There has been massive growth in endodontic treatment in recent years. This upward surge of clinical activity can be attributable to better trained dentists and specialists alike. Necessary for this unfolding story is the general public’s growing selection for root canal treatment as an alternative to the extraction...
The Dark Side & Post Removal Industry Payments to Academics & Removing a Screw Post
This show opens with a brief announcement that the Academy of Laser Dentistry has released a new issue; laser enthusiasts may want to check it out. Then we journey to the contentious reality and, at times, questionable ethics of academic endodontists accepting industry payments. Next, Ruddle is at the Board discussing the removal of screw posts. Stay tuned for a super-sized Ruddle Rant on a topic that REALLY gets Ruddle’s blood boiling: evidence-based research. Did someone say controversy?
Show Content & Timecodes00:43 - INTRO: ALD – New Journal Issue 06:21 - SEGMENT 1: The Dark Side – Industry Payments to Academic Endodontists 27:21 - SEGMENT 2: Post Removal – Removing a Screw Post 54:09 - CLOSE: Ruddle Rant – Evidence-Based Research
Extra content referenced within show:
Other ‘Ruddle Show’ episodes referenced within show:
Downloadable PDFs & Related Materials
Ruddle on Shape•Clean•Pack Supply List and Supplier Contact Information Listing
Ruddle on Retreatment Supply List and Supplier Contact Information Listing
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.
… So, what do you see here? Well, you see lousy dentistry! That’s a good place to catch floss, isn’t it? It’s just done for laughs. It’s a joke for the patient to enjoy…
INTRO: ALD – New Journal Issue
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle.
I hope everybody is doing more that good.
Yes, we definitely do. So let’s get right to it. At the end of last year, Dentistry Today News published a press release by the Academy of Laser Dentistry announcing the release of the latest edition of its peer review publication, The Journal of Laser Dentistry. Now since we’ve talked about lasers on our show a few times, we thought some of you may be interested in checking it out. And if you weren’t already aware of the Academy of Laser Dentistry, it was founded in 1993 with the merging of three organizations; the International Academy of Laser Dentistry, the North American Academy of Laser Dentistry, and the American Academy of Laser Dentistry. So the Academy of Laser Dentistry, which I will now refer to as the ALD; it is an unbiased, non-profit organization devoted to laser dentistry, and its membership includes clinicians, academicians and researchers in all laser wavelengths.
So when they announced the release of the new journal, they did release the Table of Contents to that you could see what was in it. And so looking at the Table of Contents, was there anything that really sparked your interest that you really wanted to learn more about?
There really was. In fact you already said it so I’m being redundant, but on this show we spend a lot of time talking about 3D disinfection – of course that’s different lasers and different wave lengths of light on the electromagnetic spectrum of light. But when you get down to the lower lasers, not 2780, or not 2940 in the case of Er:YAG; if you get down around the 6, 7 or the 8 and 9 hundreds, they showed this thing that they’re calling photobiomodulation, PDM. And photobiomodulation is nothing more that what used to be referred to as low level laser therapy, LLLP. And this is low wavelengths of light and it can be used to treat a lot of things, and that’s what fascinated me. If I was a general dentist, I don’t know why I wouldn’t have one in ever room, literally, because they’re tabletops, they’re small, they’re compact. But we see a lot of people that as they live longer they get cancers of different kinds. And so there’s chemo radiation induced xerostomia, there is also oral mucositis; and those are really tough for patients when they don’t have salivary glands. So they can use these low lasers around more than sublinguals and submandibulars and these different salivary glands, and they can not only get them to rejuvenate to some extent, but also produce more saliva. And of course you get xerostomia with things other than chemo radiation induced xerostomia. So that was very fascinating for me for those patients.
I also saw that they could do sensitive dentin, and who doesn’t complain of sensitive dentin? Patients are coming in all the time and they’re complaining that they can’t get cold on a tooth – and again, as a periodontist, I’m making this all up; psycho drama role playing – and maybe they’ve had apically repositioned flaps, osseous contouring. And so now they have some exposed cementum, but then the cementum is curetted off by the hygienist and now you have exposed dentin. So they’re sensitive. So they can be used on – a light can be passed over these exposed roots; people respond to that.
Other things I notice were – well I went to a really interesting lecture with my grandson in [Las Vegas] some years ago at SiroWorld, and I listened to a woman talk about obstructive apnea, the sleeping disorders. And what happens is the soft tissue kind of collapses – it’s usually in more obese people and overweight people, and that soft palate can collapse. But they’ve targeted eight regions – tonsillar pillars, soft palate, base of the tongue – where they can pass this light over it. And you have to go like a couple seconds each time – you might do it Monday, Wednesday and Friday, and for two months – but they got rejuvenation and a lot of times more collagen formation, increased blood supply. It was really remarkable, about 65 or 70 percent actually got improvement from snoring; and of course obstructive sleep apnea is linked to heart attacks and things like that, so it’s serious.
There was probably one more I didn’t mention, but what would that be? I guess that was just a crown leak; that’s common. Caries subgingival; you’ve got to clean it out, now you’ve got bleeding. So you can do like bloodless cautery incisions with these lasers. So I would think pretty much everybody is going to want one, because there are so many applications that we see in our patients that visit us daily.
Yeah, well nice. Apparently all of these clinical topics in the Journal too are also – they include interviews, commentary and other learning resources. So you might want to check it out; I’m not really sure what it entails. I think you might have to be a member of the ALD to view the Journal.
