Ruddle Glide Path Management Technique Card featuring ProGlider (rotation) & Gold Glider (reciprocation)
Fresh Perspective & Apical Divisions Fast Healing & Irregular GPM and Cone Fit
The show begins with Ruddle and Lisette revealing what they like to watch on TV to unwind or relax. Then, have you seen those ads that promise “fast healing” when certain technologies are utilized? Ruddle gives a Fresh Perspective on what exactly “fast healing” means. Next, Ruddle is back at the board to address glide path management and cone fit strategies when there is an apical division. The season concludes with some bloopers… rare, as Ruddle and Lisette are the consummate professionals! Wink, wink.
Show Content & Timecodes00:41 - INTRO: Bedtime TV Show 06:16 - SEGMENT 1: Fresh Perspective – What Exactly is “Fast” Healing 26:32 - SEGMENT 2: Apical Divisions – Irregular GPM & Cone Fit 57:11 - CLOSE: Bloopers
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Other ‘Ruddle Show’ episodes referenced within show:
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Downloadable PDFs & Related Materials
New and potentially disruptive technologies come to market each year, proclaiming to improve on what came before. Many of these newcomers have virtually no evidence-based research to support claims of better, easier, or faster...
Many times over several decades I have described various concepts, strategies, and techniques for shaping root canals. Although the concepts and strategies have essentially remained the same, the techniques have evolved...
This article will briefly review the ProTaper system and technique, and will then focus on the various considerations that will influence predictability and success when finishing the apical one-third.
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.
…How are you doin’ out there? I hope everybody’s ready for the show – Number 80!
Okay, well – well, wait… Okay, I think it’s 82?
Oh, it’s 82…
INTRO: Bedtime TV Show
Welcome to The Ruddle Show. I'm Lisette, and this is my dad, Cliff Ruddle.
How you doing today?
Pretty good. How about you?
Excellent, and how are you doin' out there, today? Show 82, here we go!
Okay. Well, I don't know about you, but one of the last things we do before we go to bed at night is, we watch a little TV. Now, not together, but in our own private houses. So, I really love sleeping, and I really love falling asleep. For me, it's like the opportunity to think about whatever I want to imagine. I can travel anywhere I want in my dreams in any time period. So, I really like sleeping, and because of this, and because I view it as a sleep journey, I'm pretty particular about what I watch before I go to sleep. Like, I generally do not watch anything news or politics.
And I don't watch something that's really loud, like, with sirens and car crashes and screaming. I steer clear of that. That -- that doesn't set the stage for a good night's sleep, for me. But what about you? What is your bedtime routine, and do you have a favorite TV show that is your go-to?
Well, Phyllis is the one that likes to watch movies. I usually watch just sports and news. But when I come downstairs, after whatever I'm doing upstairs, a lot of times, endodontics [laughingly], the TV is on. She may or may not be awake. And I get into these shows vicariously, through her. But one of them was The Big Bang Theory. And there was Sheldon and Leonard, and there was -- I don't know -- who -- help me out. Howard and --
Amy -- Amy.
Well, I don't want all the -- I want the scientists.
Raj, Howard, Sheldon, Leonard. They're scientists that play on the show, and then, there's some ladies that accompany them, and one of them is very smart -- physicist. Anyway, I like that show, because -- I can't really put my finger on it. It's -- it's easy. It's -- it's funny. There's a great -- there's great sense of humor. There's chemistry, and there's actions and interactions between this eclectic group of scientists and astrophysicists. I like how they fill up the board with formulas and stuff. And then, just their personalities.
I like the little funky place they live. I have this impression it's a tower, and there's a center stairway that goes around and around and around. The elevator's been broken ever since I started watching the show. Anyway, they come up around the stairs. So, a lot of the movie, they're going up and down and up and down or just going up and up and up.
But another one I've gotten into is PBS's Masterpiece Theater. Phyllis really likes that, and one of them is in Yorkshire, northeast of London. And it's All Creatures, Great and Small. So, it's a wonderful story about three veterinarians who meet different people in this little, wonderful community and save animals' lives. And I kinda like that, too. What I really liked about it, you were talkin' about melancholy, this is an area of farms and hamlets and incredibly -- beauty. So, I love it when they drive out to help some horse or a cow, and you're goin' down these rock-lined walls on the highway, and there are little roads, and it's just fabulous.
And of course, I won't -- I'm running out of time, but Poirot is another one, a British mystery. And I like how he walks, and his stealth, and he solves things with penetrating perceptions. And a [laughs] --
The Agatha Christie character.
-- yeah. And he said his walk is nothing more than being able to hold a penny between your cheek -- buttocks as you walk. So, you know, you can try that on your own and see if you can get that up.
Well, I --
How about you?
Well, I -- I haven't seen the two shows you were talking about, but I have seen The Big Bang Theory. That is very funny.
Isaac recently watched the whole series. For me, for a long time, my go-to -- for years, my go-to bedtime TV program was some version of Star Trek. So, I just really love the sound of the space noises. I find it really relaxing. Recently, though, in the last few months, my go-to bedtime TV show is Twilight Zone. And I really like what the narrator says, the monologue he says at the beginning of every episode. I would want to actually play for it for you now, but because of copyright things, I -- I guess I'm just gonna have to say it, myself. So --
Well, can you --
Here I go. [Music coming up.]
"There is a fifth dimension beyond that which is known to man. It is a dimension as vast as space, and as timeless as infinity. It is the middle ground between light and shadow, between science and superstition, and it lies between the pit of man's fear and the summit of his knowledge. This is the dimension of imagination. It is an area which we call -- The Twilight Zone."
Wow! I'm ready to lay down and take a nap and, through imagination, travel into the realm of creativity and possibility. That's very good.
It's a -- I don't even think I ever get to the finish of any episode. After that, I think I pretty much [laughs] drift off to sleep, after he says the little opener.
Okay. Well, we're gonna -- you know, actually, I -- before we go, I actually just wanna recommend, a good bedtime TV show is The Ruddle Show, maybe [laughs].
