Ruddle Shaping & Finishing Technique Card featuring ProTaper Ultimate
Delving Deeper Progressive Tapers & DSO Troubles
Welcome to Season 10! Ruddle and Lisette begin by bringing you up to speed on what they have been up to… Hint: podcasts and vacation. Then, focus turns to the business of dentistry and some uncertainty in the DSO industry. Next, Ruddle is back at the Board, delving deep into progressive tapers; what does this mean exactly and why is it important for a file to have progressive tapers? The episode concludes with another Head Scratcher case. See what Ruddle did… Would your strategy have been the same?
Show Content & Timecodes00:42 - INTRO: Welcome Back / Update 08:02 - SEGMENT 1: DSO Uncertainty & Is Your DSO Failing? 30:37 - SEGMENT 2: Delve Deeper – Understanding Progressive Tapers 55:59 - CLOSE: Head Scratchers – “Mysterious” Healing Case Report
Extra content referenced within show:
Other ‘Ruddle Show’ episodes referenced within show:
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...
The goal of endodontic treatment is to prevent or cure, when present, Lesions of Endodontic Origin, at times referred to as apical periodontitis. The role of bacteria in the pathogenesis of endodontic disease is well established, and therefore, it is critical to eradicate these pathogens by employing the highest level of presently developed standards...
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.
…Are you forced to reuse your single-use file?
Man, I re-launder my paper points and hang them on dental floss at night so I can have paper points the next day...
INTRO: Welcome Back / Update
Welcome to Season 10 of The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle.
How you doing today?
Pretty good; what about you?
I’m doing great, and I want to welcome everybody. I’m looking into that camera again, and even though it’s kind of empty behind the camera, I think I see hundreds of people – they’re my friends. I like reconnecting. This reminds me of the good old days.
Well we’re pretty excited about the new season. Every season is like its own little journey and it’s really neat to see it unfold in front of us. Of course you can always count on my dad to deliver the same outstanding, educational content; that’s a constant. But maybe you’re wondering what controversies we’re going to discuss, what new segments will be featured, or who will be our guest. So yeah, it's pretty cool to see it all come together.
Oh, but then – I just talked about the journey, but there’s also the behind the scenes journey as well, right?
There’s an old expression: you don’t want to know how sausage is made. Okay, well she set me up for that one, didn’t she? Look. There’s five of us that make this happen, and so you probably think that Ruddle is the endodontist so he’s the leader. No, I’m not the leader. I have a very narrow lane and it’s called endodontics. But we have – I’m trying to say we have four other very creative people. And when you get creative people around, of course there’s always consensus isn’t there? It’s easy to get the consensus because when you have fantasies and big imaginations and you get all these people together, we don’t always agree and sometimes we have upsets. And sometimes those upsets get pretty interesting.
But you know what? The think I’ve learned about the upsets – it’s just like everything else in life, in your office and everything else – you learn to manage the upsets and you learn to get over them. And all of a sudden what I realized is – I’ll be personal – like sometimes I don’t have – maybe I have an idea that could be better. So I’ve learned to stand back a little bit, because a lot of times I don’t have the best idea. And I think we really arrive at consensus, and then we’re all in, and then we can be creative and imaginative and all the things that make the show so much fun. So that’s a little bit about the sausage making.
Yeah. And I think I’m right when I say both of us, and everyone that works on The Ruddle Show, the whole organization, we all learn a lot during the season. We learn about what we’re presenting; we learn just little things about how to work better together; we’ve learned so much about how to make the show better. So it’s definitely a learning thing.
And I mentioned the glitches. There were a few glitches that kind of – well it sabotaged a couple of podcasts we were going to shoot, and I had a whole lecture thing that I’m going to still do and you’re going to get to see it. You can hardly wait; I know you’re just on the edge of your seat.
But anyway, there were some glitches and you wouldn’t think it, but we lost our connectivity. You want to talk about that?
He’s referring to the internet was down. But now it’s back up so that’s all good. And I heard you just mention podcasts, and that’s what we’ve been doing; we’ve been learning how to do podcasts. We’ve actually shot three of them. And I have a note here; oh yes, it says for real this time. So we actually, really shot some podcasts; there’s three of them. One is on diagnosis, one is on Season 10 planning, and the other one is on technology and how it affects or doesn’t affect the standard of care. So those are available to watch now; we’re still trying to work it all out. Some will be free; some will require a subscription. We’re going to make a lot more.
What did you think about doing podcasts? Did you like the podcast format?
I do. I’m a rookie, and I actually started watching other people outside of endodontics do podcasts because I wanted to know what are the people that get 4 or 5 million or they have these huge followings; what is the thing that’s going on that seems to attract people? And what I’m learning is it’s the connectivity. So for me – and I’m thinking out loud – lecturing around the world for across five decades, I’ve met a lot of people. A podcast is a chance for me to get connected and to stay importantly in relationships with people. And then we can have, like you said, guests or we can even have panels on and discuss some things in a very controversial or a very fun way. So I like the relationships, the connectivity.
I think it’s good that it’ll be video and I’ll be doing some things, both of us at the board. But a lot of it could be audio, which means you could be driving down the highway of life, you could be working, you could be sweeping the floor and you could have ear buds in there and you could be listening to everything Ruddle and Lisa have said; you’re going to just love it. So I think that’s cool for flexibility.
What else do I have here? Well I like – I forgot the most important. I am not locked into time as much. I mean I have to be aware of time, but we could go an hour; we could go an hour and a half, hour twenty; we could go as long as we wanted to. Whereas in the show, everything is pretty much boom, boom, boom, boom. It’s kind of like a dental practice day. You’re on the clock.
Yeah. It was – we were able to take some breaks, so we spoke for like 30 minutes and then took a break and came back, so there was a lot more freedom there.
