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Censorship in Dentistry Censorship in Dentistry and Overcooked Files
Although we live in a country that highly values freedom of expression, we are confronted with censorship daily, and dentistry is not immune. After discussing censorship, Ruddle gives the short presentation on overcooked files that got him banned from the AAE! Stay tuned for an informative Q&A at the end of the show.
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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.
INTRO: How Do You Start Your Day?
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. So, how are you doing today?
I’m feeling just terrific.
Well, it seems like you have a lot of energy, and I – I think it’s pretty important that we start our day off right, to get the energy we need, to get through the rest of the day. So, why don’t you tell us, how do you start your morning off?
Okay. Well, you know, I roll out of bed about 5:00. This is boring stuff, but you asked.
I think people wanna know, because it sets the stage for your whole day ahead, how you start your morning.
Well, for me, it’s actually [laughs] one of the secrets to amazing success [laughs].
Well, okay. So, I get up about 4:30 to 5:00, and I do 3 things regularly. There’s stretching. You know, when you get to be this aged, you have to get loose. So, I have to work on the hamstrings and the back and get loose. So, I stretch. Then, I meditate. Meditation puts me in a really good space. And then, I read the news. The news could be world news, it could be international news, then maybe the U.S. news. And sometimes it’s endodontic news.
So, you read the news out of an actual newspaper?
So, yeah. People still do that. [laughs]
Or on my phone, or on my phone, sometimes.
So, that’s the first hour. And then, I hit the trail. So, most of you don’t know where I live, but I live in Santa Barbara. You knew that, but you didn’t know I live on a little hill or a mountain, called the Riviera. Called Riviera, because it faces south. So, we’re about a third of the way up the hill. So, my daughter --
Not me. [laughs]
-- not her, nope, not you. We’re gonna talk about her routine. It’s much more strenuous. We got out, and we walk for an hour. And I actually take a loop. We go up the hill, down, and around, and up, and I go right by her house, okay. So, I do a bed check, but she’s been gone for two hours.
But then, we finish the walk, my daughter and I, and it’s a chance to watch the sunrise, the changing light, the colors across the ocean, because we look out on this walk, same with you, we look at the city below us. And then, we look at the harbor. And then, there’s the channel, about 20 miles out to the islands. So, the lighting’s always changing in the morning, and I know you picked up on that. And then, of course, I get to talk with Lori about business, about life. Her daughter walks with us sometimes. She’s that girl that was part of that Santa Barbara tennis team that won, the Channel League. So, I got baptized in the Channel League and the matches and the competition. So, by the time I get home, it's time to shower and shave and get goin’, but I feel ready to go.
Do you have breakfast?
Oh, yes. After showering and the shaving, I have a huge breakfast. It’s oatmeal and a banana.
Every day, pretty much the same thing?
Every day, pretty much oatmeal and a banana.
Yeah. My routine is the same every day, and it’s really the same, whether or not I even go to work. Like, even --
Rain or shine, for you.
-- [laughs] like, when I – even on the weekends, I do the same thing. So, I wake up at 5:00, every day, pretty much I’m out the – brush my teeth, I’m out the door, running, go – I run 3 miles a day, come home, just maybe do a few little chores. But the running is really important to me. I think getting out – I wanna say a little bit more about that, because when I run every day, that’s when I think about my day, I think about my life, I think about a lot of things. And it’s kind of like – almost like a meditation time, where you just kind of assess everything that’s going on. And so, that’s kind of like how I start my day. I don’t ever have breakfast, but I have coffee every single day [laughs] [crosstalk] [laughs] --
I’ll interrupt. Coffee, for her, is much like one of the world’s great religions.
It’s a necessity, right?
Even when my kids were little, they would say, ‘Don’t you think that you want some coffee? Because you’re always happier when you have coffee.’ So [laughs], yeah. I definitely never miss my coffee. So – but – yeah. I think that pretty much the coffee and the running is what – and also, while I put my makeup on, I listen to “Get Up”, which is a sports show on ESPN. I know you watch that show, too.
So, that’s when I hear all about the sports teams and – my team’s hardly ever mentioned [laughs], because it’s not doing very well. But yeah. I follow sports that way, too. I know you watch that show, too. I think we talked about it, before.
Yeah. Sometime, we’ll have to do a show on just our teams and what happened specifically, after the fact.
[laughs] Yeah. Well, that’s great. Okay. So --
So, what’s the message, maybe, to everybody at home?
-- I think that, you know, the message is, maybe have a plan for your morning. Maybe actually do something that’s gonna get you on the path you wanna be on, instead of – so that you maybe just don’t wake up floundering. I don’t know. What do you think the message should be?
Well, the message should be, whether it’s morning or evening or during the day, because we all have these windows of opportunity, but I would say, take some time for you. And if you feel good, you’re gonna do good. And the better you do, the better you feel.
Yeah. Okay. Well, that’s a good way to end this segment. So, let’s get started with our show. Today, we’re gonna talk about censorship, specifically in dentistry, which is an issue. I mean, it is a problem, and it is – you know, censorship’s a problem everywhere, but it’s even a problem in the dental profession. And we’re gonna discuss that. And then, we are going to – or he’s actually gonna give a presentation on files that have been excessively heat treated. And this is actually very connected to our censorship segment. So, you’ll find out more how that all connects, later. But let’s get started with the show.
