3D Tomosynthesis Special Guest Presentation by Dr. Don Tyndall

Top of the show is “Top of the List”: Who are you going to make it a priority to contact in the coming days? Next, Dr. Don Tyndall will give a presentation on 3D Tomosynthesis, a relatively affordable diagnostic imaging option that will be a game-changer for many. Next, Ruddle and Lisette share some opinions and insights in a brief post-presentation discussion. The show concludes with a return to Demotivators… Don’t discount the ability to motivate through sarcasm, ridicule, and mocking laughter.

Show Content & Timecodes

00:40 - INTRO: Top of the List – Person to Contact
07:29 - SEGMENT 1: Guest Presentation by Dr. Don Tyndall
36:06 - SEGMENT 2: Post-Presentation Discussion
41:49 - CLOSE: Demotivators

Extra content referenced within show:

  • Special Guest: Dr. Don Tyndall
  • Surround Medical Systems: www.surroundmedical.com
  • Portray Xray: www.portrayxray.com
  • Tyndall Research Listing (see downloadable PDF below)
  • FAQ Listing re: Portray Xray: www.portrayxray.com/faqs
  • Demotivators: Courtesy of https://despair.com
  • AAE Discussion Open Forum: https://connection.aae.org/communities/community-home
  • Riley P: The Winner Within (featuring “The Disease of Me”). New York: Berkley Publishing, 1993

  • Other ‘Ruddle Show’ episodes referenced within show:

  • The Ruddle Show S02 E07 – “The ProTaper Story – Part 2: ProTaper’s 20+ Year Journey as Told by the Creators, the 3 Amigos”
  • The Ruddle Show S09 E02 – “The Dark Side & Post Removal: Industry Payments to Academics & Removing a Screw Post”
  • The Ruddle Show S07 E08 – “Artificial Intelligence & Endodontic Concepts: Update on AI in Dentistry and Q&A”

  • Select PDF content displayed below. See Ruddle's complete library of downloadable PDF content at www.endoruddle.com/pdfs

    See also Ruddle's complete Just-In-Time® Video Library at www.endoruddle.com/jit

    Downloadable PDFs & Related Materials

    Tyndall Presentation
    "Research Listing"
    Apr 2023

    The Research Listing referenced in Dr. Don Tyndall's presentation on 3D Tomosynthesis

    Ruddle Article
    "Endodontic Diagnosis"
    Oct 2002

    Dentists are trained to thoroughly review medical and dental histories and perform comprehensive extraoral and intraoral examinations. Yet, in spite of these efforts to optimally serve patients, the dominant clinical reality is...

    Related Polls

    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.



    …OK, so let’s dumb it down and just leave **** behind; let’s be sloppy.


    OK –


    Let’s be dumb…


    Yeah, let’s –



    INTRO: Top of the List – Person to Contact


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


    How you doing this morning?


    Good; how about you?


    I’m doing really good. I’m very excited about some of these topics that we have to go over.


    Yes, we have a great show planned for you today. We’re going to start with another edition of Top of the List. And I’ll explain again what this is about. So we pretty much can agree that most everyone is very busy with almost all areas of their life. So the point of this segment is to identify who or what is at the top of your list regarding one aspect of your life. Now it could be a vacation destination, it could be a new technology addition to your office, it could even be like your favorite teacher of all time.

    So last time we talked about house projects. This time we’re going to talk about who is at the top of your list to contact. So this can be a long lost friend or relative that you haven’t talked to for a long time, it could be someone you have a conflict with and you need to resolve this conflict, or it could even be something like the plumber or your kid’s teacher. So who is at the top of your list to contact, either by email, text or phone?


    Professor Pierre Machtou. Isn’t that great? Probably one of my oldest friends in endodontics, certainly internationally he is, and a dear, dear friend; and I’ve known him for across four decades. He first invited me to France to go to Society d’Endodontie de Paris, something like that. (She knows French so that was not so good.) But anyway, that got me over there, and I met this guy and actually kind of fell in love with him, endodontically speaking.

    To set this up, you know Pierre is a hall of fame clinician; he would be in the hall of fame as a teacher; he was at Paris 7 as the Chair, ran endodontics for – I don’t know – 30, 40 years; has hundreds of students around the world that he’s trained. And so this is kind of a guy I fell in love with.


    They’ve met here a few times on our show; like we’ve dealt with him a couple times, I believe. And we talked about him because he was also a co-inventor of a lot of products we’ve invented.


    And so beyond all the other things I said, he’s a writer, he’s published many, many articles; he’s an inventor. And many of you, whether you know it or not, you’re using products that he helped invent every single day that you roll up your sleeves and decide to do clinical endodontics.

    So I mentioned inventing didn’t I? So we’ve invented many things together. We’ve had meals all over the world, we’ve been in three, four, five continents; I’ve been in his home; he’s been in my home. But we’ve invented a lot together – that was one of the things that really I learned a lot about him. And he has, as I’ve said on this show, a most beautiful mind. I love his mechanical mind.

