There has been massive growth in endodontic treatment in recent years. This increase in 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...
Controversies & Iatrogenic Events Sharing Knowledge Pros/Cons & Type II Transportations
Learn how to apply the principles of Feng Shui to create harmony and prosperity in your dental office; allow the Qi to flow like a gentle wind. Then, Ruddle and Lisette explore another “Tough Question” (for some): Should Endodontists teach GPs? Dr. John West weighs in as well! Next, Ruddle is at the Board discussing Type II Transportations. The episode concludes with a contemplation of the longtime unsolved mystery of Stonehenge… Can we finally shed some light on this puzzling architectural wonder?
Show Content & Timecodes00:39 - INTRO: Feng Shui in the Dental Office 06:00 - SEGMENT 1: Tough Questions: Should Endodontists Teach GPs? 29:47 - SEGMENT 2: Managing Type II Transportations 55:39 - CLOSE: Favorite Unsolved Mysteries: Stonehenge
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Downloadable PDFs & Related Materials
In a previous interview, Endodontic Therapy and Dr. Cliff Ruddle discuss nonsurgical retreatment and the integration of traditional and modern techniques for achieving excellence and producing predictable outcomes...
Mao Tse Tung wrote “The foundation of success is failure”. Clinicians who strive for endodontic excellence appreciate the elements that comprise success and use these criteria to evaluate the causes of failure. Endodontic failure occurs for a variety of reasons, but what all failures share in common is leakage...
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.
… the power of microscopy! How about that? Oh I wish I had a microscope; I wish I had a microscope. Well, get a microscope…
INTRO: Feng Shui in the Dental Office
Welcome to The Ruddle Show. I'm Lisette and this is my dad, Cliff Ruddle.
Welcome, and we're glad you're here today. Let's get going.
All right. Well, we thought we would start off this show with bringing a little Chinese mysticism into the dental office.
So, you might wanna consider applying the principles of feng shui to create harmony and balance between you and you environment. Feng shui literally translates to "wind-water,” and the idea is to ensure that the energy that's called the chi can freely flow like a calm breeze or a gentle stream, creating health, peace, and positivity. When the chi is blocked, that's when business can stagnate, patients might have more fear and anxiety, and then negativity can creep in. And this somehow all connected to the kidneys.
Why don't you explain?
Well, before we get to the kidneys, I should explain that many of our patients do come in, just as Lisette said, with a lot of anxiety and fear and especially to endodontic procedures, where they don't know the endodontist. So, of course, in Chinese medicine, fear and anxiety and all those negative energy things are linked to the kidney, and the kidney, of course, is a water source. And it's a massive filtration system. And so, water could be calming. So, if we had a fountain, or if we had like a fish tank, that could be pretty useful in allaying and mitigating some of that apprehension.
Speaking of fountains, you gotta know that fountains also bring other good things. Besides relieving fear and anxiety, they also tend to create some wealth, and they create energy, like a lot of positives. See, we talk about negative. This is positive energy. So, if you can get some of these things integrated appropriately in your office, you're gonna see everything becoming the chi.
Okay. Well, it seems also that adding some living plants or some bright flowers are good, because they give off vital energy and fresh energy as well. But you don't wanna have so many plants that it restricts patients' movements.
So, feng shui is about avoiding clutter. So, you want to make sure that you throw away the old magazines and maybe thoughtfully place your objects. And then, another thing is, you might wanna decorate the walls with, like natural, inspiring scenery. Or even something abstract can be soothing, too, if the colors are right. And colors -- playing with color is very important to the concept of feng shui because there's this idea that different colors and their placement can affect different areas of life.
I'll kinda go off script, but some years ago, we were gonna do our office for about the tenth time, painting wise. And so, the lady came out -- and a kind of a crazy painter -- and long story short, six weeks later we were still looking at various shades of taupe. We were looking for soft, warm energy, though. And I didn't even know much about color, but then I went to school on color. Eventually, we did choose the color. It was taupe.
And eventually, I did have a woman make a scaffold in my operatory, and she laid on her back and she painted elements of the Sistine Chapel and part of the -- in Florence, the Duomo, elements of that, so when the patients were laying down, they were looking up, and they could be quite interested. There was even a bird in flight. So -- hmmmmmm, we really got the chi going, I think, on that one.
Okay. Well, another suggestion is to keep the bathroom doors closed --
-- because this is somehow -- it protects the finances. So, if you're storing your valuables in the bathroom [laughs] -- well, that's one thing. But also, maybe keep the toilet seats down to further protect the finances [laughs]. Anything else?
Wow! Maybe that's what happened. I've had those lids up too long. Well, you know, the other thing was -- also connected to the kidney to the ears is music. And so, one way we could get music is, we could have chimes. But when you pick your chimes, be careful --
-- yes, wind chimes. And you have to hang them strategically. I mean, depending on the sound, it might go on the west, the northeast. But remember, you can get pipes that are -- you can get three pipes, five pipes. You can get metal, you can get wood. You can get nine pipers. Oh, those melodious sounds help you follow the curvatures and reach patency, and the patient's grinning while you're doing that.
Well, you -- if we had weather like yesterday, though, with the wind blowing, basically, the rain sideways, maybe take down the wind chimes [laughs], because that could create more fear and anxiety.
All right. Well, even if you don't believe in the mystical art of feng shui, there's a lot to be said to paying a little extra attention to your office design to create a more inviting, functional, and just clutter-free environment. So, your patients will then be more comfortable, and your staff will be more energetic and lively, and prosperity will surely follow.
So, we have a great show planned for you today. So, we wanna get going on it?
Yeah. And get those operatories and get those offices up to speed.
SEGMENT 1: Tough Questions – Should Endodontists Teach GPs?
All right. Today we have another Tough Questions segment. And in case you haven't seen this segment before, it's where we explore a tough question that maybe doesn't seem to have a clearcut answer right off the bat. But our hope is, is that after our discussion you will at least have a better idea of where you stand on the issue. So, some examples of tough questions we have done on our show are, who pays for treatment if it fails, what is the appropriate canal shape? And then, last season we had a real tough one, should you pull out your child's loose tooth?