SEGMENT 1: Censorship in Dentistry
Okay. Today, we’re gonna talk about censorship in the dental profession. Is that all right with you? [Music playing] Oh, it looks like you’ve been censored.
[laughs] Okay. So, in the United States, we have freedom of speech, and we think that we can pretty much say whatever we want and not – we don’t really have much fear of repercussions, especially if we’re speaking the truth or just reporting our own experience or reporting someone else’s experience. We expect that if it’s true, that it’s not gonna be censored. However, we also have the idea that certain information may not be appropriate for all groups of people, at all times. Like, probably parents wanna keep some things from their children, because they’re not mature enough to deal with a certain amount of information.
But when information is withheld that could be helpful to others, and when this information is held for selfish reasons, like maybe to protect a product, then, I think censorship becomes problematic. So, we’ve actually had some experience in recent years and even in recent months with my dad being censored. Why don’t you tell us about an article we just recently wrote for “Dentistry Today”.
Well, I’ve been kind of noticing more heavy-handedness in the last decade. It probably has a lot to do with commercialism and just technology and where the field’s going and how it’s driven. But just to tell a quick story to the audience, I’ve written for “Dentistry Today” for decades. I usually do four articles a year, and they’re on a variety of different topics. Oftentimes they’re – in fact, we make a point not even to do commercial – I think the last couple years, there’s been nothing commercial we’ve written about.
So, back to the story, I got called by the Editor in Chief of “Dentistry Today”, and he said that he had a colleague who was gonna write an article called “Focus On”. It’s a one-page editorial. It’s an opinion piece. And he said that the guy that was going to do it from Hawaii was ill, got sick, and he was desperate to have somebody fill in for him. And he chose us, first. And he said he thought we could get it done, and we only had about 40 days. And normally, we have, like, months to prepare to write an article.
And just to be clear, when we’re saying, ‘we’re writing’, it’s because he writes the articles, but I – I’m kind of the editor. So, that’s – we do it together. It’s a joint project [laughs].
You can actually give her a little more credit than she humbly said. Sometimes I just throw out ideas, and it comes back to me in a draft that reads pretty well. Anyway, so, we took on the assignment. But I said, ‘I have one reservation, Lisette. I’d better talk further with the Editor in Chief, to make absolutely certain that what I’m gonna write about is acceptable.’ Because I wanted to write about GentleWave, and I wanted to write the truth, unvarnished, and what my experiences have shown me, from talking to countless people, over the last two or three years.
And it said it was perfect. He thought that the whole point of a “Focus On” article was to be a service for the readers. And it’s an opinion piece, and “Dentistry Today” certainly has many, many articles that are written about clinical techniques, new technologies, business, insights into the market, and they’re always opinion pieces. So, with that directive, we went to work, and we carved out, in about 30 days, a really good article. And this article was completely and fully documented. Everything that was said, I had written supportive evidence behind me, to support it. And when I turned it in, it was declined, almost immediately. And we were pretty upset about it.
And I’ll just cut to the chase. It’s kind of a long story. But the Editor is my friend, and he was for the publication. I think I can say his name, Damon Adams, and we’ve known him for years and years. Before him, it was Phil Bonner, years and decades. So, anyway, we know the people at “Dentistry Today” because we publish there. So, what was interesting is, the article was supposed to be in October, originally. Then, it got moved to November. Then, it got canceled in November, and it wasn’t going to be permitted to be published this year, but surprisingly, I still don’t understand, it would be okay for it to be published next March.
So, right now, the article didn’t ever get published. We’ll still get it out, as you’ll explain to the audience. But that was an example where I thought we’re serving patients. And the whole reason for “Dentistry Today” is to offer little insights, clinical techniques, tips to help us better serve our patients. And whether the truth is favorable to a product, or whether it’s not, still, dentists need to know about it. And as a teacher for 45 years, I’ve always told the truth on stage. And sometimes people don’t like it, but it’s always been accepted.
And as I’ve gotten older, I’ve noticed over the decades, people really appreciate when you share with them insights that you’ve gathered through your experiences with others.
I also want to add that when we approached this article, we already knew that GentleWave was very polarizing in the marketplace. We already knew that there was a lot of different opinions. So, we really tried to approach it as objectively as possible, pointing out the good things and the bad things, and not really trying to take a side, but just to present it – the information, like report it as objectively as possible. So, we actually took that approach. And it’s interesting that, when they put it off till March, they said, ‘We will publish it in March and not change a word, because your words are fine. But it needs to wait for March.’
So, then, we start thinking, ‘Well, why [emphatically] does it need to wait until March?’ Apparently, there was – we never really got a very clear answer. Apparently, someone else is writing a pro-GentleWave article in March. So, it would --
-- there would – or April, so there would be more of a balance. Apparently GentleWave is a big advertiser with “Dentistry Today”, and there might be some issue with – that they had with the article. We don’t even know exactly why it wasn’t published. All we know is that we were put off for a while. And we felt that the information that we wrote maybe might not be so relevant in that many months in the future.