Another fun thing we did this summer is we took a family trip, all 12 of us, and we haven’t done that since before COVID, since 2019. So we took a big family trip and we went to Maui, and we had the best time. We came back, and three weeks after we got back we heard about the fires and what happened to Lahaina and other parts of the island. So we’re kind of left a little bit ambivalent; like we just had a great time in Maui; it really holds a special place in our hearts. We’d go there every two or three years with the kids while they were growing up. But then there’s the terrible devastation there, the loss of life, homes, businesses. So yeah, it's kind of -
Yeah, I was going to report in on some of the wonderful things that happened during my 10-day period there, personally. But I’m going to ignore all that; that’s not really relevant today. And I think our attention turns to the people that live there. Many of you have gone there, just like we have over the years. Many of you want to go there. And some of you have it on your bucket list to go there. And then I want to also point out; there’s tragedies all over the world. And so for all the people that have been caught up in these terrible tragedies, whether it’s a fire or a hurricane, earthquake, whatever; our heart goes out and maybe this is a good chance to reach out and help a little bit financially to your favorite charity, because the people need us.
Okay. And of course you’re probably seeing this show a whole month after we’re shooting it.
That’s a good point.
Things are going to be changing daily.
The new lunar cycle will be in there.
Yeah, so later on this season we’ll show you a little video or a slide show of our trip, and it will be kind of like a celebration of Maui. So that will be coming soon.
Okay, but right now we have a great show planned for you today and we’re going to get going on it.
SEGMENT 1: DSO Uncertainty & Is Your DSO Failing?
Okay, so we first talked about DSOs on The Ruddle Show a couple years ago, when we were Zooming with Dr. Gary Glassman from Toronto, Ontario in Canada. And it so happens that Dr. Glassman is Chief Dental Officer for DentalCorp, which is a dental support organization in Canada. And I have to say that after that interview, we were left with a very positive impression of DSOs. It sounded like a great way for dentists to focus on what they love, practicing dentistry, and not have to deal with all the business and administrative duties, ultimately enhancing a work/life balance which was the main theme of our interview with Dr. Glassman.
But back to DSOs. Some benefits of joining a DSO are a less expensive product because DSOs can buy in bulk from suppliers. And then also you have access to legal support, mentors, CE, and state of the art technology. And I think I even said at the time of the interview with Dr. Glassman that DSOs sounded ideal for dentists.
Now yes, the DSO concept is an ideal concept. But sometimes when it’s applied in practice maybe the reality is a bit harsher. So what have you noticed in the last couple of years about DOSs?
It’s kind of complicated, and I’ll just mention the graphic behind me. Some DSOs are on the high seas and they’re sailing very well towards some destination; but not all of them. But the trend is definitely more DSOs. The answer is going to be a little bit – not convoluted, but you have to have some perspective.
For perspective, in the last five years DSOs have gone from about 5% in the United States to 13%. So that’s quite a trend if you think of about 192,000 dentists.
And clinicians who belong to a DSO?
Yeah. So we have about 192,000 dentists in the United States and that’s the numbers. Well the AGD, the Academy of General Dentistry, has said actually if you’re less than 35 years old, it’s 18%. Now that’s getting close to 1 in 5. So I wanted you to just set it up; she said what do I think about DSOs. Well you can see they’re trending upwards. But there also are some warning signs, and some of the warning signs that prompted this picture. If you start going out there and really reading, there’s quite a bit of turbulence and not is all well on the high seas.
So one of the things I’d like to point out is the enormous debt. What’s driving this? Well, it’s enormous debt. Kids are coming out of school; it’s over $300,000 US dollars for North American schools. And that’s an enormous debt. Now throw in COVID at about what, 2000?
2020, thank you. I was thinking of an even number. But you have the debt, and now all of a sudden COVID, and the opportunities kind of shrunk and went away. Endodontists did pretty well because people still got toothaches, but a lot of elective treatment just got canceled. So I’m trying to say things that have driven the trend.
So then you get out and you have all this debt. You don’t have a lot of knowledge because you just got out of dental school, so you’re a little bit insecure and timid. You don’t have expertise on business and structures, you have no more money because it’s harder to get money because money has been drying up for dentists as well as DSOs. Dentists used to go into a bank and they’d write the loan. Well if you already have $300,000 or $400,000 of dental school debt – I didn’t even mention collegiate debt – and now you want to dump some more cash into an office, but some equipment, set up your operatories, it’s a big number. So there is a lot more concern about it. There was a couple of other things I wanted to mention. They’re trending upwards because dentists love freedom, and there’s perceived to be more freedom.
But now I’ve got to bring us back to the reality: what’s happened lately? I mentioned COVID. During COVID, about seven trillion dollars in the US was dumped into the economy. This means you have too much money chasing too few goods. So the problem was with DSOs, they had easy money. They could go get massive amounts of cash, entrepreneurial money, private investment, PE firms, junk bonds. All this was there but it started to dry up because with all that money in the economy, inflation took off. And as inflation took off, guess what? Interest rates had to climb because you need higher interest to tamp down inflation. So with interest rates up, when we borrow money we pay interest on the money.
So as the interest has gone up, all of a sudden a lot of the money that DSO’s could easily operate with has kind of gone up. And this has led to mergers and acquisitions, and it’s led to some chaos. Because when you start to have mergers and acquisitions, what’s the first thing if you come right back to a little, small dental office in the community? Well maybe the receptionist is now gone. Maybe the new owner, the DSO owner, wanted to have different people. Maybe they wanted more economies of scale; maybe they wanted to have you do your procedures a little faster.
Anyway, that’s what’s happening, and all that change and acquisition and buyouts and sellers and mergers, that’s caused a loss of stability in the dental offices. Not the DSO perspective; I’m now the dentist, so this is my perspective. It changes the culture and it changes how people think. It changes – you have different management people a lot of times that come in; their styles might be a little bit different. The systems and structures changed; there might be a great emphasis on this investment from a DSO versus maybe back behind – and we’ll talk in a moment about inter-operatory investments. So those are some of the things I saw.