    So we were doing a big project together, and it started in 2015 and it went across a lot of years. The slowness wasn’t related to him and me and our third partner, Ghassan Yared in Lebanon. It was related to corporate and the mysteries of corporate and the molasses of corporate and the snail pace of corporate. So after about seven years, I decided I was going to bail out of the project, and I did. And I wanted to let them know, Ghassan and Pierre. And anyway, we won’t go into the details, it’s not important because things just happened. You know, shit happens in between your plans. So one thing led to another, and I got an email from this one and an email from somebody else – these are different parts of the world – and then yesterday Phyllis got one. Not me, it was written to Phyllis.

    So Pierre – I want you to know that I love you like a son, maybe like an older brother; a much, much older brother, Pierre. You’d be very old, but I’d still love you like an older brother, and you’re my pal forever. And as I told you in a text yesterday, look for the show to be released on April 5 to hear these words from my mouth to your ears.


    Okay. Well for me, I think the person at the top of my list to contact is my best friend from high school, Kathleen Dillon. And I found out sort of at the beginning of COVID that she had breast cancer and that it had also spread. And it was around this time also that I actually stopped going on social media, so I didn’t really have any contact with her.


    You lost your link.


    For various reasons I stopped going on social media. But I did get some updates from my mom and sister, because Kathleen was actually close to our entire family.

    So then time passed, and then more time passed, and then I started thinking has too much time passed? Maybe it’s too late now.


    Never too late.


    Then Kathleen started appearing in my dreams, and actually the last one I had we were sitting in the back seat of a car and we just had a full conversation. So Kathleen, if you’re watching this, I want you to know that I love you, I think about you all the time. And please don’t confuse my silence with not caring. I think Kathleen knows that I do care, and she probably knows me better than a lot of people that I interact with daily, just from growing up together. And she knows that I can also be very socially awkward. So anyways Kathleen, I just want you to know that I think about you a lot and I will be contacting you in the coming days.


    Well I guess that’s terrific stuff. What I guess I’d tell all of you out there is you have to have somebody that’s at the top of your list – a mother, a father, a sister, a brother, a friend, an enemy – really? Sit down with them and have a little chat. You’re going to feel so much lighter.


    Yeah, there’s a quote that I’ve seen many different versions of, and I’m not even sure who it’s attributed to. And I’m probably not going to say it correctly; I’m just going to kind of paraphrase it. But it’s something along the lines that friends are like stars in the sky. At sunrise they disappear; we can’t see them but they’re still there. And I think this kind of, you know – I know that Pierre is one of your very good friends, and Kathleen is a good friend of mine from the past. So yeah, they’re still with us all the time; even if we don’t talk to them.


    Well don’t forget, it takes a long time to grow an old friend.


    All right. Well we have a great show ahead planned, and let’s get to it.

    SEGMENT 1: Guest Presentation by Dr. Don Tyndall


    All right. Well today we have guest presentation, which you will see momentarily, and it is by Dr. Don Tyndall who is a professor with the Division of Diagnostic Sciences at the University of North Carolina. So if you are thinking that the presentation is related to diagnostics, you are correct. It is on 3D – synthesis, and we’ll learn more about that in a moment. But first, why don’t you tell us how it came about that we even have the opportunity to show our audience this presentation today.


    Well I have a friend named Steve Andregg, and we used to work together. He was in Dentsply Tulsa Dental Specialties, and he was the West Coast representative. So I knew him pretty well because he was there for decades. He called me recently, and he said you know what Cliff? We have some really, really exciting new technology, and I think you’re going to want to know more about it. And so then he told me about his company, Surround Medical Systems, and then he’s at Portray X-ray, and it was a diagnostic machine that was going to help us see better. So I was pretty excited about that, and I said well why don’t you come on and give a presentation? And he said well actually I’m not the radiologist; let’s have a professor do that who’s at UNC.

    So that took me to Don Tyndall, so I Zoomed with him about a month ago, roughly; spent about an hour and a half. He’s a delightful guy; learned a lot about his field in radiology. We look at films as colleagues do in dentistry, but he knows a lot about the physics behind it. So what was so exciting is it’s going to be a way for us to see much more effectively preoperative conditions, and you’ll see that shortly. There’s an old expression: if you can see it, you can do it. So treatment plan for no surprises. So I think you have some more to say about him.


    Okay, well let’s just give you some information about him. I mentioned that he is a professor at the University of North Carolina. Additionally, he was Director of Radiology there from 1988 to 2019, so about 30 years. And he also created the graduate program in oral and maxillofacial radiology, serving as its director from 1993 to 2006.