Like, that gives them a chance to fix [laughs] all the problems that we were pointing out, which is good, if they fix the problems.
But still, I mean, why would we write an article that we thought was really relevant, to be published now, and then, to be put off six months?
So, just to come back a little bit more and play off of Lisette, I think when you write about a product, you have to be a journalist in the truest sense of the traditional meaning, which means, like if you’re John West, he actually bought a GentleWave unit, because he didn’t wanna talk about what other people’s experiences were. He wanted to have his own personal experiences. So, we try to really get to the heart of the matter. There’s very, very happy GentleWave users. I meet them. We said that it cleans probably as well as anything in dentistry today, but there were some negatives, and we can’t sweep that under the trash.
There’s an old Yiddish expression, ‘Don’t sweep it under the rug.’ So, I think, if you’re teaching, we can pound on how great something is, encourage people to buy that technology. But remember, we’re treating patients. We’re serving the general public. And when there’s bleeding problems, significant hemorrhage problems, and post-operative problems, this just needs to be brought up, just as easily as we say it cleans really well. So, I thought they were manipulating the message, and I thought that the timeliness is right now, when the marketing is the most intense, and there’s declarations the company wants to go public.
So, I’m only left to speculate, but it could be that the delay in my article, that it could be published, word-for-word, many months from now, could have to do with the ambitions and the financial directions of Sonendo itself. Now, I don’t know that “Dentistry Today”, right now, does a lot of – takes a lot of advertisements from Sonendo, because Sonendo’s dominantly been an endodontic tool or device. But somebody above Damon Adams was very concerned, because what I heard on the phone call was, ‘Almost all of our revenue comes from advertisements, and we can’t upset the advertisers.’
So, no names were specifically mentioned, but --
-- the implication we got was that, ‘This is gonna rub people the wrong way, that are giving money to the magazine.’
So, that’s an example of an article not being published, but there’s also been a situation where you’ve actually been banned from the AAE and maybe even more than on one occasion [laughs]. But recently, you were banned, and it was because of a presentation you gave. And actually, it was because of a small part of a presentation you gave. But why don’t you describe what happened, there, at the 2017 AAE meeting?
So, you want me to spill my guts on all the trash?
Actually, life’s very good, being an endodontist. It’s just that things change, and as the decades go by, you start to realize how programs are put together, how organizations work. I’m talkin’ about ADA, AAE, Chicago Midwinter, et cetera. But – okay. So, 2017, the AAE meeting was in New Orleans, and I had been asked some months earlier – probably over a year and a-half earlier, to give a one-hour presentation. I’m gonna throw an old friend in here, John David West. John West is from the Tacoma, Washington, area, a fabulous clinician, gifted teacher.
He also, at the same meeting, was givin’ a one-hour lecture. Both of us gave completely different lectures. John’s lecture was entitled – I think it was entitled something like, “Becoming and Being a Successful Endodontist”. And he had three things he was stressing, 20, 20, and 20, to make his hour. And it was, ‘Always be a student’. So, he was challenging the audience how to be great, and always be a continuous student, for life. The second thing was, ‘Be a vision maker’. So, look beyond your four walls, and look out into the future, and look at ways you can improve your practice and your level of care you provide your patients.
And then, finally, he said he coined a word. You’ve heard of ‘entrepreneurial’, but he said, ‘Be an endopreneurial [sic].’ And that means, get out of your office and make a difference in the community, and – we’re gonna talk about this in “Lifestyle and Communities” on our show. So, back to the presentation. We both had an hour. We both gave about six minutes to an imitator file that is making a lot of claims. They’re flat-out not true, or they’re deceiving or deceptive.
And so, when we were done, I got a standing ovation. We gave lectures concomitantly, so I wasn’t in his room. But I had about 500 or 600 people, standing room only. And when I was done, I got a standing ovation . I probably had 150 people come up and say to me – that’s a lot of people. I’m not exaggerating. And they waited patiently, little groups, and finally they would come up and say, ‘Thank you for telling the truth.’ And I said, ‘What do you mean?’ And they said, ‘Well, we never understood what you said, but when you talked about it, all of a sudden, we go, “Wait a minute! That is happening!”’
So, to make my point, because, to me, if this is something that’s my truth, but it’s not your truth, then, maybe it’s irrelevant. But the challenge from West and me is, ‘Discover your truth. And if your truth is trying out the product, and if you have similar experiences, you’ve learned something. If you can make it work in your hands, different or better or more effective, that’s your truth.’ So, the following year, we were both – well, shortly thereafter the meeting, we were told we were both banned, and we were banned from speaking at the next year, 2018 meeting. And just for the record, John and I speak almost every year at the AAE meeting, and we’ve both been in the business close to 50 years.
So, many, many times we’ve spoken there, and I have never been banned, ever. And I have given – not this lecture, but similar lectures in – across the decades. It’s always been received with a lot of interest by colleagues and gratefulness, because you’re giving them little insights. When we all become endodontists, there’s no one, magnificent thing we learn, and it’s like, ‘Wow! [emphatically] That changed my life!’ It’s all about those little things, and all those little things in concert are what make the difference.