And I just don’t know what that entails, but I know a lot of dentists are purchasing lasers nowadays. I mean they’re expensive, but more and more dentists are acquiring them in all different disciplines. So we’ll definitely be talking about lasers more on the show in the future.
But now for today, our focus for today, we have a great show planned. It’s not about lasers, but it’s a great show, so let’s get to it.
SEGMENT 1: The Dark Side – Industry Payments to Academic Endodontists
Okay, so we have a new segment to introduce today and it’s called The Dark Side. You’ll notice that the lights are turned down to create a certain mood; we’ll bring them up momentarily. So in this segment, we plan to discuss issues that some may say cast a dark shadow on the noble profession of dentistry with its goals of healing and helping patients. So some potential topics we might discuss in a segment like this are controversies, self-interest, inequities, dangerous products or technologies, malpractice issues, and maybe even cover-ups.
So for this first segment of The Dark Side we’re going to discuss industry payments to academic endodontists. Now this is not inherently bad things, but it does raise some concerns regarding conflict of interest, and we’re going to discuss this more shortly. But first, why don’t you tell us where the inspiration for this particular segment came from?
Well I think first of all, let there be light; let’s bring light to the dark side. How about that? So here we are in full light, and I feel the heat of the bulbs – well, they’re LED, so not too much. This is a guy that I read his article; his name is not nameless – His name is S for Stephen Craig Rhodes and he is at the St. Louis University in St. Louis, Missouri, and he is the Department Chair of Endodontics. And I think he actually says he is head of advanced dental education, the Center for Advanced Dental Education.
So anyway, he wrote a pretty poignant article and it appeared in JADA in 2021, I believe, so just a couple of years ago, and he really started bringing attention to industry payments to academic endodontists. And he defined academic endodontists as chairpeople, women and men, adjunct professors, part-timers, faculty, the whole people that keep the infrastructure going, and he wanted to look at them specifically in academics and see what kind of money was going that way. And his emphasis then was to look at the inter-relationships between industry – think dental companies – and these academic endodontists – I just mentioned who they might be. And there’s even others outside of the academics, right, like maybe me.
So anyway, he was talking about academic endodontists, and finally he wanted to talk a little bit about how to set this up because there are some discrepancies with women compared to men; we see an under-serving of women in these payments as compared to the men counterparts, and there might be reasons and explanations for that. And then also he got all of his information, it was very objective. He went to the open payments database, and there you can get a list of – pretty much every laundry list of where and how money moves.
Okay. Well I want to make two disclaimers first to start the segment. So Dr. Rhodes devotes a majority of his article to really analyzing and organizing the data and putting into graphs. Now we are not going to go into huge detail in this regard, but we will have access to the paper in our show notes if you want to go and look at all the statistics yourself.
The second disclaimer I want to make is a lot of you are probably aware that my dad, who has now been in endodontics for around 50 years; well he receives royalties and that’s an industry payment, but he receives royalties for a product he invented. And we will actually discuss this more at the end of the segment and give you some insight into his personal journey.
All right, so now let’s get back to the paper. Why don’t you give some just broad statistics so our audience can at least have a general understanding of what we’re discussing.
Well first I’d like to say this. If you’re a statistician, you’re going to just love this paper. I mean there is every way of looking at it, different contexts, and oh my God. I’ll try to just fly at 30,000 feet.
There were 300 academic endodontists in the study. And I saw at one other place 302, but 300. And he found out that 80% of those, that’s 240, were actually taking money; so 240 out of the 300. And it was small, it was like $400 or $500.
For the average.
For the average. And then you want to know, well what about maybe the ones that were at the other end of this curve, and it was funny that only 10% - so you take 10% of 240 and that’s 24 – so 24 got about 86% of the money; 86%. And that turned out to be considerably more; $24,000.
On average; these are averages. And so I’m sure he had all kinds of ways to weight the study so they’d be fair and balanced and could be interpreted by all. But that was kind of it.
He also found out that women didn’t get paid as much as men, even women doing the same exact job description. And he does quite a bit of a deep dive into that, and then talks about why that might be. I’ll just interject real quick. When I went to dental school back in the ‘70s, the mid- ‘70s – more than the mid; a little earlier – there were 100 in our class at the University of Pacifica, San Francisco; 98 were men and two were women. So I can begin to see why as the years went by why it was like that. But then if I go out now and speak to the post graduate programs, I notice that more than half the time there’s about 50% or 60% women as compared to men. So he thinks this might balance out with some time.
And what else do I have here? I think that was it. There’s a lot of different things if you’re interested, and you can find different groups of people and how they might get paid, but that was basically it.
Okay, well how are the payments being made? Like what is the nature of the payment? I mentioned earlier that you received royalties, but that doesn’t even nearly represent the bulk of the money being paid out, correct?
Right. The bulk of the money paid out, as you might expect, was consulting. And consulting is a huge umbrella, so you can put shoes and socks and gifts – I mean it just goes on – on lectures, hotels, flights, per diem, ice cream. I mean I even saw gifts. I said gifts; I haven’t gotten any gifts. Well I got books; people gave me books. But anyway, yeah, there was that. But I just want to give the audience a little more rounded perspective of how money can flow between industry, dental companies. NYU is an example and this is a good thing; it’s not a bad thing.