Agreements that were made with your original DSO do not necessarily go through to the new DSO. And remember, in all of this, when the shit hits the fan, don’t ask the dentist to get the money on the payouts. It will be the dentist walking, the staff will be walking, and it will be the DSO that’s splitting up the crumbs that are left.
Yes. I did read a fact that I thought was quite staggering, and that was that it is not so unusual for a doctor to have been employed by three or more DSOs within the past year. So that’s like wow! That seems very unstable, an unstable environment.
I wanted to now go on to what you’ve been hearing on the AAE discussion forum, because I know that you go on the forum almost every day, because you like to keep your finger on the pulse of what’s going on in dentistry or endodontics specifically. So what are they saying on the forum about DSOs? About the DSO structure?
Well that’s a great question; I’ll try to be really quick. Just to preface what I’m going to say; the DSO model is working different. They’ve already learned from whether you’re a younger dentist or an older dentist; whether you’re a general practitioner versus an endodontist. So we’re having this general discussion as if all dentists were alike, but there’s different things to be concerned about, if we’re talking about should we be concerned, whether you are young or old or a GP or endodontist.
The big thing I hear on the forum to say it very quick; obviously the biggest enticement of a DSO is cash. Let’s just say it. Cash and then revenue sharing. What’s revenue sharing? It used to be you got 100% of it; now you might get 60-70% of it because the DSO is taking the margin to run the administrative that you talked about, and all the other systems and structures.
So older dentists, more mature practices I should say; they are very happy because it’s harder to sell practices today. Because if they try to get their full value, this younger endodontist in an endodontics situation is probably debt ridden and probably is not good to go out and get another massive loan. So there’s a little bit of up and down, because if you’re older, you think it’s terrific; you’re getting your cash out. If you’re younger you’re going wait a minute. I just got out of school and now I’m going to go into this DSO, and it’s already been sold, so the practice has been sold, and now what do I have to sell?
So that’s kind of the dilemma appearing on the forum. Is it good for the old guys or is it best for the young guys? And the younger guys are saying we want our opportunity.
Okay, so it sounds like the old structure of an older dentist taking in a younger dentist out of school maybe into the practice. Working for -
- many years, maybe a decade. And then eventually the older dentist wants to retire and the younger dentist has the opportunity to buy the practice. Well that’s kind of gone if the DSO has already bought the practice a long time ago.
So it sounds like the DSOs could be both good and bad for young dentists; because good in that they can offer that short-term financial help and guidance, but maybe bad in the long-term because it’s limiting future opportunities for young dentists to maybe one day own their own practice. That’s kind of what I’m hearing.
One of the biggest investments you ever make in life if you’re a dentisto is you have a practice that you are building; you have systems and structures over decades of your life, certainly many, many years; you have the right people, you just get that thing humming; it’s got value. And then you buy a house. And those are probably a dentist’s two biggest things; their practice and their home. The mortgage or they own their house outright.
Okay. Well one of the – let’s go on now to the technology, because we did mention that one of the big benefits of joining a DSO is access to state of the art technology. But from what I’m reading, it seems that DSOs are failing in large part with their technology strategy. And when I say technology I mean not only the technology that you use clinically, but also the technology to run the office.
So what is going on now with the technology strategy of DSOs?
Well just to be clear because we have an international audience. So maybe DSOs; I have no idea if we have DSOs in Asia. I have no idea about Latin America. I don’t know about Western Europe; I have no idea. I’m talking about the United States. So maybe we ought to say this. When she talks about technology – come, join me, I’m a DSO – because Lise, I’m going to do all your administrative work. Well the administrative work – we’ll probably be real quick; insurance, billing, collecting, recalls, purchasing (she mentioned that), marketing, recruitment, legal, payroll, human resources, and tax services. That’s the IT they speak of.
If you bought into a DSO, as an example; would you want them to buy you the CBTC that isn’t in the operatory? What about the microscope? What about some of these big ticket items? Who’s paying for that? The DSOs haven’t notoriously been doing that.
Now if you’re talking about the endodontic model, those are pieces of equipment that are already there. So when they buy it, they’re already buying all that, and the young dentist that’s practicing there that isn’t a DSO person would get the benefit. But a lot of general dentists – because I’m a teacher – they say when they go back to their DSO, they go well can I buy the Obtura gun; can I get the motor to drive the NiTi files; can I get this, that? The guy or the woman that owns it says no; you can do with what you have in the operatory. If you want to get it, maybe go out and buy it yourself.
So that’s what you’re talking about. There isn’t the long-term leadership that looks at the operatory because the foundation starts in the operatory. How you take care of people, how you make people feel about themselves. People never remember what you say but they’ll always remember how you made them feel. So if you work on the operatory and build out from there, you’re going to have a great practice and then we can dump the money in the upper structure. So it’s kind of like where’s the money going.
Go ahead because I was all done at that moment.
Okay. Well it does sound like there’s a lot of uncertainty in the DSO industry, at least in the United States. It would be interesting to talk with Dr. Glassman to see if DSOs in Canada are having the same types of issues. Maybe we do a podcast and we can really go into depth on it.
The main thing I’m going to say again that’s fleshing this out is the lack of availability of money. That’s because of the international economy, and specifically the United States is in horrible debt. We have trillions of dollars of debt and we’ve flushed so much money out that our interest rates are up, so that’s what’s making the money dry up, the interest rates.
Okay. Well now let’s talk about – say you’re a clinician and you’re in a DSO, and you’re wondering if your DSO is struggling. So we saw an article -
Yeah, are you this or are you sailing along?
We saw an article that came out in Dentistry Today News at the end of last year, and it was called Five Tip-Offs Your DSO May Be on Thin Ice; and it was by Dr. Michael Davis from New Mexico. We actually have a list of the five tip-offs, and we’ll go over this list now.
So one sure sign that your DSO may be struggling is are they curtailing bonuses and salary increases?
Yeah. We’ve kind of already said this, but basically we all live to work hard, make people happy, and then we hope we get acknowledged. And over a little bit of time, we’d like to get some bonuses and payouts. This is the mother’s milk of good culture. People are excited.