[laughs] Except maybe they'd have a nightmare if they watched The Rant.
[laughs] Right. Maybe without The Rant episode.
Okay. Well, we -- this is our last show of Season 8 -- or 9, our last show of Season 9. And let's do it. Okay?
SEGMENT 1: Fresh Perspective – What Exactly Is “Fast” Healing?
Okay. So, it's been a while since we've done a "Fresh Perspective" segment. So, we thought we would do one today. And if you don't remember, I'll remind you. The point of this segment is to challenge you to think of something in a different way than you have maybe up until now. We often accept ideas and claims without really questioning them. So, essentially, with this segment, we want to activate your critical thinking skills and get you to think outside the box. Today, we wanted to talk about the advertising claim of "fast healing." We wanna talk about what actually constitutes fast healing; and if the healing is indeed faster, is it even statistically significant?
Wow, that's a good one, because on earlier shows, as many of you recall that are show watchers, we talked about the laser. And of course, there's all kinds of lasers and wavelengths on the electromagnetic spectrum of light. But the ones we talked about were really in the nanometer of wavelengths around 650, if I recall, to about 900, 950 -- under 1,000. And those laser lights, they're operating in the red, infrared zone. They can pass over many, many wounds, injuries, like from basketball or a blow, pathological instances, where aphthous ulcers, you know, things like that. They show -- and there's remarkable evidence on rapid healing, as compared to just letting a virus or something like an aphthous ulcer just truck along and do its whole course.
So, they've shown dramatic reductions in inflammation, rapid wound healing, and of course, this makes people happy. So, that's -- that would be an example. And companies have oftentimes used these slogans to promote either through their products or their technologies, to promote that product to the marketplace. So, when dentists see "fast healing," and they look at lasers, that's really something to look into, because there's a big, big body of evidence from around the world. It's not just one location that's reporting this.
Probably the other classic example I'd like to report is on implants, and I don't do implants [laughingly]. We all have heard about implants. I talked a little bit about the Branemark implants, way back in the '50s, and how they kind of came along, and they were titanium, is what most of us thought. And then, they even got coatings. But there's this new thing that's being promoted, and I might just say Zimmer Biomet, they got together 30 scientific papers with clinical applications, and they have this body of evidence to show this BioBoost Effect.
"BioBoost" was the buzzword. And the BioBoost Effect, you know, I was kinda thinking, well, what is this? Some chemicals we're putting in the bone after we drill the hole? No! It has to do with the implant itself. And the implant is called tantalum -- tantalum. It's element 73 in the periodic table, and it has characteristics even better than titanium. And what has been noticed is, it's not a solid implant, nor does it have a surface treatment. It is actually 3D. It -- it simulates trabecular bone. So, if you have an implant that has trabecular bone in its body, then you can see how osteoid and vascularization and precursors for bone formation can rapidly happen.
So, this is also another really good implant for people that have medical compromises, like diabetes. So, it's getting a lot of noise. A lot of people are going towards this Zimmer Biomet thing because of the tantalum. And -- and Branemark validated tantalum, back in 1950, roughly.
Okay. So, you gave two examples, the lasers and the implants, of advertising -- advertisers claiming fast healing. And I just think that first of all, we just need to clarify, to say that something heals fast or faster, that implies the existence that there's also slow healing or slower healing. So, we just need to keep that in mind. And -- because if you're gonna say something's faster, it has to be faster than what?
Yeah. That's true.
Right? And you gave the two examples. And for the first one, the laser example you gave, I have to say that it would make sense to me intuitively -- on an intuitive level, it would make sense that laser -- procedures done with lasers would heal faster than procedures that used a scalpel, because that -- because without breaking the tissue, you would think that there would be faster healing. So, intuitively, that makes sense.
With the other example you gave, you talked about the implants that have more naturally occurring growth factors, and that would make sense that that would heal faster than implants without those naturally occurring growth factors. And plus, you said that it --
Especially with the evidence [laughs].
And you said there was 30 clinical articles that supported it. So, right away, when you're trying to assess if a claim rings true or not, you can say, does it intuitively ring true? And then you can answer that question to yourself. Is it supported by evidence-based research, a lot of it? Then, that helps give it credibility. So, what would be an example of a problematic advertising claim of fast healing?
Well, I guess I'll just say -- and this will get my whole family upset -- but I'm gonna have to return to GentleWave. And remember, they threatened a lawsuit against us. So, that all went away, because we said everything correctly on the show, and I'm gonna say everything correctly today. It has to do with them. They funded a paper called "Endodontic Healing Success Rates." I think -- I can read the exact title. Lori will promote it for us. "Six-Month Healing Success Rates After Endodontic Treatment Using the Novel GentleWave System." And it was published in the Journal of Clinical and Experimental Dentistry in 2016 of July.
So, what about this? Well, they talk about fast healing. And what I had a problem with, in the paper, we all know, from the very first time you go to grad school, everybody has to do a research project. Some get published, and some don't. But you go through the steps, so you learn a lot. And there was no control. So, when I say "control," they should have -- you know, they were very good at describing their exclusion and inclusion categories. So, we're past all that. And the medical history is all inside that, how they might exclude you, if you were an uncontrolled diabetic, as an example.
But then they did very careful accesses and described that, how they reached length, working length. They talked about how they shaped. So, we understood that perfectly. They didn't talk at all about how they irrigated during this opening up the canal to get some kind of a shape. And some of you might be misunderstood because you think GentleWave means minimally invasive. This group of scientists, out of NYU, they used the F1 ProTaper. That's a 20.07. And they used that because they wanted to have a standardized cone to fit at the end of the procedure. So, it was a 20.07. So, they explained all that, but they don't explain anything about how they irrigated, the frequency, the volume, the temperature, the concentration. None of that's discussed.
And then, they put the GentleWave on the top of the tooth, at the end, and they ran the cycle. So, they report at six months -- and we'll get into that a little bit later -- what the healing looked like. The problem is, compared to, as you said earlier, compared to what? And then, the other thing is, there's no controls. Compare -- you know, controls, I just mentioned, I'm sorry. There's no comparisons. Now, they say they did a lot of comparisons.