So, that was an example where the Board of Endodontics was influenced by big money. I better look at the camera. The AAE was influenced by big money, because I know for a fact that the name of the guy that runs this company made a $750,000 donation to the AAE. And suddenly, John and I were banned. So, there’s an example where --
The owner that runs the company of the file that you were maybe exposing some --
-- deficiencies with. Okay.
Yeah. And that – a big donation was made. I heard from people who sit in that Board Room. I heard privately in – from their mouth to my ear that they were pressured heavily to ‘Get these two guys off the stage, because it doesn’t help our sales.’
Well, this is kind of interesting. It looks like, in both the cases of the article and with the AAE, that you were censored, because you were saying some things about a product, and they were maybe construed as negative by the company that makes that product. But you were just trying to help people and get the truth out there. And then, they wanted to suppress it. Is that correct?
That’s correct. I mean, here’s a little analogy. I’m a car dealer, and you’re on the lot, and you wanna buy a vehicle. What if I didn’t tell you that the steering’s about ready to go out? So, the car’s fine, looks fine. On the test drive, it’s fine. But I know -- I didn’t have my mechanics check the steering, and I know from the previous owner, there was some problem. Are you okay if I sell you the car and don’t mention this? So, to me, it’s a rhetorical question. It’s with files. Every file has its strengths, every file has its deficiencies. There’s different costs for files. That’s all fine. That’s been going on for as long as I’ve been alive, in the profession. But the thing that we gotta focus on is deceptive marketing, if it creates misinformation that deceives not only the general dentist but again, the patients they serve.
And you gave the car example, but we can also think of the opioid crisis, you know, like, how long was information known, before it was – it was, like, just suppressed, and then people become addicted. Or the cigarette companies, or any – it’s like, this is information that should’ve got out sooner, to protect people. So, it’s – the -- what – his lecture, the six-minute presentation that he gave to the AAE that was the problem that got him banned, he’s actually going to be giving that same presentation, right after this segment. So, this will be interesting to see.
With the tape on, or the tape off?
Oh, with [laughs] – yeah. [laughs] Okay. With the tape on. Okay. I wanna talk about one last thing about the ADA. You just recently learned something about the ADA, going forward, in 2023, that they had an edict. What is that about?
Well, it’s the changing face of professional education. And I’ve watched it evolve. I mean, not to get too historic, but if you look at the world of NiTi files, if you tell me the file, I’ll tell you of the name of the doctor behind it. There – it’s rare in today’s world to have any files that are just made by a company, hoping they give us the right product that will work clinically. So, this means, starting with about 1991, -92, when NiTi came to market, McSpadden and Ben Johnson introduced the world’s first NiTi. Many – Buchanan’s introduced instruments. Our team has introduced several instruments. So, the – Bruder, Peters, Cutler, there’s a lot of people.
But my point is, every file has names of people behind them. So, what we noticed over the years is that it was really important for us to tell the audience if we had a commercial interest in – there might be something that needs to be disclosed to the audience, so we could be really clean. So, we saw that come in, and that was always – had to be written. Then, it had to be announced before you got onstage, usually the – your introducer, the moderator would say, you know, ‘Dr. Ruddle is the inventor of ProTaper. He’s gonna speak about ProTaper today.’ And it was like, ‘Oh, gosh. Where’s the tape?’ But anyway, we did that for a while.
But now, what’s coming -- I was just talking to Gordon Christensen. He’s heavily involved with the ADA, as you’ve known, for, like, I don’t know, 40 years. And I saw him in Las Vegas about four weeks ago, and two weeks ago I saw him yet again in Provo. And in those instances, he said to Phyllis and I that having served on some of the committees, planning CE going forward, that in 2023 the ADA will not allow any speaker onstage to mention a single name of any product.
Well, when I heard that, I said, ‘Gordon, you’re kiddin’ me.’ He said, ‘No. As an example, you’ve invented ProTaper and WaveOne Gold with your teams.’ And, he said, ‘You will now just say “file”. And when you have a new composite material, and it has a name brand, you’ll just say, “Use a composite.”’ And the thing that’s so --
But even so much as you can’t even say ‘Clorox’. You have to say, ‘bleach’, right? I mean, you told me – I think that’s what you told me.
-- it would be generic.
So, it – generic on a very even basic level.
And so, of course, this isn’t education, because, for decades, you know, people came from all over the world to our classes in Santa Barbara, because they wanted to learn what Cliff did. And the idea was, if others can do it, and what we teach is so transferable, that it’s easy for other people then to go home and do it, too. So, if you just said to a colleague that took a course, blindfold them, and have him work with files when they went home, would that really be a useful course? So, we all use products, we all drive cars, we get on bicycles, we have TVs in our home. Everything is a product. Everything is commercially driven. Everything has a margin, hopefully.
And so, I think we need to disclose our biases and our potential prejudices, so the audience knows where we’re coming from. But I think we should have permission and true, unvarnished, censor-free education. We should be able to tell the truth, and we should be able to tell, if you ask me how I do it, I should be very specific with you.
Yeah. Because the point is to be helpful, and if we’re not being helpful because we’re withholding information, then [laughs], it’s – it kinda defeats itself.