So if you don’t do that, you might ask where is it going? Well a lot of times there’s a big squeeze on trying to make the capital payments. The DSO itself is running maybe 30, 50, 100 practices; it takes enormous cash. And if the cash isn’t there, they might then have to forego the bonuses and the increases in salaries.
I think it would be very frustrating if they gave you some benchmarks to try to meet and you were meeting them, and then they said oh well, sorry. We’re just going to have to postpone your bonus.
Well that has happened, and I’ve actually seen and read stories about that.
Okay, another warning sign. Are vendors being paid or are they not being paid?
Well, which camera? Okay, eanie, meanie, minie, mo? Okay, this one’s good. What if the laboratory work’s not back, and then you call the lab and they say well the bill wasn’t paid. That’s just one example. What about supplies; just daily stuff that comes in that makes the office go? What if it’s been put on hold because there is a little outstanding payment on there? What about the laboratory products not coming back? So when you start to see a little bit of chinks in how things are supposed to be moving and flowing like an orchestra; that’s an indication that all is not well upstairs at ownership.
Are you forced to reuse your single use files?
I re-launder my paper points and hang them on dental floss at night so I can have paper points the next day!
Okay, number three: high staff turnover.
You know we’re seeing a lot of that, because when management comes in, everything is beautiful. We have a guy here in town that joined one. Everything’s perfect! You got the cash in there, he’s revenue sharing. All of a sudden you look up and the front desk is gone. Oh, there’s a new one; oh, there’s another new one; oh, we’re looking for another one. When staff starts to leave and gets pushed out, what happens is a DSO typically will take – I’ll just make this up. A lot of my receptionists had been with me for like 10, 15, 20 years. They know everybody, they know all the systems and structures, they’re the mother of the year, people drop by to say hi to them and bring them candy, flowers and cookies. Okay, it’s that kind of a person. Well when they get pushed out because their salaries are a little high, then all of a sudden the new one comes in. Well everybody on this show today knows that when you have two staff members and you add one more, it didn’t get more difficult by 33%. And when you add the 4th one, it’s like an exponential curve meshing all those personalities for the greater good. So when you have turnover it’s devastating, and a lot of times the newer people in are less experienced, they do more of what the DSO wants them to do, they don’t really know about the culture of the practice, they’re coming in to save the day.
And this is motivated by cost cutting; because you’re letting go the more expensive person that gets higher wages, they’ve been with you longer, for the newer person that’s not going to get paid as much.
Saving money. You get the same – I might be jumping ahead of our flow here, but there’s time to say it. A lot of times there’s a lot of pressure to reduce fees. Because they’re a big organization; they’re – just say 100 offices (I made that up) – but some do have that. Some have a thousand offices. Hartland Dental has over a thousand separate satellite offices. So all of a sudden if they say well Lise; we’ve noticed you’re spending an hour on that molar, but our statistics here say that that molar can be done in 40 minutes. So there’s – give me your arm – you need to get a little faster. All right? And so there’s pressure on that. And then if they lower fees because they figure all of those little private offices out there, they can crush them by lowering the fee and get underneath Ruddle; and now Ruddle gets fewer referrals because they go to a cheaper place.
So anyway, it’s a long topic; it’s complicated. But those are the constraints and the forces in the marketplace.
Yeah, and just to return to this high staff turnover for just a second. It’s not only high staff turnover in your office. When you talk to the DSO regional manager, is it always a different person? I mean there also might be a lot of staff turnover in the DSO.
Okay, number four. Another warning sign: is there a lot of pressure on doctors to purchase DSO equity?
Again, are you in the general dentist category? Young or old? You’re an endodontist? Yes, there is pressure. And if people that say that, that haven’t been out in the marketplace really talking to people? But there is a lot of arm twisting at some point. Like come on Lise. Lisette! You’ve got to get in here. Come on, you’ve got to build for your future; you’ve got to invest. That means probably there’s shortages of cash.
Yeah, and I think that – well I read that a lot of doctors are really feeling like they’re forced to buy shares. That if they don’t, maybe they’ll be relocated or compromise their employment somehow. So they actually feel like they kind of have to.
Yeah. And then the last one is what is your DSO’s standing in the subprime bond markets?
Well Moody’s is an investment firm that gives advice, and you can go to Moody’s and they can rate different junk bonds. I mean why do you think there are junk bonds? There’s junk bonds because credit scores are lower, so normal banks won’t give those people loans, so they have to get subprime loans that are more expensive interest because they’re a bigger risk. So a lot of times you can find out whether a company is going down; find out if they’re quite strong.
What else did I want to say about this? I just really want to come back to the defaults, the partial defaults, and the debt acquisition swaps. That’s what’s happening a lot behind the scenes. And so most dentists are just like sssh; they’re back in the office doing the dentistry.
Right. Okay, well if you look at our DSO journey, which is basically our history of talking about it on The Ruddle Show, we’ve gone from a very positive impression of DSOs to now being a little bit skeptical. And would you say this is true?
It’s absolutely true to be skeptical. I mean any – whether you’re buying your favorite home or you’re joining a practice and you’re thrilled; there’s always the really exciting news, but you need to probably do a S.W.O.T. analysis. And for those that don’t know, you need to analyze your strengths, your weaknesses, and the threats and the opportunities. I didn’t say it in the same order, but that’s the S.W.O.T. analysis. And if you sit down with your tax people, your business people, your staff, you’ll know exactly what your strengths are. We’re growing really fast, we have wonderful care, our reputation’s superb; so wouldn’t you always be a value to the DSO later? So when you’re growing your practice, it’s going to be good if you sell to somebody private. It’s going to be good if you sell to the DSO. So work on your practice; that’s your strengths. And I won’t go through it all, but there’s lots of opportunities. You’ve got to worry because they can buy in mass scale, so maybe I pay $5 bucks for a file; they might get files for $2.50 because they’re buying 50,000, a million more files than Ruddle is buying.