Dentsply Tulsa, Dental Specialties, redid their clinic; I’ve been there. It’s like state of the art. Who benefits? Kids. Generations and generations of kids. So payments can be helping a university remodel; that means benches, chairs, everything, free clinic included. Then sometimes you’ll have a scope company go in and they’ll put a few scopes in. And sometimes they’ll have motors; they call these grant programs, so the industry goes in and puts motors. I don’t know about CBCTs, but I’m sure there’s a few of those that are granted to the schools so their kids can use them and research can be done. They get a lot of money for research. I mean people don’t think that a paper that you’re quoted, it takes a lot of money. Probably this one didn’t because it’s not an animal study or it’s not a mechanical study where you have to have sophisticated equipment, you’ve got to the lab time, and sometimes these labs have to be accessed during certain hours only. So money is exchanged across the board. I’ve never really thought it was a bad thing; I thought it actually helps everything. The main thing is if we report our conflict of interest. So COI is what he’s really harping on.
Okay, so we’ve already established the fact that many academic endodontists are receiving payments from industry. And a lot of these endodontists are speakers; they publish articles and they teach residents. So if these endodontists are receiving money from dental companies, shouldn’t we expect them to be somewhat biased towards that company’s dental products? And apparently according to Rhodes, the payment doesn’t need to be large to create bias. Even small payments can influence decisions.
So how is this all mitigated? You said something about declaring conflicts of interest?
Yeah. I mean the main thing I think I have emphasized in all of this is you do really need to know whether it’s a speaker in front of you at a study club or it’s a packed ballroom, whether you read a scientific peer reviewed article or a trade journal; we’re really obligated to tell our audience before we get started. So for example, Ruddle always says at the beginning of every lecture after I do my pleasantries and how are you and what we’re going to do today. I’ve got a little disclosure to make and I have invented over 12 products that are used internationally around the world; I get paid royalties on those. And so without any further ado, let’s get going. Please don’t throw your tomatoes at me yet; hold back the fruit and the oranges until later.
Okay. Well the transparency is important, and that’s what Rhodes said should be happening. But regarding publication, it’s not only the authors that need to declare conflicts of interest, but also the members of the editorial board. And Rhodes points out that scientific journals tend – they tend to be very strict and rigid enforcing conflict of interest rules with authors, but not so much regarding the editorial board. And if you just think of like the JLE for example; a large portion of the editorial board are academic endodontists who are receiving industry payments. And more transparency here I think here would be important, especially to create trust and credibility in the peer review process. Because aren’t these editorial board members involved in that?
Well you and I looked it up, and we actually were going to vacillate from many to most. And I think we decided after looking at the editorial board of the JLE, most of the editorial board has affiliations commercially. And that is never coming out to your point. So your point is your pop submits and article; I can get pounded over and over about it, even if I have my disclosure, just about other stuff. We’ve said ProTaper one too many times.
So anyway, if somebody is on the board, and let’s just say they have an affiliation with EdgeEndo – just make that up – or SS Wipe, are they going to be as favorable to my paper coming through the process? They might be. They might be able to be benevolent and sit back. Or they might say you know; we’ve had enough rotary instrument articles. Let’s take a pass; we’ll do it another time. Because I know many, many fabulous clinicians, researchers who haven’t gotten their papers published because maybe it sounded a little too commercial.
But you know what? Everything we do, everything you do in your private life, everything you – right now, these readers. Somebody is making a margin off them. Somebody is making a margin off the papers. That suit, the tie; you buy – you use things in industry. I think we need to get over it and understand people are there to help us do better work.
I want to make one critical distinction. For me, I haven’t had any problems with consulting. There might have been a day when I got consulting, like years and years ago. But Dentsply Sirona doesn’t give consulting. So I’m really proud of it. I got paid for IP. That means ideas that could benefit -
We’ll get to your personal journey in a second.
I want to go into now about regarding teaching residents. Like say for example there’s a program director who receives industry payments. Is there a danger of this program director creating a residency program that’s maybe more tailored to his own financial benefit than providing a balanced and unbiased education to the residents? I’m not saying this is happening, but it seems like there could be a danger here of that happening.
There’s a definite danger, come on. Let’s just say for fun I’m on the board of GentleWave and I own stock and I’m at a school. And all of a sudden I find that Biolase or EdgePro from EdgeEndo or Lightwalker wants to put a laser in. Do I let a laser come in? Or do I say no, we’re good, we have GentleWave. That would be a conflict of interest. But I would think you’d want both technologies. Fred Barnett, a really good guy at Einstein in Philadelphia; I notice he likes to post that his residents are using the EdgePro, or maybe it’s the Lightwalker, it doesn’t matter, up in the 2940 wavelength. They’re using GentleWave, they’re using all these things at school; that’s open, that’s completely open. But it’s not like that at every school, is it?
No. Yeah, I do think that there could be some conflicts of interest there. But I guess if you – maybe if everyone’s aware of what’s happening, there just should be – all different types of products should be represented; laser, CBCT, GentleWave, it should all be represented I think.
Should the EndoActivator be there?
I think it should be. I think a lot of things should be there.
If you were fair and balanced it would be.
Okay, well let’s look now at how you have balanced your role as an educator with the fact that you also receive royalties on products you’ve invented. Because I have seen your personal journey myself, and having worked in the office, I want to give a couple of examples. Because I really admire, Dad, how you have conducted yourself – as your daughter I really admire it – in your career.
So my first example is a lot of times doctors would call our office asking about our Shape, Clean, Pack DVD, which features ProTaper. And Laurie and I were always instructed when they asked this question to really emphasize that you teach concepts. And it’s not so much about it so happens that you prefer ProTaper yourself, but you’re really trying to get the concept of a root appropriate shape. So it can be accomplished with other file systems as well, and we have to remember that you practiced for what, like a couple of decades before ProTaper was even invented, still getting the same shapes. So you’re about teaching concepts, not so much about teaching a technology.