Exactly. So, you know, you didn’t think I was gonna say this right now, but one of the big incentives to do this show, besides working with family, was to get the word out and not get into a queue with a publication, where you wait about a year to get published. And during that year the whole world of endodontics flies by, and what you thought was so relevant here, is maybe irrelevant a year from now. So, the show is completely designed to bring you just-in-time education, to talk about what’s going on, right now [emphatically].
And we could’ve easily called our show, “Ruddle Uncensored” [laughs].
But now that that part is over, I will put my censorship mask back on.
Oh, no [whispered]. [Background music playing] Okay. That’s it for our segment for today [laughs]. So, now my dad is gonna give his presentation that he gave at the AAE lecture. Also, you can find the article, the GentleWave article that was banned – or, not banned, but just was gonna be postponed, you can find that on our website as well.
SEGMENT 2: Overcooked Files
It’s great to talk about stuff that we all learned, we all agree on, and there’s consensus. That’s easy to talk about. But what’s not as easy to talk about sometimes is our disagreements, our differences, and those lead to controversies. So, if we look at the game of shaping canals alone, it was very innocent, through the ‘50s and ‘60s and ‘70s and the ‘80s. But when we got to early ‘90s, we got our first 2 instruments, NiTi, rotary, mechanical files. And it was still pretty innocent, just a couple colleagues, a couple companies. And there was a big market, and the competition could handle it.
Then, we begin to see 30 systems, 50 systems. Today, we have over 100 NiTi systems that we can choose from among to shape canals. So, there’s a lot of controversies, as everybody picks up on ways to get that market share, the old market share. That’s what every company wants, is you to buy their files. So, you can see the controversies, not a complete list, certainly, but the dimensions of a file, how big the shape should be, skinnier, wider, four percent, six, eight. The file designs, without going through a whole bunch, we have the NiTi, we have metallurgy now, heat treatment, and of course, we have all kinds of cross-sections and helical rake and cutting angles.
All these begin to design and build a file that we imagine can cut a really great shape. We have progressively increasing tapers, progressively decreasing tapers. That was a ProTaper thing. Well, everybody’s proud, and they want talking points. So, the marketing is always done to get you interested, to get your attention. And of course, it has led to the price wars. There’s definitely a lot of discussion about prices on files, and some files are half as much as other files . And so, they have been continuously harped on, in the marketplace. With all this trifecta, we shape canals. The shaping allows us to have a reservoir of irrigant, so we can clean in three dimensions. And then, of course, cleaned root-canal systems can be three-dimensionally filled.
So, what’s guiding all that is probably what? It’s probably the concepts you use, that you choose to embrace, that guide your clinical actions. So, here we go. Let’s take a little look. So, that’s a normal kind of a shape. It’s somewhere between a 40/.06. That means a 40 at the terminus, with a 6-percent taper. If you look at the Wallace review article, he looked at probably around 100 articles that verified a 40/.06. And that was old, traditional literature. Baumgartner was more current with his thinking, and he showed that a 20, only a 20, down here at the terminus, was sufficient, if one insisted on improving the deep shape, so, the shape that we see, in the apical third. 20/.10, is what he said.
Well, then, of course, we’re in the era of minimally invasive endodontics. So, the big emphasis is on how small we can be. I’m kind of being a little bit exaggerative. But, really, there’s been a lot of interest on keeping the terminal diameter at somewhere between maybe a 15 or a 20, and then, the taper could be 2 or 4 percent. So, kind of slim kinds of shapes, a lot smaller reservoir or reagent, if you look at these and compare. But of course, there is technology. So, whatever you do, remember it’s the trifecta, cleaning, shaping, filling. So, when you change one, you change everything. So, if you change the shape, how do you get your reagents in here? What is the tool or the method you’re using for activation, so you can actually get that reagent to penetrate, circulate, and digest tissue, from the uninstrumentable [sic] case? Okay?
So, think about that. And then, of course, how are you gonna fill? Can you do – get your vertical condensation stuff in here? Is it a single cone, now? Maybe you’re compromised, and you have to go to a single cone, because you can’t get your armamentarium. Maybe a carrier-based obturator. It’s too skinny. It squeegees the alpha gutta-percha off the core. And so, that is a compromise. So, it’s led to a lot of single-cone stuff. And then, of course, when you’re shaping roots, remember, probably over half of ‘em are not round. And the distal root of the lower molar, what comes to mind is the furcal side concavity, and we have to shape away from furcal danger. And these are ribbons, very complicated.
And I like to run instruments down like the buccal side or down the lingual side, find out if these are common foramina or if they’re separate and distinct, two or more separate apical portals of exit. And of course, the tissue in the isthmus gets rounded, gets cleaned out, gets eliminated, through our irrigation. I kinda hate the marketing schemes that always show that most colleagues are doing that, and of course, they’re trying to promote a thermal file that expands and does all kinds of things with temperature changes. There was a self-adjusting file, the Israeli file, all clever ideas, but really, they’re needless complications to non-existent problems. Okay?
