Clifford J. Ruddle, DDS, discusses predictably succesful endodontics in the context of preserving healthy tooth structures...
Endodontic Access What is the Appropriate Access Size?
Given new trends, the appropriate access cavity size is evolving. This show reviews the various endodontic access types and the related goals of each, while also delving deeper into the current controversies surrounding access cavities, in general. Pay special attention to the wrapup and how a “demotivator” can be turned into a motivator!
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Endodontic performance is enhanced when clinicians thoughtfully view different horizontally-angulated, pre-operative radiographic images, visualize minimally invasive, yet complete, treatment, then use this mental picture to guide each procedural step...
There is an old expression... “Start with the end in mind.” Before initiating the access preparation, think, visualize, and plan to more effectively execute a predictably successful result...
Since the beginning of endodontics, every decade has witnessed controversy. Currently, there is ongoing debate regarding the concept of minimally invasive endodontics (MIE)...
TheRuddle Show S01 E04 “ENDODONTIC ACCESS - What is the Appropriate Access Size?” Access References Mentioned
Supply List: Ruddle on Shape•Clean•Pack
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INTRO: Similarities between Sports/Endo/Life
Welcome to The Ruddle Show. I’m Lisette, and this is my Dad, and this is my dad, Cliff Ruddle. Today on our show, we’re – first, my dad is gonna present to you the different access types. And then, after that, we’re gonna talk about the controversies surrounding each of the different types. But first, I know what I did this weekend, and you probably did the same, was watch a lot of sports.
Yes. Yes, indeed.
And there was quite an international event. We watched American football, and I know a lot of you are huge football fans, but we watched [laughs] American football. And we do have – my kids play soccer and tennis, and my niece and nephews do. So, definitely, we do care about more sports than just is what is right here. But this is just a little representation of what we’re gonna talk about.
Well, why do we show these?
We chose these, out of all the others.
[laughs] This is what we had, that [laughs] we could come up with, on short notice [laughs]. So --
Well, or maybe it’s the ones I played.
-- right. So, we watched American football that took place in London. There was UFC fights in Melbourne, Australia, for the Middleweight Title. Baseball playoffs started, and that’s quite an international sport. So, the reason we wanna talk about sports is because there – we see a lot of similarities between playing sports and practicing endodontics, and even living your life. Like, why don’t you tell us a little bit about how this is similar.
Well, I grew up playing these three sports. That’s why [laughs] they’re featured. Not to be rude, we just didn’t have the others. But, anyway, having played these three sports, and these two, the most, there was teams. And I noticed as a kid, growing up, that teamwork is what really fuels societies. It’s the teamwork that fuels civilizations and countries. It’s the fuel that drives us towards success. So, teams come together, like in our practices.
And in our practices, we’ve gotta get the right receptionist, we gotta get the right assistants around us. We have to get the right hygienist. We do use a hygienist in the endo office, to give anesthesia and to do other kinds of things that are important. You have a whole personnel, the whole team. The team has to click as one. There has to be common goals. There has to be measurable ways to assess performance, and we can’t just hope we get better. We can’t --
And chemistry, working together as well.
-- you gotta have chemistry. And just like in team sports, you see players get injured. They go. You see ‘em get cut, they get traded. We do that in our offices, don’t we? We sometimes don’t always hire the right person, and we find out, regrettably, a little bit later, that we don’t have a person. They might be a really good person, but they just might not fit in our organization and our goal. So, yeah. We gotta have the right team and the right chemistry.
Like, so often, we hear of teams that are doing badly, and they’re kind – the announcers are kind of wondering what’s wrong, because there’s – they’re all good players. But they just can’t work together.
You know, that happens in endodontics. A lot of times, we have pretty good people around us. Like, I’m an endodontist, so I can hire a great assistant from a restorative practice, but they don’t know anything about endo. So, I’ve always tried to hire people at airports, walking into a store, a restaurant. If I see a fabulous person, and their interaction with people is impeccable, and they’re kind, and they’re polite, and they’re fun, and they’re interesting, I give them my card. I say, [laughs] ‘If you’re ever lookin’ for work, you know, [laughs] you need to be callin’ me first.’ Right?