The second example I want to give is when ProTaper Next came to market. Now you aren’t an inventor of ProTaper Next, but ProTaper IP was used to create ProTaper Next, and so it was set that you were going to receive a small royalty on it. However, after it came to market and you noted that there were some specific deficiencies in the product that you really felt like you couldn’t stand behind the product, you actually declined the royalties.
I actually tore up my contract in front of the general manager, to his chagrin. It was the funnest day of my life. I just went heeee, like that.
Well Dad, you are just an example to me of ethical behavior; of someone who is not just about the money. And I just want to say, I really admire how you’ve conducted yourself throughout your career, balancing educator with inventor.
Thanks. Yeah, I don’t have anything to say or I’ll get a tear in my eye. I think what was pretty easy for me is they always say who you are is where you were when, so that means I was raised by my pop. My dad was a minister; he lived to be 95. I think he was pastoring on the last day of his life. So I always saw this, helping others and doing good for other people and trying to make a difference. So that was easy to do in dentistry wasn’t it because you’re seeing people that have needs. And then I told you the name of this woman, Ruth Stafford Peale; but she was the one that coined the word “find a need and fill it.”
When I first was teaching rotary, there was basically ProFiles and GTs; that was basically it. I mean McSpadden had something, but it was a small thing compared to Ben Johnson’s ProFile, which was international, and Steve Buchanan GTs. There were deficiencies in both, but they were the first – pretty much right around the first – so they were really good, but there was so much more that could be done. So we taught, we saw what the problems were, we heard people’s complaints, and so Machtou, Professor Machtou, John West and us, we got together and we changed the taper on a single file, which today is used almost all around the world. I was telling John yesterday; you should have had IP on the file and not had Dentsply get it, because then you would have gotten paid from all these, like SSYP; all put either decreasing or progressive taper. So anyway that was a big deal back then. So find a need and fill it. So anyway, between having a need, having a background that kind of steers you towards that, then filling that need.
The other things I guess that happened that fell my way is I never took – Phyllis wouldn’t let me – I thought we worked hard enough to do it. Because I told on this show, three million miles by the end of 19 – what was it? Just before COVID – 1999? No, 2020 was COVID. So just the year before we had logged three million miles.
Yeah. So I had a lot of friends out there, and there was a lot of reason to keep going. So I took a lot of the money from the royalties and plowed it back into education. I think if you’ve seen me lecturing around the world, people say well, Ruddle you’re not so good, you’re just average, but your animations were outstanding; I learned a lot. So we plowed a lot of money into animations as an example. Bob Sharp will tell you; we put in a couple million dollars in the EndoActivator; where do you think that came from? I didn’t take it out of your piggy bank. So you can take money that you get off royalties to try to help improve disinfection as an example. So we’ve always plowed our money back into education and the business. Some people might think it’s really the thing to do, go get royalties. But maybe if you just wanted to make a lot of money you’d just stay in practice five days a week, and do that for about 35 years, you might find out you’re about in the same place. But if you have an inclination to do this stuff, go do it. Because it’s not just treating patients that makes the difference; it’s doing all the things that get people the products so they can do better dentistry.
And finally, you pointed out that this is our 76th show. And of course The Ruddle Show is free isn’t it?
We’re not charging anybody. But if the audience out there thought about it, they’d go oh my God. He has a shooter in the back room, his grandson; he’s got a couple of daughters, he’s got a granddaughter, he has a wife. Oh, they all work for free. You live for free in Santa Barbara, you’re homeless, you have permanent – outside under a tree; you’re all set. Anyway, money gets spent in lots of different ways, and it’s how we use our money that makes the difference.
Yeah. You’ve always kind of told me; really try to find something you like to do first and something that you can help other people that’s rewarding for you. And then somehow figure out how the money can follow after that.
All right, well I just want to say Dad, again, I’m really proud of you. I think that we all saw in this segment that the dark side does not necessarily need to be dark. With transparency it can – well I think for example, this segment has shed some light already on the dark side.
Can I make it really simple? All this will go away and the paper can be thrown out if everybody honestly reports their conflicts of interest, and the audience, the reader, always knows that we can move forward. We don’t have to have jealousies, backstabbing and all that.
Yeah. I guess my personal take on this is that if you’re an academic endodontist and you’re receiving payments from industry, that puts you in a bit of a position of power. Just remember to use your powers for the good, for the greater good and not for evil.
Thanks for all the information and that’s the end of this segment.
SEGMENT 2: Post Removal – Removing a Screw Post
Hi, Cliff again. And it’s Ruddle at the board. I have been in endodontics across five decades. And probably most of my early inventions were in the world of non-surgical retreatment. So that was kind of an important field for me; I got a lot of failures, they came in from everywhere. And of course when you see failures and you have to get creative on how you might address the chief complaint and ultimately move that case towards a successful retreatment conclusion.
So in retreatment, it’s never just one thing you have to think about, is it? It’s several things. But today we’ll focus on what you can see behind me, and that is screw post removal. Screw posts of course are active posts because they’re engaging. They’re threaded and their active, and as they’re placed, they’re turned clockwise and the threads engage dentin. So the post has gotten kind of a bad name when it’s done improperly, because it can develop a lot of internal loads in the root; so it’s been associated with fractured roots. But there’s been some innovations in posts, especially screw posts, and one of the is the flexi-post. I’ll let you Google that, but basically a flexi-post has a slot up the active portion, and it makes it into two hemispheres that can flex as the post is threaded in. And presumably the load will to into the post versus the root. But anyway, you probably don’t really care about that. You just are a clinician, you’re chairside, and you’ve got to get this thing out.