    Now currently he is president of the American Academy of Oral and Maxillofacial Radiology, and he serves on the editorial board of JADA, the Journal of the American Dental Association. So needless to say, we are very honored to have the opportunity to show this presentation today. Let’s see it.


    Roll tape.

    [Guest presentation video]


    Hello. My name is Don Tyndall, and I’m a professor of Oral and Maxillofacial Radiology at the University of North Carolina, Adams School of Dentistry, where I’ve taught for approximately 43 years. What I’d like to talk about today is a new type of imaging technology which I think might be a game changer; in fact, I think it will be. And I’d like to thank Dr. Ruddle for the opportunity to participate in this podcast.

    So what I’m going to be talking about, as you can see in the title, is Stationary Intraoral Tomosynthesis, or sIOT, A New 3D Vision for Dentistry. And the unit itself is called the Portray Unit, as you can see here, and it’s manufactured by Surround Medical Systems. However, I’d like to state that any opinions and views expressed in this presentation are not necessarily those of my dental school or university, or its constituent departments. In addition, this presentation is informational and should not be considered as an official endorsement of the Portray Tomosynthesis system by Professor Tyndall. However, I believe this is good technology, and I’m happy to endorse technologies, things that might help the dentist, the endodontist, the specialist, anyone who’s treating patients, with systems that will give them more information with which to treat their patients. When I do have an opinion, I’ll state that this is my opinion; I’d like to put that on the record as well.

    Well, let’s face it. The Stone Age didn’t end because they ran out of stones. Why did it end? Well, they discovered new technology that worked better. And we’ve seen big changes in dentistry, recently in terms of digital dentistry, and huge changes in imaging with digital radiography, Cone Beam CT, and now we have Intraoral Tomosynthesis.

    So this is Socrates, and many of you know that he taught by using the Socratic Method which is based on asking questions. And so I’m going to ask four questions and answer them during the presentation. (1) What is the history of Intraoral Tomosynthesis and its place in dentistry? (2) What is Stationary Intraoral Tomosynthesis and how does it work? (3) What are the comparable radiation doses and risks that are associated with the sIOT System from Surround Medical Systems? And what are the potential clinical applications for this new imaging technology, the Portray System?

    Well let’s take a look back in history. This is the first dental radiograph; it was taken in 1896, a mere three months after the x-ray was discovered, and it took 10 minutes to expose. Well today we have much better detectors which we can get superior image quality compared to 1896, or even really 10 years ago.

    Next we have x-ray sources. Well this is from 1916; this wire here is carrying 70,000 volts of electricity. That’s quite a bit and it shows that radiation wasn’t the only hazard in the dental office at that time. And exposures now in this case were about a minute or two. But today we have microprocessor control intraoral units that can make exposures in less than a second. But if you think about it, we’re still imaging in terms of our intraoral radiography like it’s 1896. So we’re passing an x-ray beam through a 3-dimensional object and getting a 2-dimensional image. And as you know, this has its limitations. Its benefits for sure, but also limitations.

    So here’s a simple demonstration of the problem of imaging 3D objects in 2D. This was taken at the Museum of Natural History in Chicago, and this is a Tyrannosaurus Rex fossil, appearing to bite the head off a visitor. Of course we know that’s not happening, but this is superimposition when you collapse 3-dimensional space into two dimensions. But here’s your primary problem with 2-dimensional imaging, and that is it’s basically the end of the road for improvements in diagnosis and treatment planning. Now 2-dimensional imaging has served the dental profession very well. But it does have its limitations, and most of you I’m sure are aware of that. But the research shows that we’re not getting any better with our diagnosis from intraoral radiography, panoramic imaging and 2-dimensional images. So our caries detection, periodontal disease detection, periapical problems, any dental alveolar issue we’ve reached a plateau with 2- dimensional imaging. So we have only one direction to go, and that is to 3-dimensional imaging.

    So what is the history of intraoral tomosynthesis and its place in dentistry? Well let’s talk about history a little bit; not so much the Parthenon which you see here, but the first attempts at developing a dental system based on Tomosynthesis was called “tuned aperture computer tomography” from the early ‘80s to the early 2000s, and it is based on the tomosynthetic principle. This is how it works. If you look at transmission radiography, which is what we’re doing today, mostly with intraoral imaging. You have an x-ray source that projects a beam through an object and it hits a detector; so there’s zero angles. With CT scanning you have an object and the x-ray and detector rotate around the object and form a 3-dimensional volume. Now tomosynthesis is in the middle, and you see in this case it’s taking pictures from different angles. It works like human eyes. You have a left eye and a right eye, and that gives you depth perception. It’s very similar with tomosynthesis. And so it lies somewhere between our standard transmission radiography or basic intraoral imaging and CT scanning.