So, anyway, teamwork is good. Now, we gotta talk a little bit about practice, because we can have teams that – in sports that need to get better. And in our practices, we always need to get better. So, we gotta really focus on training, training, training. Perfect practice makes perfect play. So, that’s an important thing.
A lot of times, probably, you develop a strategy at the beginning of the day, maybe. You get – like with your assistants. But then, stuff happens, and maybe you have to adapt?
Yeah. I think she’s getting to the very heart of it. In endodontics, it’s called emergencies, and oftentimes your day starts off beautifully. It’s perfectly set up, but you know what? The phone rings. And when the phone rings, Doctor A has an emergency that needs to be seen, right now. 20 minutes later, somebody lost a crown, they have problems with hot and cold. And blah, blah, blah. So, teams have to adjust during the game, and offices. And the team in the office has to adjust constantly, to the changing environment.
And what about execution? I know I had some opinions over the weekend about how [laughs] things were executed, thinking that they could be a lot better. I know that, as a fan, I expect flawless execution.
Flawless execution. Very interesting. Can I tell a short story?
Go ahead [laughs].
Okay. So, I was at Miramar Base, in San Diego. It’s where they shot “Top Gun”. And I snuck away from the group, and I was invited with Phyllis to come into the Officers’ Club and eat with the officers. And when I say, ‘officers’, these are like 23-, 24-year-old kids, and they’re flyin’ F-22s, F-18s. They’re landing on aircraft carriers. They can release a nuclear weapon. Ugh! And I wanna know all about what happens in the cockpit.
But I finally had the courage to say, ‘Well, you guys’ mantra, it’s on the wall. It’s everywhere. “Flawless execution.” Do you guys never make mistakes?’ And this guy looked at me, and he goes, ‘We make lots of mistakes, but flawless execution isn’t about not making mistakes. It’s about solving problems as they occur.’ Just like in endo. You can’t find the canal. You gotta adjust [emphatically]. You gotta move the axial wall, a little bit. You break an instrument. Aah! Ultrasonics trephine procedure, pop goes the weasel! Out comes the file! So, there’s different things we can do that overcome these upsets, that are normal.
So, upsets aren’t good or bad. They are. And I think how the team learns to handle those upsets is what’s gonna drive you to greater success.
That’s interesting. I also think that something – sorry. I’m thinking that it’s one thing I notice is that there’s a lot of controversies in sports, just like there’s a lot of controversies in endodontics. And we’re gonna be actually talking about one of those controversies today. But as far as I know, there’s [laughs] some things about women and men getting the same pay. Right now, we’re getting our basketball season started in the United States, and there’s supposed to be exhibition games in China. And there’s controversy going on there, because someone in the U.S. said something that the Chinese were offended by. So, yeah. There’s controversies.
There’s always controversies, and controversies, like everything else, they just need to be managed. The team needs to stay together. They need to openly be able to disagree and put forth different ideas in ways that could be a common solution, that we could all embrace. But yeah. Don’t try to dodge controversy. Just try to get a great team. And it’s like the Air Force, you know, you’ll be solving problems as they occur.
Okay. Well, let’s get started with our show. And in case you didn’t see the connection between sports and dentistry, right here on this bat, you see, it says ‘Dr. Clifford J. Ruddle’. So, this kinda ties it all together, for us. So, let’s get started with the show [laughs].
SEGMENT 1: Common Access Types/Goals
Before we get into access cavities, just a few things to comment on, that are actually gonna directly influence future treatment. In other words, access is going to dictate a lot of the downstream steps. As an example, when we talk about the endodontic triad, we’re talking about shaping canals. Of course, shaping canals means finding the orifices, negotiating skillfully and masterfully to the full working length. Then, those secured canals can be shaped.
We shape canals to hold a reservoir of reagent, and this reagent can work into all kinds of fun anatomy. And we can actually see multiple apical portals of exit cleaned, where our files never reach. And of course, we wanna use a three-dimensional obturation system, because well-shaped canals become cleaned root-canal systems, and root-canal systems can be filled in all their dimensions.