So, our tough question for this segment is, should endodontists teach GPs? Now, this question has sparked some controversy for some time now. Sometimes it is more front and center. Sometimes it's more of a background issue.
But you, being an educator and also having some endodontic friends who are educators, have personally received some backlash. Right?
More than you would expect for trying to do actually what I would think is a kind of a selfless thing.
Okay. Let's get a little context going. So, I've been teaching across five decades and I've had groups come to Santa Barbara for just two-day seminars and week-long courses for a very, very long time -- since '83. That was probably, though, a strike against me, as I learned later. I'll tell you shortly. Well then, because we were teaching and working, people wanted to know if there was any follow-up DVDs or anything to help them remember what they had seen in the course and keep learning. And then, of course, some people who never took the course wanted them, because they wanted to learn.
Out of all that -- so we started selling what we called affectionally "The Brick." But it was four -- it was a brick of four DVDs on all phases of nonsurgical retreatment. We had one on clean, shape, and pack. And I got banished from lecturing at the AAE annual meeting for some years. And I was told this by people on the board who went to the headquarters in Chicago, and they would talk about who, you know, can and can't speak. So, that's kinda my situation. There was many other things that I could go into that are direct "don't-be-teaching" things from our organization.
But what came up again was on the discussion forum. And on the AAE Discussion Forum, there was a big discussion about a recent course promotion that was talked about. And the promotion was for the course called "IDEA", [Interdisciplinary] Dental Education Academy. There's multiple teachers from all over the world, and they're some of the best educators on planet Earth. I mean, really, they're some of the who's-who in implants and restorative and materials. It's -- it's fabulous. They're four-day courses.
So, they had as marketing -- apparently the hot buttons were -- it was a four-day mini-residency. Oh, that was terrible! The word "mini-residency." Can you imagine the endodontists around the country? Ooh, they did it in four days. I missed that part. I had to do two years.
Okay. And the other button was that they could pretty much take the course and do all cases. Well, nobody thinks that's possible. But that was also part of the marketing, I guess. Separate marketing from reality. And then, of course, they didn't like the -- the what? I guess that -- oh, they were concerned about -- would you get the right armamentarium? So, if you didn't know scopes, and you were turned onto scopes, they were really concerned about the follow-up. And I was thinking, didn't they learn to use a scope? Did they ever go to a scope course? When they left the course, how come it was okay for them but not somebody else?
Anyway, that was what happened. And out of that then, of course, lots of people started weighing in from this colleague. I won't mention his name, and I won't mention his state, and I won't mention that he's above the rim of the United States, north. He's up somewhere in there. It wasn't Canada, either. Okay. And then, there was a lot of people started weighing in. Some of the responses were, from a guy back east -- I won't mention his name, either, but he's in Boston.
He was very concerned about it, and he said that these courses are just teaching like endo carpentry. And you know, it's just how to use a file, as an example. And he was saying that in his courses -- because he's a teacher, and his courses don't stink, they're very pure -- he teaches diagnosis and treatment planning. [claps] And he says, that's very important. It is. It's absolutely critical. Then he goes on to say, they need to know about the histomolecular breakdown of pulp tissue. And they need to know about the disease model.
Then he talked about "the look" and the courses that teach "the look." That gets kinda sensitive here, because Schilder talked about the look, and the look was always reserved for exquisitely treated cases that when any colleague would look at [laughs] it around the world, it had all the elements of success inside that x-ray. So "the look." If you see a pretty woman, I think there's a look. If you see a beautiful car, you're not looking for the Edsel that's rusty. You're looking for the shiny look. So, the look shouldn't be made negative. It should be a positive thing.
So, there was a lot of bashing this course. And so, I realized there's a lot of jealousy. And I came to an article by Brett Gilbert, a friend of mine in Chicago. And he's a --
Well, let me stop you for a second, because I think it's important right now that we really emphasize that general practitioners do about 75 to 80 percent of the endo being done in the United States. So, they do actually a majority of the endo in the United States. And from you, I learned that GPs only get minimal endodontic training when they become general practitioners. So, if GPs are doing so much endodontics, it really is a no-brainer that they need to seek out endodontic training. And I think this kinda relates to what you were going to say, like seeking out endodontic training.
Yeah. I was gonna say this a little earlier, but it doesn't matter, it's perfect. The point was, if 80 percent of the North American endodontics is done by endo- -- general dentists, then it's a no-brainer that the people that are taking shots on the website need to understand that they need help. Because back to another point she just made, when I was at UOP, I did about 20 or 25 single canals. Okay? That was it, and we were called a clinical school. When I went back to postgraduate school in Boston, we were required to go over and teach undergraduate dentists at Harvard. And they were required to do two canals, maxillary anteriors. Okay?
Now, that's all in between that, and that was a lot of years ago, but it's -- they're now doing more endo in undergraduate [laughs] work today, because there's more things to learn. There's so much more that we didn't have back then. So, it is critical that general dentists across the world have a place to go to get training. So, for us to start harping on the trainers, it sounded like a lot of paranoia, jealousy, and things like that. So, I was gonna mention this article by Brett Gilbert in Chicago, a really fine endodontist and teacher. You might wanna look at his website.
He says that -- from a survey -- they did a survey of thousands and thousands of dentists, their number one, two, and three complaint was not enough experience, they felt incompetent, and they felt a lot of insecurity. Okay? Inexperience, incompetency. How do you overcome that? Do they all go back to the schools where they trained? A lot of those schools offer one course a year. Some of the schools offer no courses per year. And some of the courses are the same courses that have been taught for the last 30 or 40 years.