So we’re going to come back to this case, but just to set up a couple little things. Let’s really look at these things through very thoughtful eyes. Notice we have a heavily restored quadrant, and particularly on this tooth a porcelain fused to metal crown. So decision tree: are you going to take the crown off? We’ve talked about how to do that in other shows; I’ll just come public: metal lift. Or are you going to work through the crown and use some various kinds of burrs – diamond high-speed is the primary – and are you going to access through that glass up on top – the porcelain. Then there’s the metal; transmittal burr. You’d switch to a transmittal burr, because now you’re going through metal, presumably pretty thin. And then of course you get into the cores and the buildups. And when you look into these chambers, they can have amalgam; they can have all kinds of adhesion dentistry type materials like composites, bonding; you can find amalgam and you can find just about anything, cements, etcetera.
So there’s the crown, then there is the chamber materials. But I want to really emphasize freeing up all the materials from around the head of the post, and then let me talk about the head of the post. There’s a variety of different heads that are often obscured under the casting radiographically. So they can have like Christmas tree configurations, they can have arms, they have retentive, different diameter heads. Sometimes those have to be machined down so that we can actually get ahold of that post mechanically as I’m going to show you in just a few moments.
You know it’s an active post because you can see thread patterns, and when thread patterns are kind of on an angle – that’s called the pitch – then you know it’s a screw; it’s a screwed post. And if you basically see the threads and they seem to be lining up perfectly – and they don’t. See this first one here you can see it’s more like that. So then you can say that’s just a post that has retentive grooves versus threads. And then apically of the post, we don’t know what this is. We’re probably thinking it’s gutta percha. It could be paste. The MB and the ML, I see one’s treated a little bit short. Many of you like that position; I don’t like 1mm short because I’ve made a living out of retreating 1mm short cases. And then of course the ML is much shorter. So there are several things you’re thinking about, and you don’t know if this is paste. Now you’re starting to think well maybe it is paste. This looks like something here; the radial density between these two is not that different, so kind of map it out.
Something else I’m going to talk about right now – I don’t do this very often – but I think if you really start to look carefully at this tooth, I want to show you the concavity. I want to show you the furcal side concavity. So in between those lines is the concavity, so we want to shape and remove materials away from furcal danger, and that’s something we’ve talked about before, but I’ll illustrate it again right now.
So let’s use a little animation – I know you’re getting real excited so the animation will really bring you in. It’s going to be the first row of seats; it’s going to be right in the main colosseum, you’re going to be right on the floor; right on the floor with the play. So you’ve got a screw post, but I want you not to look at the gutta percha and all that. Look at the core and look at the materials in the pulp chamber. I just alluded to that, but now I’m showing you an animation of what you might uncover as you progressively work your way down to the pulpal floor, get those axial walls peeled back, and you might even need some thin ultrasonic instruments to use in tight places where a burr would be too big. Let’s try to protect coronal tooth structure. So core materials are there; dentists place them all the time and there’s a great variety.
Now this is probably you’re thinking a little too basic for this assignment, but it’s always useful. Because I’ve taught across five decades, and I can tell you; I still hear from endodontists, well what do you use – bla, bla, bla. Well then let’s just talk about it. Primarily I’m using the surgical length burrs. These are surgical length because they can extend a lot further into the chamber. That by definition, if this is the handpiece head, it kicks the head of the handpiece further away from the occlusal table so you have a corridor of vision. So I want to emphasize surgical length burrs. I want to emphasize a surgical length diamond. A surgical length diamond and maybe like round burrs 2 and 4. So those are the burrs. But didn’t talk about the transmittal burr. The transmittal burr we’ve talked about several times, but it’s really good to machine down heads of posts so you can make them pretty round. They’re not going to be theoretically round because clefts on the handpiece and you’re bouncing around on that metal; but you can pretty much get it round – I’ll show you. And then of course we have ways; we have taps that we can grab that machine downed posts so we can get a mechanical advantage, and jack that post up and out of the canal.
Okay, so that’s the tools. I do want to come back to John Stropko again. John is down in Arizona, but he has the normal tri-flex syringe – you can see it, you have it, everybody has it. Take the stem out and throw it away, and you can buy Stropko’s, the quick connect, and they have different lengths. There’s a shorter one that’s about this long, and then there’s the long one. So you can have a short and you can have a long, but the main point is you have luer lock threads internally. And those lure lock threads allow you to put different industry cannuli, and you can thread them on so when you push down on the valve, you don’t blow this thing across the room and put out your least favorite assistant’s eye. Yes, yes.
So we’ll keep going. And of course, most posts, as you know because you have some experience don’t you – and some of you have a lot of experience. You know the number one choice for post removal, once the head of the post is completely freed up and the whole post that’s in the pulp chamber is freed up, and you can even in irregular shaped canals, even in the irregular shaped canals, if this is the post, you can even use ultrasound here and in here, lateral to the post, so you can blow cement out as long as it’s safe and you stay on cement and not on dentin. The more you can undermine that post, the more successful is the removal effort.