So, that’s as little bit about why we wanna look at access, today, because access is really going to influence all those steps. So, when we spin this tooth, you get to see it in a little bit more of its anatomical three dimensionality. And what that means is, you can begin to see how different kinds of access patterns are going to influence maybe furcation and the concavities we see between roots. We can also understand access cavities are gonna influence directly tough anatomical challenges that we’ll talk about in just a little bit.
And so, a little bit about access, then, to take it to the clinic and look at some actual cases, where everything’s been accessed, you can see the shapes are appropriate for the roots that hold them. Shaped canals allow us to fill root-canal systems. We can get multiple apical portals of exit. We can see a lot of anastomosing in there. And then, of course, the palatal root’s resected, but you can see the MB root has a third system, with its own portal of exit, furcal canals, multiple apical support. Hey, this is endodontics! This is why we have so much fun doing endodontics, because if they were just simple, little canals, it wouldn’t be that much fun. But they’re called systems.
So, today we’re gonna talk about how to treat root-canal systems. You can see lots of wild anatomy, loops anastomoses, deltas, apical [laughs] bi-dentities and tri-dentities. It’s all fun stuff. And in our last case, we’ll feature the furcal canal, the three apical portals of exit on the mesial system, a couple on the distal. It all starts with access. If you wanna get this kind of anatomy, you have to have an access that allows you to win. And if you’re a basketball player, you gotta play above the rim on these, okay?
So, here we go. Access concepts. You know, there’s been a lot of discussions on minimally invasive endodontics and how that might influence access cavities. Again, the goal would be to balance this out, because we have systems to treat, we’ve gotta maximize the remaining dentin. But we still have to get in and be successful. So, one idea that has been advocated in the last few years, really to minimally invasive, is the so-called Ninja Access. The Ninja Access, of course, is just a smaller opening. It leaves the cornice. It leaves the root in certain places. And the idea, through a smaller opening, you can come down and get your files into these canals and begin to work. The question begs, ‘What about residual pulp tissue? Can we actually get it out?’ It’s a question.
When we pack cases, we use sealer. What is sealer gets trapped up in these difficult areas? Sealer’s been known, in the aesthetic zone, to influence aesthetics, because it can discolor teeth. So, if we slide this over, and you look at the other perspective, you can see there’s a lot of more attention to saving a lot of circumferential dentin. We’re gonna talk about what these references mean, related to various accesses, in just a moment. Now, there’s another one that’s been talked about. It’s been reported in the “Journal of Endodontics”, the “International Endodontic Journal”, and even trade journals, and it’s called the Orifice-Directed Access.
In this access, we basically leave the occlusal table alone, and we just make small, little openings with appropriate-sized burrs, to get in. This is even more concerning for me, as a teacher, because there’s a lot of pulp tissue, right in here. There’s pulp tissue out in here. And we’re gonna talk in a little bit about these triangles of dentin. These triangles of dentin really influence everything. When we put a file in here, without addressing the triangle of dentin, the handle will be off axis, and we’ll talk about how to remove the triangle, to upright the handle, to get it more on axis. So, these are considerations. Again, there’s more articles, and we’ll explain a little bit more about these references.
Just so you know [laughs], they’re not suggesting or supporting the accesses I’m showing you. They’re actually showing negative things, iatrogenic events that are encouraged, when we make a different kind of an access. So, really, if you look at the very end game, there’s probably a lot of different kinds of accesses. But we can basically say there’s the small one, the Ninja, there’s the Orifice-Directed one, and the one I’ve been teaching for years is Complete Access.
And in just a moment, we’ll look at Complete Access even further, because what you’ll see in here is, you got a tongue, okay? These are tongues. This is like a lip of dentin. This is another tongue, another lip of dentin, and that’s what’s deflecting our file off axis. So, we’re gonna really focus in on why Complete Access gives you a chance to see the floor anatomy. It allows you to find hidden orifices, aberrant orifices, previously missed orifices, how about that one? And then, of course, fractures. Fractures can come down these axial walls, and they can get thinner and fainter, as we get to the pulpal floor.
So, Complete Access gives us much more command at diagnosing fractures and their extent, so we can determine, is it really appropriate to proceed with endodontics, on this particular patient, at this moment. So, I’d like to close with the access cavities by just saying, I wanna talk a little bit more about ‘em. I think I’ve identified three commonly taught ones today. And of course, there’s different technologies that are involved in each one of these. So, with that said, that’s look at access from another vxiewpoint, another standpoint.