So, they're going to go where they feel -- the market will rule, and it will rule unmercifully. And they're going to go where they get treatment that helps them better serve their patients. So, I wanted to mention his article. And then, I wanted to mention Manor Haas. He wrote a really good article. This article was "Endodontic Engagement" -- I guess I should read the title, "The GP and the Endodontist can Achieve More as a Team." And then, this one was "Do Root Canals Matter? Who Does Them? Endos or GPs?"
I wanted to read verbatim the last line if I can. The last line was, "The take home message for this study of 500,000 initial root canal treatments in the root canal therapy has a very good long-term success rate. There is so -- there are even cases performed well over a decade ago and they can be done before the availability of today's improved armamentarium that it would be critical to be teaching the general dentist through continuing education tailored for the general practitioner." So, that's how we -- a rising ship -- you know, a rising tide raises all ships. You gotta teach them a little to help them come up to speed.
So, I also see on the same forum we nail GPs because they recklessly perf, they do this, they break instruments, they don't refer on time. I'm just saying take a look in the mirror. If you wanna get busier, you can get busier. And you'll probably ask me another question now. Maybe.
[laughs] No, actually, I think --
Not the stud clubs.
-- I -- well, okay. I think now would be a good time to actually hear the perspective of someone who has been teaching GPs and endodontists for pretty much decades, and that's Dr. John West. So, let's actually take a moment, and let's see what he has to say.
Oh, great. Go, Johnny.
[Guest video clip]
Hey, Cliff, how you doing? John West here. I'm thrilled to be invited to The Ruddle Show and address your question, should endodontists teach general practitioners endodontics? And I love the question because it's a question we've been asking ourselves since I can remember. So, let me give you, Cliff, my short answer, my medium answer, and my long answer.
The answer's yes, absolutely, profoundly, yes, Y-E-S. Okay. Got her done. Did my assignment. Thanks, Cliff, for the opportunity.
No, but that really doesn't do it justice, does it? My answer, yes. So, I'd like to walk you through my thinking of my answer, yes, from three points of view. One, the general dentist; two, the endodontist; and three would be what I'll -- an area I'll call sharing.
So, first, the general dentist. I learned many years ago that dentists are hungry, and they want more. They wanna be better. It's as simple as that. And I'll tell you a story from the late 1970s. Three of us in different cities, endodontists, we wanted to promote ourselves. And we also had the opportunity to write this off, because in the old days that you could go to the Bahamas and do a 15-minute presentation, and the rest of the time you could rest and take tours and swim and so forth. Can't do that anymore. But back then we invited 10 dentists to Acapulco, Mexico, and we intended to give a presentation from 7:00 to 9:00, and then go to the beach.
And so, the first day at 9:00 we said, okay. Time to go to the beach. And the restorative dentists said, wait a minute. No, no. We want more. What about this? What about that? And so, we ended up speaking with them and them with us until 4:30 in the afternoon. The next three days, we went to 5:00. Well, when we were done, the dentists were thrilled. They couldn't wait to treat their first endodontic patient when they returned. Meanwhile, the families, who thought they were gonna have a wonderful vacation with their dentist husband, were upset, and my wife was included.
So, from that point of view, the whole trip was a failure. But from the dentists' point of view, they got what they wanted. They got what they needed. So, I learned that the need is there, and there is an opportunity to fill it.
The second area would be the endodontists. And there is -- there are some endodontists that might say no to your question, Cliff. And one reason is because of trivialization. They and I am concerned, also, that a company or inventor, somebody's gonna come to your office and say, buy this tool and the rest of your career will be successful. Well, you know that's a bunch of baloney.
And The Ruddle Show -- and Cliff and I teach at the -- Gordon Christensen's class in Provo, Utah. We alternate that each year, and I teach three or four times with my son Jordan in the Bay Area at a group called IDEA, Interdisciplinary Dental Education Academy, and we never trivialize. We always taught, whether it's short or long presentation, the -- the thinking, the philosophy, the access cavity, the glide path and how to follow, and eventually -- you know, talking now about the slide path, how to slide down these systems and the marquis skill of endodontics, and then finishing, which has to do with the shaping, the three-dimensional cleaning, cone fit, and then obturation. So, we don't trivialize, and that's a bad way to go.
So, the second reason that endodontists are a little bit concerned is if they teach everything they know to you that you won't refer to them anymore. They won't have anything to do. Nothing could be further from the truth. There are approximately 25 million endodontic procedures per year, and there's only 3,500 endodontists or so. And even if we wanted to do them all, we couldn't. So, 80 percent of the endodontics is treated by you, the restorative dentist, and we want you to do better and be more successful and make it easier. And so that's really, really key.
And then, I would also point out that we are getting older and that we wanna look good and smell good and appear successful and take a part of this. And we're discovering that implants maybe aren't all they're cracked up to be. But as we pile on more and more dentistry, the pulp is gonna say, good grief. I'm at terminal circulation. I'm encased in unyielding walls of dentin, and I'm outta here! And so, I'm gonna need endo, and these canals are -- because of calcific degeneration are gonna become smaller and smaller and more difficult. So, we all have to grow and learn to do this better.
My last comment to the endodontist is that if I was to treat -- to teach, rather, a group of dentists how to do endodontics, one third would say, my gosh, I can't believe endo's that easy. I'm never gonna refer. The other third might say endodontists -- endodontics is impossible. I didn't realize how hard it was. I'm gonna refer every patient. And then, the third group would be smarter. They would say, I'm gonna take the easy cases because they’re easier. I'm gonna refer at the right time, when the problem is smaller, so that it's easier to solve. Because nobody looks good when a retreatment is required, and especially when it's more difficult.
And so, not to worry, endodontists or dentists. We have lots to do, and teeth are gonna be an important part of our future. And so, there's enough for all of us. So, let's share like crazy.
My third area is sharing. And if I said to you that knowledge is power, would you agree with that or not? I would disagree. Knowledge in itself is not power. Sharing knowledge is power. Think about these philosophers of the old days and the scientists of the new days. Sharing is what has enabled us to evolve as the most extraordinary species that ever existed, that we know of. And so, sharing is really key to the future of everything, from small endodontics, you know, to the world, for that matter.
