. And this is now from the other side. So, that was buccal. Now this is lingual. So, we're coming from the lingual, and we're looking straight on. And then, mesially, we'll -- and again, from the other side, you see tissue's not gonna be dissolved, and we have a few more places of untouched walls. So, what's the bottom line? What's the bottom line? When you open up a tooth, grab your 10 hand file, make sure you have a little space. And if you do it, a 10 file doesn't have to go to length. It just has to go down in the body. If it's nice and loose, grab an SX, compressed geometries, brush away from danger to the greatest bulk of tooth structure, and then the files will slide to length easier.
You'll have stronger teeth mechanically. You'll have less fractured teeth. And you know what? Lasers, GentleWave, EndoActivator, EndoVac, they all do better when there's a nice, clean flow channel. So, best wishes as you brush across the year.
CLOSE: Head Scratchers – Cemento-Osseous Dysplasia Case Report
[Music coming up] Okay. So, we have a new close for you today, and it's called "Head Scratchers.” And when you say something is a head scratcher, you mean that it might be confusing or hard to understand or maybe even a little bit mysterious. Now in this close, you will present one of the cases that you had over the years that was a head scratcher. Maybe you had to put some extra effort into deciphering what was going on. Maybe you had to come up with some creative strategy on how to treat it. And the thing that's interesting about these cases is that usually, they represent the atypical or anomalies.
And so, they're not generally included in your lectures, which you know, are trying to teach. You're not trying to teach the 1 percent; you're trying to teach the 99 percent. So, the point of that being that clinicians haven't really seen these cases of yours because you don't -- they're not generally included in your lectures. So, this is exciting. This is your opportunity to present the strangest of the strange, the real head scratchers.
So, I'm gonna walk away now. I present to you Dr. Clifford Ruddle and his Head Scratcher case.
Thank you. I guess in the old days, when I was really young, they talked about zebras. And it was always kinda like if it's North America, and you hear hoof beats, it's horses. So, don't talk about the zebra today. So, we're gonna talk about zebras, not horses. I'm sure you're in this kind of a middle state at different times in your life, because maybe you see an anomaly. Today we're gonna talk about radiographic -- jaw radiopaque lesions. So, radiopaque lesions.
And I'm sure there's some of those you see, and you're going, this is just a little bizarre. And of course, many of you have other dentists in your offices, so it's nice to get a second opinion. And it's also nice sometimes to get on the computer and Google a little bit, like I did, because as Lisette just said, I had to do a little homework just to do my Head Scratcher case that I saw about 5,000 years ago. And over the years, you -- you accumulate a lot of cases that just don't fall into little, neat bins where you do this, you do that, you do that. So, Google, talk to your friends, talk to the oral pathologists at the school.
But today, let's look a little bit about radiopaque jaw lesions, because they're not so common. They're not even gonna be seen every week. I don't even know if you're gonna see them every month. Maybe if you're in a dental school you might, but not in private practice. At least across five decades of practice and being involved in this, I have seen some of these things one, two, or three times, to just make it -- you know, not -- not so common. So, we have a lot of big words here. And today, I will not be describing each of these radiopaque jaw lesions and be showing you different X-rays to go along with it. I could. I could, because I already started, but I'm gonna let you look them all up.
But you know, these are all radiopaque, and they're all something that represent a pathology that you don’t' see in the trabecular pattern of bone and the cortical plates, where both teeth are set inside. You know about condensing osteitis. Osteoblastoma, you know, is pretty dangerous. You'll look at that. This one is kind of a funny one, because the World Health Organization has changed the meaning of cemento-osseous dysplasia. The nomenclature's changed several times. You might know this as a cementoblastoma. And in a pure form, a cementoblastoma is an ectomesenchymal tissue of odontogenic origin.
So, you know, you gotta learn a little bit about the dental school that you were at 25,000 years ago. You're gonna have to pull some of that back together. At my school, it was Leroy Eversole [phonetic]. Then we'd have to go to that pathologist, and he's still kicking, so he still gives opinions. But this is a subcategory -- cemento-osseous dysplasia is a subcategory of cementoblastoma. And then, you have hypercementosis. So, let's look at -- today we'll focus on my Head Scratcher, cemento-osseous dysplasia, also known as periapical cemental dysplasia, also known as other things.