SEGMENT 2: Controversies with Access Types
Well, thanks for presenting the different access types. One thing regarding the Ninja Access, just the very name itself kind of sounds like you need to be highly skilled and that not everyone can do it. It sounds a little intimidating, just that it’s called the Ninja Access. But that said, we’re gonna – on our show today, we’re gonna talk more about the controversies surrounding the different types of accesses. One thing we’re not gonna talk so much about is just the step-by-step how to do radicular and coronal access. That will be a future show.
Today, we’re gonna mostly talk just about the controversies surrounding the different access preparations. So, first of all, can you tell us, what do you think is driving the different types of access cavities? What is the motivation behind it?
Oh, I’ll be happy to. Really, what’s driving all of this is the words ‘minimally-invasive endodontics’. It’s a noble concept. It’s a measureless dimension. It’s more of a thought about maximizing and preserving remaining dentin. So, that’s probably what’s mostly behind it is, just try to maximize tooth structure. The thing is, as we’ll talk about – as we go along here, there’s gonna be some kind of a give and take. I’ll let you use the word [inaudible] between which size we decide to carve out.
Well, what type of access do you prefer, and why?
Well, it’s really easy. I prefer Complete Access, because as a teach for over 40 years, a practitioner closing in on 50 years, it’s all – with all this experience and seeing clinicians around the world, in workshop settings, when they – groups used to come around the world, as you know, to our office, and we watched them in two-day courses perform and do things. We noticed that everybody, endodontists and well-trained general dentists alike, always did significantly better when they opened the tooth up. Now, the access needs to be appropriate. It needs to be anatomically driven. And as I’ll talk about a little bit later, not too big, not too small, just right.
And of course, we can debate about that. What’s too small? What’s just right? But the thing is, when we have small access cavities, as I said earlier at the whiteboard, it’s much harder for clinicians to find these orifices. They can’t really see fractures down the axial walls and read their extent of propagation, especially the ones that start to go below the orifice a little bit. So, we have visual problems here. As I mentioned, leaving large amounts of roof or inter-roof between systems of mesial and distal roots, you can trap tissue post-treatment. We can see sealer in these areas. Sealers, a lot of ‘em discolor with time, and in the aesthetic zone, with a high smile line, teeth can discolor.
So, these are just needless complications, and if we just focus on getting it off – the roof, get the roof off, we’re gonna be able to look into these things, see the axial wall, see where the aberrant hidden and previously missed orifices were or are, and it’s just gonna give you more control, more confidence. Looking ahead, you want files just to slide effortlessly down these internal, smooth axial walls, right into orifices. Looking ahead, you want your shaping files to come in unencumbered, not having coronal interferences.
And then, of course, looking ahead to disinfection and filling root-canal systems, what armamentarium are we planning to use? And can we get that armamentarium in there properly, based on the access? And I think you’re gonna talk a little bit about some of the inherent costs associated, because you just can’t go out and do this access and have really much success at all, unless you have the appropriate technology. Most dentists around the world can do that kind of an access.
Well, I know you just said something about the importance of removing coronal interferences. And what about triangles of dentin? I know that you advocate their removal. But some clinicians don’t. And can you tell us more about that?
Oh, great, because, you know, when we look at furcated teeth, the canals come into the pulp chamber at pretty much awkward angles. They don’t just come up into the pulp chamber. They come and bend in coronally, into the pulp chamber. So, when colleagues start to come into a canal without removing the triangle of dentin, you’ll see the handle of the file frequently off axis. In fact, when I teach, I even say, ‘You assistant knows you’re doin’ it wrong.’ [laughs] Because she looks over, and she goes, ‘My God! The handle’s way over here. How is he gonna negotiate the recurvature deep?’
So, you wanna get those triangles out, because the canals, when they bend in, what I didn’t emphasize and we’ll have graphics in another show, those canals anatomically, before humankind has ever entered a tooth, are closer to the furcal side concavity than the outer wall. So, if we’re looking at the mesial root, under that molar, and we have a triangle of dentin that I showed at the whiteboard earlier, if we leave that triangle on, those canals are already closer to the furcal side. So, as you drop a rock into a pond of water, you’ll get concentric, emanating circles.