So, I'd like to close by saying that I know Ruddle and I wanna make this comment, or least I'm saying this for him, for myself. And that some endodontists would insist or intend for the restorative dentist to perform at a lower, lower, lower level, where we are intent on dentists and endodontists to perform at a higher, higher, higher level. And I've been doing endodontics long enough and been an educator long enough to know that I'm right, and it can be done. And you can do this, too. And so, I wanna close, making sure you've got, Cliff, my key overriding message, which is yes to answer to your question.
And lastly, to acknowledge you as The Ruddle Show, because you are the only sustainable educational platform in the world today. I know it's a lot of work, and I know it's a lot of fun, and from one colleague to another, it's worth it. Keep it up. Thank you for the opportunity to answer your question, and for now, ta-ta. See you again.
Thanks, John. That was just awesome, and I really liked your three points. There was the perspective from the general dentist. They wanna learn. They're dying and they're thirsty to learn more. There was the perspective of a lot of endodontists that you've surveyed over the years. You didn't mention that, but I know you have. And that was concern and paranoia and maybe there won't be enough to do if we teach them how to do everything. And then, I really like your third point, and that was not just knowledge, but the power was sharing that knowledge.
So, that was really good. I think his clip said it all, and I think having been a professional teacher like John's been for all these decades, he certainly has perspective.
Yeah. And I've heard you say a lot of times, too, that by the very nature of teaching and the dialogue that happens, that you actually end up learning, as a teacher. So, everyone's learning.
Well, I'll say it different. Teachers learn more than the students each time, every time, all the time, because the teacher teaches most what he needs to know.
Okay. Well, I wanted to consider a scenario that maybe speaks to what some endodontists are concerned about, the concern of losing business to GPs. So, what if you practice in a location that you think already has an adequate number of endodontists, and you're concerned that if GPs start taking on more endodontics, there's just not gonna be enough endo for everyone to do? Is this actually a thing?
I would say if you are a little underemployed or you would like to be busier and your title says "Endodontist,” start giving back. Start being selfless. Start a study club. Years ago, what you're alluding to is, I started a study club, and we froze it to 20 members. And soon we had a big waiting list, and I started a second study club, all in Santa Barbara, all Santa Barbara basic dentists in the surrounding little communities. That became full with a waiting list, and I had three study clubs going at one time. That would be like 60 dentists in a town, where there were maybe a 180 or 200 dentists at the time.
I can say this. If you look in the book, there are -- depends which book you look at -- there's about 10 to 13 trained endodontists that are practicing every day in Santa Barbara. How can 13 endodontists trip, stumble, and fall over each other, unless there's enough referrals to keep them alive? So, teaching in my own community actually was the rising tide that raised all the ships.
Okay. Well, let's go back briefly to the phrase that got everyone's blood boiling on the AAE Discussion Forum, the term "mini-residency."
Now, I don't think anyone wants to literally say that you're gonna learn more in four days than you did in two years, but I imagine that the focused education you're getting in these courses is really emphasizing the practical and probably gives you a foundation that you can then, when you leave the course, build on that foundation. I mean, there's a lot of information available online. There's -- nowadays that we didn't have then. So, you might actually be able to practice and build up from -- based on the foundation that you got in the course.
Yeah. You know, I think what the web got all upset about -- the discussion forum specifically -- is that, like you said, that they could really even imply that a lot of learning could happen in just two or four days. I have had that comment. You can ask your mother. That has come in [laughs] by email, it's been said to me to my face, it's been said to my staff. "I have learned more at the end of this two-day course than I learned in my entire dental school program in endodontics." So, that is not so unusual.
I've had endodontists -- for the AAE Forum people -- I've had many endodontists take my course and say they learned more about clinical, technical endodontics in a two-day course than they learned in their entire program. Why? Because there was no really microsurgery for a lot of endodontists that are trained today. There was really no disassembly and taking teeth apart back in the day. So, a lot of this has to be disseminated, because even young kids, ask them how many posts they've taken out, how many broken instruments have they taken out, how many perf repairs have they done? Okay. It goes on and on and on.
So, the courses need to be given, and I would have to say that the most important thing is it's probably what is disseminated, because in an endo course we don't teach histology, pathology, physiology, vascularity, breakdown, disease flow, all the -- pharmacology. We don't teach that. We teach very technically focused, clinical, everyday endodontics. And we teach concepts. We don't teach here's how to use this pair of glasses, and here's how you use this file, because they come and go like dirty laundry.
Okay. Well, I'm thinking that it probably depends a lot on the teacher, and maybe the question isn't so much, should endodontists teach GPs, but maybe which endodontists should teach GPs? That's kinda what I’m thinking.
Well, I'll set you up for this, because you have a wonderful quote. But I wanna just say in closing, if you are a teacher out there, be encouraged, but try to teach concepts, because they endure. They're time honored. The other stuff comes and goes. But what was that fabulous quote?
There's a quote I saw by William Arthur Ward, and it's about teachers. And it's "The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires."
So, I want all of you out there to be inspired. Go take a class, and if you -- if it says it's a mini-residency, don't judge the course by the cover, and don't read the marketing words and have an opinion. Look a little deeper behind it, who the teacher is.
All right. A great discussion about a tough question. Hopefully, it's been helpful to a lot of you. Thanks again to Dr. West for his perspective, and that's it for this segment.
SEGMENT 2: Managing Type II Transportations
Welcome back. Today we're gonna talk about how to manage Type II transportations. This is a topic that needs to really be explained because there's an easy way to start moving the terminal diameter that was instrumented. So, today I wanna talk about Type II's. We've talked previously about Type I's, and we've also -- we'll get to Type III's. So, there's three types.