Yet, Cliff made up this a long time ago – I think it was the early ‘80s – it was Ruddle’s 10 Minute Rule. 10 Minute Rule. And my 10 Minute Rule is if you’re using ultrasound and you’re going to work in this zone right here, right in here. On this version, this is a private label, Dentsply ultrasonic generator made by Satelec. So Satelec is all over the world, and there might be a little different look today, but the guts is the same. And you’re going to work in that red zone because we need more energy, and if we’re going to send a powerful wave of piezoelectric energy, like a sinusoidal wave, and we can get that tip moving. It moves – this is an animation, but it’s only moving about a 1/10 mm in linear motion. So you put that up on the head of the post, as you know, and you go circumferentially around the post. And of course you go up and down along its length and you try to hear maximum displacement, that sound; you try to feel the energy up your arm, you can feel the vibration on the post, so going around the post is quite useful. So the 10 Minute Rule; if you’re vibrating and nothing’s happening after 10 minutes, you need a fall back position. So if you have experience out there, they don’t all come out with ultrasonics; although most of them will. But as we’ve gotten into better cementation, materials and bonding posts in, and then you throw in an active post, you can begin to see that you could vibrate and be unsuccessful. And of course keep the post cool while you’re vibrating because we’ve talked about thermal injury. And even though dentin is a poor conductor and you’re not going to get heat moving through dentin out into the attachment apparatus, it will begin to happen quickly if you don’t wick off the heat. So a little caution on your ultrasonic endeavors.
All right, so we’ll go forward. So you’ve got the burrs and you’ve got the Stropko, and now you’ve got ultrasound. And we’re coming back to the case I showed earlier and let’s just progressively disassemble. I’m going to use a metal lift and take the crown off. Once I get the crown off I can isolate the tooth – I’m using an Ivory 26. And I have a blue rubber dam on and I have an isolated field, and I use a surgical length diamond and I start to trough around the head of massive post. And you can see the post in here; this color probably isn’t going to be that good, but I’ll go black. But you can see, there’s the head of the post and there’s all these little configurations. Well, you can run your ultrasonics through here and you can run your ultrasonics through here and you can clear out all that; but you’re not going to use the little tool that comes with the post; that’s to screw it in. It’ll break these little tines off, so you have no chance.
Then I want to really emphasize; all core materials are totally liberated from the pulp chamber. And what we’ve done is we have used the trans-metal burr and we have machined down the head of the post which is up in here, and I’ve machined it down roughly to a pre-determined diameter – you’ll see it in just a moment. And then I can take a tubular tap, a tubular tap, and it has internal threads, and I can begin to actually thread the tap onto the post and get a very strong, powerful mechanical grab; I can grab that post. And so this is what I was doing with the trans-metal burr right here. We were getting – like you might have had a Christmas tree head on here, like this and it might have been like that. You can’t tap that, so you’ve got to machine it down. So by machining it down like we’ve talked about, you’ll be able to grab it. And now I have a tap coming down in here. And this all came from this kit we’ve looked at in another season, so I’m not going to review the whole kit again. But we’re using these trephines – there’s five of them – and then there are five taps; so taps and trephines. Trephines are different diameters, starting at 0.25 mm, and they go up to bigger sizes. So I want you to see that you can have different choices, but always take the trephine that will fit over the post sloppy. Get the one that’s sloppy – well it’s not going to work is it? So you’re going to go to the smaller one. And as you go down, pretty soon you’ll find an inside diameter that won’t fall over the head of the post; that’s the one to pick, that’s the one to pick.
So you’re going to start over here at 1.6mm, and if it’s too big, you’re going to drop down to this one, and that one would be 1.35mm. And then you’ve got a 1.1mm, okay, and they keep going down by 25/100. So pick the biggest trephine that just won’t fall passively over the head of the post. And you’ve machined this down to trans-metal burrs, so it’s not perfectly round, but it’s pretty round.
These are corresponding. If you use the four tap – you’re going to use the trephine, the tap, paramount. And what you’re going to be able to do is machine down the head of the post, then you choose the tap; and I want you to notice the taps are counterclockwise. This is why I made it this way, because there was an older kit that came from the basement of a friend of mine. Professor Machtou had a friend – that’s what the story is – I think it was in the ‘40s or ‘50s in Paris, he was a dentist, and he made the old extracting plier system. But it was very complicated, it wasn’t as refined and it could really be improved, and then it had a lot of pieces; it overwhelmed people. We made one kit and we made everything not to clockwise like the old French kit; we made it go counterclockwise. So when you’re tapping, you’re encouraging the unscrewing of that post; that’s exactly what you’re trying to do. So that was a good idea; people liked it. But remember, these taps turn counterclockwise to engage. I’ll say that one more time. I’ve had people call me, email me, talk to me at meetings like I can’t get the tap started. And you finally say, did you remember it’s counterclockwise? They go oh; okay. Okay, we got that cleaned up.
You will never, ever use the extracting plier. This is to pull the tap out if it’s a tapered post, a cast post, a parallel post, any post in the world that is not active. So you’re only using, again, trephines and taps, and you’re not using any of this stuff; this is the idea. You will use this; this is the torque bar. The torque bar can pass right through the port – you can see the little port in the handle, they all have them. You can pass this torque bar right through that port, and that can help you clinically get a little bit better mechanical advantage on unwinding and backing the post out of the canal.
So here I am, fully engaged. Out the post comes and we go to the post-op. So I’ve extended treatment in the ML all the way down to the terminus. I’ve extended treatment in the distal about 2mm all the way down to the terminus. We’ve still got good dentin up in here, so I think our minimally invasive people should be thrilled because we got many, many more years out of this tooth; the tooth that presented with signs and symptoms to I can’t bite on my tooth. You could think it’s fractured, but you could just think that endodontics, it doesn’t look right so maybe we ought to retreat it.