So, if we look at cemento-osseous dysplasia -- we'll just say COD now, be a lot easier -- I got all this stuff from the 4th Edition of THE guy, S. N. Bhaskar. We all got that little book, right, green and red, red print, green text, very nice. Every conceivable disease known to mankind is in that book. Soft tissues, hard tissues, et cetera. And cementomas are a subcategory of this, and they have three stages. The first stage is periapical, and it's a radiolucency that you'll see around a root. So, it could mimic what? A lesion of endodontic origin. But if you watch that -- but they're asymptomatic.
So, the patient is asymptomatic. The teeth aren't moving or getting into malocclusion. So, not tooth drifting. Some of those other categories of radiopaque lesions, the teeth start to move. Okay? There's pain. And not any pain with a good old cementoma. There's no movement of the teeth. So, you got that. They're in the mandible, and they're usually anterior. So, they're called periapical COD, and periapical means, though, in this category, according to WHO, anterior. The same lesion in another place, when it goes to the posterior, in one single quadrant, not two, but one, it's called a focal COD.
And finally, if you get down to this one, florid cemento-osseous dysplasia, it's gonna be in multiple quadrants. So, that's something you can begin to think about right now, radiopaque lesion. Where is it in the mouth? Is it posterior, or is it anterior? And now we'll take a look. So, I pulled these slides out, because I don't show this in lectures. Like Lisette said, this is not something when you travel the world that people want to hear about the zebra.
So, anyway, this patient came in. They were asymptomatic. It was a woman. I won't give you the incidence and frequencies and the epidemiology across the world, but it's typically about a little more in women, a little less in men. It's usually a little younger person, like less than 50, not 50 and above. So, put the ice on the tooth. Do your sensibility -- vital pulp testing. Ooh, pulp testing. And make sure the teeth are vital and alive versus necrotic and needing endodontics. These teeth all test within normal limits to vital pulp testing. The hand signals, they feel immediately, the short duration, and it goes away.
So, that's something that you could say, oh, gee -- you could do a head scratcher, and you could say, you better go to an oral surgeon. You better go and get a biopsy, you know, you're gonna die. You have cancer. It's terrible! I can see it's coming! Well, no, you need to -- before you alarm anybody, why don't you come up to speed a little bit so you can speak more intelligently? Because there's nothing to get a patient concerned about, and some people will get really concerned if they hear the "C" word.
They've come back because we saw this patient and recognized what I thought it was. So, we had them on recall, and we had them on six-month recall. But this is about a year later. And you can see the radiolucencies are gone, and you can see these radiolucencies have developed -- the cementoblasts have really been elaborating a lot of debris, a lot of calcific material. And you can start to see, in this stage, you have opacities. So, you start to see opacities where the cementoblasts have elaborated hard like tooth structure on the root, the cementum, and all of a sudden, the lesion's evolving towards a radiopacity.
What's the third stage? The third stage is pretty subtle, but you can notice these PDL's. You can see PDL's, PDL's, PDL's, periodontal ligament space. I know Terry Pannkuk would like me to say it means Pure Dental Learning, but you should go to that website, because Terry's a good teacher. But PDL means periodontal ligament for me today. So, you see PDL's. Well, there's like a little PDL that starts to crawl around, and it begins to be circumscribed. It's called a radiolucent rim. So, I'll take the markings off, and you can begin to see the radiolucent rim. So, that's the three stages. How about that?
And if we look at them all at once, in closing, again, Stage 1, it's osteolytic, it's bone loss and a radiolucency. Then, we start to see some opacity forming within the radiolucency. And finally, you get to see the radiolucent rim. It's pretty subtle. And when you see that, you've just figured something out. So, how about that for a Head Scratcher?
[Music coming up] Okay. Well, that was very informative, dare I say intriguing. [laughs]
I don't know about that.
That's our show for today. See you next time on The Ruddle Show.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
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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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