So those are things that – do the S.W.O.T. analysis and you’ll kind of know where you are.
Yeah. I think just to close; I think that DSOs’ popularity over the years goes up and down. I think that probably before COVID, maybe people had a more negative impression of DSOs. Then all of a sudden they became like wow; I want to get in a DSO. And now we’re at the other end of the spectrum going well, is this really worth it?
So yeah; I think it’s just the kind of thing that hopefully will fix the problems that are happening right now and in a few years, all of a sudden it will be very popular again.
And what’s it all about? Money. If there wasn’t any money issues, you wouldn’t even be looking at DSOs.
All right. Well thank you for that discussion. And now we will move on to progressive tapers.
Oh, I think I want to delve deeper.
SEGMENT 2: Delve Deeper – Understanding Progressive Tapers
Welcome! Today I’m pretty excited about delving a little bit deeper into progressive tapers. But before we do, you can start to play the game with me. These are two cases done about 35 years apart. The one on your right was done probably in the last 2-3 years, and you might have seen it. The one on the left is a case that was done a long, long time ago. And they have similarities, don’t they? If you start to look at the shapes and the flow of the canals, you could say wow! But they were done with completely different armamentariums.
So the first thing you’re noticing is wow; you could do that with two completely different armamentariums; armamentariums that are separated by decades of work? Let’s take a look. Let’s delve deeper today into progressive tapers, and let’s look at how we can come aboard to the modern era, and we can do things easier, better and faster.
So my pal, John West, did this taper case with ProTaper Gold; and that’s a progressively tapered file. That means progressive is the umbrella; that means there are decreasing percentage tapers and there’s increasing percentage tapers in the family of instruments.
Over here, Ruddle did this case a long, long time ago. But yet when you look at the differences, you can see maybe one is digital, one is analog, and you can make those kinds of distinctions. But basically you would say both cases seem to fulfill the biological objectives; but they were done with different tapered files.
So for Ruddle, I used about 10 hand files, and that was able to be worked primarily just in here. So basically all these files were working in a little zone of about 3-5mm; and that 3-5mm is the apical one-third. I also then to get the body opened up – to get the body opened up, we used a series of GGs, with each larger GG introduced at a shallower depth than the previous one. So by blending the GGs from small to big, we could get a pretty good, uniform taper if we were using the brushing motion. So together, they worked as a concert. ISO .02 taper hand files with Gates Glidden. Gates Glidden is restricted to the straightaway portions of the canal, whereas the instruments that are carving that deep shape and blending it back into the body were done with hand files.
Let’s look a little bit more. So we had a manual prep; you can see there’s a lot of tedious work; it’s easy to maybe have some bumps and little transitional areas between GGs. But lots of files and lots of instruments. Stainless steel was the day; that’s what we did back in that era, and we had a lot of technique sensitive issues, and we took more chair time.
And if you look a little more about these instruments and how they actually work, I think it’s good to review them. We should delve a little bit deeper. Everybody knows if you’re talking about the International Standards Organization that all companies that produce files have nomenclature, and we say D-0, that’s at the first rake angle; it’s almost the end of the file, but it’s actually up about a quarter to a half millimeter. And then if we go 16mm up, that’s the last cutting flute, so all ISO files have 16mm of cutting blades. And of course there was a 0.32 was the taper over the 16mm. And so if you added 32 to the number on the handle – 32 plus 10 is 42, 32 plus 15 – and you can start to read them right out. So those were 02 taper, and if you did the math and you divided actually – 32 – I don’t know why I went back to white, but we’re going to go back to white; I insist – and you divided that by 16, you can see you get the 02 taper. That means every instrument gets bigger by .02 of a millimeter every one millimeter you go up; and it also means that the files – the gap is .02, so it gets bigger by .02/.02, so there you go. You’ve got the taper.
Well what’s next? The GGs that were confined to the straightaway portions; always teaching brush away from furcal concavities, move the canals intentionally to the bulk of dentin, and we could get pretty good with our Gates Gliddens couldn’t we? And that’s how endodontics was done for decades after decades after decades. So that’s kind of an old look at what we had.
And then we got into rotary. And with rotary, the big problem was how do you get these tapers that we wanted? How do you get tapers of 6, 7 and 8%? Steve Buchanan even came out with this for the early or middle ‘90s I guess, and it had 10 and 12% taper. Well you have to restrict the taper to just a few millimeters of flutes; that’s the key. You can’t run these big tapers out. Because in the first 4mm from D-0 to D-4, the taper we said was .32. So 4 times – okay, you can begin to see it. Add 32 to 25 and you have 57. So it just keeps getting bigger and bigger. And up here, a GG #6 is equal to 1.5mm. So we’re even bigger than a Gates Glidden 6, and who uses Gates Glidden 6? Maybe in a deciduous tooth on a young patient; but generally in adult teeth, we don’t even use a 5 or a 6; and only a 4 is one bud depth below the orifice; one bud depth.
So that’s the problem when we were starting to think how do we go from ISO stainless steel to NiTi? Because NiTi was more flexible. But one of the things that I want to point out is it was the beginning of the thinking of change the taper. Buchanan likes to say he was the first file system to have changing tapers. Yeah, changing tapers between and among files, we actually – the ProTaper concept was to change the taper on a single file. That’s the distinction.
So Machtou, professor Machtou, John West and Cliff, gave this feet and we started to run with it. That was in ’95, and by 2001 we launched a regressively tapered file and a progressively tapered file. But notice a regressively tapered file eliminates this big number. These big numbers are greatly reduced. And if you superimpose this file over the fixed, tapered NiTi file up above – forget the gold treatment; that even helps more – but we’re just talking about the silhouette; the dimensions of the instrument over its active portion. So in every instance you can see, it helps to reduce the tapers. Because if we do this little stunt and superimpose that instrument, you can begin to see how much tooth structure.