And this is kind of interesting. They looked at a lot of studies around the world, where people assessed healing at six months. But the pathway that those clinicians around the world went through, in terms of deep shape, the final shape, the irrigation protocol, the concentration, the temperature, all this other -- it was different in every study. So, here again, you're comparing this study, that I just mentioned, to all of these other studies. Those are called "comparisons." But everybody around the world did their procedures differently than they did their procedures in this paper.
So, those aren't even really comparison studies. The only thing you can compare is, they did something, you did something, I did something, the producer did something. We did it all differently, and then, we're reporting our healing rates. So, they're comparing healing, but we don't really know what the comparison was against.
Well, it does seem actually a little bit difficult or problematic to say that a single device -- okay. Well, first of all, irrigation's just one part of root canal treatment, right? There's also shaping and obturation as well.
There's many, many steps that go into start-to-finish endodontics, and irrigation is one single step.
So, it seems problematic to associate success to just one technology used in one aspect of the root canal treatment. It just seems that there's a lot of variables that you're trying to control. You're trying to set up an experiment, where every -- all the technology used and everything done is exactly the same, the only difference being the technology used for -- or the -- the irrigation device. But then again, there's no comparison. I guess they did try to set up an experiment, where everything is controlled, right, except the irrigation device. But do you agree with their protocol?
Well, no. That's -- I'm being redundant to the audience. Sorry. But you can do all the things they did. They -- they mapped them all out. They used a 10 file, working length, ProTaper F1 was the finish. We don't know what they irrigated through. The didn't work dry, and that was several minutes of chair time that could already clog up a canal. But then, they do -- used GentleWave, which has been said and heralded as a very effective way to clean. And they go into big depths in their paper about other papers they've done -- or other cohorts of theirs that have done papers. Usually, these are people that are on GentleWave's Scientific Board of Advisors, and they're academics.
So, they quote a lot of these other papers, but again, comparisons -- if you do a root canal and compare healing at six months, and I do a root canal at six months, and we show something the same or different, we don't know what it was that was different, unless we know what you did exactly and I did. So, no comparison. For me, really simple. Do everything they did, every single step, more or less perfect. At the end, no GentleWave versus GentleWave. Now, you have a head-to-head comparison to see, is this the only factor that made the difference? Because a lot of times, people, studies, they attribute success to things that really aren't part of the success story.
And I kinda jumped ahead a little bit, but -- but that's what needed to be done. There was no control. That's the biggest thing. And the comparisons they talked about, to me, are irrelevant, because we don't know how those studies were done.
I think they actually say, at the end of the article, that more studies would need to be done, and they would need to compare the -- it -- the GentleWave system in the experiment being used and that maybe another -- with other technologies on the market that are currently being used for irrigation. So, they didn't even compare -- not only just GentleWave versus a control, which I guess would be something like hand-held irrigation or something, but there was no comparison even to a control or to other disinfection technologies on the market today. And then, they looked at it at six months, and they said healed or healing, but faster -- fast healing. But there's no comparison. So, it's just -- it's -- it's not like they even showed faster healing or fast healing. They just showed that healing happens, I guess [laughs].
Well, and I guess I wanna say this. I wasn't part of the paper, nor am I. But everyone out there that's practicing is their own researcher, because your pool of patients that you see every day is giving you a lot of feedback. When I heard all this healing -- they gave other papers, and some were 50s and 60s and 70 percent. They were 97-some percent.
Well, how did they measure the healing?
Well, that was what was kinda crazy. They divided -- okay. First of all, they wanted the patients to come back, and they could assess them at clinical examination and a radiographic examination. So, they did that. And then, they divided the groups into three: healed; progressive healing but unhealed, but progressive; and diseased. So, most people were over in these two categories, and they said some very nice things about what they found. But within these two categories, you tell the audience what was in both categories that was so alarming.
Some sensitivity to percussion.
They said that the people in A., healed; the people in progressive healing had sensitivity to percussion. Ruddle has never had a patient that's healing that's sensitive to percussion. It doesn't even meet any -- it -- it defies everything I know about my experience. But my experience isn't their experience. But one last comment I'd like to make about it, most of my patients could eat and chew, left to right, pretty much the night or within 48 hours after the pack. Okay?
And I did a -- my own study, decades ago, to demonstrate that. Because you don't know if it's the sodium hypochlorite that gets out. You don’t' know if it's the file that pushes debris out. You don't know if it's the sealer. You don't know if it's the gutta percha. You don't know what it is that makes a person hurt. So, you gotta control everything, and the only difference could be GentleWave versus no GentleWave, no controls, comparisons are irrelevant, and it doesn't meet my clinical experience.
I mean, people -- we used to see people -- kids heal faster. We were having this big discussion about don't kids heal faster? Well, they controlled that in their inclusion group. They had ages, I think, 18 to 79, something like that, across the board. Of course, kids can lay down bone quicker. But I saw people even on their deathbed, brought in on gurneys and stretchers, to get a recall x-ray. I wasn't even sure why they were there. But we saw healing even on terminally ill patients. So, to me, my experience isn't sensitivity to percussion in the healed or progressively healing group. In fact, I'll say "progressively." Bone's filling in. The tooth should be totally comfortable, unless there's a what? A radicular fracture.
Well, if I had -- if I had a root canal, and six months later, I had sensitivity to percussion, I would definitely consider myself as not healed. And I would be going back to the dentist, to try to figure out what was going on.
I wanna say something. The paper is not my problem. The paper's just the paper. I said decades ago, they should have a journal of retractions, okay? So that people have an opportunity to put their journal up and remove it, once and for all. The paper is just another paper, okay? And if you don't control things, we don't get upset about it. What is the problem, in going back to almost your first question, is when companies and industry takes these papers and starts using them for promotional pieces, to promote their product. And that can send out the wrong message, because they say "fast healing" in the paper. The website says, "faster healing."