So, as an inventor of a file, I’ve been on the team that did ProTaper and WaveOne. Both are gold, heat treated. So, here’s ProTaper, and that’s my disclaimer. It’s the number-one-selling file in the world, proud of that. And even with all the price wars – my pen won’t work. But this is supposed to say, ‘Number One’. Okay. So, we also have files that have come into the marketplace. As IP and patents have expired, there’s opportunities. So, people, companies, commercially embrace making maybe a cheaper file. They don’t have the R&D, they don’t have the IP, they are able to just take something and reverse engineer it, and here’s an imitator.
So, oftentimes, for the last five years, in multiple journals per month [emphatically], we see, ‘Twice as good, half the cost.’ And I’d like to challenge that a little bit. Just out of the block, this is brand-new files that have been professionally photographed. And over here, on your right, you can begin to see discoloration on the shaft. These are pressed in. The shaft is pressed into the handle. Over here, they’re glued in. The glue has been shown oftentimes in micro-CTs and SEM, to run down on the shaft. You get discoloration. The glue’s been determined to even be cytotoxic. Does that matter? I don’t know. But why would you do a – use a cytotoxic file in a patient’s mouth? That’s just interesting to me.
So, you can see there’s some quality issues, right off the bat. If you look a little bit further, this same company, Edge Endo, has made the claim, ‘Twice the cyclic fatigue, half the cost.’ ‘Twice the quality, half the cost.’ So, the imitator file, they put it in a slot. It’s a stainless-steel canal. It’s manmade. It’s 90 degrees. And they run the file around 90 degrees, and they spin it and keep track of the rotation – number of rotations, until it fails. And you can see – remember, 60 seconds still equal a minute, so we’re up here to about 10 minutes. The file ran about 11 – a little over 11 minutes, before it broke. So, the marketing hype was, ‘Wow! We run almost twice as long as ProTaper Gold, the competitor.’
Here’s the problem. How long is your file working inside a canal, working progressively towards the length, and finally reaching the terminus? How long? How much time? So, it’s nice to say we can go for 11 minutes, but here’s the key words. Once you have the glide path – remember, a glide path is a smooth, reproducible glide path. So, once you’ve secured – we call that a secured canal. Once canals are secure, and you run the instrument into the orifice, it takes somewhere between 5 or 10 seconds to achieve length. And even if the file bogs down, you gotta take it out, irrigate, recapitulate, and reirrigate, and clean the flutes to make sure the file can go back in, and a fresh file back in, with no debris, will always advance along the glide path.
So, we have found out that if you’re doing a four-canal [laughs] molar, okay? There’s now 4, 4 times 15, this is about 1 minute. This is about 60 seconds, right here. So, if you really wanna exaggerate, we have a big buffer or safety on gold, because it can run for about, what, 60 into 300 is about 5 minutes. So, we have a huge buffer of safety. So, okay. So, on paper, just evaluating resistance to cyclic fatigue. A man has a shirt. When the man bends the shirt, it has compressive stresses on the inside. It has tensile stresses on the outside. So, it’s like taking a paper clip and doing this over and over, until the paper clip fails.
So, cyclic fatigue is the resistance to failure. So, you can see, it’s pretty impressive number. But what do we give up? Life is about the good news, bad news. There’s usually the yin and the yang. So, let’s look a little further. I gave this presentation to show you that in this challenging S-block – you can – anybody can buy the S-block from Dentsply My Fair [sounds like]. It’s harder than dentin. The plastic’s not harder. I’m saying the technique is harder. It’s less forgiving in plastic. So, if you can do something in plastic, you can take it to the mouth. It’s transferable. So, what I wanted to show you was, with 4 tapers, with 4 files, shaper 1, shaper 2, finisher 1, finisher 2, 4 instruments following the ISO color, we could shape 11 S-blocks without any unwinding or fractured instruments.
And of course, the idea of shaping is, how do you know you’re done? When you got the shape. How do you know you got the shape? When your apical flutes on the file are loaded with debris. So, if you get a beautiful shape, cones fit easily. So, I’ve always talked, for years, when can you pack? When you can fit the cone. When can you fit the cone? When I got the shape. How you know you got the shape? When the apical flutes are loaded. You could write home, this file just cut its shape in the apical one-third. So, that’s pretty impressive, right? Pretty impressive.
We looked at the imitator. This was Edge Endo’s Sapphire. They’re marketed around the world as replacing ProTaper. They’re marketed around the world as replacing ProTaper, and they’re marketed around the world as half the price, and they’re the same instruments, you don’t even have to change your technique. The only problem is that’s not true. If you look at the company’s own “Directions for Use”, DFUs, nothing is bigger than six percent. But in ProTaper world, the yellow is a 20 tip, 7 percent. The 25, at the tip, 8 percent. So, they are not seven or eight percent. They’re six percent. So, of course, they’re gonna be more flexible, because they’re smaller in their cross-sectional geometries along the active portion.
Well, let’s look and see what happened when we start shaping the S-block, because we use the block, because teeth vary in length, canals vary in diameter, cross-sectional diameter, and in curvature and re-curvature. So, we use a block that anybody in the world can purchase. They all have the same length, the same diameter, and the same curvature, and the tolerances are quite good. I could not use a series of instruments and make a shape in this block. You know what? Don’t believe what I’m telling you. Make your own discovery. When John West said at the AAE, and I talked about this in the previous section, ‘You’re to be a continuous student, for life.’ Okay?