    And here’s what we learned from all that research years ago. (1) Improvements in caries detection, both primary and secondary, improvement in periodontal bone assessment, implant in bone assessment, apical radiolucency detection, we have fewer retakes due to contacts being open – you recall that you can take pictures at different angles and get these contacts opened – tooth fracture detection was improved, and better localization of objects. So this sounds great, doesn’t it? Well the only problem was it wasn’t ready for a clinical setting; because you had to use multiple exposures with a conventional x-ray source, move it from here to here to here, and end up taking let’s just say seven images (bite wings) to make a 3-dimentional image.

    Now I want to emphasize that this is not a volume; it is a stack of images. But TACT wasn’t very clinically ready. But one day, thinking to myself, someone’s going to invent an X-ray source with miniature sources inside of it, and that’s what’s happened with the Intraoral Tomosynthesis System. Little did I know that this x-ray technology based on carbon nanotubes would be developed here at my home university, University of North Carolina.

    So, let’s talk about today. What is Stationary Intraoral Tomosynthesis and how does it work? It works kind of like this. Several images from different angles – and you see this is a diagram showing how it works; each one of these squares is an x-ray source – and it’s taking pictures at different angles and making a stack of images, much like a loaf of bread. So not a volume, but a stack of images. So you can do virtual dissection to the teeth and alveola bone. It’s approximately the same dose; it is a little bit higher, but if you get more information then the radiation dose is going to be worth it. The same resolution – and this is where it differs from cone beam CT, another very useful 3-dimentional imaging source. With cone beam CT you don’t have the same resolution, and you also have of course metal artifacts.

    But with Intraoral Tomosynthesis it looks like a bite wing; only you have slices that you can go through rather than just one static image. And there’s no motion blur because there’s no tube movement, so motion is really not an issue here as it can be with some other technologies. And the workload is basically the same. You’ll see in a few minutes it looks kind of like a regular x-ray tube; actually it’s lighter than your standard x-ray sources. What we have is a seven- source array, and these are pictures – the rendering of a carbon nanotube – this is what they look like under a microscope, almost like tiny hairs. They serve as a cathode, the source of electrons, which is going to strike the anode and produce x-rays. And looking inside this unit you see seven ports or squares, and they’re set at a 12° angle. So X-ray beams coming out; within a matter of a few seconds you can get the images. You have a standard digital sensor with special software, and this is the unit itself. And the detector holding device is magnetically coupled to the unit, so this gives it rigid geometry upon which this is based. And you take seven intraoral radiographs in seconds, and then use a CT algorithm to reconstruct a stack of images.

    So it’s going to work something like this. We have carbon nanotube array, and again in this case seven so these are all focal spots, and there’s about a 2° angular separation which adds up to 12°. You have a receptor, and then the x-ray beams are going to take pictures of teeth at these different angles. And they’re going to form what we call basis images, and these are the images with which the tomosynthetic image layers are based on, so they’re called basis images. And the result is a stack. So they’re processed, again, using a CT algorithm. And you can see, this is one slice. You can see that it’s a stack, you can see the layers here. And you can see fractures of teeth better, you can see the dental enamel junction better, and I’ll show you some more images in just a few minutes.

    So this is a picture of teeth, an alveolar bone, and it’s surrounded by soft tissue equivalent material. We took a periapical radiograph, and this is early work about six years ago so 2D image quality has gotten better, and what you’re going to see in the tomosynthesis images, they’ve gotten better as well. But this will illustrate the principle. So there’s our standard 2D, and this is one slice from the Stationary Intraoral Tomosynthesis unit, which as I mentioned earlier is manufactured by Surround Medical Systems, called the Portray Unit.

    So you can see the buccal roots are better; better visualized. The periodontal ligaments base, the lamina dura; all of these are better visualized with this system. Here we have the palatal root, and you might notice a few fractures here that you do not see in the 2-dimentional image; buccal defects which you can see in the 2-dimentional image, but they’re better visualized in the image stack; and then tooth fractures as I pointed out earlier. And this is sort of a video as you’re scrolling through the images. So you’re going to be anywhere from 12-15-20mm in thickness is what you’re looking at. So you get seven basis images and you get a tomosynthetic image stack.

    So what’s the workflow like? We have a conventional unit here, and we have a Portray Unit here; the workflow is the same. You’ve got a computer, you’ve got an x-ray source, you have a detector, and you have film holding device. The same with the Portray Unit.

    Another question – What are the comparable radiation doses and risks that are associated with the Portray sIOT system? So let’s talk about those. When people ask – and I’m sure you’ve been asked this question before – how much radiation am I getting; what are they really asking? Well, they’re asking what’s my chance of getting cancer from this? Or if they’re pregnant, a chance of a birth defect? We can rule that out right now; there’s absolutely no chance of a birth defect from any diagnostic system, and that includes dentistry, of course. How do we know? Well birth defects are like sunburn; you have to be out in the sun a certain amount of time. It’s not like cancer.