Yeah. I guessed that.
So, I don't know what faster is. I don't know what fast is. I would only know fast if they define slow, and you already made this point. I'd only know fast if you said regular, slow, no -- okay. I get -- we get all that. But I don't know what -- I -- they said, "fast healing," but maybe fast, compared to what? Their experiences. How about that?
Okay. Say you could prove that it actually is faster healing. So, then, I'm wondering, like, is this even statistically significant, though? Because if you told me that I -- if I -- if this technology was used, I could heal in three months versus six months, I would say, like, wow! It's cutting the healing time in half!
I'm definitely -- I wanna do that. But if you told me what used to take 180 days now only takes 177 days to heal, well, I would kinda think, like, who cares?
Would you repeat that -- would you repeat that again? That was in the paper. Say it again.
Oh, well, I don't know about those numbers. I just actually made it up. But if you could tell me that what used to take 180 days now only takes 177 days, well, I would not really care too much about those 3 days, as the patient.
If you were asymptomatic because you would know if you're comfortable, probably, deep in the bone, the osteoblasts are doing their thing.
And then, I guess there's also a bit of an issue, I -- I heard you saying, about assessing things at six months and then that being the end of the experiment, because don't a lot of - a lot of root canals heal fine in six months, but maybe problems might be down the line?
In my experience -- and there plenty of exceptions -- but in general, almost anything works for three to five years. So, you might have a really poorly performed root canal. Postoperative, there might be some pain, some swelling, maybe some phone calls. And then, they kinda settle down, and then, they become comfortable. I made a living out of doing retreatment. I got to a point where 90 percent of my caseload was people that had already had endodontics. So, that's where the three to five years come from. Almost everything works for three to five years.
What separates time, it -- great work is time. And time really, for me, is 15-, 20-, 25-, 30-year recalls. Maybe one last comment about what we should look for, as colleagues. We shouldn't really get too overly impressed with statistics, with I guess indices, tables, references. This paper was very heavily loaded with the best that science can offer, in terms of supporting stuff that didn't really answer the question. Fast? Faster than what?
Yeah. And I also wanna just tell our viewers that this is actually -- beware of seeing a reference slapped onto the end of a statement and thinking, oh, yeah. That's proven. Because just -- not even in -- only in dentistry, but in other areas, in the last year, there's been many times I've actually gone to look at the reference of what was cited, and they're not even saying what the person is, like, interpreting them to be saying. They're not even - they're not even being properly represented in the study.
Is it a friend? [laughs]
No, it's just other things I've gone to check out over the years --
Sometimes we reference our friends.
-- over the last couple years. Yeah. It seems like it's very -- become very popular to just slap a reference onto the end of a statement and think that that's gonna, you know, cover it. But if someone goes and reads that paper, then they might be left wondering, well, I'm just wondering how they got that out of this article, because that's not what I got out of it.
Well, here. Let's give them a challenge. I'll shape 50 canals to a 25.08 or a 20.07. I'll do all my irrigation protocol. And if I do active irrigation after my -- let's make a distinction. Irrigation protocol versus activating the irrigation protocol. I'd like to see my work head to head with their work. I don't -- I would argue, because of my experience, I'm gonna be 97, 98 percent. I mean, so I don't take their claim that the only variable was GentleWave.
Okay. Well, good discussion on fast healing. And I just really wanna encourage all of our viewers to just not blindly accept, you know, what you read and -- and to use critical thinking and -- and ask yourself, does this even intuitively make sense? Check out, is it supported by evidence-based research, that kind of thing. All right. Well, thank you.
Yeah. And I guess in terms for me, on this show, don't believe anything you see and only half of what you hear.
SEGMENT 2: Apical Divisions – Irregular GPM & Cone Fit
I'm absolutely delighted to be with you today again at the board. Set B. This is Season 9. This is show 8. This is the last show of this season. Don't be too disgruntled, because every ending has a new beginning.
I'm really delighted today, then, to talk to you about something that we haven't really addressed, specifically. We've danced all around it. We've talked a lot about glide path management over many, many episodes. We've talked about irregular glide path management, but I've never tied these three things together. And this is something for the learned clinician, for the novice clinician, and from the kind of experienced clinician, there's something in here for everybody. So, we'll look at some different ideas and some concepts, obviously, to learn and learn together.
Now, I know there's tens of thousands of people that watch these shows, and we're very, very proud of that, and we wanna thank you for your participation, so authentically. But I'd like to make it more personal, like I'm talking to you. Okay? You're the only one out there, and it's just me and Cliff and -- and we're visiting today about a topic, how do we do maybe, say, a cone fit? Or how do we do glide path management, in the instances of apical divisions? Let's get started.
All right. So, we have a spinning tooth to remind us of the mandibular bicuspid. Frequently, it's a complicated tooth. It has loops, deltas, extra canals, deep divisions, re-anastomosing, and more divisions. So, it's a tough tooth, and we have a pretty nice one here to show you. And as it comes around, you can see some of the anatomy I just described. So, it's always anatomically driven. Endodontics is anatomically driven.
So, I'm gonna look at three cases today. Not six, not ten. We'll come back to this topic, because we can go to molars, and we can go to individual roots, for example. But I'm just gonna show three single-rooted teeth. They appear to be posterior teeth. And here we go.
So, when you look at this tooth, you all saw the lesion on the molar. Okay? You saw that big lesion down here on the molar. That was asymptomatic, and it's scheduled for treatment. It was going to be treated. The patient was having clinical symptomology with the bicuspid. And you see that first bicuspid has lost its filling, because it had recurrent decay. So, the patient's complaining of a lot of sensitivity, spontaneous pain, and it's a vital pulp. I always say all that because we know necrotic pulps are easier to eliminate and remove from the root canal system than collagenous tissue, as an example. Tenacious, tacky, sticky, hard to remove.