Well, that’s what a rotary file does. It cuts blindly north wall, south wall, east, west wall. So, the preparations drift, and they get closer to furcal danger. And sometimes there’s overt strip perforations.
So, people who don’t wanna remove them, they’re pretty much concerned about removing too much tooth structure? Is that --
You know, that’s exactly it. They are focused on precious – I think it’s been called ‘precious’ cervical dentin. And on the outer wall, the opposite side of the furcation, they don’t want that outer wall reduced, at all. So, what they’re not appreciating is, the canals are already not centered in the mesial, distal dimensions of the root. The canals are a little off-centered, because of the way that canals bend in abruptly, into the pulp chamber, coronally. So, they’re focusing on preserving the outer wall. I wanna preserve the furcal wall, because that’s, from my experience over 40 years, that’s where all the problems occur.
Now, if you’re thinking about fracture, if we learn to move that canal away from furcal danger, and we’ll show that on another show, the right tools and all that, how to do it, but with a brushing motion, we can move the canal, and we end up histologically with centered preparations between the mesial and distal aspect of the root. So, if we think about that, that’s a better result. That’s more endodontically strong tooth, and it’s a tooth that’s less likely to fracture over time. And of course, we’ll talk about the restoration in just a minute.
Okay. Well, do you – are there any situations where the – where a certain type of access would be contraindicated? Like, for example, I think it was last show, we talked about a high incidence of taurodontism in – when you were in China. And that’s the really deep access cavity, right?
So, if you had a really deep access cavity, maybe you wouldn’t try a Ninja Access, because that might be even too Ninja? [laughs]
[laughs loudly] Well, I’m laughin’, because it’s hysterical. You know, these people that draft up these clever schemes, listen, let me be kind. We have some really masterful clinicians, and they have CBCT, and they have oral scanners, and they have microscopes. Okay? So, they can do these kinds of things and post a few cases, and, really, [claps] a round of applause, in a very authentic way, here. The thing is, that’s not what the masses have. I already said on another show, I think less than three or four percent of the nation’s, U.S. nation’s dentists use a [laughs] microscope. Okay?
So, we’re telling people to do things they don’t have. And how many dentists are gonna run out and buy a CBCT, go buy a microscope, an oral scanner, and those all have learning curves and prices attached to them? So, as a teacher, when you go to Latin America, the Caribbean, Southeast Asia, Japan, Russia, China, India, Europe, when you go anywhere in the world, we’re all tryin’ to do the same thing. We’re tryin’ to address the anatomy of the human teeth. And so, these can be done with high skill and technology, and I will say, even to those colleagues, you’re still making some compromises. You’re still having some loose ends.
And now, if we think the masses are gonna embrace this, that’s a good joke. It’s not gonna really happen in a serious way. So, Complete Access really shouldn’t be terrifying. It’s not a school of thought. It’s not Ruddle. It’s not your dental school versus my dental school. It’s anatomically driven. And so, where the orifices are is where they are. And really, there’s been no articles that have ever shown leaving a cornice or part of the roof intact preserves tooth structure – well, it preserves tooth structure, but it doesn’t make teeth stronger or weaker. Stronger or weaker. Once you punch through the roof, that arc has been violated, and once you break the integrity of an arch, that’s the strongest form in nature, taking the roof off and the soffit off is not a big deal.
So, maybe certain types of anatomy might imply that you should not do a certain access, or --
Let me play off you a little bit better. Yes. Taurodontism is really [laughs] – that’s that really deep pulp chamber, maybe past – definitely sub-crestal, and probably occlusal table, apices, probably about halfway down. So, this is gonna be terrible compromising. Of course, there’s other things we talked about last time, in our anatomy in China discussions. We talked about entero moralis, and we talked about radix paramolaris. So, we have those two radix, a little extra root on the distal lingual, on the distal buccal of mandibular molars. It’s gonna be hard to find those, even with CBCT.