Well, students have to think things through. You can’t just accept what comes out of my mouth. It could be nothing but garbage. So, you have to have your own discovery. So, my job today is not to be too hard, not to be too joyous over something. Let’s just look at the facts. Let’s be journalistic, okay? So, I want you to try it. I could not get through a single block without unwinding at least one file and oftentimes two. So, back to the slogan, ‘Twice as good, half the cost.’ If you have to replace an instrument or two, along the shaping journey, across four files, is that really saving you money? Oh, that was a question! Okay.
Then, we looked under the unwinding area, and you can see the stretching of the flutes. So, here’s another thing. Even when the instruments get to length, it's not the same shape, because the file stretches. And when the file stretches, you get a different shape than if the file didn’t stretch. So, cone fit is reported around the world. ‘Hey, man, I’m havin’ trouble fittin’ my cones!’ [angrily] Well, maybe ask yourself, did you stretch a few files? Did you really get the shape you thought? All right. So, this is interesting, but it’s always a balance, then. When you’re building files, I can give you huge resistance to cyclic fatigue. I can give you 11 or 12 seconds. It’s no problem.
And there’s even things well beyond what I showed earlier, that if we wanna just look at how resistant we can get that file, spinning around curvature, how resistant to fracture we can get that. We can get it way up there. But you lose efficiency, because you have to overheat the files. This is called heat treatment. So, they take NiTi, they put it in ovens. Files are put in, in cassettes. They go up to a proprietary temperature, and then, they let it cool down. As it cools, oxide forms on the NiTi, making it look gold. You can get pink, you can get blue wire. You can have all these different colors, based on your heat treatment.
So, when you overcook, we say affectionately, when you overheat or overcook a file, guess what? It’s soft. That’s why it can go so long without breaking. But the edges are also soft. The edges roll over, the file’s less efficient, and it doesn’t cut very well. It starts taking more time, but most dentists are so thrilled with the money they’re saving, per file [emphatically], that they don’t ask the question, ‘What do I not know?’ So, I asked people, in a lecture of 500 people, in – at the AAE meeting [laughs], New Orleans, I said, ‘You don’t know, but ask your assistants. Your assistants know how many files you’re replacing, because they’re the ones that load it all up and give it to you.’ Okay?
Well, all the sudden, doctors started going, ‘You know, I’m using more files than I thought. I never really thought about it, until we kept track!’ So, if you don’t measure stuff in life, you don’t really know what’s happening. If you wanna know who won the Olympics, you know, somebody won, but they kept track of time or the height they jumped, or the length they jumped in the broad jump. So, measure, measure, measure. That’s how you get better. I have two kids, and they do sports, and they measure, and that’s how they know if they get better with time. So, if you wanna have heat treatment, we have to have heat treatment, but we have to not go so high, so we still keep a sharp instrument with blades that can cut, and our patients benefit, because procedures take less time.
So, this is the bad news [laughs]. In life, in most human endeavors, there’s the good news and the bad news. I have bad news and worse news [sarcastically]. Oh, boy. What’s the worse news, Cliff? Well, is it really twice as good, half the cost? Well, we wanna take into account the global shaping time, not only how many instruments are unwinding, but how long does it actually take to do the procedure? So, what we did is look at time, and we compared efficiency. And we compared yellow, ProTaper Gold, the gold, with the imitators, in white.
And you can see, with every instrument, with a little tolerance across – plus or minus error, you can see with every instrument, in every instance, ProTaper Gold cut its shape significantly less time than the imitator. So, if you look at this whole sequence, the whole global shaping time, guess what? It took 65 percent longer to shape an S-block, using an imitator, Edge Endo Sapphire, than ProTaper Gold. Okay. So, is it really -- back to the marketing slogan, remember we talked about price wars, talked about marketing, advertisements? [Sound of cash register ringing up a sale]
Wow! You know, when I looked here at this, I thought we had a problem on the set. So, I had to enhance something, because I saw dollar bills. Well, if you’re doing -- a general dentist that does maybe three, four cases a week, you might be doing more. But if you start taking a count, how many files are unwinding, and the 65 percent more chair time, and you multiply it by a patient, by another patient, by a week of patients, by a month of patients, by a year of patients, my God! Grr! It wasn’t really dollars! [emphatically] I think it was actually maybe – whoa! Whoa! I think it was that! [yelling] So, be smart, pay attention, and find your own truth.
Okay. We’re gonna close our show today with a Q&A, and I have in front of me here some questions that were asked of you at a recent Webinar you did. So, I’m just gonna randomly read some of these, and you can answer them. I’m gonna read them exactly as we received them. So, if it sounds a little funny, maybe it’s an international person that had the question, and English is not their first language. So, just keep that in mind, when you hear me read the question.
So, this first one is, ‘Recently had a patient present to my office after root-canal treatment completed on number 14. Root-canal treatment appeared to be sound, with the exception of .5 millimeter overfill on the palatal canal. I referred to endo, but my question is, how long would you expect the patient to have discomfort from mastication, in this case?’