So, if you look at the caries, we begin to look at the teeth. And we usually try to read canals. You know, preoperatively, we try to read canals all the way down and try to see where they might terminate. In the tooth in question, I can see a canal coming down nicely, nicely, nicely, and it kinda plays out. You know, I know, we all know that when canals play out, as we move towards the terminal part of the root, that usually suggests to the clinician a division. So, already, you're alert to that. With vital tissue, we don't have enough breakdown to know exactly how to pre-curve the file and guide it to a specific site, because it hasn't had enough osteolytic activity yet to destroy bone.
So, these are some of the things Ruddle notices. I have pretty good canal widths, pretty good canals widths, and pretty good canal widths. So, I'm looking at this tooth, and I'm thinking, what do we do first? Well, I've been teaching for a long time, now, with new instruments, new cross-sections, new geometries, new heat treatment, we can do a lot more than maybe if you heard me five years ago, three years ago. But with the launch of Ultimate, there was a new glide path called SLIDER. SLIDER has a different cross-section as compared to Gold Glider, which is for the single-file, WaveOne technique. ProTaper Gold had ProTaper -- it had a, you know, glider. And now, this is a SLIDER. It has a little different name.
You get confused by it, I know. I get confused, and I'm an inventor with my pals, Pierre and John. But you can see, it has eight changing tapers. It's a progressively tapered instrument. That was our initial idea. Everybody's copied that now. You can see in the box the numbers, so you kinda look at the -- the cross-sectional diameters as you move up the file, to see how big it is. It's 1-millimeter diameter wire. So, that just means that it shuts down at 1 millimeter, 99/100ths, right at the last blade. So, we have progressive tapers; we have a very nice instrument, with good geometries, to open up the canal quickly and effectively; and we have a different cross-section that balances rigidity and flexibility.
It's funny. You talk to dentists, you read magazines, even from other clinicians, and they're always looking for floppy, like wet-noodle flexibility. You need to have enough rigidity to hold the cutting edge on your blade so it can cut and move in. So, this instrument, the KOL's -- the key opinion leaders -- from around the world, many of them -- many of them, over several months, validated that 63 percent of the time, in posterior teeth, the glider, the SLIDER, the SLIDER will go right to length in 2 or 3 passes. Okay? So, 63 percent, thumbs up. So, if that's the case, we know we have a pretty decent canal. I'm not really sure what's gonna happen about right here, but let's get started.
Okay. So, you're gonna use a mechanical instrument. Why not? You come in here, it takes a few seconds. Let it float. Say, "float." Can't hear you. Float, follow. You float and follow. This is just as kind as if you went down here with a 10 or 15, and it wouldn't go. It might even be kinder, because usually manually, you try to -- there's this tendency to try to force it a little bit. So, if you just let it float in, as long as it's moving and progressing apically, stay the course. If it seems like it might be because of debris loaded on the flutes, take the file out, clean the blades, and let it go. But if it doesn't go, it doesn't go.
Either disarticulate this file from the handpiece and take a film, or take the file out, throw in a hand file. That's what I did. And yep, goes right to what you might think. Right to what you might think. So, you can then push the stop down, and if you thought for an example that this thing might have been 23 millimeters, we know that at about 17 millimeters, there is an impediment. This is where we would have the impediment. So, you can put a different instrument in there. And let's see if we can get a little bit deeper. But when you're stopped, don't try to go deeper. What do we always say? Pre-enlarge. Open up the body.
This is the most used instrument internationally. I guess I'll say this, for GentleWave people. I get paid a royalty on these files that I helped invent, along with my colleagues. They brought that up, you know, and we'll talk about that later. But yes, I need to say that I am a coinventor on these instruments. And this instrument, Shaper X, it's different than the Shaper X from the ProTaper Gold family. It's different than from the ProTaper Universal family. ProTaper Ultimate has a new cross-section. In any event, this is the geometries as you move up the file. Oftentimes, Ruddle only puts the file in about halfway.
Well, let me change this. You might not know this. You're thinking every file has 16 millimeters of active portion. Actually, S-X has about 14 millimeters. So, half of 14 sounds like it's about 7. So, about 7 millimeters up, we're probably about a 77. Okay? So, what this does is, it rapidly opens up the body. And by pre-enlarging the canal, we create space, and now we can take a little, small hand file, and we can pre-curve it, and we can drop a pre-curved file in a pre-enlarged canal. How about that? And when we arrive at the impediment, we have a curved file. If we don't pre-enlarge, there's so much restriction that we can curve the file, but as we pass it through the restrictive area, the curve is knocked off the file, and the file arrives, unintentionally, straighter than you believed. So, open it up.
I've shown this clip before. I've seen lots of other companies, what they call "orifice openers." They're stiff. Look how flexible this is. It's sloppy flexible, but it has big geometries, and I only run it in about halfway, just about halfway. And by opening it up, I can take a 10 file, and I can slide it where it wouldn't go before, because the rate of taper of the 10 file, early was greater than the taper of the canal. So, it wouldn't go. A lot of you dropped to the 8 and the 6, then. We just simply opened it up, take the same file, and you can see, we got it registered, and it's sneaking through, and we're open and patent. So, that's a quick way, a quick trick to get to length is pre-enlargement. This, we have talked about several times.
But back to our bifidity, you can get your 10 file. You can put a curve on it, like I just mentioned. You can pass it through that pre-enlarged region. You'll arrive in the curvature curve, and then, it's a lot of watching this little unidirectional stop. That little unidirectional stop tells you if you're going north, east, west, or south. Maybe you're going southwest. Bu you can find the vector, the pathway to the terminus. And once you get in, we talked about that in a previous show. I think it was Show 5 this year.
But we talked about the finger motion, the watch winding motion, in the apical one third. And that's what draws that file down and to length. When you get to length, it's in, out. You change the motion of your fingers, no more watch winding. It's in, out, in, out, in, out, until the file is -- oh, yes! Loose! If you start working with loose 10s, your endodontics all gets easier and better and more fun.