    Now, there are thresholds. If you have too much radiation to the uterus or to the developing fetus, you can get one; you can get a birth defect. But the amount of radiation needed to produce a birth defect with dental radiographs; you’d have to take somewhere between 1,000 and 10,000 bite wings all at once. That’s not going to be possible. Let’s go ahead and get rid of the notion that diagnostic radiation in dentistry can cause birth defects. It’s flat out impossible. This is not new research; this is at least 30 years old. Look it up and put your patients at ease.

    But let’s do talk about radiation doses, because there’s still a risk of cancer to the patient. The risk of course is small, and it depends on the radiation dose. So one of the most common questions people ask about any new technology, one that uses X-radiation, what is the radiation risk? So in order to know the radiation doses upon which risk is based, you need to know the X-ray source settings (mA, kVp, time, etc.), the volume of tissue irradiated, the detector type (direct digital, PSP would be photo stimulable phosphorus), the region irradiated, and the sensitivity of the tissue exposed to X-radiation. So the chest is going to be more sensitive than say the mandible, the jaws or the brain. And if it’s a child or an adult; children are of course more susceptible.

    The unit of measure is effective dose, and it’s measured in terms of microsieverts; so never mind that term. What we really want to know is what does this compare to in real life? And it compares to what we call background radiation. Now the figures I’m giving you in background radiation pertain to the US. In some countries it’s greater; in some countries it’s less. It’s interesting that no matter how high the background radiation – and sometimes it’s much higher than what you see in the US – in those areas there’s no excess of cancer. So maybe our estimation of cancer risk is a little bit too high. But never mind that. If you’re looking at background radiation, over a year it’s about 3100 microsieverts. But what we really want to know is how does it compare to other systems. Let’s compare it to cone beam CT. That’s a well-proven, effectively utilized, 3-dimentional imaging system that we have today.

    So if you look at the worldwide literature – and this was done by a colleague of mine, Dr. John Ludlow – and he looked at the worldwide literature plus some of our own data collected here at the University. We can divide this up into three types; large volume, medium volume and small volume. We know there are fields of view in between. But for a large field of view, the average is 212 microsieverts. For a medium field the view is 177 microsieverts. And for a small field of view it’s 84 microsieverts. Now we’re going to focus on the small field of view because that’s what tomosynthesis is; a very small field of view. And we’ll talk about what the technique is, the effective dose, and for sIOT it’s about 12 microsieverts; these are approximate. The days of background radiation, about a day and a half. If you’re looking at a single bite wing or PA taken with a photostimulable phosphor and round collimation, which is what most people use, that’s going to be a day. So we’re a little bit higher than what is typically used. If you’re looking at a full mouth series, then you’re looking at 21 days. Now that’s a full mouth series with storage phosphor. If it’s with direct digital it’s 10½ days – and again these are approximations. And if it’s at a cone beam CT, it’s about 9 days, as you can see here. So if you want to explain this to patients, the best way to explain radiation risk is days of background radiation. And for those of you outside the US, you’ll have to look it up and see what background radiation is in your region.

    So the last question, and one that most people are pretty interested in, is what are potential clinical applications of sIOT? Well, because we can produce this image stack, we can use it in full mouth series, bite wings, periapicals, and you can scroll through the stacks. This is what the software looks like; it’s not active. But I can just click on any of these and what will appear is the image stack. And you can scroll through it, facial, angle, it does not take a lot of time; and it does not take a lot of additional training, if any, to interpret, like with cone beam CT. With this, if you can interpret intraoral radiographs, you can interpret tomosynthetic radiographs.

    So bite wings. You can see a single conventional image, and here is a tomosynthetic image stack showing some caries. And this is the software. So you can display it in stacks, or you can make what’s called a synthetic image. It looks like a regular intraoral image, but with your scroll wheel, you can move the contacts, make them open; you can shift the teeth, which is a big advantage. So panoramic and bite wings or a full mouth series. Whatever you can use with intraoral imaging you can use the tomosynthetic system.

    So here we have – same case – 2D image, tomosynthetic slice. Again, you can see a fracture there; periodontal ligament space appears better. Now one thing you do have to realize; teeth are curved. And so over here the apex isn’t quite in view, but the crown is. But as you go through the image layer you’ll see the rest of the tooth in sharp view. So you’ve got better definition, you can basically see more, and in most cases you can detect more. For instance, I think it’s hard to notice, but there’s a small carious lesion here, totally invisible on the 2-dimentional image, and there’s the fracture. So this is just more comparisons, 2D images, and a single slice from the tomosynthetic image; and again you can see a carious lesion here. You begin to pick it up a little bit in this view as well. So synthetic image as I was mentioning, rather than going through a stack like this, you can move it with 12° and open up contacts.

    So now the question is, when do you use 2D or 3D? Well, with the Portray System, it can be used for almost any application that you’d be using intraoral imaging for, as opposed to cone beam CT where you need specific reasons to use cone beam CT. So anything you can use your traditional system for, you can use the Intraoral Tomosynthesis.