Today, though, you can see that this happens quite a bit. You can imagine it happens quite a bit in this world of endodontics. And of course, a lot of this happened even more so with stainless steel files. And stainless steel files were either as they came -- became stiffer, we had a physiologic terminus, that little red disc, but you could see with a little bit of time the foramen was dragged on the external surface to a new, manmade location. And these are tough to -- you're not gonna see them radiographically, typically. But you're gonna get into the case, and you're gonna discover it because there's bleeding and there's separation sometimes coming up.
And then, when you throw files in, you're gonna notice that they're binding way up in the body, and they're loose at length. So, we have what we would call reversed apical architecture. And remember, the original canal gets dragged out to a new, manmade location. So, that is a teardrop or a tear or a rip. Any of those words work for me. Schilder called it a transportation. Ruddle identified it further as a Type II. Okay. You might ask yourself, well, can I just make the terminus bigger, so I don't have to go do surgery?
And then, I might have blood coming in here, but we talked about it in a previous show, which you can go back and look at, that we can begin to understand what is the terminal diameter. And you'll only know what the terminal diameter is if every successively larger file uniformly steps up and out of the canal. Then, you could be sure that the file that is snug when you tap the handle, it's snug at length, and it can't be displaced, that is the terminal diameter. Because the next bigger file is about a half short, the next one's one short, one and a half, two. And you can see that stairstep, and that's funnel shaped, that's your control zone, that's your capture zone. That's how you're gonna irrigate safely and fill root canal systems and develop hydraulics.
So, you can play this game for a while, and the game would be -- let's take a bigger instrument in and maybe even a bigger instrument. And as I've taught on previous shows, the instrument that is snug at length is only snug, again, redundantly, if each successively larger file uniformly backs out of the canal. You can go to a 35. In today's world with heat treatment and NiTi, you can get pretty flexible 35s. The ultimate family has manual handles, and I would recommend in these cases when you're managing not this area up here, the body's fine, but the terminal shape is what you're trying to control, I would say you can get these bigger instruments around the curves.
And manual would be a little safer, in my mind, than trying to do it mechanically. Because you can really control by turning the handle on the file. So, you can take -- I've noticed even in posterior teeth, even with some curvature, you can oftentimes get a heat treated NiTi file, like the Ultimate has a 50, okay? And it has sufficient taper behind it. If you're doing it in a manual world, you would wanna know that it in fact does equal 50 by putting a 55 in and a 60. I don't even own a 70 or an 80, okay? I don't. But because they get bigger by a tenth of a millimeter versus 0.05, there'll be a bigger gap here between instruments, a bigger gap between instruments. But this is letting you know you have that control zone, that capture zone.
So, this we've sort of all talked about. I've shown this case, too. This is a patient that came from the oral surgeon's office. The general dentist was working on it on a Monday -- I'm making this all up -- went to about a 30 or 35. I didn't make that part up. Then, he had them back on a Tuesday of the next week and went to a 60, and it kept hurting. So, he went to a 70 and an 80. Then, pretty soon he arrived at the biggest file that's made [laughs] -- the biggest instrument he had in his office, and that was a 160. Something like that. He said it's the biggest file they make. I don't know what that meant. Maybe he went to Sears & Roebuck and got it off the shelf.
But when he exceeded apically the ability to increase the diameter, and pain was still persisting, they were referred for an extraction to the oral surgeon, because it had to be one of those fractured teeth. It wasn't. It came to me, and we did the case, and I won't tell anymore of the history. Go back and listen to the whole history. The taper is pretty parallel. We have a little -- emphasizing, we have a little taper going. So, when we push into a constricted area, we have resistance form, and we can mush our material laterally. It'll capture those walls, and vertically we can put a plug of warm gutta percha right into the terminal diameter. And that's what we did.
And the size of the lateral canal is bigger than any file you have in your office. So, I was very pleased with this case. I had excellent control because I could get a little bit of shape, and with warm gutta percha and vertical condensation, not a [laughs] single cone, not a carrier, okay? Think about that. How are you gonna fill something like that with a single cone? Please. All right. So, that would be a Type I. We've talked about it. But what we're gonna talk about today is the II. So, the I, you can see would be a little bit of a movement of this anatomical foramina. And this -- if it's torn a little bit, it's a I. If it's a bigger rip, it's a II. And these aren't hard lines in the sand, but they're clinical decisions that will tell you what's the next step.
And if you had a really significant tear, you're probably gonna be doing orthograde treatment, where you have both ends open, you're working through the occlusal to get the thing recleaned and change the biology, and you'll be working through a surgical flap, probably, because there'll be no resistance form and you'll push material everywhere. So, III's are usually surgery. Let's get going. I've talked about this material before. I have repeated this discussion that we're having today. It's been written in textbooks around the world. This is one textbook, and it's about 50-some pages of where we go into this in a lot of different ways, and I show a lot of cases.
Today, until we get to the podcast, or we can drill down, and I'll show you my 10 examples or 8 examples and we'll have curvatures and different clinical challenges to overcome, today we're understanding the concept of a II and how we might manage it. And we have references and even articles, besides books. If you don't wanna buy a book, you can come to our website, and there's even articles on this stuff. But it's MTA. You can use Biodentine. You could use a number of other materials that were pretty much highjacked from MTA, but MTA is the original material.
It's the most researched material, it's the most reported on material, it's the one everybody copied. But it's one of those tricalcium silicate cements. It likes moisture, and so you can mix it. I'm showing this again because I have gotten so many comments from people around the world, talking about it. I'm reading in the discussion forum how hard it is to mix MTA. Don't worry about it. It's about one drop to about one shovel of powder. You're going, well, which shovel and which dropper? Okay. I get all that. Don't worry about it.