All right. So, you're at length, and you're actually open and patent. You've confirmed patency. It was already patent before Ruddle. It should still be patent after Ruddle. So, that's that branch. You can take a film and say, there it is. So, we still know the impediment's about right here, and there we are, heading off to the distal. Just keep your eye on this. There's a little bundle down in here. There's a -- a little anterior shunt on that neurovascular bundle, and we have close proximity to a neurovascular network.
Okay. What do we do, next? Take it out. Let's take it out. And take the same instrument, that's pre-curved. The curve is much closer to the tip. It's not a sweeping curve, like in the envelope of motion, up in the body. This curve moves towards the terminal part of the file, two, three, four flutes, and now, you can begin to try north, try south, try east. If you get a little catch, the tendency is to pull out. If you get a little bit of pressure, the tendency is to pull out and go to an 8. Don't go to an 8, unless you have it open, and you've identified this orifice, and you can get into it on a deliberate and reproducible basis. On your way down, you go in and out.
Ruddle says, do that to smooth, expand, and refine, and give yourself a greater opportunity on the next sequential file to get right back in there. West -- John West calls those "smoothies." But when you're down, and you're at length, you take a film, and you can see, we are working a bifidity. So, we're talking about apical divisions. Now, sometimes, you don't even know this is here. A lot of us don't ever get into it. We just work the more apical branch. That's fine, because if you're using active irrigation, a lot of times, we can clean laterally -- okay -- where our files never reach.
Another thing, it's nice to get in here, because when you start to open canals, and you start to shape canals, you shorten the length of the lateral anatomy. You shorten the length of the lateral anatomy. And by shortening the length, it's easier to clean. So, we don't always even get into them. So, some of you are saying, well, gee, I've never been in a bifidity, in my life. Well, a lot of us haven't been. But some of us have. And so, I'm saying, if you do get that catch, this is what it means. Think about it. Now you can imagine it, and now you can reproduce what Ruddle's just talking about. This is all reproducible.
So, you got in here, and you're thinking, I'm ready to go something different. But if the 10 file was the first hand file you used, you're going to want to go to the SLIDER. And you could try a rotary, but it'll probably still hang up, right at the bifidity. So, we know that we can clip a handle on. A manual instrument that's working about four millimeters this, and about four or five that way, do you realize how fast that is? Do you know your finger -- you can -- before you can chuck this up and put it in, and start to discover everything, you've already done it manually. So, don't dismiss manual instrumentation in specific kinds of cases.
I'm showing you this slide, because you could think, well, I already have a 10, and it's purple. Well, you could say, I go to the next instrument in the Ultimate family, or maybe I go to a shaper in another family, or I go to a finisher in another family, or the ProTaper family. But I need you to go back and use this instrument. This instrument must be used, because look at the difference! It's about 60 percent different at D0. It's about 44 percent different at D4. So, you can see, this instrument's doing a lot of progressive work. You don't want any instrument to do too much work. You want it to do its fair share of work. So, you divide the workload out, over two, three, four instruments.
So, now, you're gonna use that one. You can pre-curve these and go back and watch a previous show. Yes, you can use the apical file bender. You can [laughs] -- you can use the orthodontic bird beaks pliers. You can put a nice curve on NiTi. It'll hold it, if you know how to do it, and if you have the right design of an instrument. So, basically, you have this catheterized, you have working length, and you have patency. Things are startin' to get all together, now. So, now, you're coming in, it's gonna be easier to get in there. Remember, a 10 file, up about 4 millimeters is a 10, a 10th of a millimeter at D0; 12, 14. It's about 16. It's about 16 or 18, up there.
And if you're doing some smoothies, it's getting a little bit bigger, and you're refining a little bit more. It might be almost approaching a 20. Well, now, it's pretty easy to get in there every time. And then, of course, you can take the same instrument, again, pre-curved, and again, because you've mapped it in your head previously with a 10 manual file, you'll now take that action to your manual SLIDER. Now, when you start to get to this point in treatment, you start thinking ahead, don't you? You're like most of us. You're going, start with the end in mind. How am I gonna fit a cone in here? Can I clean it okay? Can I even shape both branches? Is there one branch that's more straightforward? These are all decisions that Ruddle makes.
A lot of times, one branch will just be -- your file will just fumble into that easier, and the other one takes a little bit more intentionality to direct the terminal part of that file into that other branch. So, in those instances, you might just say, this is my primary canal, and I won't really do any more enlargement. I won't do any more enlargement on that branch, because that will be my secondary branch. And I'll use sealer in there, and I can get some warm gutta percha with vertical condensation, and I can get some GP warm in here. I can have my cone fit down here. And I might be pushing sealer on out past this piston of warm, thermal-softened gutta percha. And as it drives the hydraulics, you'll get up the puff. Boom!
So, Schilder used to say, “Don't worry about what's in the lateral branches.” Sometimes it's all gutta percha. Sometimes it's a mixture of gutta percha-sealer. And sometimes, in the smaller ones, it's all sealer. So, these are -- this is a decision tree, right here. So, I fit the cone to the longer branch. That was this one, right here. That was where the master cone would go pretty easy, every time. And I didn't have it hit the septum, trip, and roll over. You've had that happen. And now, the cone's not to length, the cement's startin' to set up, and the patient's tired, and oh, my! You gotta take that cone out, and you gotta fit a new cone, and it's not -- not fun.
So, you might just think about fitting the cone to the longer branch. Realize, when you down pack, using the Schilder technique, warm gutta percha, where you fit the cone, and where the canal -- the foramen's more round, you have a theoretically round gutta percha cone, you get just a little sealer puff. Where you don't fit cones -- where you don't fit cones, you're gonna have a little bit of GP, certainly, but you're gonna have sealer, and you'll have a bigger puff, because you're not gonna get the control you'd get with a cone fit. Now, some of you could even squirt this. So, we're talking about ideas. We could've fit a gutta percha master cone. I did.
We could've even squirted. That was another idea you could've done. You could've put a cannula deep into this preparation and squirted. I'll say one thing. If you're gonna squirt, take your last file that easily got to length, pick up a little bead of sealer, and go down deep, and go one way, and go the other way, streaking some sealer on both the sealer -- reduce the surface tension, because warm gutta percha's sticky and tacky. And I'm talking to you. Just remember that 101, so we're just havin' that easy conversation. Where's your coffee? Okay.