So, getting things off helps us get the radix paramoralis, the radix entero moralis, the taurodontism, and the C-shaped molar that we talked about. And then, I would say, maybe if you have brick of dentin, you have significant calcification and mineralization, and maybe there’s no observable pulp chamber or pulpal space on our well-angulated film, yeah. That’s when we start to talk about maybe small accesses that are guided with microscopes, CBCT, oral scanners, X-Nav. Then, we can stay right on the money and drill maybe to mid-root or maybe even deeper, before we pick up a remnant of a canal that we can stick a file in and begin to slide it to length.
I guess, obviously, if you were retreating a tooth, then --
-- it would already be failing, and maybe you need to see and [laughs] get inside the access cavity, and see what’s going on? [laughs]
Okay. So, this is what I heard. What I heard is, ‘We’ll do it really small, and we’ll hope it works. And when it works, we’re thrilled, and everybody’s clapping. “Look at the tooth-saving device they did, with those little punched holes!”’ But what I really heard is, ‘When that fails, maybe it’s time to see.’
‘And maybe it wouldn’t hurt to see and get in there and take a look, and are there some staying fractures?’ There’s a great article in the “Journal of Endodontics” just recently, that showed extending – when fractures extend subcrustal. And if you – I mean, two or three millimeters. They were talking about packing it below that fracture. So, here’s the orifice, fracture extends a little bit below the orifice. They were packing gutta-percha from here down, but they were putting bonded materials up here, and that was saving the life of the tooth, for several more years. So, this all comes, though, with vision. And vision means – look. There’s a lot of controversies here. There’s no right or wrong. A lot of it just has to do with your training, the technology you have aboard, and experience.
So, you need – I heard you say a few times already that you need to have a lot of technology, to be able to do these types of access --
-- cavities. But I’m also wondering, if you’re doing this type of access, is it gonna take a lot longer to do a root canal on a tooth than this one? Like, if I’m a patient, and I’m going to a dentist who’s gonna do a Ninja Access on me, can I pretty much expect it’s gonna take twice as long? I mean, I’m just [crosstalk] --
Well, you gave me the book, so I’m gonna remind you what you gave me. It was Glad – what’s his name? “Outliers”? Malcolm?
-- you – Malcolm Gladwell, yes.
Okay. Malcolm Gladwell said, probably, if you’ve been trained up – we’re not talkin’ about a person on the street, but if you’re trained up, and you’re a dentist, how many hours was it to find mastery?
It was 10,000 hours. So, you can have all the technology and the algorithms with your software to use X-Nav, and you can do guided access cavities, sleeve guides, all this stuff. We can talk about all that. The point is, it does take longer. It takes a lot longer, especially with sleeve guides, because you have to make a 3D-printed device out of the operatory, so you can bring it into play when the patient comes. X-Nav’s eliminated the sleeve guides, as we talked about in our China discussions, but the X-Nav requires the technology you just mentioned.
I’ve watched several live demos. I saw a guy start off with a orifice-directed access cavity. 15 minutes later, he said, ‘Diamond, please.’ Diamond comes. ‘Let’s peel the walls back a little bit.’ Another 10 minutes went by. Peeling it back. Finally, the joke I had with some of my friends that also saw it is, at about 30 or 40 minutes, they had the access --
-- what I would call the Complete Access. And they said, ‘Now, we’re ready to work’, and they were really excited. So, they only [laughs] showed this, to get started, and ended up over there, each and every time, because they couldn’t see, and they were struggling. So, maybe if you did 10,000 hours of this, you would do it just as quickly. But my observations is, it will take more time, and it’ll take time to even understand the technology and how to use it proficiently. You’d better get your staff trained up. And there’s costs associated with all this technology.
Right. And I also heard you say, when you were lecturing about the concepts, that your access will influence shaping, disinfection, and also obturation. So, how would that influence those things?
Well, I won’t mention names, but it’s the other guy in Santa Barbara. But there’s actually several guys in Santa Barbara that are endodontists, but it’s one of the other guys. Yeah. It’s one of the other guys.