So you’ve got to put all these ideas together. You want the shape; you want the shape that allows for cleaning; you want the shape that allows for controlled filling; you want the shape that maximizes residual dentin; you want the shape that preserves the tooth for as long as possible.
So all these ideas were put into place, and that was 2001 that we launched ProTaper. ProTaper, ProTaper Universal, it was ProTaper Gold, now it’s ProTaper Ultimate. But always, regardless of the iteration, there was always the progressive concept. We were the first file in the world. And I might add, just to be a little bit mean spirited; we are still the only file in the world that offers tapers of 7, 8 and 9%, on F1, F2 and F3. And what I want to say is there’s a lot of companies out there and they say replace this with our file; they’re the same. Half the price, Doctor.
Well that’s just bullshit – let’s just call it what it is. If you go look at the company, Edge Endo, and you look at all their ProTaper replacement files, listen. You’ll see they’re 6%. Their maximum taper is 6%. So when we compare 6% to 8% or 7%, it’s apples and oranges. So if we’re talking about deep shape – we’ll just keep going; we’ll not get ahead of the lecture – just keep going and you’ll get to see then this other idea. So when you get rid of your stainless steel files – maybe you used 10; you might have used 11 or 12; some of you might have said well gee, you forgot the 55 back there in the lecture. We didn’t really need a 55, because from 50 to 60, the difference is 10/50ths, that’s 1/5, that’s 20%. So that’s a lot less than the jump between a 10 and a 15; 10-15, 5/10ths, 1/2, 50%. So we didn’t need to use all the stainless steel files, but we used at least 10. And now we can do 10 files and get them down to typically 3 or 4 files.
So this is Johnny West’s case. So it’s a rotary prep, fewer instruments, he got to use heat treatment; it wasn’t just NiTi, it was nickel titanium gold – that’s a post machining event – and it was very safe, very flexible, good resistance to cyclic fatigue. Listen; you don’t need running times of cyclic fatigue for minutes and minutes and minutes. A file is in a tooth – even if you do four canals – less than a minute. If I was wrong, it’s five minutes. That means you’re there for all day. But you know what? The marketing is what is confusing you; that’s why we’re delving deeper today. We’re delving deeper because marketing likes to show long running times with some files. Well that’s why they’re so flexible you’re thinking; because they’re over treated, they’re over cooked. So now they’re not very efficient, but they’re very flexible and they’ll run for a long time. But we don’t run them for a long time, so we don’t need that so-called distinction.
So that’s a little bit about the tapers, and how we got from stainless steel. Now on a previous segment just last season, I told you, you could take an .02 tapered file, and if you used Schilder’s envelope of motion concept, you could bend a file, get a belly on the file, and you could get more taper than 2%. And you would run that instrument in, and you would cut on the outstroke, and you could have that belly randomly hitting the various walls of the shaped canal that’s developing. And it was a beautiful thing, and you could get tapers of a lot more than just 2%.
We also know in the step back pressure preparation, if you had a 20 at length, we want the 25 at the end of the prep. The confirmation was where’s the 25, where’s the 30, where’s the 35 and 40? And when all subsequent larger files, uniformly and sequentially backed evenly out of the canal, we could get tapers of easily 8 and 10% with .02 tapered files. But we can reduce the number – and that’s the key – while using much better metallurgy than stainless steel.
So let’s delve deeper. Let’s look at Ultimate, that’s the newest iteration, it’s been about two years now this coming September. And you can see there’s shapers and there’s finishers. Here’s the series of instruments. There’s some auxiliary files over here that I’m not showing, and you’ve got this guy here that’s a little bit short, but that’s our Shaper X. Now Edge Endo does make an 8% taper orifice opener, so some companies do have – I’ll call them fatties for opening up the orifices – but nobody – I’ll repeat, nobody has 7, 8 and 9% in the apical thirds on instruments that are designed to be going to length. So when I hear they’re just the same, half the cost; twice as good, half the cost; just the same, use them just the same; we’ll take a look at that and see if that’s true.
So our concept was progressive tapers is a concept, but you can have increasing and you can have decreasing. I don’t think anybody in the world has increasing percentage tapers. They all say they do, but they don’t. I mean go look at the specs, okay? Look at the specs. Everybody has copied decreasing percentage tapers, because that makes the back end of the instrument smaller in its profile, it saves dentin, and it encourages a more minimally invasive prep.
Let’s take a quick look. If you look at the three shapers, they have increasing. They’re designed to push the workload up. Away from the apical third and up towards the what? The bigger, the stronger and the more efficient blades. They pre-enlarge; they open up the canal. That’s that concept. They pretty much run in the glide path loose. They’re just following. They’re just like an e-car with IT, driverless, you know, following.
So it would look like this – we’ll just take a look at one file. This is a shaper in the Ultimate family. It’s the only shaper; it’s a single shaper. And it starts at 2%, but it’s not uniform; the numbers keep getting bigger and bigger. And you can look over here and read the charts, but at the critical areas on files, critical areas, it’s that part of the file that goes in say about 8 or 12mm. You can see the dimensions are very, very kind to the root; it’s maximizing dentin.
You know I’ve read a lot of things; oh, you don’t want to use those progressively tapered files, they really blow open the roots. Well you just don’t understand and you listen to the wrong people. You don’t understand. You could understand if you chose to understand.
So this is an old case. We did all the work upstairs; all the upstairs work was done with Gates Gliddens. All the deep work was done with 10-60; 20-25 at length was usually the foraminal diameter; and then the 20, the 35 and the 40. And when those instruments backed out of the canal uniformly, you knew you had deep shape. And if we have a furcal side concavity, we know to make the mid mesial a little smaller prep than its counterparts, because we don’t want to have it drift off towards furcal danger and predispose the tooth to longitudinal failure. Fractured teeth are a reality. So maximize dentin.