    So we can get improved caries detection, both primary and secondary. I was visiting a dentist just yesterday, and he was showing me his Portray System, and we saw a carious lesion that was totally invisible in 2-dimentional imaging, but quite visible with the tomosynthetic. And many studies are going on at several other universities to further investigate clinical applications for this. But caries detection, periodontal bone assessment, and you saw how well the periodontal ligament space, lamina dura stood out, implant bone assessment. Because you’re not going to have the metal artifact that you have with cone beam CT if you’re following up an implant or you suspect peri-implantitis. Apical radiolucency detection is better, and you have fewer retakes because the contacts are being opened. Unless the teeth are really overlapped, then you can’t open them. Better tooth fracture detection, you’ve seen that as well. And localization of objects – what’s facial, what’s lingual – you can do that as well with this system.

    And you can see right here, a standard bite wing, and you can see the caries better. And what was ground truth? Well, it was micro CT, which you see here; so we knew exactly where the caries was. And then we asked dentists to identify carious lesions, and equally important, to identify healthy teeth as well. So you don’t want too many false positives. So there was an overall improvement in diagnostic efficacy, an increase in sensitivity, the ability to detect lesions with the same specificity; that’s the ability to detect healthy surfaces. So we don’t want increased sensitivity, but also increased false positives. There was a 35% improvement in sensitivity with no loss of specificity. Now that was bench top, and sometimes clinical reality doesn’t quite reach the bench top but we think 35% is pretty good. Clinical reality may be slightly less, but it’s great potential.

    Now from the scientific literature we can read articles that point to some of the limiting factors in detecting carious lesions, particularly small lesions which of course have small mineral loss. Well incorrect horizontal angulation is of course intuitive; superimposition of hard tissues also. But if we look at the accuracy of caries detection from the worldwide literature, 49%. The specificity is around 90%, so that’s good. Now this was in 2001 from the Journal of Dental Education, but a recent study in 2019 showed the same results. So that’s what I mean by we’re at a plateau; not just for caries, but also for also for periodontal and periapical assessment.

    The bottom line here is we have better visualization of dentoaleolar structures in all the examples that you see before you. So here are examples of opening contacts. You see the contact between the first and second molar are closed, and you can see they are open depending on which slice you look at. And we also did a study of overlap; 253 surfaces. Conventional images had an overlap of 13%. Now in research settings, everything is lined up just right. So in reality that 13% is going to be more. With the Stationary Intraoral Tomosynthesis System, 1%. And maybe in reality a little bit more than that, but you can see the result. A definitely, significantly improved result in opening contacts. This I think is one of the great advantages that we’re going to see with Stationary Intraoral Tomosynthesis is just opening contacts. Also for implant assessment. You can see here, you can see the bone implant interface much better than in a standard 2D, and certainly better than cone beam CT.

    Fortunately in the US there are already codes for reimbursement – you can see them here – and there is quite a bit of significant research that’s been published based on Intraoral Tomosynthesis or Stationary Intraoral Tomosynthesis. I just wanted to show this to you – you don’t have to read all these obviously – but there’s a lot of research, good solid research that’s going on. And there’s more research, as I mentioned here, on this particular system.

    Now I’ll end with this one advantage that you’re going to see with any imaging system that’s based on reconstruction software. The same applies for cone beam CT. When you have software developing the images, then you can have improvements in software. You can by the same hardware, like with cone beam CT; five years later and perhaps even ten years later you have an improved system. Why is that? Well, you can get upgrades. The images are produced by software. Therefore you can improve the software and improve the image quality, and the level of diagnostic information. This is one reason that cone beam CT has become so powerful in many dental practices; you continue to get upgrades without having to change the hardware. I think that’s a big advantage. Certainly it is for us at the dental school where we don’t have the money that people might have in private practice.

    So these are the advantages of the Portray System; multi modal, tomosynthesis or synthetic imaging. Of course you can open contacts. Interpretation requires minimum training. With cone beam CT, you need a certain amount of training to read CT scans. Same workflow as 2D. Radiation dose is comparable to PSP with round collimation. You get increased information related to caries, and of course contacts aren’t overlapped as much.

    Some of the disadvantages – You still have a few metal artifacts… a lot less than cone beam CT. This requires a slightly longer acquisition time, maybe 1½ to 2 seconds. And the current radiation dose is slightly more as well.

    Well, a big thanks to many of the colleagues who made this technology possible, and this presentation possible.

    So this is my opinion. 3D won’t be the diving board into the future of radiographic imaging dentistry. I believe it will be the pool itself. This is the way things are headed. So I think it’s a good time to give consideration to advanced 3D imaging. But remember, what are we here for? We’re here to help patients. And we remember that a sad tooth makes a sad patient, and a happy tooth makes a happy patient. Thank you very much for your kind attention. I appreciate the opportunity, again, to do this podcast, and I wish you all the very best.