Just incorporate some water into your MTA and just make a nice, creamy mix. If it's too wet, I learned from my wife, Phyllis, about 25, 30 years ago, take a fiber-less gauze -- that's a gauze that won't leave lint -- lint free, and just wick, and you'll pull out -- you'll wick out the surplus moisture and you'll have the correct viscosity. So, that little trick you saw with the two-by-two gauze, that's how you get the proper mix with the right viscosity so you can pick it up. How do you pick it up? Well, I'm coming back and showing you a little different hitch in the lecture. In the old days, we used spinal tap needles. They came from medicine. We had a number of different gauges, 18, 22, 24, 26. They were all useful. They had that internal plunger, and we'd cut them down and customized them chairside.
Well, that was too hard for most of you to even comprehend. Then, the medical companies stopped making them, and they had changed the design. And then, they became very difficult to use interocclusal. Let's just go with MAP. The MAP System, you can Google it. It's made by Dentsply Maillefer. And you can see that it has a number of different cannulas with internal plungers so you can pick up different diameters or little aliquots of premixed MTA. The MTA's already been mixed.
When you pick it up, you usually take a tube, and here's your slab. So, if you have a glass slab and you've mixed it, you go down vertically and scrape off. That pushed -- that pushed mud up into the lumen of the tube, okay? It pushed it up. If your assistant does that a second time and a third time and a fourth time, you're gonna get so much MTA up in this tube that when you go to push with your internal plunger, you will not be able to deliver the aliquot into the target area. So, the key is, pick up the right amount. I have not mentioned that before more than to say, usually put in about two or three max.
Now, once you deliver these little aliquots or segments or little logs into the body of the canal, that's fine. I hear people trying to get a smaller one and a smaller one, and they're trying to pre-curve it a lot and get it really down deep. That's ridiculous. Don't do that. Just get it below the orifice. How about that? Just get it below the orifice. Well, then, how do you get it deep? How do you shepherd -- how do you corral that MTA and begin to shepherd it down in a straight canal, much less a round curvature, to a root defect? The root defect could be a transportation. We've talked about that as being a Class II. That'd be iatrogenic.
Too big of files trying to make the curvature or going back repeatedly with a NiTi file, over and over. A lot of them have some shape memory. So, they're always gonna try to get straight. So, when you're going around a curve, you have the dentinal wall to hold the file. But if you keep going back and back and back, the file has shape memory, and you'll start to get that teardrop, that tear, or that rip that we've talked about. So, when you take a big, non-standardized cone -- I said, "non-standardized cone," because they have quite a bit of taper -- and you can cut off the ends appropriately at whatever diameter you think you need to get it down to within about five millimeters of length. And three to five would be a perfect world.
So, you wanna fit your flexible cone that can go around curvature to about three to five millimeters. We only have to get our little bullets in here, like this, they'll be all kinda coalesced together. We just have to get the mud in the target zone. That's all we're trying to do. And then, we can vibrate it. Now, the reason this is updated is we now have something that gives us really about 3- -- I think it's about 3,000 cycles per -- cycles per minute. The old EndoActivator was a lot higher than that. Okay? It was more like about 7- or 8,000. So, it was too much back-and-forth motion on the polymer tip. The flexible polymer tips will not cut.
And if you ever did concrete work, you know you put a vibrator in the concrete. And it moves and shakes the mud, and then the mud will slump, it'll adapt, and it'll become very three-dimensional. If you didn't do it in construction, you certainly did it in dental school, because in dental school we all poured up an impression material. So, we'd take an impression material, we'd get an impression of a particular tooth, we'd pull it out, run to the lab, and we'd mix stone, and we used a vibrator! And the vibrator adapted to the stone, so when we took the impression material out of there, we didn't have voids in our stone die model. Okay?
So, I wanna show that we have better RPMs with the new SmartLite Pro EndoActivator as compared to market version activator, and that means we can adapt beautifully. We could already do a really good job before, but now, we can do it very, very controlled. So, that's that. So, if we look at how to do this -- clean up the model -- but I wanna just map this. This probably would've been like this. Okay? You know, that would've been the foramen right there. And then this would've been your other wall. But as the instruments came around, they started to tear, and now you have a big old rip.
So, I'm showing you a manmade rip in a plastic S-shaped block to show you a little bit of the dynamics of how the mud is put in, how the mud is shepherded, and how the mud is vibrated and adapted into either a pathologic resorptive defect or an iatrogenic rip. I didn't talk about this before, and I get a lot of questions about this, so it made sense for me to come back to an old case and be a better teacher. So, everybody has said this is what they've -- and if you've done this, if you're really doing retreatment, this happens all the time. So, I talked about the perfect mix, I talked about the fiber-less gauze that can wick out the moisture, have a perfect viscosity.
But what happens when you put in, let's just say two or three aliquots? Well, when you get on here with your flexible plugger, and you start to plug, this starts to adapt. You have a tapered wall, right? Then this starts to adapt. Then all of a sudden, this all compresses, and it won't move! And you're going, oh, my, it's blocked! Blocked canal! I wanna talk a little bit about how to hydrate! Never talked about that with you before. That's just something I do. It's like breathing. If something gets too hard, in the mechanical world of material science, you need to add a little liquid.
So, what you can do is take your file, like a 15 or a 20, dip it in a Dappen Dish of water, and just run that file, the flutes of that file, through this material, and just go chook-chook. Go little in-out, in-out strokes, back and forth and back and forth. You're rehydrating, punching through the little block. Now come back with your plugger and begin to work it down. You might have to do it again on the journey. You might have to do it down in here, rehydrate. So, you can rehydrate with the EndoActivator.
You could just take the EndoActivator and stick its polymer tip in a Dappen Dish of water. You could take a file, like a 25 or a 30, I just said that. There's a lot of ways you could rehydrate. You can even take a dropper and stick a drop at the orifice and try to run some water down there. It doesn't matter. If you get too much, we're gonna wick it out with what? A paper point! Oh, my goodness, we're learning! Paper points. So, that's how you hydrate. If it gets too soupy, and it's now too runny, now we need to do what? Dehydrate. Take a paper point and stick it in. Take the paper point, flip it around, and put the butt in first if you're way up in the body of the canal, and that paper point will pull moisture, and you'll have the perfect mortar, if you will.