Let’s look at decreasing tapers and let’s delve a little deeper into that. Decreasing tapers are not designed to work in the body of the canal. They’re designed to be loose. You notice there’s no engagement. They just work apically. And I’m going to just keep saying it. You notice the tapers are what? You notice the tapers are what? 7, 8 and 9. Nothing in the industry has 7, 8 and 9 to go around apical curvature, give you the flexibility, and still give you deep shape. So a progressively tapered file, just like it says, with a new cross-section is only fixed downstairs, only in the apical third. Then it will have decreasing percentage tapers, regressive tapers, over the back end. That’s a thing that was understood in ’95; it launched in 2001. It was a minimally invasive concept before its time. Now it’s copied; almost every system in the world has regressive tapers.
I’ll challenge again. They don’t have progressively increasing percentage tapers; just decreasing. And the biggest taper is 6%. I’m just hammering that, because why? Why am I hammering that? We’ll see it right here; 7, 8 and 9. Just to work in the apical third. They really aren’t designed to be working up in here. These instruments pass through an already pre-enlarged canal; they’re passive, and they’re cutting and they’re blending and carving out your deep shapes, in the apical thirds.
So what are the ideas with deep shape? Do you think it’s just a fun word? Look down here. One of the most commonly loved instruments in the industry is a 25/06. All of our competitors stop at 6%. What do you see here? If you look at the article and you look at the literature, you can find out that 6% compared to 8%; 8% gives you 19% more fluid volume. And if you have more fluid volume in here, guess what? You have more volume to what? Exchange into the un-instrumental portions of the root canal system. So that’s a really good thing. Everybody can have more volume, more fluid, more exchange. Theoretically if you’re exchanging better, you’re going to clean laterally better. And if you clean laterally better, you’re also going to have a control zone with decreasing tapers to fill the terminus, to hold your hydraulics and your obturation materials.
So we don’t have the accidents like we see with some of the technologies. Gel Wave doesn’t like to hear that. You can get sued from them; you can make the lawsuits go away, because you know what? We’re just going to say the truth here. But there are sodium hypochlorite accidents. Well when you have skinny little preps, like 13-something; 13/03 or maybe you’d like to have a 14 or a 15/03, or a 15/04, those little skinny preps. It’s more of a what? It’s more of a 2-way street where irrigants can go either way. And we don’t like irrigants to get outside the tooth.
And finally we have better compaction, more hydraulics, and filling into root canal systems. If you look at these images – I think there’s 8 of them there – you’ll basically see just a lot of anastomosing in here, an extra system – a mid-system in the apical third. You saw this one earlier; three portals of exit, lots of anatomy, lots of anatomy. Okay, another mid-mesial down here, lateral canal and curvature, more anatomy. It’s all fun. You get that with deep shape. You get that by having shaped the 7, 8, 9%. We have almost 30 years of research on this.
So to close this out quickly. If we really want to delve deeper and understand it, ProTaper is a symphony. And the orchestra are the shapers and the finishers. So the shapers are going to remove canyons of restrictive dentin in the body. Now our finishers can pass passively through that pre-enlarged canal, and they do their job in the apical third, the shapers do their job in the body, and together they complete the music.
So that’s kind of how they work. And we like the deep shape; just keep coming back to the deep shape.
Hey listen, everybody wants to fill root canal systems. Everybody’s on the forums showing all their cases, their lateral canal, their first furcal canal. I’m happy for them too. Some of us are happy because we’ve been teaching this for almost across five decades, and we’re seeing the love and the passion from all of you out there. Hey, the people that are on The Ruddle Show; we’re kind of a family. We don’t see everything the same. Some of you might have very strong disagreements with me. But one thing that brings us all together is our love for endodontics, and we want to treat root canal systems, right? And most of you here, we have a lot in common so we must go forth together to spread this message.
And we’ll look at the last case, but we’re going to look at that second mandibular bicuspid. You can see the canal traveling through what would be called the pretty straight root. You can see something over here; we’ll talk about that on another day. So the idea is to get into here. Well what did we just learn? We just learned that shapers work upstairs, whether it’s the SX, the old fashioned ProTaper Gold (I love it; it’s still one of my favorites). Okay and add S1, S2, purple, white. The Ultimate now only has one shaper. But all of those instruments together, they work dominantly up in the body of the canal to give the clinician access; unfettered access into the more restrictive apical third.
What do we find in the apical third? Most roots, however what? Divisions: bifidities, trifidities, deltas, curves, all that stuff. So when we get access to it with a progressively tapered, increasing percentage tapered file, good things happen when we use a decreasing percentage tapered file. So first you’ve got to carve out your glide path, manual instruments, 02 taper are still wisely used. Go back to that last season when we talked about the envelope of motion is up in the body; the watch is in the apical 1/3, and the patency is in, out, in, out, in, out; keep that patent foramen. It was patent before you started.
So you get a file going to the left, you get a file going to the right, and you’re starting to work root canal systems. Sometimes we can instrument, sometimes we can’t; and we rely heavily on irrigation, back to deep shape, delve deeper. Why would you want 7, 8, 9? Because you’ll have more reagent; it’s more forgiving; you’ll have a control zone. Less accidents with the packing, and you’ll be treating more root systems. And all of that together is what gives you a spring in your step. That’s why you love coming to this show; because you like to have things reinforced that you know to be true.
So you can fit cones in these cases. This is known as single cone. Single cones might be called hydraulic sealers because they us hydraulic sealers in the discs out there; get confused. We’ll have to delve deeper into that too. Hydraulic sealer: it’s a completely different idea that a hydraulic technique. So your tricalcium silicate sealers are hydraulic; they need moisture to set. I’m talking about hydraulics where you can get a plugger in here; and you can come right down that root with a plugger, and you can push on thermal softened gutta percha that’s been moldable and softened. And if it’s been thermal softened, you can mush it up against the wall-to-wall and drive it apically; and wall-to-wall and apically your 3-D and your core; out with the anatomy. And then you can just see the backpack.
Now these are pretty good cases, because if you look at our wall thickness – all you people that worry about 7 or 8 or 9% down there – I didn’t say we had to blow out tooth structure. That’s the whole idea. If we delve deeper into why we have increasing percentage and decreasing percentage; they’re different concepts for different regions of the canal.