    SEGMENT 2: Post-Presentation Discussion


    Okay, well that was a great presentation; very clear, organized, easy to follow. And Dr. Tyndall seems very professional and friendly. And I thought he did a really good job differentiating between 2D radiography, 3D tomosynthesis, and CBCT, with lists and examples. Also, I did notice a very clear disclaimer and conflict of interest statement at the beginning of the presentation. It was almost as if he had seen our show from last week.


    Well yeah. He did a beautiful conflict of interest. It made me just want to say I have a conflict of interest. I liked the thing about where he we’re at the end of the road, and he had that barrier there – it really sunk in. What he meant was – and you just saw it – but to remind you what I mean when I say it, he said we can’t really go any farther with our digital x-rays because it’s just basically hardware. But when you buy a hardware machine like Portray X-ray, through software, you can keep getting adjustments and additions and enhancements, he said maybe out for ten years. So boy that sure made the investment sound like it might be worth it.


    Do you know about how much it costs; like a general price range?


    Well we’ll do another show another time (our inside joke), but yeah, it’s about $50,000 and that includes the sensor, the x-ray machine, the software. Yeah, it’s not so bad really when you compare it with a $100,000 CBCT, and when you can see so much better than just regular digital analog radiography, then it’s not so bad.


    Well, it seems like there’s a lot of benefit that this technology can provide, and really be a game changer in your practice without breaking the bank. Because not everyone can afford CBCT or maybe you don’t even have a place to put a CBCT unit. So maybe just summarize some of the most notable benefits.


    But first, endodontists always are buying everything that comes out; they just have to have it. So if they can buy a Gentle Wave and lasers, hell, I imagine every endodontist in the country will have one of these soon.


    Like what are some of the benefits again?


    Well didn’t you like – instead of the round analog head where we have the x-ray beam come out, we had a rectangular device; and there were seven ports, seven little windows. And every one of those can have nanotubes in it like the size of our hair, and those nanotubes are what’s firing the energy. So you take a film and you get a stack of images, and you can scroll through them and you can see – because they’re about 2° apart, you get about 12°, you can start seeing different angles from these different ports that are emanating these x-rays. So anyway, I thought that was fascinating and it was very easy. You just sit down, use your mouse, and you can flip through the images and you can see different things. Gosh, you can see fractures, coronal fractures – he showed several of them. That might have been a cadaver skull and you could see the cracks a little more because it’s dehydrated and things open up. But still, caries was more detectable, periodontal disease where the bone is, peri-implantitis we’ve talked about on this show, but evaluating implants. You don’t get that artifacting, that hard beam where you get all that scatter and you can’t see a lot with the CBCT.

    So anyway, there were a lot of advantages, minimal training. It’s what you always do with the workflow, so you bring it over the head and nothing’s moving so you don’t have that vibration because the sensor is hooked to the mouth. So I’m pretty interested in having a really deeper dive into it. But I would think if you’re out there and you’re a dentist practicing every day, this is the future.


    Okay. So now I know you were just introduced to the technology and you haven’t tried it yet. But you did talk with both Steve Andregg and Dr. Tyndall a lot about it. Do you have – just for fun, do you have any suggestions that you’d put in the suggestion box about how to maybe better this technology?


    Well I don’t know any more about this machine than the viewers that are listening to us today who have never heard about it. But I do have a mind and I’ve invented a lot of stuff and I’m always thinking, so I see things and I’m always thinking how can we improve it. So when we had that February 13 Zoom call that I mentioned earlier with Tyndall, me and Tyndall, I said then okay, we can kind of get that sagittal and that coronal; could we get the axial slides? And he went like this. He said you know, that might be possible, Cliff. And I said well, that’s what endodontists would want is that old axial slide so we can find where that root form is and where is that canal inside that root form.


    Okay, well thank you. A big thank you again to Dr. Tyndall. It seems like a really practical technology and it gives clinicians more choice, and I think that’s important. So great discussion and we’ll have more information about Dr. Tyndall and maybe even a little bit more information about this technology. Because I actually did print out – I was reading through all the FAQs about it on the Portray Website, so maybe we’ll have a link to there or something.


    Great. Thanks Professor Tyndall. It was a big pleasure talking to you privately and then seeing the X-ray lecture that itself was very enlightening. Thanks.

    CLOSE: Demotivators


    Okay, so we though we would make a return to Demotivators this season; we took a break from them last season so just to remind everybody what they are. They’re these cards and they have a nice picture and a little saying. And they’re meant to motivate, sort of; they’re kind of cynical and sarcastic, but with reverse psychology you can still kind of get motivated by them.


    You’ll be okay.