Last case. Screw post, active post. Now that one’s a long one. It looks like a pole vault from track and field. I think it could probably be a pretty good pole if it would flex like a fiber post, but no; that’s a metal post. This is a flexi-post. Flexi. And if you look at the active part, I’ve told you there’s two spheres. Your engagement threads are out here. Your engagement threads are out here. So if you screw this in, this part can flex in and this part can flex in, and that’s what I meant when I said the loads can be transferred ideally then into the post – according to manufacturers – versus the root. Still be careful. These posts when they’re done right, they are probably the most retentive posts in the business. That’s what I want to say.
So what do you see here? Well you see lousy dentistry. That’s a good place to catch floss isn’t it. It’s just done for laughs; it’s a joke for the patient. Do you notice the internal resorption? Do you notice there’s a furcal problem in here? Do you notice the treatment is not very – look; endodontically things look so parallel in this zone. There’s no taper. Taper means you don’t get hydraulics when you pack, because you’re not packing into resistance for them. You’re packing into something that’s more parallel, and if it’s more parallel, you’re just going to be probably shooting stuff through the root; like I see, about a millimeter or two overextended. Can we get that out? Did you ever hear about the Hedstrom displacement with the solvents? Okay.
The DB, I’m seeing the DB is right around in here. The palatal is up in here, so now you’ve kind of mapped it out. So now I can get the crown off, I’m going to get the core materials out of here, they’re kind of a big access. I’ve got to free up that, get that out, extend treatment, pack; let’s see if we can do it.
So I like you to think; I like you to measure twice because you can only cut once. And here we are after the crown’s been removed. That metal lift – go back and watch that clip. You can take so many crowns off in less than five minutes, oftentimes three minutes. You’ll spend more time bla-bla-bla, telling your patient about risk versus benefit. What’s kind of ironic; if you didn’t try to save the crown, you’d just cut it off and throw it in the waste basket, so there should be no issue trying the metal lift.
I’m using a very thin ProUltra tip from Dentsply Sirona. Yeah, I invented them many, many years ago, decades ago. And the thin ones can work in a tight space between an axial wall and the post. You can run a burr. I know a lot of general dentists just take a big brrrr, and they grind it out. Well, you might want that tooth structure. I don’t know. I keep hearing all over the world: minimally invasive dentistry; minimally invasive endodontics! Okay, let’s be more minimally invasive if that’s what you want. That’s what you want. I think that’s what most people think is appropriate to save tooth structure.
So now you can see we have a huge post, and you can begin to see the trans-metal burr; it’s in here. I even machined it down because there was a Christmas tree configuration. So the post was looking like this and I can’t grab that with a tap – there’s no chance – so I’m making it post-like. So make the head of the post post-like, pretty round; and you can see this is looking pretty good to your eye; pretty good to your eye. Another little trick is did you notice I got a little taper going here; got a little taper going here. If you have it like this and you put your threaded tap on, and you strip off, you may not have another chance to grab it. So I like to have the part that sticks out pretty big and have a taper; because as I put the tap in, I’ll be able to catch the threads. So if I have a little taper and I’m putting a tube down like this, you can see that that will encourage the head of the post to go up into your tube, and then you can start putting your threads on. Now you can’t thread too far because you’re going to get a lot of pressure and then you’ll blast out and break the tap.
All these things to learn. You know, if you really wanted to learn it you’d be reading my chapter, wouldn’t you?
Okay, so there I am using the 3, but I’m using the 3 a little different than you’re thinking because I’m using it just partway down. You can see how big the post is; it’s off the screen, comes around, you can see it right in here. So I have machined down around to save tooth structure. I’ve machined down at the expense of the metal post versus dentin.
Here I have the 4 – you might be able to barely see it here – that’s the 4 upside down. And you’re thinking, I thought you used a 3. Well I went back and used the 4, because as I put the 4 over, just like I said, it fell over easily and then it bound about 2 or 3mm up from where I had tapered it, so now I’m grabbing threads. And sometimes you can just turn this neural – this is a neural for your anti-slip feature with your gloves – but sometimes you’ll have to take the torque bar that I showed you earlier, pass it through the port in the tubular tap, and that’ll give you a little bit better mechanical advantage. And you can use one figure to keep it really steady. You don’t want that tap to be going like this. You want to hold that so it’s threading, threading, threading, so you don’t put a lot of torque into the root where you can invite a root fracture.
Well, I broke the post deep in the tooth. So as I was unwinding and using more and more pressure, that flexi-post, we heard a little crack. The patient’s eyes went like that, and I said how you doing? And they said what was that noise, and I said everything’s coming out. Right? So they loved it. And you can see the flexi-post; look right in here. See that? See that? Well you can run your ultrasonic tip right through those two halves and get that loose. You can go out here and get more cement with your thin ultrasonic tip that’s about 1/10th as big as a 2 round burr so you can reach way up there. You can use a Stropko, chh-chh, and blow out this dust so you have continuous vision as you’re using ultrasound. And it’s all fun. Here you go; you can see it’s a little deeper. We’re up about right in there – that’s where we are – so you kind of have an orientation. So we’re looking from the top of the tooth – which is about right in here – and you’re looking way up that post. And I know my producer is going to say try another color; come on, try another color.
So I’m going right up here; I’ve broken it. You’re looking at the two little spheres here and here and here and here. And let’s just keep working, and we’ll go with a little patience. Now they’re breaking up. Now the hemisphere is coming up, and it’s out. Isn’t it great when we can look up here and see gutta percha? Isn’t it great when you can finally see gutta percha? You can even see where the point of that post was right in that gutta percha; that thermal softened gutta percha. Why is it thermal softened? Because we were using ultrasound; the by-product is heat; heat transfers to metal, metal is a conductor and that will thermal soften the gutta percha a little bit. So then you can get out your gutta percha, and I want to explain everything and then we’re done.