He was talking about this, publishing artless about this, doing it on live demos. So, now, we know who it is. But in a more recent discussion, on “DocMatters”, he said, ‘Get rid of the pulpal roof. It’s interfering with the agitation and movement of fluids.’ So, it’s actually – a limited access is ruining the hydrodynamics of the $70,000 machine that is supposed to be agitating clean root-canal systems. So, he said, ‘Get the roofs off, completely deroof.’ So, you can see, controversies are always ongoing, and then, there’s always – what was the word you had me talk about? Something about controversies. They’re shifting. They’re changing, always. We move from one --
-- they’re trending. So, it’s a trend. You can do it. You probably should. Everybody goes, ‘yeah. We can now really embrace minimally-invasive endodontics.’ Listen, it sounds like I’m a little harsh here, on – I shouldn’t hit my mike – on minimally-invasive endodontics. It’s really noble, in all sincerity. But you have to be smart.
Balance? That’s the word I’m hearing, without hearing specifically that word. I’m hearing that balance is needed. Like, you need to still respect the concept of minimally invasive endodontics, but at the same time, not compromise the treatment objectives?
So, if there was one thing that you would want a young dentist to take away from our show today, what do you think it would be?
Okay. Cut an access cavity that is not based on your philosophy, the school you went to, or something you read. It should be based on anatomy. Say it after me, three times. ‘Anatomy!’
Anatomy! I think we heard it three times. So, it’s anatomically driven. That’s number one. And two, if you’re a brand-new dentist, don’t try to do something heroic. Do maybe 10,000 of those, and really get used to holding teeth in your hands, if you’re a teacher. And then, your clinical work that supports all that. And now, you begin to have a library in your brain of every tooth that you’re entering, and you kinda know the anatomy and the variations and aberrations within that normal anatomy. So, make an access that you’re comfortable with, that you can actually do the subsequent steps that you referred to, shaping, cleaning and filling. And get comfortable.
And if you wanna get a little smaller or – a lot of times, decay – we’ll have caries, recurrent caries. Sometimes when we clean out caries, that’s part of our pathway in that, can we – that can be utilized, to get tools into canals. Marco Martignoni, in Italy, wrote a nice paper. I think we’re gonna show some references, later. But in those references – or we’ll show the references – it showed that, a lot of times if you have big mesial blow-out caries, you can actually de-excavate, get all that stuff out of there, and you have a good pathway already, into the distal. And so, you might have a modified Complete Access, based on if there’s existing caries. So, that would be number one, be comfortable.
Number two, be sure to appreciate this word, ‘balance’, that you’ve been hearing, because the main thing is, you’re tryin’ to save this patient’s tooth. So, there’s gotta be a balance between doing the right job and fulfilling the endodontic goals – not a bad idea – and then, looking ahead to the restorative effort. Can the tooth be exclusively restored? Speaking of restoratives, very little is talked about any of this. If you go talk to the prosthodontists in the country, that could be a guy like – there’s some really respected ones.
We have some in the Northwest, Kois, John Kois. We have – I can’t – Frank Spear. I had heard their lectures. I’ve asked them these questions. But we got to think about, with all this adhesion dentistry, it’s nice to think we’re bonding, bonding, bonding. Still, mechanics plays a huge role, and they talk about the importance of the circumferential ferrule. And that ferrule is – needs to be two- to three-millimeter collar, circumferentially, around the tooth. So, when your casting goes over, your restorative, it’s squeezing and holding that tooth together and giving you cuspal protection. Okay?
So, you know, the ferrule isn’t so important, Lisa, on the mesial and distal parts, because teeth are lined up. And even if you’re edentulous, the loads are buccolingual and vertical. So, work – jaw slides to work, balance, vertical loads, those loads are withheld and withstood, if we have a circumferential ferrule. And the mesiodistal ferrule is not that important. It’s the buccal rugal [sounds like] ferrule that’s critical. So, back to triangles of dentin and put a circle around that. You would rather move the canal away from a thin furcation and have it go to the outer wall, if you have a ferrule. So, restoration of the endodontically treated tooth is crucial.
And then, I guess my last thing I would say is, and this is supposed to be a joke, so, come on! Get ready to laugh, please! Okay? So, if we use a car engine analogy, and our engine fails on the freeway of life, would it be more logical to just raise the engine compartment lid, or should we try to repair the engine through the tailpipe?