    All right, so here’s the first one. It’s called Meetings, and it looks like this. It says, “None of us is as dumb as all of us”.


    Oh yes, there it is. I hate meetings. Meetings are what people do when they don’t know what to do; so they have a meeting so they can plan what to do. Now meetings can be good, but they should be, in my opinion, infrequent. Because if you’re really having a dynamic office, the coaching occurs across the day; it doesn’t wait for a meeting in a month or two. So try to work things out as they unfold and then the meetings can be for the future and be uplifting, and can get you on a new track maybe mentally, new technology’s coming in.

    Anyway, meetings can be good or bad, but I prefer to turn that quote around. Napoleon Bonaparte said there is somebody smarter than all of us – oh. There is somebody smarter than any of us and that’s all of us. So maybe back to the meeting. If you’ve got the right people, if you have the right leadership in the meeting, if you have the correct agenda, can you imagine how you could blow the lid off it and all of a sudden everybody’s going in the same direction, same page, same bar, same music note? Oh, it’s a thing of beauty.


    Well that’s almost the opposite of what this says. This says, “None of us is as dumb as all of us,” so that’s -


    Do you want me to get personal?


    Well it makes me kind of think a little bit about social media, or maybe even the AAE Discussion Forum. Because each clinician might just be a great, outstanding clinician; but when you get them all together arguing, sometimes it can seem a little bit not as intelligent.


    I guess I’ll say this very quickly. I was going to use the Forum because the Forum is really good. So if you’re out there and you’re on the Forum, feel good about yourself. But you do see the group think, don’t you? I mean five people basically.

    So a guy does this beautiful ambient root; it’s a single system that goes around a curve. About 5mm from the terminus, it splits and divides into two with two apical forums of exit; it was beautiful. It’s what everybody on the Forum tries to do; especially all the people that bought all of the latest technology so they can do that with the disinfection stuff. So then this guy writes in, and he says well; according to Gary Carr, most of those lateral canals and bifidities are filled with dirty tissue. Okay, so let’s dumb it down and just leave **** behind; let’s be sloppy. Let’s be dumb.


    I think that some of this gets to be – like the dumbness comes from just a lot of arguing and stuff in meetings, and a lot of like -


    Inflated egos!


    Yeah. So maybe that’s what it’s about.

    Okay, so here’s the next one. It’s called Individuality. It says, “Always remember that you are unique; just like everybody else.”


    Well that reminds me of a quote that you have shared with me and that we’ve used on this show. And it was Madame de Staël. And I think she said, “Wit was knowing the resemblance of things that differ, and the difference between things that are alike.” So even when you think those snowflakes are exactly the same, if you start to drill down – put on some readers, then if you put on some thicker glasses, then you use a microscope, then you an SEM machine, you can start to see that there’s a lot of differences even among the things that look so similar.

    So where am I going with this? I think basically understand that it’s our differences that is our strength. Thank God we’re not all snowflakes or that all humans don’t look and act or behave just alike. Celebrate the differences, because that’s the power of our civilization, and that’s what powers endodontics into the future.


    The thing I like about this one is it reminds me of something you always talk about that Pat Riley spoke about; the Disease of Me. And that’s just that everybody likes to say, “I’m unique, I’m special.” We always focus on ourselves. But then I think this kind of just reminds us that maybe you should look outside yourself a little bit; because everybody is unique, and you might find some interesting things or learn new things from other people as well.


    Very good; I like that. Pat Riley: “The Disease of Me.”


    Well maybe we have time for one more.


    Oh do one; be very quick.


    Okay, this one is called Incompetent. And it says, “When you earnestly believe you can compensate for a lack of skill by doubling your efforts, there’s no end to what you can’t do.”


    So I was going through the library yesterday, and as I’ve mentioned before, I have more than 10,000 images. And I have this section – I can’t say to the audience what we call it between our team – but it’s a really, really bad endodontics. And it was not generated overseas; it was generated here in Santa Barbara from – what was the card again? The people that are really doubling down their efforts?




    So I saw slides with four posts in a lower molar. One isn’t good, try several; try to hold that damn core on there. Then I saw another whole section of pins, and there was one pin, two pins, six pins, seven pins; pins going straight, pins going laterally, pins going out the side of the root. That’s really doubling down your effort! I mean that’s really – okay, they’re not clean are they? So let’s get the file, 25, let’s grind those bigger instruments in, let’s get the 60, 70; yeah, I’ll get it clean! Bring on more files! Like double down!


    Yeah, I think this one’s just really funny. If you were trying to do something and you don’t have the skill for it; instead of like thinking I’m going to learn this skill, you instead you think well I’m just going to try really extra hard with my limited abilities.


    Maybe wake up and work on your training.


    All right. Well these were some fun ones. That’s our show for today; hope you enjoyed it. 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.

    Watch Season 11


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    Season 11

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    SHOW 91 - Delving Deeper Again
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