So yes; you can go and find something on this. I’ve written a paper here about – let’s just say ProTaper, because it’s a concept more than a file; and it’s the concept that endures where files come and go. The concept of progressively increasing and progressively decreasing has been around now for a long time, and we see it on all the instruments. So you must know; if you have your ear to the ground and you’re listening, you must know there must be something to that. But what I really want you to pick up today is learn to get deep shape.
And here’s an article from my dear friends. This is Machtou right here with the glasses on. And this is John West; he’s got big hair. You know he went sailing and he never came home and probably didn’t even get a shave. So anyway, those are my dear friends from the past, and we authored that article a little while ago. And it’s available on my website and you can go there and get it.
So in closing... Progressively tapered files, they can be increasing or decreasing depending on the region or the zone you’re working in. They’re not all the same. There’s a lot of marketing hype. Be very careful of marketing hype. Replace this file, doctor, with this file; it’s the same. And the color is the same, the stripes on the thing, they both look gold. And you’re going it is the same. It cuts really quite well and you’re thinking they’re the same. They’re not the same; you need to delve deeper.
CLOSE: Head Scratchers – “Mysterious” Healing Case Report
All right. We’re going to close our show today with a head scratchers case. And when you say something is a head scratcher, you mean maybe it’s confusing, hard to understand, maybe a little mysterious. Basically something that screams cognitive dissonance.
So in this close, you will present a head scratcher case from your many decades of practicing. And maybe it’s a case that you had to put some extra effort into diagnosing, or you had to be kind of creative, coming up with a strategy on how to treat it. But this is your opportunity now to present the strangest of the strange. And a lot of these cases, he’s told me, are so atypical that they aren’t included in his lectures. So that means that this is the first time they’re being shown. So that’s kind of exciting.
So everyone, I present to you Cliff and his head scratchers case. I will step over to the side.
Boy, I feel like I need to scratch my head a little bit.
Listen. She just said it all; I don’t have much to say, so this will probably take us all of 3 or 4 minutes. Because some things that shouldn’t work, do work. And so this is going to be this head scratcher.
So you can have a wealth of knowledge around; you can have all the textbooks in the world; you can have your binders by your discipline; you can finally get nothing out of all that. You’ve got all of your journals piled up, and then you go to your computer because that’s on time. And you still can’t find it, and you’re always remembering Hess’s work, so you know that guides your every move.
So this case was sent in. It’s pretty straight forward isn’t it? You have two separate, distinct, and unrelated problems. On the posterior abutment, it is a tooth that has some ill-placed pins. You know pins are not good really, but they’re used a lot so I’ll get over it. But they’re great for endodontists because they create pulpal problems. And then you have a tooth that has really an enormous lesion. I mean everybody sees a big, diffuse lesion with a big furcal blowout.
But wait a minute! You’re out there waving your arms; wait a minute Ruddle, you didn’t see it, it’s that one too. Okay, so we’ve got another lesion. So what I said to the patient is this seems to be like something we can do. It’s straight forward. We’ll make an access, we’ll negotiate the canals, there’s some curvature in here and re-curvature. We’ll get the cleaning done and we’ll get the packing done, and I would expect that to heal. But it won’t completely heal unless we come back and revisit the bridge abutment, the most posterior abutment.
And I see we have recurrent caries. There’s been an attempt to patch it. So I said we’ll do a root canal here; patient said I’m all in, let’s go. And then I said when we’re done here, we can come back here and we’ll talk more about it. But it’s been treated previously, and I need to extend treatment here a little bit apically, because in the old days, we were taught to work a little bit short; so that was okay, standard of care, ha-ha.
But then sometimes they didn’t work, and when they didn’t work, we had to go back and renegotiate the canal; just to vertically extend treatment – and even laterally with lateral canals – to the terminus. Yeah, yeah, that sounds good. Let’s do the molar; the second molar.
So I do the second molar. And I spend a little bit of time, I get some shapes going, I was quite happy. This was done in the old ways with the 10 files I showed you for the downstairs work; they blend the deep shape into the body. And I used the GGs upstairs, and I got a pretty nice pack. So I was pretty happy.
So I totally expect it to heal. I even got a furcal canal, so that would explain the furcal lesion. Boy this thing really wants to deviate off of white. So I want you to notice the furcation. I want to even go back to show you the furcation. When you see this line here and you see this line over here; that is the depth; that’s the furcal concavity. So we’ve got to shape away from furcal danger and we did it and there it is.
So I then said take and catch your breath. Get your things, your life in order financially. And when you’re ready, you can come back and we can schedule this. In the meantime I’ll schedule you for a 6-month recall. So they came trotting in, in six months, very happy, very pleased, totally comfortable, asymptomatic, good chew equally well left or right.
And they came back and I said wow. I have good news and better news. What’s the good news? The second molar; complete healing. We’ve got all that bone deposition; it’s a thing of beauty. The body does really well when you just give it a little push in the right direction. And I said but my gosh; you used to have a lesion down here. I didn’t see any re-treatment. And all they did is made a repair. So they took out the caries, stuffed some amalgam under the margin, and they walked away; it’s done! And they said let’s see how that goes. Well let’s see how that goes.
So the head scratcher is sometimes things that aren’t supposed to work aren’t supposed to work. And you know all the stuff in that distal root still stays there; but if it’s incarcerated and entombed and locked up inside that root, you can see the body is pretty good at growing bone. So I don’t know if that’s a long-term result or if that’s a short-term result; but at six months both lesions are healing.
All right; well that was great. And if you were left feeling a little confused, then that’s the point of the segment. So yeah, that’s great. I like that case. I like that maybe a little bit better than the last one you did.
Well what I’m really trying to teach them is when you have frank endodontic lesions, don’t do root canals; just do a new crown.
Okay! Well show one down of Season 10. We’re all on the road now, so see you next time for show two of Season 10 very soon.
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.