MTA's like the mortar that went between the bricks. So, you can make the material perfectly capable to be worked, total control, in long ones, in skinny ones, and in more curved or recurved ones. That is the trick of this lecture. You've seen the case before. We've walked you through it. But rehydrating and hydrating and how much material you put in, that's the key. And again, we do not even try to vibrate until our material is in the target zone. So, the pluggers, you can see the gutta percha down here, you'll see the gutta percha down here, you can see the pink. It's not a perfect science.
You're pushing it down, in this case, around the curve. You can take a filament any time, interoperative, to see what's going on. You can turn on the vibrator once you have the mud in proximity, and it will go wall to wall, and it'll be vertical. And when I first started dong these cases in Santa Barbara decades ago, dentists were amazed. The endodontists would say, geez, did you flap that, Cliff, and do surgery? Did you elevate a flap? Because it looks perfect. When you're not packing, like a plugger activity -- when we first got this material in the '90s, we were packing it like gutta percha. We pushed it everywhere, probably right into the sinus and maxillary teeth.
But we learned over time return to the construction model and just use vibration. And because there's usually a lesion around these teeth, because they've been ripped, and they're usually chronic -- so, when you have chronicity going, then you'll have a lot of granulation tissue in here. That mud will just kiss that granulation tissue, and you'll get maybe -- maybe a little nail head. Maybe you'll get just a little -- a little slump sometimes like that. But you're gonna have remarkable control. That's what I wanted you to see.
So, if we come back then and look at a case you've seen, you can see tremendous reversed apical architecture. You can see we have a lesion up there. It's like a trumpet. If you tried to get a shape -- if you tried to get a shape going, you'd probably be back like about like this, and you'd probably be back like this. Well, now you're gonna be so parallel that you're gonna probably push material everywhere. So, this is a case to vibrate. And of course, you talk to your patients. And if you talk to your patients, what might you tell them? Well, forget the bridge and the whole story. It's been chipped.
But we're gonna disassemble, we're gonna take the post out, we're gonna clean this. Here we go. But tell them you might have to flap it. You might have to, based on what you discover as you work along, you might have to reserve the right to go back in and clean up. But you think the tooth is salvageable, and you think the prognosis is excellent, and you communicate that a new bridge, new prosthesis in here would be quite nice for the patient and clean up that smile. How about that, clean up the smile. So, we'll go really quick. But you know, we've had other lectures on taking posts out.
But basically, using the ProUltra, and you can see through vibration you can blast out -- bridge is off, of course. Dentist took the bridge off, put a resin bridge on, so the patient came in provisionalized. That helps the endodontist. So, if everybody out there, whether you're an endodontist or a GP -- did you hear that part -- interdisciplinary treatment planning. Blow out the composite. When the post is taken out, there's some debris up in here. But you can see all this debris. This looks like a toilet! My goodness, it's time to flush. Flush! All right. When you flush the toilet, it gets better immediately.
And you can see the reflection. This is fluid at the foramen. So, you're looking all the way through this tooth, and you're looking to some fluids pooling right there. That's what you're seeing. You're seeing that dot. That dot is at the end of the root. I guess I just told you a little bit about the power of microscopy! How about that? Oh, I wish I had a microscope, I wish I had a microscope. Well, get a microscope. Here we are, putting plugs in. You can use the West trowel. I showed that as part of this case because we can use a West trowel. We did.
But you can also use your MAP System, or you can use a tube that you've fabricated and customized. And remember, only about two or three. You're thinking it's so much room that you should be putting maybe six or seven in. You'll never get it past the coronal one third, okay? So, just a little bit so you can get it down there. There's the flexible cone. I like the cone cut at the diameter where I can actually have a working surface that's efficient and can -- like a snowplow, can get on that mud and start moving it. So, tamp it into place.
Take a radiograph, and you can say, well, Ruddle said if I got it within about three to five, I'd probably be in Fat City. Well, I'm thinking that's about five millimeters. So, now, to get it to slump on out into the various pathways, we can come back and vibrate, like we've already talked about. You can use your EndoActivator, and you can stir the soup. You'll get some splatter. You'll throw that mud around, but you want the low RPMs, just a brrrrrrr, and you'll see bubbles coming up and the material kinda slump down. It's adapting laterally, it's adapting vertically, and you're not plugging. You're not plugging. Okay.
I put the patient's own post back in. I put a temporary material, cement, Temp-Bond, to cement the post. And you can see cement lateral to the post. And you can get it back to the general dentist so that they can take off the resin bridge and start the construction of the prosthesis. So, I'm using the old post that I blew out. It's gone through the autoclave, it's been sterilized. Okay? So, it's gonna go right in there. MTA needs moisture to set up. The moisture requirement is fulfilled on the periapical side, but you will put a wet cotton pellet -- a moist, wet cotton pellet, not soaking -- and you'll put on top of the mud and then provisionalize and say bye-bye.
That moist cotton pellet is going to help drive the reaction so that the MTA can actually set, just like mortar, just like concrete, just like dental stone. MTA is like dental stone, isn't it? If you start to look at the ingredients, it's dental stone. All right. So, now that we've talked about that, when you have the patient back, you take the provisional off, the dentist would take the post out, and they would take and explore, and they would sound. I use the word they would "sound." And they're gonna see if this material is firm or is it runny and loose. About four or five times in my entire practice career, it has been not set up.
And Mahmoud Torabinejad, the father of MTA, from Loma Linda, has hypothesized many times that maybe the MTA didn't set up, because there was so much inflammation up in the periapical tissues. That means more acidic, and it's neutralizing the basic MTA, you know, the OH radical, basic. So, I have had to put MTA in a second time, three, four, five times across decades. Okay? And I've never not had the MTA set up on the subsequent visit. So, moisture on the outside drives the set. Moisture on the inside drives the set. Subsequent visit, it should be firm. If it's firm, you can go right on with the restorative and repair the case.