So, lubricate, so when your tacky, sticky gutta percha hits that area, it can slide, and it can move, and you won't be disappointed. Little trick. Carry sealer into the lateral branch was the trick -- manually. Streak it. And then, back pack, and there's your case. So, that was an example, fitting one cone, but working two branches. Working one branch a little more than the other, and keeping the secondary branch just a little bit smaller. Now, we can go quite quick, as we finish up. Okay. Yep. Nice shape.
You know, they always talked about when, you know, God makes canals, they're usually about 1/3, maybe 1/5, of the total mesial dimensions of the CEJ. And so, minimally invasive dentistry's gotten really excited about this. I look at some of my cases that were done 25, 30 years ago, and I'm going, I hope this is okay for the minimally invasive boys. We're still not 1/3, 1/3, 1/3, and we got a nice, residual, circumferential dentin structure to help support the load above.
Let's look at the next case, quickly. So, we got a bridge. Maybe you see this, maybe you don't. But there's caries under here. So, we have a problem with this abutment. You look, you see chambers, you see -- looks like a pin's in the chamber. I doubt it's in the chamber. It's probably lateral to the chamber. We got chambers. But you can kinda see, the canal pinches off about right in here, gets kinda small. Everybody says, oh, yeah! There's an apical lesion. But you know what? How many of you saw this one? See that? If you look at your films with a more discerning eye, you can begin to see things, other than lesions at the apex. Lesions occur circumferentially or periradicularly around the roots.
Also, again, try to find the canal. Got a little tighter in here. And then, in the apical third, I don't even see a canal. So, I'm thinking it probably branches. So, you take off part of the bridge. I'm in here with two files, go left, go right. I blocked -- in this case, the trick is, I blocked one branch to try to get another file to go into the empty space that was left. So, that's how we did that. And both files are at length. They're probably a little bit long. So, I love that because that means I'm patent. Make a flow channel! Look it, if we're gonna brag about 3D disinfection and all the contemporary and all the traditional methods being used today around the world, they all work better when there's a flow path!
So, you can brag all you want and tap and pat your back and do hugs, you know, and really feel good about yourself. You cleaned out a canal you never put a file in. Yeah. That can happen. Feel very lucky. It's much better to catheterize that canal and have a flow channel. Then, you can go forward. Here we are, down packing. I've down packed right up to here. I've back packed, put a piece in, put another piece in, put another piece in. That's a post space for the referring dentist. But we down pack out with those branches, and notice that lateral canal with that button! And it's boom, boom, boom, boom, boom, right out of the heart. That lesion's right in the heart. The lesions form adjacent to the portals of exit.
And which one's important? This one looks about as big in its size as the one I put files in. So -- and everybody thinks these lateral canals don't matter. I keep hearing this, and I keep reading about it. What world do they practice in? Have they ever practiced? Did you hear that? I was talking to you personally, and you're going, yeah, Cliff. I practice all the time. Maybe we're not talking about you. All right. So, let's get this one done. New post, new bridge.
Retreatment's very -- it's very expensive. Retreatment is very, very expensive, when you have to redo things. Let's do them right. So, bridges, post. Notice all the PDL. Look it. It's all in there. Beautiful. Bone's butted up, bone's coming in apically, bone's coming in laterally. Wow! It's a perfect world. It's a perfect world of apically and lateral healing.
Last case, real quick. Look at the size of this root. Now, I saw this case many years ago, when I was reading on the AAE Discussion Forum, and there was a whole bunch of discussions about these so-called J-shaped lesions! Oh, my goodness! Those J-shaped lesions have been thought to be fractured roots! And then, all these people came out of the woodwork, and they said, no! It's only suspicious if it's a J-shaped lesion around a previously treated tooth! That was a good distinction. On virgin teeth, you're obligated to get in here. This thing probes the whole way to the apex.
So, that's the first thing I want you to see, is not condemn the tooth because it's fractured. Let's just do a little pulp testing. This is vital, this is vital, and this is -- this is necrotic. Okay? So, we have reason to go in. And I want you to look at the dimensions of the root. I want you to look at the dimensions and the length. This is a massive root! It's right out of a chimpanzee, maybe! I was very afraid of this patient. They had a very big tooth, and I was afraid they might be very mean, and their meanness might be commensurate with the size of their tooth! No, they were a nice patient. All right.
So, here you are, and I’m showing you now fitting two cones. And you're gonna go, well, wait a minute. How do you do that? Well, let's take a page out of the old playbook. Everything old is still relevant, sometimes. Sometimes it's still nice to have that old-fashioned training from the past, because new kids really don't think about this stuff. They really don't. So, how did we fit two cones and pass it through the body and not over-shape the canal, and remember minimally invasive and loads and occlusal loads, and is the tooth gonna break? Let's think about all that.
And here's the solution. You have system-based gutta percha master cones. You know that; I know that. And you're thinking, I'll just grab one of those, because the last file to length, it'll have a cone that will be commensurate with that size. That's good. But it will occupy all the body, which means you'll either have to carry sealer in here, like we've talked about. You could squirt it, you could use a carrier-based obturator. My producer will say, why didn't you mention that earlier? Vertical, CBO, squirt! You have three ideas down here. But I like to fit a cone.
But you need another idea, don't you? And the other idea is, in special situations, you need to think about the past. In the past, they made non-standardized gutta percha master cones. Okay? But this is the key word. And they came in size fine-fine, medium-fine, fine, fine-medium, medium, medium-large, and large! Some of you old-timers remember that! I'm grabbing the fine cone. Look at how skinny it is. Now, you're gonna say, well, wait a minute. These non-standardized cones, they come right to a point. And they were called gutta percha points, instead of gutta percha cones. These are cones. This is a point -- gutta percha point.