Okay. First of all, for our international guests, tooth number 14 that we speak of in the USA might be known as number 26, upper left quadrant, first molar. Okay. And so, the question was, ‘How long should we have post-operative symptoms when endodontics has been completed?’ I guess the key word, I’d like to say, can we assume that the quality of treatment was excellent? So, the simple answer is, if you’ve truly cleaned and shaped and three-dimensionally filled the root-canal system, then, it’s my experience over decades that people are sore for two or three days. In fact, a lot of people can eat and chew equally well, left or right, the night of the pack, okay?
So, of course there’s some irritation caused by doing a medical procedure. Here’s the root. There’s an incoming nerve and blood supply. There’s an amputation. There’s a little injury above the roots. We probably push a little bit of debris through the roots. We have an immune system, and the body’s good at getting the macrophages around cells, histocytes in there, to clean all that up. If it – if you gave the patient an antibiotic, as an example, the antibiotic can get in there, because it’s exterior to the tooth. Our biggest problem today would be leaving necrotic tissue or potentially necrotic tissue in avascular root-canal systems, after pulp death.
So, I’m not worried about the 0.5-millimeter overextension, if the root canal was sealed. So, Schiller [sounds like] used to call that ‘well filled and surplus after filling’. So, we don’t fret about a little bit of surplus material as causing long-term, post-operative problems, because sealers of all kinds, after about 48 hours, are biocompatible, dimensionally inert, and healing can usually begin right away.
Okay. Next question. ‘Do you recommend using a viscous chelator in all cases, or just vital cases, where there is a lot of pulp tissue? Is there any chelator that removes the smear layer?’
Okay. Well, basically, there’s a couple kinds of chelators. And Lisette says, ‘viscous chelators’, examples would be ProLube, Glyde, RC Prep. And what these are is, it’s ethylenediaminetetraacetic acid in a methylcellulose suspension. So, the three advantages we get off a viscous chelator are lubrication, that helps the file move and slide. It prevents the re-adherence of vital tissue. So, when you have a file in a hole, and it’s bleeding, and it’s collagenous tissue, when you pull the file out, the tissue reattaches to itself. It re-adheres. So, when you grab the next sequential larger file, there’s no favorable pilot hole. So, if we can prevent the re-adherence of vital collagenous tissue, we’re well ahead of the game.
And finally, the last thing to talk about would be the debris that the file’s generating is more effectively held up in suspension, so it can be subsequently liberated from the tooth through irrigation procedures. So, when I’m going where man has – oh, wait, I love this part! So, how many times in your life can you say, ‘I’m doing something today for the first time, that man has never, ever done before’?
Well, geez, when you climbed, what was it, K2? You saw a flag there --
-- and you said, ‘Gee, somebody’s already been here. This is a problem!’ And so, when I went back in the forest, and I got way in the back, there, there was an outhouse! [emphatically] And I said, ‘Somebody’s been here before.’ But when you open a tooth for the first time, you are going into where humankind has never gone before. So, when you’re going into places, you need to – that you’ve never been, you need to show restraint. Remember, Hess’ anatomy, the curvatures, the re-curvatures, the dilacerations, the hooks. You need to show restraint, and a viscous chelator lubricates the file, keeps that debris in suspension, and especially in the cases that believe they’re the most dangerous, so, you – it prevents the re-adherence.
So, I’m using a viscous chelator where I’m using small-sized stainless-steel hand files. Once I go to a mechanically driven file, whether it’s spinning or rotating, then, it’s all sodium hypochlorite, about six percent, for all the rest of the procedure. So, we secure canals, we create a smooth, reproducible slide path with viscous chelators. Then, they’re eliminated, and it’s a big bath of sodium hypochlorite, during all the subsequent shaping procedures. 17 percent EDTA, okay, is used during – during and at the conclusion of the shaping procedure, to eliminate the smear layer. And the smear layer is a biproduct of the mud.
So, the files work, they carve dentin, and the mud could be shreds of pulpal tissue, it could be mud itself, dentin mud, dentine mud. And then, it could also be, when bacteria are present, there could be bacterium. So, it could be a cocktail. And once we get that off the walls, then, we open up the tubules, and now, the 17 percent EDTA removes that smear layer. Now, our Clorox can penetrate deep, mini microns, about 400 microns it can penetrate back into the dental tubules. So, that’s the three things, sodium hypochlorite, viscous, and aqueous chelators. Viscous, RC Prep, ProLube, and Glyde. Aqueous, 17 percent EDTA.
Okay. Well, that’s all we have time for today. We’ll do more Q&As in the future, because we get a lot of questions, maybe even a whole show Q&A, at some point. [Background music playing] But that’s it for today. See you next time, on The Ruddle Show.
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Comparisons & NSRCT
Chelator vs NaOCl and Managing Type I Transportations
Special Guest Presentation
Dr. Marco Martignoni on Modern Restoration Techniques
International Community & Surgery
Breaking Language Barriers & MB Root Considerations
ProTaper Ultimate Q&A and Flying a Kite
Rising to the Challenge
Working with Family & Managing an Irregular Glide Path
Controversy... Or Not
Is the Endodontic Triad Dead or Stuck on Semantics?
Zoom with Dr. Sonia Chopra and ProTaper Ultimate Q&A, Part 2
Carrier-Based Obturation Removal and MTA vs Calcium Hydroxide
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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.