So, here it is provisionalized. You might be able to see some little hint here of pontics -- pontics in here. But this is now going to go on and become the brand-new bridge abutment. So, all that work, you might say, seems like time consuming, probably quite a costly, but what was your alternative? Learn to do the retreatment procedures. And if you can't do them, learn to refer them, because there are endodontists that know how to do this. And I've trained hundreds if not several thousand of them around the world to actually know how to do this.
So, I know you can find somebody in your community to help you do transportations, Type II. Next time -- I'll see you, but it won't necessarily be sequentially Type III, but we'll get to Type III's in the future.
CLOSE: Unsolved Mysteries – Stonehenge
All right. Well, we have another installment of our "Favorite Unsolved Mysteries.” We've talked about the infamous Alcatraz prison escape and the disappearance of Amelia Earhart while attempting to fly around the world. Today we're gonna talk about Stonehenge.
Now, Stonehenge is located at the south -- in the south of the UK, about 90 miles west of London. And it was built thousands of years ago in the Neolithic Age, so factual information about it is minimal. The mystery around it is not only what it was used for, but also how it was built. And it has even included theories about Merlin the Magician and space aliens. But there are essentially three fundamental credible viewpoints and -- or theories. What are those?
One was an archeologist's viewpoint. Of course, these people, they like to dig, and then they like to sift, and then they like to observe, and they do all that. And then, of course, they had carbon dating. And then, there was other dig sites around the world, Neolithic period, that they could learn from those things. So, that was one thing, just to look at it physically. The other one was the archeoastronomers. They were looking at things like the solar system, planetary movement. And they were looking at equinox, and they were looking at what? What's the word I'm looking for? Solstices. We just had one. Yeah. Solstices.
And they think it's been built and positioned according to that. And then, of course, there's this New Age viewpoint. And that was kind of a religious worship type thing, maybe a spiritual place. And if you look at modern-day pictures, pretty modern, you'll see Druids. And they're very interesting in their robes, but Stonehenge predated the Druids by I think a few hundred years.
Okay. Well, let's start with how it was built.
And I think maybe -- let's put up a picture of Stonehenge behind us just for some reference. Okay. We're gonna start with the bluestones, and they weigh about four tons each. They're the first stones. And it has been determined that they came from Wales, which is about 200 miles away.
So, how did they get the stones 200 miles, these stones that weigh 4 tons? Well, there's the -- the popular theory is that they were brought by boat and then rolled on logs to the site. But probably a more plausible theory is that they were carried there by glaciers during the Ice Age. So, that's the theory behind that. But what about the larger stones called the sarsen stones?
Well, you can see them. They're the vertical members, and they were about -- what you can see is about 13 feet high, and they're about 7 feet wide. And I guess they're about 25 tons. That's about 50,000 pounds, if you're trying to make the conversion and you're overseas. So, they're massive, and about one third of their overall height is submerged under the ground. So, that's kind of a little bit about those. Those came from not so far away. They're about 20 miles away, but these massive stones, they're wondering how they got there.
And just to put it in perspective, modern-day people have calculated that it would take 1,000 people 10 years to move 1 sarsen stone into place. So, either there was massive armies, or we don't completely understand it yet. And then, the other thing that was interesting is how you get the horizontal members, you know, up on the vertical stones. And of course, there was a postulation that they built earth ramps up so they could muscle these things up, maybe pulleys and stuff to get them up there.
It is pretty cool, though. They're all carved, they're all joined perfectly, and this is before the age of metal. So, they weren't using metal to carve rocks. They were carving rocks with rocks.
Okay. Well, it's definitely a mystery that they could build something like that without modern-day equipment.
But also, let's look at the mystery of what it was used for. So, some plausible theories have been that it's a sacred burial site. And there are several burial mounds around the vicinity. And recent evidence suggests that perhaps it was a burial place for wealthier people or royals. Then, it definitely has an astronomical use. And certain of the stones are aligned with celestial bodies, so -- but they -- but the general idea is that the purpose goes beyond just astronomy.
Some people also think that it -- there was a healing aspect to Stonehenge because the bluestones are thought by other ancient societies to have healing properties. And there is evidence that people might have traveled long distances to go to Stonehenge, and some of them seemed to have some pretty serious physical injuries. So, maybe the idea was to go there and be healed. But I guess apparently the mystery of why Stonehenge was even built in the first place was maybe just recently solved, about a year ago. Right?
Yes, in trots Professor Timothy Darvill, Darvill.
Timothy Darvill is a professor at the University of Bournemouth, and he said it's really pretty simple. It was nothing more than a massive calendar. It worked to divide the seasons, the days, the weeks, and the months. So, he thought it was pretty simple.
I guess having some knowledge of other calendars during that time period, it works in a very similar way. So, perhaps mystery solved regarding why it was built, but still, we'll probably never know exactly everything that went on there or --
But stop. You and I have talked about this, and I have to have you tell our audience, it's the big mystery is how it all got there. Do you have any remaining lingering mysteries now that you hear the theories about what's conspicuously not there?
Well, the missing -- I guess there was originally more stones, and they are no longer there. So --
If they're so easy to bring [laughs] --
-- maybe they just put them on the back of a bus and took them away?
Lori suggested -- my sister and his daughter -- suggested that over time maybe they were taken away and used to build castles or something.
Yeah. They got a bunch of horses, and they saddled them up, and they tied them to the stones and it was a hip-yay! Hee-aah! And off those stones went. Because you can see, the stones are gone.
Well, hopefully you found this interesting. I do find that when we do these unsolved mysteries, for days after we even shoot the segment, I'm still thinking about it.
And apparently, it was also interesting to one other person, too, because you might have noticed in Dr. Tindal's presentation --
-- there was a mention of Stonehenge at the beginning. And we had already decided before we even saw his presentation that we were gonna talk about Stonehenge. So, it was kinda serendipitous.
Well, that's it for today. Hope you enjoyed the show. 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