I’ve put the crown back on provisionally because we don’t like that. That’s totally unnecessary. I don’t know which came first, that or that. I even have extra writing capacity with my – sometimes I’m using many writing tools all at once. Well I won’t do it. Okay, so you have that; the crown is just provisional. The patient is very aware that if we get the tooth to heal, if it calms down, if all the symptoms abate, then we’re going to put more dental dollars into this particular molar and we’ll put a new casting on it; the dentist will. I took a distal view, so the camera is coming away from the distal – that throws my MV root anterior. The DB is superimposed over the palatal but I’ve extended treatment up here in the palatal. You can see we’ve extended treatment in – and we’ve pulled out that over extended cone that was up here, remember that? We pulled that out with a Hedstrom. We’ve filled into a resorptive defect, out with a lateral canal to a lateral root lesion, a furcal lesion, so that’s all good. And then let’s just show you maybe about two years later, and we’ll come around and not so mesially angulated in the horizontal position; we’ll come straight on and we’ll see the result, the cleaned up dentistry. And what we can do in endodontics, and we have a few ideas about how to take posts out; whether they’re metal posts, we’ve talked about non-metal posts, ultrasound is your first choice, Ruddle’s 10 Minute Rule. If you can’t get it, you’ve got a fallback position. You can mill down the head of a post, you can trephine it, you can machine it and tap it, and then you can engage it and you can a lot of times pull them out.
So the good news is we’ve never been able to do so much for so many people at this moment in time. Best wishes in screw post removal!
CLOSE: Ruddle Rant – Evidence-Based Research
Okay, we’re going to close the show today with another Ruddle Rant. And when we were brainstorming for potential topics for you to rant about, there was one that became very clear that this would the one, and probably one minute wouldn’t be enough. So today we’re actually going to have a three minute Ruddle Rant. And just so everyone knows, these go up to 30, so they’re in the potential for having a 30-minute Ruddle Rant.
I asked for the 30 minute timer because I have a lot to rant about.
Today we’re going to do the three minute one. So are you ready to go? Shall I tell you the topic?
Okay, I’m pretty calm. Yes, I’m ready to go now.
So the topic for this three minute, heavy duty Ruddle Rant – because you have a lot you need to get out; this is ranting therapy everyone. The topic is evidence based research.
Okay. Well you know everybody out there – and I lecture around the world – everybody is just evidence based, evidence based; is that evidence based? And I’m looking at these people like are you crazy? I almost said so. Anyway, are you crazy? And I know there’s academics, I see them in the front row and I see them over there, so you’ve got to be respectful. Okay. We have wonderful evidence on microbiology, histology, pathology, inflammation, all these kinds of things, pharmacology. I mean tick it off; we have great evidence. We have no evidence on virtually anything we do that guides start to finish endodontics.
Are you ready? Do we all agree on the best diagnostic schemes? Come on, do we? Is it hot? Is it cold? Is it the cavity test? Oh, oh, maybe it’s the electric pulp test? And even within those four ideas, you don’t even do them all the same out there. Does everyone cold the same way; do you all put heat on the tooth the same way? Okay, access. We have great evidence for access don’t we? Yes! Big ones, little ones, small ones, ninja, complete access, traditional access. Come on, just get into the tooth and do endodontics. Everybody’s ahh – look how small mine is. It’s smaller than yours, dammit! All right, oh Jesus!
Okay, so then we have the access. We’ve got all the evidence on that, right; that was guiding the evidence. No, we don’t have any evidence on that. In fact most of the evidence says that smaller accesses cause more problems. Come on! And then of course shaping. Oh, I forgot glide path management. I’ll just ram these rotaries down there. We’ll just go down there; we don’t need glide path. Do we agree on glide path, do we agree on working length, do we agree on patency? No! How come I see so many of you on the discussion forum and you’re still short? You’re short, short, short! Oh, you love short don’t you? Whooo! Wow, short, okay.
I’ve got to get off this, ranting, go further into the rant. Okay, what about irrigation? We don’t agree on the volume, the temperature, the sequence. We don’t agree on the strength of the irrigant. Oh, I used advanced techniques. You didn’t use advanced techniques four years ago! You never got later canals in your whole life; now later canals are important! Get every lateral canal, get a laser, get GentleWave, they’re the only hope! The hope is for the technology; it will make us more than we are. So you see, there’s a lot to do. How are we gonna fill? Oh, oh, I’ll use single cone. Is there a lot of evidence for your bio ceramic hydraulic sealers? My God! Oh, I have time; I have more time.
Whoa! Now I’m really rolling. I’m getting into my complete rant now. Would you get her a saltshaker so I’ll have more time!
So obturation, single cone, what sealers? You’re going to give up a 40-year sealer that has decades of research – gosh, she’s trying to get it to go faster – and you’re going to go with something that everybody’s using!
Did you get it out?
No. I actually need just a little bit more time because I was just getting started. That was just a warm-up. So we really don’t have a lot of evidence, as you can see. I’m trying to be a little funny, but do you think you have evidence to guide your every clinical move? Come on. We’re all over the place. People say no, it’s like this, it’s that paper. Look. Train, keep your ear open. There’s lots of ideas out there; there’s no truth. Find your own truth.
Well thank you. That’s our show for today. We’ll see you next time on The Ruddle Show.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
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