So, what you do is, you get the little jig, as an example, from Maillefer. They're owned by Dentsply Sirona. And they have this little Maillefer jig. It has holes at one end that are very small, and it has holes at the other end that are very large. Just stick this cone through to coincide with the last file you carried to length. If it was a ProTaper 25, here's 25.08, okay, red. Then, stick it through the 25 hole, use a scalpel, whatever you use, fingernail, gloved, and trim it off, and it'll be perfect. And once you get that done, you'll have a cone that is exactly corresponding to your apical length that you carried a file.
Now, notch the cone. Don't notch the cone typically, with pliers across the whole cone. Just get half the cone. Just get half the cone. Why? The notch serves two purposes. It gives you the length of the canal, but it gives you -- like your rubber stop on your file, it gives you a unidirectional mark to help you guide the cone in. So, a lot of you are going, well, this is just fabulous, Cliff, but it's a straight cone! Well, I know you curve your cones. I curve my cones. So, put a curve on it. Just take your fingers and rub it through your gloved fingers, and put a nice, sweeping curve on it. See? Kinda looks just like that, doesn't it? Looks just about like that.
So, you do that. Well, Cliff, how do you -- how do you hold the curve? Well, you use isopropyl alcohol! For you chemists out there, you got the formula, right? So, isopropyl -- 70 percent isopropyl alcohol -- if you put the cone in it for 5 seconds, the cone will get decidedly more rigid -- way more rigid than a master cone out of the box. And now, when you butter this cone with sealer, and you start to put it in, at 17 millimeters on the other case, or whatever this example is, you take the curve so it's headed away from the other branch and direct it to come this way. And if you direct the cone to come this way, you can bypass the septum and steer it right into the other branch. So, that's the alcohol trick.
And then, you can down pack and get right down there and move warm, thermal-softened gutta percha sealer complex into the anatomy. You can back pack, and you can watch the bone heal. So, there we are. And you can see big, broad roots. Sometimes you have big, broad roots. They have more bulk, more form. You can make a little bigger shape. You can fit two system-based cones. But now, you have an idea that if you can't get the body open, for whatever reason, and you want longevity out of this tooth, so it can't be weakened, then you can fit a smaller cone that's in a non-standardized work.
Last case. I won't show anything more than this. But you probably saw this. You probably saw this. You probably saw a big lesion there. You probably saw the open margin. So, we have to disassemble. Remember, repeated dentistry is expensive dentistry. Notice the significant branch, right out to that big lesion. Notice we had a bifidity. We've been talking about this all day. We don't worry about that bifidity, because that bifidity is so small, we wouldn't get into it. And if you did, you'd have to be Houdini. And then, of course, you gotta trust your reagents, your active irrigation protocols. They'll get most of this stuff, even in spite of our deficiencies.
So, I hope you've really enjoyed this session. I hope you've understood that we have things to think about in the instance of apical divisions. See you next season.
All right. So, that's a wrap on Season 9. Thanks for watching.
Yeah. Thanks a lot for joining us over the shows. Some of you are new, and some of you are just discovering us. But regardless, the show's supposed to make you laugh a little bit. We wanna inspire you ever closer to what you are supposed to be doing on this earth. And of course, there should be educational value. And I hope we've done that across the season, and I look forward to Season 10.
Okay. Coming back to the laughter part, we're gonna leave you with some bloopers, as you can see from this sign behind us. It might be really hard for you to imagine that we even have bloopers, but we do. So, we'll leave you with those. And see you next season, in the fall, Season 10.
10, 9, 8, 7, 6, 5, 4, 3, 2 [laughs], 1--
Welcome to The Ruddle Show. I'm Lisette, and this is my dad, Cliff Ruddle.
How you do, you Lisette? [laughs]
[laughs] I know, we do it again, right, because it's a tough word for me!
I never heard of that one [laughs].
Never heard of my daughter before, plus, it was "Lisa" for all my life!
I would say -- I would say, “Hi, everyone,” first. But -- and then, say hi to me.
Hi, out there, everybody!
Season plan of eight shows. We [coughs] -- excuse me. Oh [coughs], my goodness.
Okay, I’ll take it from the top… take your time, take your time --
Okay. Keep it live.
Hi, how are you? We're telling jokes on the set, so we better get serious.
Okay [laughingly]. So, to start, I -- we have -- okay. [laughs]
Good to have you with us again, and I guess we'll get going and start talking about things I'm wearing.
Well [laughs] –
… faith in humanity…
All right. Well -- hang on. Ugh. I have a hair or something in my lipstick. One sec.
Why don't we just keep going, live?
-- to see if the case is simple or -- wait. Okay. It seemed difficult, but are they? So, let's go to the board.
Let's make the easy cases difficult!
I'm gonna pedal it and go for it! Yo!
-- that may initially seem simple, but are they, really? Let's go find out.
So, let's go to the board! All right.
Today, we are introducing a new segment, which will be recurring, hopefully, if -- if this goes well today. [laughs]
[laughs] Guess I'm gonna take off, here. Are we censored, already?
How you doing out there? I hope everybody's ready for the show. Number 80.
Okay. Well -- well, wait. Okay. I think it's 82?
Oh, it's 82.
…I knew [crosstalk] --
Don’t forget the cameras.
Yeah. I'll -- I didn't even remember I had a camera.
Yeah. It has really changed for Ruddle. Great camera work. Anyway --
How you doing? Glad to be here. Good to see you. Start over again.
What was I supposed to say?
Those types of -- the stuff you just said.
All right! Today, we're gonna talk about obturation. [laughs]
Oh, hold it! I think I should say I'm Cliff Ruddle?
…Minimally invasive dentistry and making people happy.
System shut down.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.
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The Ruddle Show
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Progressive Tapers & DSO Troubles
The Dark Side & Resorption
The Resilon Disaster & Managing Internal Resorptions
Advanced Endodontic Diagnosis
Endodontic Radiolucency or Serious Pathology?
Endo History & the MB2
1948 Endo Article & Finding the MB2
To Be Determined
To Be Determined
To Be Determined
To Be Determined