Whoo-hoo! Yeah! [applause]
And so, that’s the end of our segment on the controversies surrounding access. Hope you enjoyed it.
So, to close our show for today, we’d like to share with you some demotivators. And let me explain to you a little bit what these are. About a decade ago, I gave my dad this box of these cards that are called “Demotivators”. And on every card is an inspirational picture and then a word. On this one, it says, ‘Motivation”, and then, a little saying. And some people might think it’s negative [laughs], but it’s kind of humorous and funny. And it – but there’s parts of it that actually ring true. So, I’m gonna read one, and then, my dad is gonna explain to you what that means to him.
Okay. So, here's the first one. It’s called “Motivation”. ‘If a pretty poster and a cute saying are all it takes to motivate you, you probably have a very easy job. The kind robots will be doing soon.’
Oh, okay. Well, what that means to me is, in a dental environment, is looking at a post-operative x-ray. So, we’ve all seen a post-operative x-ray, and they can spark a range of emotions, from despair to exhilaration. We can see the very good. We can see the very bad [laughs]. We can see flirts with the masterful. But the films are just that. They’re the films. And they’re a representation of the performance that’s been given. So, what I’m a little concerned about, when I see some of these younger dentists thinking technology has the solution for everything, and they forget the comment, ‘Fundamentals win it.’ Technology should be an adjunct, okay? You still have to have a skill.
Like, for example, carrying a small, stainless-steel file and getting it predictably, Monday, Tuesdays, a.m.’s and p.m.’s, it’s always going to length, each time, every time, all the time. So, we shouldn’t except a Rube Goldberg machine to overcome deficiencies in primary training.
Okay. So, basically is what I’m hearing is, you need to motivate yourself to be a skilled clinician so that you’re needed, so [laughs] robots won’t be doing your job. [laughs]
Well, yeah. You’ve probably heard me say that there’s an old model, you know, the shopping mall in the U.S. So, we have the itinerant dentist, shopping from mall to mall, seeking his stall. These are more like robotic production clinics, and they’re not that fun to work in. There’s not a lot of inspiration that one gets out of it. And, yes, a lot of technology can replace mediocrity. If you’re just doin’ mediocre stuff, it’s pretty easy to get replaced. If you wanna be harder to replace, become a master.
Okay. Let’s look at another one.
Okay. This one is called “Get to Work”. And it says, ‘You aren’t being paid to believe in the power of your dreams.’
[laughs[ Okay. Well, what’s missing in almost everything is effort. So, we all have ideas. We all have hopes. We all have aspirations, right? Yeah. But you know what? Do we act on that? So, if we don’t act on it, it’s just a hope, it’s just an aspiration, it’s just another idea. So, maybe you should get a conversation going. Conversations can get refined. I talk to you a lot about things we’re doing, creative things. And it gets refined, it gets honed. It’s like clay. It gets shaped, it gets pulled up. And so, through a conversation, you develop an action plan. And if you have an action plan, that’ll give you the result. So, life, you don’t like your results, change your approach. Just like the hand, there’s two sides. Break down – turn those breakdowns into breakthroughs. [Background music]
Okay. So, that will be it for today. We’ll leave you now, so you can get to work. And we’ll see you next time, on The Ruddle Show.
And get to work! [Music playing]
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Tough Quetions & SINE Tips
Who Pays for Treatment if it Fails & Access Refinement
Assessing Case Difficulty & Clinical Findings
CBCT & Incorporating New Technology
Zoom with Prof. Shanon Patel and Q&A
Best Sealer & Best Dental Team
Kerr Pulp Canal Sealer EWT & Hiring Staff
Ideation & the Covid Era
Zoom with Dr. Gary Glassman and Post-Interview Discussion
Medications & Silver Points
Dental Medications Q&A and How to Remove Silver Points
Tough Questions & Choices
The Appropriate Canal Shape & Treatment Options
Q&A and Recently Published Articles
Glide Path/Working Length and 2 Endo Articles
Hot Topic with Dr. Gordon Christensen
Dr. Christensen Presents the Latest on Glass Ionomers
Annual AAE Meeting and Q&A
Who is Presenting and Glide Path/Working Length, Part 2
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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.